April/May 2018

SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y

MEALTIME AS MEDICINE NUTRITION PERSPECTIVES FOR CLINICIANS AND PATIENTS VEGAN DIETS OBESITY EPIDEMIC SUPPLEMENTS CANCER NUTRITION AND THE EYE CARDIOVASCULAR DISEASE

SPECIAL REPORT A PATH TO UNIVERSAL COVERAGE IN CALIFORNIA VOL.91 NO.3 April/May 2018

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE April/May 2018 Volume 91 Number 3

Mealtime as Medicine - Nutrition Issue FEATURE ARTICLES

MONTHLY COLUMNS

14 Vegan Diets in Clinical Practice: The Power of Plant-Based Diets in Clinical Approaches and How to Prescribe Them

Neal D. Barnard, MD, FACC

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Membership Matters

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President’s Message John Maa, MD

17 Treatments to Consider: Cardiovascular Benefits of Nutritional and Nutraceutical Supplements James R. Adams, MD, FACC, ABIHM, FSCCT, FASNC

19 Addressing the Obesity Epidemic: UCSF Offers Evidence-Based Care for Overweight and Obese Adults and Children

Robert B. Baron, MD, MS; Gina Moreno-John, MD, MPH; Jonathan Carter, MD; and Patrika Tsai, MD, MPH 21 Nutrition and Cancer: What to Eat and What to Avoid

Donald Abrams, MD, and Erica Goode, MD

23 Nutrition and Health of the Eye: Dietary Guidelines and

Nutritional Supplements for Optimal Eye Health

August Reader, MD

24 Irritable Bowel Syndrome: A Look at the Causes of IBS and

the Impact of Diet

Erica Goode, MD

13 Editorial

Erica Goode, MD, MPH

37 Medical Community News 38 Upcoming Events 38 Classified Ad

OF INTEREST 8 Path to Universal Coverage and Unified Health

Care Financing in California: Recommendations to

the California Assembly Andrew B. Bindman, MD; Marian Mulkey, MPP, MPH; Richard Kronick, PhD

25 How to Feed a Child: A Basic, Ideal Diet for Kids from Birth Until Adolescence Sonya Angelone, MS

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29 The Universal Diet: A Nutritional Plan for Health and Wellness

Erica Goode, MD

37 Firearm Violence Prevention: How Physicians Can Educate and Change Behaviors Related to Firearm Violence CMA Resource Center

27 Cardiovascular Disease: Where Do We Stand Regarding Cholesterol?

Erica Goode, MD

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Obesity, Antibiotics, and the Human Microbiome: How the Modern Diet and Antibiotics Have Impacted Americans’ Gut Health Erica Goode, MD

Addressing Antibiotics Overuse: Amid Growing Calls for Action, Signs of Hope for Saving Our Miracle Drug Lena Brook and David Wallinga, MD

34 Gala: Celebrating 150 Years of Physician Advocacy and Camaraderie

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members bula, MD (D-Fresno), has introduced a bill (AB 2384) that would remove some of the largest barriers to Medication Assisted Therapy for opioid addiction, such as prior authorization requirements and coverage limits. The issue of opioid-related misuse, abuse and overdose continues to be a major policy issue at the federal, state and regional levels. Arambula’s bill is part of a larger package of legislation intended to combat the crisis of opioid misuse. The CMA will be closely following this bill package as it makes its way through the legislature.

Safe Prescribing Resources

Celebrating 150 Years of SFMMS History Four months after physicians came together to form the San Francisco Medical Society in 1868, San Francisco experienced an outbreak of smallpox. Medical society members immediately pushed for a vaccination program and established itself as a strong advocate for patients. The society also helped establish a new hospital which would grow into a nationally- and internationally-recognized institution – Zuckerberg San Francisco General Hospital. By 1870, San Francisco had become the tenth largest city in the United States, with two medical institutions – the Toland Medical School, which later became UCSF Medical School and one of the Top 10 medical institutions in the world, and Cooper Medical College, which later became Stanford Medical School.

After the smallpox battle, the medical society returned to the fight to rid the medical profession of those taking advantage of the lack of laws and regulations around practicing medicine. The founders decided that a law was needed to bring about reform.

The Act to Regulate the Practice of Medicine, prepared by the San Francisco Medical Society, became California law in 1876. The new law restricted the practice of medicine to those with a medical school diploma or who could prove their medical competence through an examination.

DHCS Begins Distribution of Supplemental Tobacco Tax Medi-Cal Payments

The Centers for Medicare and Medicaid Services (CMS) recently approved State Plan Amendment (SPA) 17-030 submitted by the California Department of Health Care Services (DHCS), allowing for the distribution of supplemental payments to physicians funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56). Issuance of these supplemental payments represents a significant victory in our fight to regain the majority of the funds dedicated to physicians through the Prop 56 tobacco tax funds that were intended to improve access to care for Medi-Cal patients. Read more at http:// bit.ly/2oZTIUg.

Legislation Introduced To Combat Opioid Crisis

Assemblymember and emergency physician Joaquin Aram-

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CMA supports a well-balanced approach to opioid prescribing and treatment that considers the unique needs of individual patients. CMA’s safe prescribing resource page, http:// bit.ly/2GaNxEk, includes current information and resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction and overdose. Resources include: white papers on prescribing opioids, links to relevant documents in CMA’s health law library, continuing medical education courses and webinars, and current information on the state's prescription drug monitoring database.

CMS Began Issuing New Medicare Cards In April

The Centers for Medicare and Medicaid Services (CMS) began mailing new identification cards to Medicare beneficiaries in April 2018, with all cards being replaced by April 2019 as required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS will allow a 21-month transition period beginning April 2018, where health care providers will be able to use either the patient’s current Medicare number or the patient’s new Medicare number. CMS has developed a web page - https:// www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html - to help physicians navigate the transition to the new Medicare beneficiary identifier (MBI) number.

Physicians Encouraged to Warn Patients of New Medicare Scam

Medicare beneficiaries are getting calls from scammers telling them their new Medicare card will arrive between April and June 2018, which is true. However, they go on to state beneficiaries must first buy a temporary card for $5.00 to $50.00 and provide personal information before they receive their new Medicare card. THIS IS NOT TRUE. Physicians are encouraged to warn their Medicare patients of this scam. Read more at http:// bit.ly/2GVP80s.

Transdisciplinary Fellowship in Primary Care Research Opportunity

A two to three year fellowship program funded by Health Resources and Services Administration (HRSA) is being offered.

This is a full-time, postdoctoral, mentored research program in Primary Care Research that includes an appointment as a Na-

SAN FRANCISCO MARIN MEDICINE APRIL/MAY 2018 WWW.SFMMS.ORG

tional Research Service Award (NRSA) Fellow at Case Western Reserve University (CWRU). Clinicians and non-clinicians (e.g., social scientists, public health professionals, and others with doctoral degrees) are being accepted on a rolling admission basis. Visit http://childhealthpolicycenter.org/t32hrsa for more information or to apply.

Apply for CHCF Health Care Leadership Program

Applications are open for the California Health Care Foundation’s parttime two-year fellowship for clinicians interested in developing essential leadership and management skills. Since 2001 more than 500 California health professionals have participated. Apply by June 8, 2018. Visit http:// bit.ly/2HwYIYC or more information or to apply.

Medical Board Looking for Expert Reviewers

The Medical Board of California is looking for physicians interested in becoming expert reviewers. Experts assist the board by providing reviews and opinions in medical board investigations, conducting professional competency examinations, and performing medical and psychiatric evaluations.

The medical board is currently looking for experts in the following specialties: addiction medicine with added certification in family medicine or internal medicine or psychiatry; colon/rectal surgery; dermatology; family medicine; gastroenterology; neurological surgery; neurology; OB/GYN; pathology (anatomic/clinical); forensic pathology; pain medicine; pediatric gastroenterology; pediatric surgery; pediatric cardiac surgery; pediatric pulmonology; plastic surgery (hair transplant expertise); addiction psychiatry; forensic psychiatry; surgery; urology; and vascular surgery. For more information, visit http://www.mbc.ca.gov/enforcement/expert_reviewer/.

SFMMS Members Participate in the March for Our Lives

SFMMS physicians, students and residents were proud to participate in the March for Our Lives in San Francisco on March 24, as well as in several events organized by White Coats Against Gun Violence during the Week of Action. Participants showed their support for the many brave voices trying to make a difference in this public health crisis.

Free On-Demand Webinar: MACRA and the Quality Payment Program

An on-demand CMA webinar is available that reviews the details of the Medicare Quality Payment Program. The webinar includes a brief overview of the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways, details regarding data submission for the 2017 performance year, an overview of participation requirements for the 2018 performance year and details on obtaining technical assistance. The webinar is hosted by Ashby Wolfe, M.D., a board-certified family physician who currently serves as Chief Medical Officer for Region 9 of the Centers for Medicare and Medicaid Services (CMS), which includes California, Arizona, Nevada, Hawaii, and the Pacific Territories. To access the webinar, visit http://bit.ly/2IOdVnF.

New Resource to Help Medical Staffs Address Disruptive Physician Behavior

A free, thirty-minute learning module is available in the AMA Education Center at http://bit.ly/2GZOza0. The module shows physicians how to define appropriate, inappropriate, and disruptive behavior, presents guidelines for dealing with these behaviors in a fair manner, and provides users with their own downloadable copy of the AMA Model Medical Staff Code of Conduct that they can integrate into their medical staff bylaws.

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April/May 2018 Volume 91, Number 3

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production by Spring Forth Studio EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Erica Goode, MD, MPH Michel Accad, MD Shieva Khayam-Bashi, MD Stephen Askin, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD Linda Hawes Clever, MD David Pating, MD SFMMS OFFICERS President John Maa, MD President-Elect Kimberly L. Newell Green, MD Secretary Benjamin Franc, MD, MS, MBA Treasurer Brian Grady, MD Immediate Past President Man-Kit Leung, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Executive Assistant/Office Manager Maria Vega Membership Coordinator Mina Yoo SFMMS BOARD OF DIRECTORS Charles E. Binkley, MD Peter N. Bretan, Jr., MD Alice Hm Chen, MD Irina S.C. deFischer, MD Nida F. Degesys, MD Robert A. Harvey, MD Imran Junaid, MD Naveen N. Kumar, MD Michael K. Kwok, MD Raymond Liu, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD Michael Scahill, MD, MBA Monique D. Schaulis, MD Michael C. Schrader, MD, PhD, FACP Dennis Song, MD Jeffrey L. Stevenson, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD Albert Y. Yu, MD, MPH, MBA CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

APRIL/MAY 2018 SAN FRANCISCO MARIN MEDICINE

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PRESIDENT’S MESSAGE John Maa, MD

SAVING SAN FRANCISCO'S BAN ON "CANDIED TOBACCO" VOTE YES ON PROP E In a 1970's tobacco industry document, Claude Teague of R.J. Reynolds once wrote, “if our company is to survive and prosper, over the long term we must get our share of the youth market.” This sentiment was reinforced by the sales team at Lorillard, who echoed “the base of our business is the high school student”.

Over the following decades, the tobacco industry created Joe Camel, marketed heavily around high schools, and created a wide array of candy flavored tobacco products to target youth.

A flavored tobacco product is what most kids are introduced to first.

Another sweetener the tobacco industry has promoted is menthol in cigarettes. Menthol is a soothing agent that masks the irritating nature of tobacco smoke on the airway. Menthol has anesthetic properties and triggers cold-sensitive nerves, creating a cooling sensation. Eliminating menthol will expose the smoker to the harshness of cigarettes and the irritation from nicotine, and result in more smokers quitting on their own by reducing the addictive characteristics of cigarettes.

In 2011, the FDA Tobacco Products Scientific Advisory Committee (TPSAC) concluded that “removal of menthol cigarettes from the marketplace would benefit public health in the United States.” The implementation of that TPSAC recommendation was delayed for several years by a lawsuit filed by Lorillard and R.J. Reynolds. As that case moved through American courts, other countries lead the way; In 2012, Brazil became the first country to outlaw flavored cigarettes. In 2013 the European Parliament agreed to ban menthol and other flavored cigarettes by 2022. Ethiopia, Moldova, and Turkey would follow suit, along with five provinces in Canada.

By early 2016, attention moved back to the United States. A Federal appeals court in D.C. ruled against the Lorillard and R.J. Reynolds lawsuit, opening the door for menthol to be banned as a cigarette additive in America. Over the next eighteen months, a wave of menthol bans would include Minneapolis, San Leandro, Los Gatos, West Hollywood, Yolo County, Berkeley, Santa Clara, Oakland and San Francisco, among several others.

In early 2018 it was announced that the State of New Jersey was considering a statewide menthol ban, after five U.S. Senators introduced legislation on Capitol Hill to ban the sales of menthol cigarettes in America.

The San Francisco ban that passed City Hall unanimously, and became the final piece of public health legislation signed by late Mayor Ed Lee, was the most visionary of all. Consistent with San Francisco’s tradition as a national leader in tobacco control, the law was expanded to ban not only menthol, but to include all flavorings in tobacco products (including electronic cigarettes) that are so often used to target children. R.J. ReynWWW.SFMMS.ORG

olds has already spent over $3.5 million in an attempt to overturn the legislation.

Notably, the tobacco industry had already concluded that a legal challenge against the San Francisco menthol ban would likely fail. Intriguing comments came from a spokesperson for the tobacco industry-funded "Let’s Be Real" opposition team. They argued that “people should be able to choose the poison they want” as an extension of the traditional argument by Big Tobacco about “choice”. Another spokesperson raised irrational fears about possible criminalization and arrests, but the truth is the only penalty written into the legislation will be for tobacco products retailers who violate the ban, who will have to surrender their tobacco sales licenses.

On June 5, 2018, San Francisco voters will decide the fate of the SF menthol and flavored tobacco products ban. Please vote yes on Proposition E, and ask your family, friends, colleagues, and all registered voters to join the San Francisco Marin Medical Society, the American Heart Association, the American Cancer Society, the California Medical Association, the American Medical Association, parents, and teachers among many others in this visionary public health legislation. Please contact Steve Heilig if you might be interested to phone bank, canvass, speak at public meetings or assist the SF Kids vs. Big Tobacco campaign.

Dr. John Maa attended U.C. Berkeley and then graduated from Harvard Medical School in 1994. He served as a captain in the U.S. Army for eight years and completed his general surgery residency at UCSF in 2002. He is currently chief of the Division of General and Acute Care Surgery at Marin General Hospital and is on the medical staff of Dignity Health - St. Francis. He can be reached at jmaa@sfmms.org.

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A Path to Universal Coverage and Unified Health Care Financing in California RECOMMENDATIONS TO THE CALIFORNIA ASSEMBLY Andrew B. Bindman, MD; Marian Mulkey, MPP, MPH; Richard Kronick, PhD Editor’s note: This version of the Executive Summary was modified from the original by the editor because of space limitations. The full executive summary and report are available at http://healthcare.assembly.ca.gov/reports.

The California State Assembly contracted with the University of California, San Francisco, in order for the authors of this report (Andrew Bindman, Marian Mulkey, and Richard Kronick) to (a) serve as research and subject matter experts to the co-chairs of the Select Committee on Health Care Delivery Systems and Universal Coverage (Select Committee); (b) assist in fact finding for Select Committee hearing preparation; (c) attend Select Committee hearings and summarize the content of the hearings; (d) assist Select Committee in identifying and analyzing the components of a sustainable and affordable universal health care system; and (e) provide a report to Select Committee summarizing the Select Committee’s hearings, including any findings and potential options.

This report reflects the authors’ attempts to explain information that emerged from the six Select Committee hearings and to assemble the findings from the hearings into a coherent set of possible recommendations for the California Assembly. What follows is the Executive Summary of the report. The full report can be found at http://healthcare.assembly.ca.gov/reports.

Executive Summary In March 2017, California Assembly Speaker Anthony Rendon appointed a Select Committee on Health Care Delivery Systems and Universal Coverage to identify the best and quickest path to universal coverage for California and to explore strategies for improving our health care system. This summary and the accompanying report document and synthesize Select Committee hearings held between October 2017 and February 2018.

Health Coverage and Care in California Today Under the Affordable Care Act (ACA), the number of Californians without health insurance fell dramatically from nearly 7 million in 2013 to about 3 million today. The majority of the remaining uninsured population, about 1.8 million, is not eligible for public coverage programs due to immigration status. Various factors including affordability and awareness contribute to others remaining uninsured.

Health care spending across California from all sources totals about $400 billion. Of this total, more than half comes from public sources, of which the largest are Medi-Cal (more than $100 billion) and Medicare ($75 billion). Employer-sponsored coverage remains the dominant source of coverage in the state and accounts for the largest share of private health care spending (between $100 and $150 billion). In addition to the portion of the $100 billion to $150 billion in employer-sponsored insurance premiums that is paid by employees, consumers pay $10 billion for premiums for individual insurance and $25 billion to $35 billion in out-of-pocket spending.

The health insurance market in California is relatively competitive and includes multiple national, state-based, and local health plans. Health plans are responsible for health care provider contracting and payment and, to varying extents, plan contracts 8

establish rules and incentives for providers to meet quality standards and achieve positive health outcomes. California has a long history of managed care arrangements within both private and public health plans. The settings in which Californians receive health care vary depending on their source of coverage (employer-sponsored, Covered California or remaining individual market, Medi-Cal or Medicare).

Challenges Under the Status Quo Despite California’s substantial progress in increasing coverage, a number of challenges remain. Even among people with coverage, some are underinsured, facing substantial financial barriers to access. Access to care also varies with coverage sponsor, geographic location, and health plan. People with coverage through the individual market and Medi-Cal report better access to care than the uninsured, but more difficulty than those with employer-sponsored coverage. Access to care in rural areas is a particular challenge, regardless of coverage source. When individuals’ health insurance status changes, they often must switch plans and physicians, which can disrupt care and increase consumer confusion.

Even as health care financing arrangements create access barriers and inefficiency, a substantial share of health care services is low-value, potentially unnecessary, and possibly harmful. Many factors contribute to subpar outcomes, including payment systems that reward volume rather than good health outcomes and a heavy dependence on specialists rather than primary care health care providers.

In California and across the U.S., prices for health care services are higher than in other developed nations and vary by type of coverage. Medi-Cal payments are substantially lower than those paid via employer-sponsored insurance (ESI) and contribute to barriers to care for Medi-Cal enrollees. High hospital prices paid by ESI reflect a lack of competition among hospitals in most parts of the state and the ability of some hospitals to command “must-have” status within health plan networks.

Billing and insurance-related costs borne by providers as they collect money from private insurers contribute to high prices.

Improving Health Care and Coverage Under Today’s Financing Structure As a part of the Select Committee hearings, presenters described a variety of policy approaches to achieve universal coverage, make health care more affordable and improve access, and make our multi-payer system less fragmented and more transparent.

Address remaining coverage gaps and reduce affordability barriers, for example:

• Expand Medi-Cal eligibility and Covered California financial assistance to people currently ineligible due to immigration status

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• Provide enhanced affordability assistance for Covered California beyond that available under the ACA

• Address underlying premium trends by limiting out-ofnetwork hospital prices

• Impose penalties for those who don’t maintain coverage (to replace the federal ACA individual mandate penalties that will be eliminated in 2019) Improve access and continuity of care, for example:

• Stabilize or expand health plan competition via a “public option” • Develop a comprehensive strategy to address health care workforce needs that better develops and sustains the primary care workforce and addresses gaps in rural areas

• Address regulatory and reimbursement issues related to the use of telehealth Reduce fragmentation and increase transparency, for example:

• Make health insurance products more uniform between Covered California and ESI

• Require that health care providers make information available on average negotiated prices for ESI as a percentage of prices paid by Medicare

• Establish an all-payer claims database

Improving California’s Health Care System via a Unified, Publicly Financed Approach An alternative to our current patchwork financing approach would be to establish a unified, publicly financed approach that assures coverage for all state residents; pools funds for health coverage across Medicare, Medi-Cal, and other major financing sources; and dramatically reduces or eliminates variations in eligibility, benefits, and payments. A unified, publicly financed system would increase equity, be simpler for patients and providers, and reduce administrative costs. It would likely increase efficiency and produce better health outcomes, although these results would depend on how well the system was managed and on mechanisms of accountability. To accomplish such a sweeping transition would require substantial and unprecedented changes in federal and state law as well as decisions regarding many design parameters.

Considerations related to integrating multiple payers: The public and private funding streams that support health care and coverage today are accompanied by many requirements not readily eliminated or easily reconciled. The federal government is the largest source of funds for health care in California today. Redirecting those funds would require federal permissions and actions such as statutory changes to redirect Medicare funds to a statebased pool. Similarly, there would be a need for either statutory changes in federal Medicaid law or an agreement on a means to track eligibility and expenditures for Medicaid-eligible populations that would enable California to claim federal matching yet preserve simplicity and equity goals. Further, Congressional action would be required if revenues linked to federal ESI tax exclusion were to be redirected to state control.

Because direct state intervention is impermissible in plans that must comply with the Employee Retirement Income Security Act of 1974 (ERISA), either the federal ERISA statute would need to be amended or California would need to devise financing approaches that do not run afoul of ERISA legal challenges and associated delays. This might involve a broad state-based payroll tax to finance health care on all employers, whether or not they currently have or maintain an ERISA plan.

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Considerations related to state financial oversight: Provisions of the State Constitution require California to enact a balanced budget each year and strictly limit the state’s ability to engage in deficit spending. Many forces and factors could introduce volatility into revenue streams and expenses associated with state-managed universal coverage. It will be important to establish and finance reserves upon which the health fund can draw in periods when costs are unexpectedly high or revenues fall short of projections. Provisions of the State Constitution also constrain the Legislature’s ability to substantially raise taxes and dedicate the proceeds exclusively to universal health coverage. These provisions render it prudent to seek explicit ballot initiative approval to dedicate new funds to health care.

Design and implementation considerations: In moving from diverse benefit, payment, and delivery arrangements under today’s fragmented financing and coverage programs to a more uniform set of expectations, trade-offs would arise. In the course of establishing and implementing a statewide universal coverage program, it would be important to consider matters such as:

• The extent to which integrated managed care arrangements would be encouraged and the role, if any, for health plans

• How provider payment levels would be set and adjusted

• Whether and how payments and delivery system arrangements might be allowed to vary based on regional differences and local preferences and needs

• How quality and access to care would be assured

• The extent to which the needs of special populations would be prioritized • What governance structures and management tools would be put in place to assure accountability and effective oversight

A host of transition issues, including job dislocation for people currently involved in billing and insurance-related activities, would also need to be addressed.

Potential Paths Forward California has made great progress in reducing the number of uninsured but has not yet achieved universal coverage. In highperforming health care systems around the globe, universal coverage is essential for ensuring access to care, improving outcomes, and controlling costs. A strong primary care system, a comprehensive basic benefit package, provider payments that reward better health outcomes, a strong social safety net, and administrative simplicity are other important ingredients for high performance.

California could take short-term steps and establish a longer term road map for system transformation.

Short-Term Steps Working within California’s current fragmented financing system, various approaches are available. California could: • Improve coverage by using state funds to:

- Expand Medi-Cal coverage to income-eligible undocumented adults

- Extend Covered California premium tax credit assistance to undocumented individuals • Improve affordability:

- Address affordability and participation for those already eligible for Medi-Cal and Covered California Continued on the following page . . .

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- Limit out-of-network prices for hospitals benchmarked to a specified ratio of the price paid by Medicare for similar services • Improve access:

- Increase the amount of Medi-Cal payment rates

- Explore a Medicaid Public Option • Simplify the consumer choice process by requiring each fully insured product in the large group market to be either a bronze, silver, gold, or platinum plan as defined by Covered California

• Increase transparency:

- Require hospitals and larger medical groups to post information on the average prices received from people covered by ESI, Covered California, Medicare, and Medi-Cal

- Establish an all-payer claims database

Short-term approaches can be evaluated against several criteria: their potential benefits for consumers and the delivery system, state fiscal cost, potential to preserve gains under the ACA, and the extent to which they either lay a foundation for or undermine potential future health reforms.

A Roadmap for a Broader Transformation of California’s Health Care System California could embrace a goal of guaranteed access to health care for all through unified public financing that improves health outcomes and keeps costs for the state and its residents in check. To achieve that goal, several preconditions would need to be satisfied:

• Diverse stakeholders must develop a sense of shared purpose and mutual responsibility to advance a health system that works well for all Californians.

• Data must be collected and analyzed to better understand the status quo and to explore how a new system could be monitored and managed.

• State budgetary implications must be modeled; financial risks must be assessed and mitigated.

• A detailed proposal would need to be developed and the Legislature would need to enact enabling legislation.

• State constitutional amendments would need to be approved by the voters.

• Federal statutory changes and waivers would need to be obtained.

The California Legislature could demonstrate leadership by establishing a planning commission responsible for advancing progress toward universal coverage and unified health care financing. The Legislature would establish the governance structure of the planning commission and provide its charge and appropriate funding. The commission would:

• Convene a stakeholder engagement and analytic process by which key design features are refined and vetted

• Establish data collection and reporting efforts to support management, evaluation, transparency, and public accountability • Model state budgetary implications and assess options for raising and managing funds

• Make recommendations to the Legislature on the de10

sign of a system of unified public financing and work with the Legislature to draft necessary state-enabling legislation and any necessary ballot propositions

•Ready the state to seek federal waivers and statutory changes by which funds managed by the federal government but used on behalf of Californians could be consolidated with other funds

• Explore operational requirements related to information technology and financial management

• Establish partnerships to coordinate activities with nongovernment entities

Conclusion California has established itself as a leader in using the opportunities created by the ACA to increase insurance coverage. Testimony at hearings identified many ways to build on that foundation, both in the short term and over coming years.

Short-term efforts to expand coverage, improve access, reduce fragmentation, and improve transparency, coupled with development of a longer-term path toward unified public financing, would help secure a future in which all Californians have access to the health care they need and deserve.

Andrew B. Bindman, MD, is professor of Medicine and Epidemiology & Biostatistics at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Marian Mulkey, MPP, MPH, is principal at Mulkey Consulting. Richard Kronick, PhD, is professor of Family Medicine and Public Health at the School of Medicine, University of California, San Diego.

SFMMS

ADDICTION SUMMIT Annual David E. Smith, MD Symposium

Friday, June 1, 2018 8:30am - 5:30pm UCSF Mission Bay Conference Center 1675 Owens Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • Opiates • Psychedelic Medicine • Legal Marijuana

• Advances in addiction medicine and primary care • Marin & San Francisco problems and responses

To register, or for more information, please visit www.drsmithsymposium.com Event co-sponsored by SFMMS, SFDPH, CAFP, UCSF CME provided by CAFP

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HEALTH POLICY PERSPECTIVE Addressing Antibiotics Overuse: Amid Growing Calls for Action, Signs of Hope for Saving Our Miracle Drug Lena Brook and David Wallinga, MD Each year in the U.S., at least 2 million people become sick with antibiotic-resistant infections, and at least 23,000 of them die. Misuse of antibiotics—both in human pa-

tients and on farms—fuels the spread of antibiotic-resistant bacteria, sometimes known as “superbugs.”

Superbugs threaten the health of every single one of us by making once-manageable infections much harder or even impossible to treat.

It also means that commonplace medical procedures—such as joint replacements, transplants, Caesarian sections, or dialysis—may soon become untenable, due to the elevated risk of associated infection.

With more than 70% of the antibiotics important to human medicine in the United States sold for use on livestock, leading public health experts warn that to combat this epidemic in people, we must stop squandering these drugs on animals when they aren’t sick. That means ending the common practice of giving drugs to animals en masse, either to speed up growth or compensate for the unsanitary and stressful conditions on factory farms.

Since 2014, my colleagues and I at the Natural Resources Defense Council (NRDC) have been calling on decisionmakers of all stripes— from federal agencies to state houses, local councils, and even corporate boardrooms—to stop the overuse of antibiotics in livestock. This past year showed signs that we are making pivotal progress.

Last fall, the World Health Organization released its much-anticipated guidelines for the use of medically important antibiotics in livestock with an unequivocal headline: “Stop using antibiotics in healthy animals to preserve their effectiveness.” With this recommendation, they joined numerous other leading voices in the U.S. medical community in making that call to action—including the San Francisco Bay Area Physicians for Social Responsibility, the Infectious Diseases Society of America, and the American Public Health Association.

Our advocacy efforts appear to be bearing fruit. Just a month after the WHO released its guidelines, the U.S. Food and Drug Administration released its 2016 sales data for livestock antibiotics. For the first time in many years, that data showed a drop in livestock sales of antibiotics important to human medicine—down 14% percent from 2015 to 2016. Despite this decrease, however, animal use of medically important antibiotics still dwarfs that of human use—a troubling fact that has remained true since 2009.

This recent drop in livestock antibiotic sales can likely be attributed to marketplace change. As consumers and advocacy and research groups like ours continue to put pressure on the food industry to improve their antibiotics policies, restaurants and meat producers have been committing to clean up their supply chains in recent years—particularly their chicken supplies. We believe that the decline in sales last year reflects those companies making good on their voluntary commitments, which started with an announcement by Perdue Foods in the fall of 2014. Since then, 14 of the top 25 U.S. restaurant chains (and approximately 50% of the chicken industry) have made some level of commitment to curb unnecessary antibiotics used in chicken.

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* Data on human use in 2016 is not yet available a FDA, Center for Veterinary Medicine, FDA Annual Summary Reports on Antimicrobials Sold or Distributed for Use in Food-Producing Animals b Center for Disease Dynamics, Economic & Policy, IQVIA MIDAS

While the marketplace has been key to moving this issue forward in recent years, we’ve also seen progress at the state and local policy levels. Last October, the city of San Francisco passed an ordinance requiring large grocery chains such as Safeway, Trader Joe’s, and Costco to report the antibiotic use practices for raw meat and poultry sold in city stores. The Department of the Environment will gather and publicize the information, making it easier for shoppers to make antibiotics-smart decisions wherever those brands are sold.

This follows recently passed state laws restricting antibiotic use in California and Maryland.

Together, the marketplace, the states, and local action are helping to fill the critical gap that remains in the face of weak federal policy.

Addressing antibiotics overuse in the beef and pork industries is the next frontier. Beef and pork together account for the vast majority (80%) of drug sales for livestock use, yet producers have taken very little action to clean up their practices. That’s why NRDC and nearly 90 other groups—including the San Francisco Marin Medical Society—delivered a powerful call to action to the CEO of McDonald’s on Valentine’s Day, urging the company to extend the commitment made to address the problem in their chicken nuggets to include their bacon and burgers as well.

We must keep this positive momentum going to save our lifesaving antibiotics before it’s too late.

Lena Brook is interim director of the Food and Agriculture Program of the Natural Resources Defense Council. David Wallinga, MD, is the senior health officer of the Natural Resources Defense Council.

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SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

EDITORIAL Erica Goode, MD, MPH

Mealtime as Medicine: The Importance of Diet in a Holistic Approach to Medicine For at least a decade now, many compelling voices have emerged, some screaming urgently, that we must keep our fast food intake and other eating habits from overwhelming our costs of medical care needed due to preventable diseases.

The results of our “modern” diet too often include common medical woes: hypertension and other cardiovascular issues, type 2 diabetes, obesity and joint disease among the overweight, dementia, strokes, cancer, and other systems-specific illnesses.

Medicine and nutrition have been uneasy bedfellows until recently. As I applied to medical schools in 1972, one attending physician at a Midwest school actually said, “Well, dear, we not only don’t favor women in medical school but we have no need for nutrition. Just go back to your public health nutrition job.” I walked out.

Luckily, Julius Krevans, MD, then dean of the UCSF School of Medicine, responded to the petition I circulated to the 280 preclinical students who had been subjected to six lectures by a gentleman who offended students and provided outdated information. The petition urged that a proper nutritionist be hired.

The next year, Marion Nestle, PhD, MPH, was teaching, and she identified all aspects of nutrition research on campus.

Now for some “full disclosure”: In 2012 I developed a HER2/ neu, E,P-negative breast cancer. It recurred in 2016 and is still with me. I believe, since I had no family history, that the illness was in part a result of eating late, 80-hour workweeks, stress, and limited sleep—i.e., modern medical life. This is why my Universal Adult Diet, drawn from many sources, includes elements other than food. Cancer, as well as all other degenerative diseases, autoimmune issues, etc., can be traced back to a hectic life and limited time to eat in a leisurely fashion, with food eaten slowly, tasted, and appreciated. Long gone is the simple prayer, “Bless us, oh Lord, for these, thy gifts, which we are about to receive from thy bounty.” One medical resident at Harvard, seeing a woman patient sitting up, bowed over her lunch tray, decided she was coding, rushed in, and began CPR! This is how far we have come from acknowledging the life-giving properties of a meal. It is difficult for people to carve out the time to shop, cook, and have a sacrosanct time to exercise. But these and all other aspects of self-care must be part of each day. Better food laws, allocation of resources, feeding children well at home, and making sure meals at school are healthful must all make up the first step in this process.

I hope my colleagues and readers will consider referring patients to a nutritionist as needed. Dietitian Sonya Angelone has updated the list first provided here in 2010. If a husband or a child is the patient, be sure to urge that the wife or mother be WWW.SFMMS.ORG

present at the visit. Many nutrition services are not covered by insurance, but try to urge that the nutrition visit be made in any case.

In the best case, have a weekly after-hours meeting for patients with a nutritionist. These can be free or a few dollars per visit to offset the nutritionist’s time. You will likely be amazed at the positive response you will get, both in terms of patient health and appreciation.

Until then, here’s the “best practice” in a nutshell: Everyone’s best bets are whole foods, recently harvested, eaten raw or with minimal cooking for nutrient and phytonutrient preservation, eaten at home or taken with you for the day. Take beverages in metal or glass, vegetables and other items in waxed paper or parchment.

A wide variety of fruits, vegetables, whole grains, herbs, and spices should be introduced early into diets of small children, to help them develop a broad approach to the foods available to us. Growing foods and herbs at home is even better. While it is not essential that we identify exactly which phytonutrient we are getting, how much or what effect it may have, the conglomeration in the Universal Diet and Lifestyle promotes health.

Need solid evidence? A large study just published in JAMA and reported in The New York Times, conducted by Christopher D. Gardner, director, Stanford Prevention Research Center, demonstrates that if people, overweight or otherwise, eat this sort of meal pattern, their desire for sweet, salty, and fatty foods falls away and weight similarly declines, without an emphasis on restricting calories. Fiber, liquid, and consistently healthy choices make the difference.

Dr. Walter Willett at Harvard’s School of Public Health concurred; he said that this diet will not support the concept of precision medicine, but he implied that reductionist research about dietary components ultimately supports a holistic, preventive approach to health. Bon appétit and great health to you and your patients!

Erica Goode, MD, MPH, is board-certified in internal medicine.

She practices general medicine with an emphasis on nutrition and enhancing health through the rediscovery of simple complementary principles. Erica holds a medical degree from UCSF, where she is an Associate Clinical Professor, and her Masters in Public Health Nutrition from UC Berkeley. Before getting her medical degree, she worked as a public health nutritionist for years and wrote a nutrition column for the Washington Post. She is a member of the Ethics Committee at California Pacific Medical Center and lectures on eating disorders, cancer and nutrition, health care reform and other topics. She has served on the SFMMS Editorial board for decades.

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Nutrition

VEGAN DIETS IN CLINICAL PRACTICE The Power of Plant-Based Diets in Clinical Approaches to Health Care Neal D. Barnard, MD, FACC Maladaptive eating habits are the primary cause of the conditions that most burden our health care system— overweight, cardiovascular disease, dyslipidemia, type 2 diabetes, and hypertension—and they play roles in many other conditions. A well-planned approach to nutrition should

be included in every patient’s care plan.

What kind of nutrition? Plant-based (i.e., vegan) diets are especially noteworthy. In 2017, the American Medical Association and American College of Cardiology called on hospitals to make plant-based meals available to all patients, visitors, and staff, echoing similar praise for plant-based diets from the Academy of Nutrition and Dietetics1 and the U.S. Government. This article reviews the application of plant-based diets for common conditions.

Weight control. Low-fat vegan diets cause weight loss even in the absence of intentional limitations of energy intake.2 This is presumably because, compared with meat, cheese, and other animal products, vegan foods have a lower energy density; that is, they have fewer calories per unit weight. This is for two reasons: First, vegetables, fruits, beans, and grains are naturally low in fat.

That is important because fat has nine calories per gram, compared with only four for carbohydrates or protein. The main high-fat exceptions in the plant world are vegetable oils, nuts, seeds, and avocados.

Second, plants have fiber; animal products do not. Fiber is filling but has essentially no calories. In a randomized one-year trial comparing four weight-loss diets (plant-based, low-carbohydrate, Weight Watchers, and Zone), the plant-based diet led to the greatest mean weight reduction (-6.6 kg, compared with -3.9 kg on the low-carbohydrate diet).3 Lipid control. Plasma cholesterol levels are influenced by dietary saturated fat and, to a lesser extent, by dietary cholesterol. The leading source of saturated fat in the American diet is dairy products, followed by meat, and both are typically high in cholesterol, as are eggs.

In contrast, nearly all plants are very low in saturated fat and essentially devoid of cholesterol. Clinical trials show that vegan diets typically cause plasma cholesterol levels to fall sharply,4 and the lipid-lowering effect of a plant-based diet can be augmented by the specific inclusion of soluble fiber (e.g., oats, barley, or beans), almonds, soy protein, and sterol-containing margarines. This combination was shown to reduce low-density lipoprotein (LDL) cholesterol levels by nearly 30% in four weeks.5 Although most plant oils are heart healthy, exceptions are saturated fat, coconut oil, palm oil, and partially hydrogenated oils. They have dyslipidemic effects and should be avoided.

Glycemic control in diabetes. Vegan diets reduce the risk of developing type 2 diabetes and significantly improve glycemic control in individuals with diabetes.6 Vegan diets have also been shown to improve the symptoms of diabetic neuropathy.7 While many patients imagine that diabetes is caused by consuming sugar, a 2017 meta-analysis found no significant effect of total sug14

ars on the risk of developing type 2 diabetes.8 In fact, those consuming the most sucrose had 11% less risk of developing type 2 diabetes, compared with those consuming the least. This is not to suggest that sugar is innocuous (it is a source of unnecessary calories), but it is important for patients to understand the actual cause of type 2 diabetes, so that they can effectively prevent or manage it.

Type 2 diabetes begins with insulin resistance, resulting from lipid accumulation within muscle and liver cells, which blunts insulin signaling.9 This fat comes mainly from the diet.

A vegan diet has no animal fat at all, and when vegetable oils are minimized, there is very little of any kind of fat in the diet. In a randomized trial, our research team showed that a low-fat vegan diet is more effective for glycemic control in type 2 diabetes than a diet based on portion control and limits on carbohydrates.10 Other studies of vegan diets have yielded similar conclusions.11 Improving blood pressure. In research studies, vegan diets consistently improve blood pressure.12 They do this by reducing blood viscosity, which improves arterial compliance, improving blood flow; by providing potassium; and by reducing body weight.

Preventing cancer. Individuals avoiding animal products have reduced cancer risk. This is presumably because (1) plants have fiber, while animal products do not, (2) plants are often rich in antioxidants and other anticancer compounds, and (3) carcinogenic heterocyclic amines form as chicken and other meats are cooked, something that tends not to occur when plant products are cooked. In addition, men who avoid dairy products have significantly reduced risk of prostate cancer.13 The association between dairy products and prostate cancer is believed to relate to milk’s tendency to increase production of insulinlike growth factor, which stimulates cancer cell growth. Dairy intake may also reduce vitamin D activation as a physiologic response to the influx of dairy calcium. For men diagnosed with prostate cancer, a lowfat vegan diet has been shown to improve survival.14 Despite the common notion that soy products might increase cancer risk, studies have clearly shown the reverse. Women who consume the most soy products (soymilk, tofu, etc.) have about 30% to 40% less risk of developing breast cancer, compared to those women who avoid soy products.15,16 Among women previously diagnosed with breast cancer, those who consume the most soy have roughly 30% less likelihood of cancer mortality, compared with those who consume less soy products.17 Reducing Alzheimer’s risk. The Chicago Health and Aging Project showed that individuals who generally avoid saturated fat (predominantly found in animal products) or hydrogenated fats (found in some snack foods) have much less risk of developing Alzheimer’s disease, compared with those eating larger amounts of these fats.18 Other studies have led to similar conclusions.19 In summary, plant-based diets are powerful for tackling the most urgent problems faced by clinicians and their patients.

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PRESCRIBING A VEGAN DIET How Clinicians Can Guide Patients into Following an Effective Vegan Diet On the prvious page, I described the benefits of a plant-based. Now I'll describe how to bring these benefits

to patients. A vegan diet is surprisingly easy to adopt. Most patients are willing to try a vegan diet, particularly when its rationale has been explained.1 In practice, they find it to be no more challenging than other therapeutic diets.2 The fact that it does not impose any limits on calories, carbohydrates, or portions makes it appealing to many.

The clinician’s job in prescribing a diet change is far easier when working with a dietitian who can provide one-on-one teaching and someone who can provide ongoing classes (e.g., in the office waiting room after hours). With this team in place, the clinicians’ time is used efficiently. It goes without saying that all clinicians working with patients on nutrition issues should adopt the same diet themselves, both for their own health and in order to be able to answer questions patients may pose about the diet and its implementation.

Here is how to begin: In prescribing a diet change, the treating clinician’s job is to briefly educate the patient as to why a plant-based diet is the diet of choice. While this takes only a few minutes, it provides important validation for the dietitian’s work. Next, the dietitian can work with the patient to draw up a menu of familiar foods, answer questions, and set up a follow-up appointment. Third, a simple in-office class series for patients and families provides cost-effective follow-up for many patients at once. Dietetic visits are typically covered under insurance policies. Classes may not be covered but, given that the time commitment may be limited to an hour of a dietitian’s time once a week, they can be provided as a free service that is greatly appreciated by patients.

In the class setting, the actual diet change is done stepwise: Step 1. Patients are asked to take a week to try out healthful vegan foods. The idea is not to give up anything. Instead, they will simply try out whatever healthful vegan breakfasts, lunches, dinners, and snacks they might like and make a list of their favorites. Over seven days’ time, they will have found many good ideas.

Step 2. Next, patients will be asked to adopt a fully vegan diet for a short period, e.g., three weeks. They should focus on the short term, which makes full adherence a more approachable prospect. At three-week “test drive” is ample time for the benefits to begin to be noticed. After that, patients are simply asked to continue.

It is important to avoid the temptation to water down the diet. Clinicians who tell patients to “just do the best you can” tacWWW.SFMMS.ORG

itly encourage them to deviate from it, in the same way that telling a smoker to just “try to cut down” is an invitation to failure.

Instead, it pays to encourage patients to give it 100%. If patients have a slip, as some will, they will soon notice that their progress grinds to a halt. Encourage them to dust themselves off and get back on the wagon.

Complete Nutrition

The basic guidelines for a vegan diet are to include foods from four groups—vegetables, fruits, whole grains, and legumes—and to add a supplement of vitamin B12. While nutrition adequacy is always a question with any diet change, overall nutritional quality, as measured with the Alternate Healthy Eating Index, is better on vegan diets than on omnivorous diets, mainly because vegan diets are richer in vitamins and fiber while being lower in saturated fat and cholesterol.3 Nonetheless, patients will have questions about common nutrients: Protein. While protein adequacy is a commonly raised concern, it is almost never an issue, even among children and elderly people. A varied diet of plant foods provides adequate amounts of all essential amino acids. The Academy of Nutrition and Dietetics holds, “Vegetarian, including vegan, diets typically meet or exceed recommended protein intakes, when caloric intakes are adequate.”4 This is true for people at all ages, including athletes. In exceptional situations, such as burn injuries or endstage renal disease, nutrition planning should be handled by dietetic specialists, regardless of the patient’s habitual diet.

Calcium. Calcium is an important issue, but one that is easily addressed. While many patients think of dairy products as a calcium source, it is helpful to remind them that cows do not make calcium. Rather, they ingest it from plants, just as humans do. Most green leafy vegetables and beans provide highly absorbable calcium.

Iron. Iron balance is easily maintained on plant-based diets, due to the iron in green leafy vegetables, legumes, and other foods. In fact, iron intake is often higher on vegan diets than on meat-containing diets. However, plants contain non-heme iron, which is more absorbable when iron stores are low and less absorbable when iron stores are high, permitting healthful iron balance. In contrast, meat contains heme iron, whose absorption is not affected by iron status and may lead to iron overload.

Vitamin B12. Vitamin B12 is essential for nerve function and blood cell formation, and is produced by bacteria rather than by plants or animals. While meat and dairy products contain B12 traces because a cow’s intestinal tract harbors bacteria that produce it, many people do not produce sufficient stomach acid to separate the B12 from the protein to which it is bound, and common medications (e.g., metformin and acid-blockers) interfere with its absorption. On a vegan diet, vitamin B12 must come from fortified foods or supplements. Adults need 2.4 micrograms per day, and all common supplements exceed this amount.

Vitamin D. Vitamin D is produced by sunlight on the skin and facilitates calcium absorption and possibly cancer prevention. Individuals who do not get regular sunlight will need a supplement regardless of the diet they follow. A daily dose of 2,000 international units is considered safe.

Continued on the following page . . .

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Special Circumstances Vegan diets are appropriate for all stages of life, and there are no life stages during which the addition of animal products is necessary. Even so, there are certain circumstances that raise questions for clinicians: Medications for glycemic control. In prescribing vegan diets for patients using insulin or insulin secretogogues for diabetes, it is essential to caution them about the possibility of hypoglycemia. Because vegan diets are highly effective for glucose management, diabetes medications often need to be reduced for patient safety.

Antihypertensive medications. As with diabetic medications, it is also important to be ready to reduce or stop antihypertensive medications for patients whose blood pressure has improved, in order to avoid hypotension.

Anticoagulants. The use of warfarin is not a contraindication for a vegetable-rich diet. While it is true that warfarin works by blocking vitamin K and vegetables are rich in this vitamin, the best course is to simply keep the (hopefully abundant) amount of vegetables in the diet more or less steady from day to day so that the warfarin dose can be established and kept stable. Newer anticoagulants do not raise this issue.

Neal Barnard, MD, FACC, is an adjunct associate professor of medicine at the George Washington University School of Medicine and Health Sciences in Washington, D.C., president of the Physicians Committee for Responsible Medicine, and founder of Barnard Medical Center. He is a fellow of the American College of Cardiology, the 2016 recipient of the American College of Lifestyle Medicine Trailblazer Award, and has led numerous research studies investigating the effects of diet on diabetes, body weight, and chronic pain, including a groundbreaking study of dietary interventions in type 2 diabetes, funded by the National Institutes of Health. Dr. Barnard has authored more than 70 scientific publications as well as 18 books, including the New York Times best sellers Power Foods for the Brain, 21-Day Weight Loss Kickstart, and the USA Today best seller Dr. Neal Barnard’s Program for Reversing Diabetes.

A full list of references can be found at www.sfmms.org.

More Information

Details on introducing healthful diets to patients, along with a complete curriculum, are available at no cost at PCRM.org.5

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Nutrition

TREATMENTS TO CONSIDER Cardiovascular Benefits of Nutritional and Nutraceutical Supplements James R. Adams, MD, FACC, ABIHM, FSCCT, FASNC Nutritional and nutraceutical supplements and nonprescription medicines are widely used. Annual

expenditures on these products are estimated to be more than $30 billion. Therefore, it behooves physicians to have more than a passing knowledge or opinion about these products. Physicians' individual opinions will vary depending on their personal knowledge and experience with these products, and these opinions may differ from those of their patients. This article aims to give an overview of how supplements differ from prescription medicines, with a few cardiovascular-related examples about which patients may be asking their physicians.

Prescription medicines are a modern-day invention, with annual U.S. expenditures of nearly $400 billion. But man evolved over the eons without their use and maintained his health by eating naturally occurring foods. Recently, however, our lifestyles have changed significantly, with much greater exposure to processed foods, less exposure to deadly infections, and greater longevity. But while our dietary and infectious exposures have changed, our responses to these insults has not, as every individual bears a unique genetic profile. At the heart of the argument for the need for and benefit of nutritional and nutraceutical supplements is the concept that our changing clinical milieu has led us to be woefully deficient in many essential nutrients. Many adults regard supplements as necessary to maintain health and as complementary agents to our powerful but potentially toxic prescription drugs.

Prescription, Over-the-Counter, and Off-theShelf Supplements

Most FDA-approved medications require a prescription.

These have undergone close inspection and study and have satisfied rigorous scrutiny to prove their efficacy and safety. This is a long and expensive process that gets translated into high drug costs for consumers. Once the patent on a drug expires, generic forms can be approved as prescription medications so long as they meet the required manufacturing standards set forth by the FDA. These same FDA-approved medications may at times be purchased less expensively from foreign-based dispensaries, through mail-order pharmacies. However, there is no guarantee as to these drugs’ manufacturing standards, safety, or efficacy.

Use of these medications is a truly “buyer beware” situation.

While not necessarily approving of their use, this author’s approach has been to require more frequent lab testing for clinical effects and possible side effects when foreign-produced prescription medications are used.

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Over-the-counter (OTC) medications differ from both prescription medications and dietary supplements. They are reviewed and regulated by the FDA through its Drug Evaluation Office IV and its Division of Nonprescription Drug Products (DNDP). Examples of OTC medications that have met these standards would be such agents as omeprazole, acetaminophen, and ibuprofen.

Finally, many products are sold directly to consumers as dietary supplements. Unlike other OTC medications, the FDA has no regulatory authority over these dietary products. However, the Federal Food, Drug, and Cosmetic Act does require that OTC products be safe and not contain false or misleading advertising claims. To assure consumers of their quality, many companies will voluntarily have their products tested and certified through independent agencies, although this is not a requirement. Hence, impurities and mixtures of unrelated substances can often be found mixed within these products. For example, many olive oil products are labeled to contain only the more desirable monosaturated fats but, when tested, can actually be found to have significant amounts of more saturated fats. Similarly, OTC omega-3 fish oil products labeled as being high in the more desirable longer-chain fatty acids EPA and DHA will very often contain high percentages of non–omega-3 fatty acids and other less favorable omega-3 fats.

Polyunsaturated Fatty Acid Supplements

Omega-3 fatty acids (FAs) are made from long-chain essential fatty acids (FAs) through a process of enzymatic elongation and desaturation, finally resulting in eicosapentaenoic acid (EPA), a 20-chain, 5-double-bonded FA; and docosahexaenoic acid (DHA), a 22-chain and 6-double-bonded FA. DHA is found in high amounts in the heart, brain, and retina, and EPA is especially useful in the heart. Besides their incorporation into cell membranes, the omega-3 PUFAs are also precursors of antiinflammatory and vasodilating eicosanoid and prostaglandin proteins such as prostacyclin (PGI2). Omega-6 FAs are also produced from orally ingested precursors and compete for the same elongation and desaturation enzymes, with the end result being primarily arachidonic acid (AA), a 20-chain omega-6 FA that is the precursor to the potent inflammatory and vasoconstricting eicosanoids and prostaglandins, like thromboxane. Thus there is active competitive inhibition between the omega-3 and omega-6 FAs for these enzymes. A diet rich in omega-6 FAs, as is found in today’s processed foods, will cause lower omega-3 FA levels, which leads to an imbalance toward more inflammatory and vasoconstricting proteins and greater degrees of endothelial dysfunction.

Continued on the following page . . .

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Fish oil supplements Intake of marine-derived omega-3 FAs, aka fish oil (FO) capsules, can alter this imbalance seen with omega-6–rich modern-day diets. However, FO supplements come in all sizes and shapes and can have varying potency and purity. Two prescription forms of omega-3 FAs are available, and at a dose of 4,000 mg daily they reduce very elevated triglyceride (TG) levels, by up to 45%. They are FDA regulated as to purity and potency and contain 1 gram of EPA and/or DHA. On the other hand, the OTC fish oil capsules are unregulated as to purity and potency and contain lesser amounts of EPA and DHA, usually around 300 mg. Hence, three to four times as many of the OTC FO capsules are needed to get doses equivalent to the prescription ones, and they may have higher levels of contaminates, such as mercury.

As with all unregulated nutraceutical products, problems can arise in production, transportation, and distribution. Oxidation from exposure to heat, light, and long shelf life can all reduce the potency of these OTC products. Foreign-made prescription medications can suffer from similar problems. Meta-analyses of supplemental FO studies have shown varying beneficial results.

While some of these may be related to inadequate dosing, none have shown adverse outcomes.

Vitamin D and Vitamin K2 Supplements

Many patients are also taking vitamin D and, more recently, vitamin K2 supplements, and physicians need to understand the rationale for these. Vitamin D acts to increase calcium absorption from the intestines and induces osteoclastic action in the bones. It has intranuclear stimulatory effects and acts more like a hormone than a vitamin. Since there is an inverse relationship between osteoporosis and coronary calcification, many have recommended using vitamin D3 supplementation as a CAD prevention measure. While recommended levels of vitamin D are controversial, levels below 20 ng/mL are considered low and levels below 40 ng/ml borderline. Optimal levels may be between 60 and 80 ng/mL. Levels above 100 ng/mL are considered elevated but may be safe up to limits of 150 ng/mL. Depending on the desired level of 25-hydoxyvitamin D, oral supplementation doses of vitamin D3 can range up to 10,000 IUs daily, although generally doses of between 1,000 and 5,000 IU are to reach desired levels. Doses of 50,000 IUs are also available and can be given on a monthly to even weekly basis. Blood levels of 25-hydroxyvitamin D can be used to monitor therapy.

Vitamin K2 is thought to have beneficial cardiovascular effects by working in conjunction with vitamin D to drive calcium into bones and away from the vascular system. There are two types of vitamin K: vitamin K1 and vitamin K2. Vitamin K1 is a shorter phyloquinone structure and is involved in the clotting cascade. Vitamin K1 antagonists (VKA), like warfarin, lead to inhibition of clotting. Vitamin K2, on the other hand, is a longer menaquinone structure that has no significant effect on clotting in lower doses and is an important co-factor for getting calcium into bone. Vitamin K2 is needed to carboxylate matrix Gla protein (MGP), which binds calcium ions and deposits it into bones and away from vascular structures. Uncarboxylated MGP is associated with increased all-cause mortality, CHD, and and greater vascular calcification.

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There are no good dietary sources of vitamin K2 and oral supplementation with purified vitamin K2 is recommended, especially in those patients on calcium and vitamin D supplements who have coronary artery calcification. Recommended doses of vitamin K2 are 100 to 200 mcg daily of the menaquinone-7 (MK7) form. While vitamin K1 can be converted to vitamin K2, there is little if any back conversion of K2 back to K1, and studies in patients on warfarin have shown doses of vitamin K2 up to 45 mcg daily to be safe. Interestingly, higher amounts of coronary artery calcification are noted in patients on VKAs, which may be due to lower levels of vitamin K2. In addition, patients with elevated Lp(a) have accelerated vascular and aortic valve calcifications, and vitamin K2 may have benefit here as well.

Conclusion

Coronary heart disease (CHD) is a chronic, slowly developing process that is very advanced by the time it becomes clinically manifest. This article has reviewed just a few of the agents used to forestall the development of CHD. There are many other vitamins and nutraceuticals, such as niacin (vitamin B3), coenzyme Q10, and l-methylfolate, which also have beneficial cardiovascular effects, and some of these are covered in the “Food for Thought” section of this issue (beginning on page 20). The challenge today, therefore, is to identify patients in their earliest stages of this disease and then to target them for more aggressive therapies. Today’s patients are very proactive with this process and much less willing to follow a wait-and-see policy.

By combining judicious use of testing, such as with coronary artery calcium scanning, carotid intimal thickness testing, advanced blood tests, and other direct measures of endothelial dysfunction, in conjunction with risk calculators, the astute physician can have informed discussions with patients about both their short- and long-term risks and help them decide on individualized treatment programs. Patients are increasingly demanding this type of personalized care, and if they feel dissatisfied, then they are very likely to seek help elsewhere. To me, this coordinated approach gets to the very heart of personalized and integrative medicine.

Dr. Jim Adams is a preventive and integrative cardiologist in private practice in Larkspur, where he focuses on lipid disorders and statin resistance. He holds current boards in integrative and holistic medicine, clinical lipidology, cardiovascular CT, echocardiography, and nuclear cardiology. He can be contacted at DrAdams@CVICare.com.

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Nutrition

ADDRESSING THE OBESITY EPIDEMIC UCSF Offers Evidence-Based Care for Overweight and Obese Adults and Children Robert B. Baron, MD, MS; Gina Moreno-John, MD, MPH; Jonathan Carter, MD; and Patrika Tsai, MD, MPH Few clinical disorders are as central to our worldwide epidemic of chronic illness than obesity. UCSF

was an “early adopter� in understanding this crucial role of obesity with early efforts in basic science and clinical research, clinical programs including early efforts in bariatric surgery, inclusion of obesity and nutrition in the medical school curriculum, and interprofessional programs for adults and children. This comprehensive approach to obesity continues at UCSF with innovative clinical programs in adult weight management, bariatric surgery, pediatric obesity, and an extensive research portfolio.

UCSF Weight Management Program

The UCSF Weight Management Program, founded in 1987, offers innovative, interprofessional programs for adult patients. Diverse programs include individual nutrition counseling; weight management classes; a medically supervised, very low-calorie meal replacement program; psychological assessment and behavioral change counseling; and psychological evaluation for readiness for gastric bypass surgery.

Located in the Division of General Internal Medicine at UCSF, the program offers care for patients with a wide variety of common weight issues and obesity-related disorders. The program can also serve patients with more complex obesity-related problems, including severe obesity requiring weight loss in preparation for bariatric surgery; weight loss prior to other surgical procedures, such as joint replacement, back surgery, or other elective procedures; and chronic illnesses such as diabetes, heart disease, and arthritis. The UCSF Weight Management Program approach emphasizes patient skills to achieve and maintain weight loss. The clinical team includes physicians, a nurse practitioner, registered dietitians, and a behavioral psychologist.

The Step-by-Step Program is a comprehensive weight-loss program emphasizing skills to increase exercise, adopt healthful eating patterns, and learn cognitive skills for long-term lifestyle changes and success with weight loss and weight maintenance. This program targets patients with mild to moderate obesity who are committed to personal lifestyle changes for better health, increased fitness, dietary changes, and weight loss. The program includes regular visits with a registered dietitian, review and analysis of daily food intake, nutrition counseling and meal planning advice, and a bimonthly evening lecture series and behavior-change curriculum. Patients see physicians and nurse practitioners for medical supervision and additional nutrition and behavior-change education. On average, patients lose approximately 7% of their initial weight but have a wide range of outcomes.

The Meal Replacement Program is a medically supervised, rapid weight-loss program featuring a very low-calorie diet with complete meal replacement. The program designs nutritionally WWW.SFMMS.ORG

complete meal plans of approximately 1,000 calories per day. This one-year program also emphasizes regular exercise, healthful food patterns, and cognitive behavioral skills for weight maintenance. This program targets patients with moderate to severe obesity with obesity-related illnesses who can benefit from more rapid weight loss. The program requires a substantial commitment to a very low-calorie diet and attendance at medical and nutrition sessions for personal lifestyle changes for one year. This program includes regular visits with a registered dietitian, review and analysis of daily food intake, nutrition counseling and meal planning advice, bimonthly evening meetings, and regular visits with a physician or nurse practitioner. On average, patients lose approximately 15% of their initial weight but have a wide range of outcomes. Many patients lose substantially more weight.

Individual consultations are also available for assessment of nutritional intake, energy balance, and lifestyle or psychological factors that influence health and weight; medical and psychological clearance before bariatric surgery; and concerns following bariatric surgery. Counseling for diet and activity change is individually tailored to work with personal goals and everyday realities. Individual consultations can be designed for patients with any weight profile interested in lifestyle changes and for pre- or post-bariatric surgery patients. Patients will see weight management specialists for personal counseling and advice.

More information for patients is available at (415) 353-2105 or online at https://www.ucsfhealth.org/clinics/obesity_and_weight_ management/. Direct appointments and physician referrals can be made at (415) 353-7999 and at the UCSF Physician Referral Service at (800) 444-2559.

UCSF Bariatric Surgery Program

Despite even the best medical care, many patients with severe obesity are not controlled with diet, exercise, or pharmacotherapy.

For such patients, bariatric surgery may be the best option, particularly when obesity is associated with related health problems such as diabetes, high blood pressure, high cholesterol, sleep apnea, or severe arthritis.

Candidates for bariatric surgery have a body mass index greater than 40 kg/m2 and have previously undergone a medically supervised attempt at weight loss. When diabetes, hypertension, sleep apnea, osteoarthritis, or other obesity-related comorbidities are present, the BMI cutoff is relaxed to 35 kg/m2.

Bariatric surgery was once high risk and only employed for lifethreatening obesity or metabolic disease. But with advances in minimally invasive techniques, refinement in procedures, and a commitment to multidisciplinary care and quality, bariatric surgery today carries less risk than other commonly performed operations like gallbladder removal or hysterectomy. Today’s bariatric procedures Continued on the following page . . .

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are safe, effective, and lasting for the vast majority of patients. The typical patient loses 75–125 pounds, and 85% maintain their weight loss for 20 years or more. Short-term complications occur in 4–8% of patients, and long-term complications are uncommon, occurring in 1–3% of patients.

An important reason to consider bariatric surgery is the treatment of metabolic disease. Type 2 diabetes resolves initially in 80% of patients, and 60% enjoy sustained remission after five years. LDLcholesterol typically drops by 20%, sleep apnea improves in 90% of patients, and many patients with osteoarthritis no longer seek arthroplasty. The risk of death from cancer and cardiovascular disease is cut in half. For many obese patients (and their doctors), the metabolic benefits of surgery are even more important than the weight loss.

At UCSF, the Bariatric Surgery Program is led by a multidisciplinary team of experienced surgeons, gastroenterologists, and endocrinologists, supported by an outstanding group of dietitians, nurse practitioners, nurses, and physician assistants. UCSF is accredited as a Level 1 Comprehensive Center for Bariatric Surgery by the American College of Surgeons, attesting to outstanding safety and patientcentered care. UCSF Bariatric Surgery also engages in cutting-edge NIH-sponsored research examining bone health, calcium metabolism, the gut microbiome, and nonalcoholic steatohepatitis.

Operations are performed with a minimally invasive approach that minimizes pain, complications, and hospital stays and offers a faster return to normal activity. UCSF is one of the few centers in the country that offers bariatric procedures to obese patients with endstage kidney or liver disease who would otherwise be excluded from an organ transplant because of weight.

Patient appointments may be made at (415) 353-2804. Referrals can be made using the Refer a Patient Form at https://bariatric. surgery.ucsf.edu.

crinology, pulmonology, and nephrology to help treat diseases related to weight problems, such as type 2 diabetes, obstructive sleep apnea, and high blood pressure. Weight management is achieved through nutrition education and behavior modification. Medication is recommended when appropriate. In severe cases, bariatric surgery may be considered. Regardless of what the weight is, the goal is to promote health in a supportive environment.

Our core physicians are pediatric gastroenterologists. Our dieticians are all certified in pediatric nutrition and have several years of experience. Our bariatric surgery team works closely with our adult bariatric surgery colleagues here at UCSF. Children need a referral from their primary care doctor to be seen at the WATCH Clinic. Physicians can fax referrals to (415) 353-4485 or call (877) 822-4453 or (877) UC-CHILD with questions. Families can call the clinic at (415) 353-7337 or learn more at https://www.ucsfbenioffchildrens.org/clinics/watch/.

Robert B. Baron, MD, MS, is professor of medicine and associate dean for Graduate and Continuing Medical Education; Gina Moreno-John, MD, MPH, is professor of medicine; Jonathan Carter, MD, is associate professor of surgery; and Patrika Tsai, MD, MPH, is associate professor of pediatrics.

Weight Assessment for Teen and Child Health (WATCH) Clinic

Childhood obesity is a global epidemic even in countries where undernutrition is a problem. In the U.S., 1 in 5 children ages 6–19 years is obese. Obesity even affects very young children, and about 1 in 7 children who are 2–5 years old are obese. Several factors contribute to childhood obesity, including genetics, diet, physical activity, inadequate sleep, and stress. Because children and teenagers who are obese are at high risk for becoming obese adults, addressing excessive weight gain during childhood is critical to establishing healthy lifelong habits. Obesity can lead to serious chronic health conditions including type 2 diabetes, heart disease, and strokes. In fact, rates of type 2 diabetes, gallstones requiring surgery, and mental health issues such as depression and poor self-esteem in the pediatric population have increased significantly because of the higher number of children struggling with obesity.

The Weight Assessment for Teen and Child Health (WATCH) Clinic at UCSF Benioff Children’s Hospital has been helping children and adolescents since August 2003. The clinic brings together doctors and dietitians with expertise in diagnosing and treating childhood obesity. The UCSF team evaluates patients and their families both behaviorally and biochemically, paying close attention to the links between biochemistry and behavior, especially as they apply to energy balance, or the balance between calories burned and calories consumed.

The WATCH Clinic assists with weight management while working closely with other pediatric subspecialists such as pediatric endo20

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Nutrition

NUTRITION AND CANCER What to Eat and What to Avoid Donald Abrams, MD, and Erica Goode, MD According to a survey conducted by the American Institute for Cancer Research (AICR), 94% of Americans recognize tobacco as a cause of avoidable cancers, 87% recognize ionizing light and UV light as causes—but only 51% appreciate the contribution of diet and nutrition. And it is estimated that 30% of avoidable cancers may be attributed to what we do and don’t eat. The Centers for Disease Control reports that 40% of all malignancies are related to overweight and obesity and that is most certainly associated with our diets. Data also continues to mount that cancer patients consuming the Standard American Diet (abbreviated SAD for a reason!) have worse outcomes than those adopting a more “prudent” menu.

The AICR/World Cancer Research Fund’s Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective guidelines, which are continuously updated, lists nine recommendations for cancer risk reduction, followed by a tenth: “After treatment, cancer survivors should follow the recommendations for cancer prevention.”

Foods to Increase or Incorporate into the Diet

Fresh fruits and vegetables are important components of a cancer-fighting diet. Frozen fruits retain less of their nutritional value than frozen vegetables. Ideally 5–9 servings should be consumed each day, but recent data from the Centers for Disease Control suggest that only 14% of U.S. adults are consuming even the minimum five servings/day.

Fruits and vegetables are our most potent sources of fiber, vitamins, minerals, and antioxidants. They also contain important phytonutrients that are known to promote anticancer activity.

Cruciferous vegetables—the Brassicas—include broccoli, cauliflower, Brussels sprouts, cabbage, kale, collard greens, and radishes, and they are particularly powerful cancer fighters. Not only are they high in vitamin C and soluble fiber but they also contain phytonutrients such as sulforaphane, indole-3-carbinol, and diindolylmethane, which have impressive anticancer properties. Broccoli has been shown in numerous scientific studies to reduce the risk of many malignant cancers.

Sulforaphane leads to apoptosis of cancer cells and was recently studied as an isolated nutraceurical in treating men with PSA recurrence after prostate cancer.

Broccoli and other cruciferous vegetables are best blanched briefly, stir fried, or steamed to retain their phytonutrients while breaking down cell walls. Two of the phytonutrients in broccoli are particularly noteworthy: Indole-3-carbinol boosts healthy hormones and blocks estrogen receptors, while diindolylmethane (DIM) changes estrogen from the type that fuels estrogen-driven tumors to the type that does not.

Strong-flavored onions and garlic, especially yellow onions, provide allicin. Garlic also lowers blood pressure and cholesterol. When onions are finely chopped, or garlic is minced, more of this compound is available. In addition, we recommend that patients add red, orange, and yellow vegetables; winter squash, sweet potatoes, carrots, and red bell peppers, to their shopping list to provide beta carotene, color, and variety to their diets. As for leafy greens, those that are also cruciferous WWW.SFMMS.ORG

provide glucosinolates as well as folate.

Just as no single food item is eaten in isolation, a synergy exists when combining beneficial nutrients. Lycopene from tomatoes is most bioavailable when oil extracted, so tomato sauce and tomato paste are good lycopene-rich tomato products. Although lycopene supplements are also available, we know that it is often best to consume these nutrients from whole foods. When beta-carotene was evaluated as a supplement in hopes of reducing the risk of lung cancer, the large CARET trial demonstrated that the supplement actually increased the risk of developing this cancer in smokers, ex-smokers, and asbestos workers. Those eating carrots most days of the week lowered their risks of pancreatic colon and breast cancers significantly.

Lignan precursors are found in fruits and vegetables; beans, flax, and sesame seeds are especially rich in these precursors, the secoisolariciresinols, which interact with the gut microbiome to form lignins. Lignans are phytoestrogens and can occupy estrogen receptors, thus avoiding uptake of harmful estrogen-like plastics and petrochemicals. Lillian Thompson, MD, at the University of Toronto, has identified 11 ways in which lignins protect women from developing breast cancer. Ground flaxseed contains 77 times the lignins of beans and fibrous fruits and vegetables. Sprinkling the equivalent of two tablespoons of freshly ground flax seeds into other foods is recommended.

As for fruits, heavily pigmented choices such as berries, red grapes, and pomegranate all contain powerful antioxidants. Whole food sources, unlike antioxidants taken as supplements, do not interfere with radiation or chemotherapy for tumor treatment. Apples, especially the skin, contain flavonoids and procyanidins, which inhibit cancer development, especially in the colon. Citrus pulp contains limonene, which assists the body as it detoxifies free radicals. These fruits also contain vitamin C, hesperidin, and naringin, which may destroy cancer cells. Further, the ORAC list provides a list of the most helpful “oxygen radical absorbance capacity” foods containing antioxidants in high concentrations.

Organic produce and grains are optimal, although more costly. They are free of herbicides, pesticides, and fertilizers. Furthermore, because they must fight to protect themselves from other plants, birds, insects, and the sun, they produce chemicals called phytoalexins, which turn out to be the same phytonutrients that benefit us. So if we let food be our medicine, organic is more potent than conventional. If a patient cannot afford a fully organic diet, check www.organic.org or the “Dirty Dozen” list.

Beans, especially soy, contain good levels of protein, fiber, and antioxidants, plus physic acid, which inhibits cancer cell growth. Women in the Nurses’ Health Study who ate four or more servings of beans per week had 33% fewer colorectal precancerous lesions than those eating one serving or less. Soybeans also contain genistein and daidzein, isoflavones that block estrogen receptors in cells. Genistein also inhibits several enzymes that fuel cancer growth. Soybeans, soy milk, tempeh, miso, and tofu all provide this benefit and are generally preferred over soy cheese, soy turkey, or soy hotdogs, which are heavily processed foods.

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Consumption of whole soy foods appears to be one of the factors that leads to lower rates of breast and prostate cancers in Asians consuming an Asian diet. Studies suggest that women with estrogen receptor–positive breast cancer decrease their risk of recurrence by consuming a serving of a whole soy food daily.

Some spices and other food flavorings can be extremely helpful.

Cinnamon tops the list. Ginger has anticancer effects and can control nausea during chemotherapy. Turmeric, and its active agent, curcumin, inhibits cancer at many stages of the cell cycle. Adding black pepper to curcumin increases its absorption by a factor of 1,000. When in the gut, curcumin helps to normalize a healthy microbiome, which lowers the risk of gut-related side effects from chemotherapy. Rosemary contains carnosic acid, which inhibits early breast cancer.

Mushrooms, whether shiitake, maitake, reishi, or enoki, all may provide immune-enhancing, antitumor, antibiotic, and antiviral activity. In addition, they contain amino acids, fiber, and several vitamins, including B12. Fresh mushrooms placed in the sun can generate vitamin D2, becoming one of the rare food sources of D vitamins. Shiitakes also contain an antitumor polysaccharide, lentinan, which triggers lymphokines, interferon, and interleukin. This cascade augments natural killer cell function. Japanese physicians often use shiitake, maitake, and enoki mushrooms and their constituents with chemotherapy and radiation as adjuvant therapies. All mushrooms must be cooked. White button mushrooms (Agaricus genus) are often added raw to salads, but these contain a carcinogen, agaritine, that is mostly inactivated with cooking.

Others in this genus include portobello and cremini. All may contain some aromatase inhibitor activity.

Foods and Drinks to Avoid or Limit

The AICR Guidelines, first and foremost, urges avoidance of sugary drinks, whether sodas, fruit punch, or pulp-free fruit juice.

The AICR guidelines suggest limiting consumption of red meats and avoiding processed meats entirely. Research has shown a direct correlation between the consumption of increasing amounts of red meat with colon and pancreatic cancer. If cows or buffalo are grass fed, this problem is reduced; they are then eating a variety of phytonutrients and avoiding pesticides. Cows that are corn fed produce omega-6 fatty acids, which promote inflammation and platelet aggregation. In addition to the omega-6 fats, red meat is a rich source of heme iron, which also feeds cancer cells. When barbequed, the burnt flesh of red meat creates carcinogenic heterocyclic amines.

Instead of beef and other red meats, encourage deep coldwater fish—Pacific salmon, albacore tuna, black cod, herring, mackerel, and sardines—all rich in omega-3 fatty acids, which are anti-inflammatory and may have an antidepressant effect. If poultry and eggs are part of the diet, these should also be organic to minimize the omega-6 to -3 fats.

Alcohol consumption, if not eliminated, should be limited to one drink per day for women and two for men. Women at high risk for breast cancer should limit themselves to one drink per week. If one consumes alcohol, the best choice would be red wine, because of its resveratrol content. Resveratrol is purported to be an anti-aging and life-extending phytonutrient. The American Society of Clinical Oncology has launched a campaign to increase awareness regarding the large number of malignancies that are associated with alcohol consumption.

Green tea is a recommended drink of choice. It contains polyphenols, especially EGCG, a potent antioxidant with anticancer properties second only to those of cruciferous vegetables. Green tea, revered in Asian countries, is attributed with preventing heart disease and strokes, regulating 22

blood pressure, reducing cancer risk, boosting immunity, increasing bone density, regulating blood sugar, helping with arthritis and weight loss, slowing aging, and increasing fertility. It may also fight colds and flu and gingivitis. Urge patients to drink five large (8-oz.) cups per day.

This diet is palatable and leads to weight management and a reduced desire for fatty, salty, and sweet foods. In this era of health care reform and focus on wellness, we hope you will share this with all patients, so that we not only create awareness of beneficial ways to reduce cancer risk but also promote a healthier lifestyle and healthier society.

Donald Abrams is an integrative oncologist at the UCSF Osher Center for Integrative Medicine. He is also the former chief of Hematology/Oncology at Zuckerberg San Francisco General Hospital.

References

1. Abrams DI and Weil A (eds). Integrative Oncology (second edition).

Oxford University Press, New York, 2014.

2. AICR/World Cancer Research Fund. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. 2007.

3. Béliveau R, Gringa D. Foods That Fight Cancer (second edition). McClelland & Stewart, 2006.

4. Gonzales CA, Riboli E. Diet and cancer prevention: Contributions from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Eur. J. Cancer. 2010, 46:2555–62.

5. Katz R. The Cancer-Fighting Kitchen (second edition). Celestial Arts, 2017.

6. Kushi LH, Doyle C, McCullough M et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J. Clin. 2012; 62:30–67.

7. Servan-Schreiber D. Anticancer: A New Way of Life. Viking, 2009.

MARIN WEIGHT LOSS & WELLNESS MEDICALLY SUPERVISED WEIGHT LOSS PROGRAMS, LED BY DR. GAIL ALTSCHULER We welcome Cassale Sherriff, Nutritionist, as we expand our options for personalized and whole food plans for weight loss and optimal health.

GAIL ALTSCHULER, MD MEDICAL DIRECTOR

CASSALE SHERRIFF NUTRITIONIST

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Nutrition

NUTRITION AND HEALTH OF THE EYE Dietary Guidelines and Nutritional Supplements for Optimal Eye August Reader, MD Several degenerative eye disorders can be lessened or avoided through excellent nutritional intake on a daily basis. Good food and a few supplements can make a notable

difference in the issues of cataracts or wet/dry age-related macular degeneration. The partial or total loss of eyesight renders one compromised in many ways. In India, which sees 4 million new cases of cataracts per year, a sightless person is referred to as “a mouth with no hands.” A burden for family and community. In Japan, the problem is solved by steering blind adults into becoming excellent massage artists. As noted, cataracts and both wet and dry macular degeneration are problems, as is glaucoma. All are enhanced by unopposed free radical breakdown. Regarding cataracts, sunlight and other factors lead to lenticular proteins losing normal integrity, almost inevitably as we age.

Vision worsens the longer these clumps of protein grow and spread, eventually affecting the full field of vision. At night, street lamps appear to have a halo.

Dry AMD (age-related macular degeneration) and central visual loss arises due to accumulation of metabolic waste products in a layer of tissue that covers the macula, with progressive diminution of light sensation by the macula. The central blurriness gradually progresses to a full blind spot. Unlike dry AMD, the wet variety comes on and progresses more quickly, requiring extremely bright light to continue seeing adequately. The root cause of both is due usually to a combination of sunlight, tobacco, air pollution, polyunsaturated fatty acids, and higher levels of blood glucose. The goal, especially with a positive family history, is to manage these factors, through polarized sun glasses, smoking cessation, and dietary changes to reduce blood sugar and PUFA intake.

Dietary changes must include a higher intake of colorful vegetables, fruits, with an emphasis on less high vitamin C-rich produce, less free sugar, and care with sun exposure. Roughly 80% of these issues can be managed via excellent nutrition and supplements.

Careful daily intake of at least 3 cups cooked or 4–5 cups raw vegetables, plus 2 cups of raw fruit, can alone reduce these vision issues by about 30%. Glaucoma and “dry eye” issues will benefit generally through these same measures, but both require eye drops, sometimes several times/day. Ample vitamin C is essential for good vision. It concentrates in both the cornea and retina, at 60x the concentration that circulates in the bloodstream. As an antioxidant, it also protects levels of vitamin E, which is also an essential antioxidant for eye health. A British study, following 50,000 women over a decade, found 45% fewer cataracts in those eating the most vitamin C-rich diet.

Apple peel is the richest source of quercetin, as are onions and tea.

Apples should thus be organic. Spinach, chard and kale, turnip and collard greens, broccoli, zucchini, and peas are all rich in zeaxanthin and in lutein, a yellow pigment. Both are antioxidants in the carotenoid family. Both concentrate in the retina, and lutein reflects UV rays from sunshine away from the retina and cornea, thus protecting both. A Harvard study showed that those eating foods containing 6 mg of lutein per day had a 43% lower risk for developing macular degeneration. All these WWW.SFMMS.ORG

leafy and other greens also contain zeaxanthin, another carotenoid, and one study showed that these two carotenoids conferred 60% protection against corneal and retinal damage.

Lutein also concentrates in adipose tissue, leaving less for the eye.

Tufts University researchers showed that, in a study of obese women, cataracts were two times more common in age-matched subjects than in lean women.

Beta carotene-rich foods, such as carrots, save night vision, as was first shown in WWII pilots. Beta carotene converts to vitamin A (as long as it is eaten with 5–10 grams of fat taken at the same meal). Vitamin A forms a pigment in the eye that improves night vision. Asparagus, eggs, onions, and avocado, as well as any raw vegetable, are all good sources of cysteine, which converts to glutathione, a powerful antioxidant. Both lenses and the macula are deficient in glutathione—containing a mere 7% of normal—among those with cataracts and AMD. Glutathione improves mineral and amino acid circulation in and out of the eye.

Blueberries and cranberries contain good levels of anthocyanosides, which improve circulation affecting the eye. Vitamin E, being fat soluble, backs up the water-soluble carotenoids. It is an extremely helpful antioxidant, and those individuals with ample levels of this vitamin are 50% less likely to develop cataracts. The requirement is about 30 IUs, the amount found in 1/2 cup almonds, 1/4 cup sunflower seeds, fish, olive oil, and wheat germ.

Wild fatty fish, eaten two times per week, reduce cataract onset by 12%. The omega-3 fats derived from these fish concentrate in the eye and increase blood circulation in the eye membrane. In the Nurses’ Health Study, women eating fatty fish four and a half or more times per week had fewer cataracts than those eating lower levels. However, other studies do not find the omega-3 fats to provide further eye benefits.

Finally, zinc helps when taken at about 25mg per day. I recommend an OTC vitamin/mineral supplement called Vision Optimizer, available at the Institute for Health and Healing store (2300 California St., at Webster, in San Francisco; parking under the building). Pharmaca pharmacies carry it as well.

PreserVision AREDS 2 has excess zinc, at 80 mg, which can lead to queasiness if taken on an empty stomach. Instead, go to Walgreens or Walmart for Vision Shield Eye Health at 20 mg. (The recommended amount is 15mg per day.) I suggest Vitamin C at 500 mg twice a day with meals to cover the needs of the cornea. And wear those polarized sunglasses every day, even if it is foggy.

Dr. August Reader is an ophthalmologist affiliated with California Pacific Medical Center, specializing in neuro-ophthalmology and cataract surgery. He has written numerous articles for medical journals on radial keratotomy, cataract surgery and lens implantation, neuro-ophthalmology, and the physiology and psychology of near-death experiences.

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Nutrition

IRRITABLE BOWEL SYNDROME A Look at the Causes of IBS and the Impact of Diet Erica Goode, MD Irritable bowel syndrome, or IBS, is common, noninfectious, and very unpleasant for the patient. It pres-

ents in one or more forms, including spastic colon, with chronic abdominal pain and constipation; alternating constipation and diarrhea; and/or painless, chronic diarrhea.

It occurs twice as often among females compared to males. Its onset tends to be in early adulthood, and discomfort subsides with defecation. IBS is the most common disorder being seen by gastroenterologists. In the U.S., more than 3 million physician visits are due to IBS. For decades, IBS was thought to be due to altered colon motility and worsened by depression, obsessive-compulsive disorder, etc. However, endoscopy has shown that it is functional, with no alteration in gut mucosa. It is not related to any increased risk for colon cancer or other digestive disorders.

It occurs more frequently during times of stress and is seen more commonly among those reporting childhood abuse or sexual abuse. A bout of bacterial or viral gastroenteritis can trigger it by making the gut hypersensitive to pain. If infection has proceeded onset, one helpful maneuver is take probiotics and N-acetyl cysteine for a month.

It is now known, thanks to work by researchers in Australia, that the culprit is a group of indigestible short-chain carbohydrates that are osmotically active, causing excessive fluid retention in the gut. These include fermentable compounds; inulin, gluten, and other insoluble food fibers play a role. Hence the term for them is FODMAPS: fermentable, oligosaccharides, disaccharides, monosaccharides and polyols.

These foods are not allergens. Rather, the individual’s microbiome is intolerant of certain food items. If avoided, the significant discomfort and bloating resolve.

Inulin is frequently added to manufactured foods; it is slightly sweet (with its multiple fructose molecules) and can improve texture. Patients with IBS need to read labels and to avoid these foods. Paradoxically, it is often grouped with helpful nutrients termed prebiotics. It is a soluble fiber and can increase calcium and magnesium among women receiving one or both in insufficient amounts in the diet. It can promote helpful gut bacteria growth. During dietary avoidance of inulins, avoidance of gluten is easy with today’s abundance of gluten-free foods; but labels need to be checked to avoid HFCS and other ingredients. Inulin is derived commercially from chicory root and is used medically to determine real glomerular filtration rate.

Food sources of inulin include artichoke, jicama, onion, wild yam, banana, chicory, dandelion greens, and garlic.

VEGETABLES Low: cabbage, carrots, celery (small amounts), chickpeas, corn, cucumber, eggplant, green beans, kale, lettuce, parsnip, pep24

pers (green, yellow, red bell), potato, pumpkin, scallion, squash (summer and winter), sweet potato, tomato, turnip, yam High: artichoke, asparagus, beans (black, broad, kidney, lima, soy), garlic, onions

FRUIT Low: bananas, firm; blueberry, cranberry, kiwi, lemon, orange, raspberry, rhubarb, strawberry, tangerine, melons High: apples, apricot, avocado, bananas (ripe), blackberries, grapefruit, mango, peach, pear MEATS Low: beef, chicken, fish, lamb, pork, cold cuts (ham, turkey breast) High: chorizo, sausage, processed meats

BREADS, CEREALS, GRAINS, PASTA Low: buckwheat, chips, cornmeal, oatmeal, oats, quinoa, gluten-free breads, popcorn, gluten-free pretzels, pasta, rice (basmati, brown, white), tortilla chips High: barley, bran, couscous, gnocchi, granola, muesli, biscuits, muffins, rye, semolina, spelt, wheat bread NUTS, SEEDS Low: almonds, chestnuts, hazelnuts, macadamia nuts, peanuts, pecans (in small amounts), poppy, pumpkin, sesame seeds, sunflower seeds, walnuts High: cashews, pistachios

MILK, DAIRY Low: almond milk, coconut milk, hemp milk, lactose-free milk, oat milk (small amounts), soy milk (from soy protein), hard cheeses, butter, chocolate (dark; milk and white in small amounts) High: milk (cow, goat, sheep), soy milk (from whole soybeans), buttermilk, cream, custard, cow’s milk, regular yogurt, ice cream, sour cream HERBS, SPICES Generally all are low

References

1. Harrison’s Manual of Medicine, 18th ed., 2013, McGraw Hill.

2. Berkeley Wellness newsletter, 3/2018.

3. Bolen B, Ludwig E, verywell.com./foods-on-the-fodmapdiet-1944679.

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Nutrition

HOW TO FEED A CHILD A Basic, Ideal Diet for Kids from Birth Until Adolescence Sonya Angelone, MS During the First Year of Life The American Academy of Pediatrics recommends exclusive breastfeeding until six months of age. Although breast milk is the optimal food for babies throughout the first year of life, there are times when that isn’t possible or desired. Iron-fortified formula is usually used for infants in this case.

Infants are ready to eat solid foods when they are at least 4–6 months old, can sit in a high chair, and show an interest in eating solid foods. Breastmilk or iron-fortified formula continues to be the primary form of nutrition, since children initially don’t eat enough solid foods to meet their nutritional needs. This ratio changes as the child gets older. After 4–6 months of age, a full-term breastfed infant may not get an adequate amount of iron from breast milk alone, since the mother’s stores are just about depleted. At this time, some form of iron supplementation, like iron-fortified infant cereal, is recommended (2 ounces per day of cereal should meet iron needs).

There are many brands of commercial baby foods that are nutritious options for a baby. Sometimes parents choose to make their own baby food. The baby-led weaning approach recommends that the first solids be finger foods and that the infant should self-feed from the beginning.

The following should be introduced at 4–6 months: • Iron-fortified baby formula or other source of iron, such as egg yolks • Pureed meats, beans, and other legumes first • Then fruits and vegetables (include one source of vitamin C to help with iron absorption) • Single-ingredient commercial or homemade baby foods Introduce one new food at a time and wait approximately 3–5 days to see whether they have a reaction to the new food. Milk, such as cow’s, goat’s, rice, or soy milk—unless specifically designed for infants—is not appropriate before one year of age. Studies show that it is important to expose children to a wide variety of flavors and textures. Many babies and toddlers need to be exposed to foods many times before accepting them, so don’t give up! Babies are encouraged to use spoons and fingers to feed themselves and are encouraged to drink from a cup starting at 6 months of age.

Sample Menu (in addition to breast milk or infant formula) Breakfast: 4 Tbsp iron-fortified infant rice cereal; 2 Tbsp banana, mashed or cut in small pieces Morning snack: ½ ounce whole grain cracker, 2–3 Tbsp whole milk yogurt Lunch: 2–3 Tbsp cooked green beans; 2 Tbsp chopped soft pears; 2–3 Tbsp pasta, small pieces; 1 ounce finely chopped meat WWW.SFMMS.ORG

Typical portion sizes and daily foods for infants (adapted from the Pediatric Nutrition Care Manual, Academy of Nutrition and Dietetics):

Age in Months Food/Portion Size

Feedings per Day

0-4

Breast milk or infant formula (2–4 ounces)

8-12

4-6

Breast milk or infant formula (6–8 ounces) Infant cereal (1-2 Tbsp)

4-6 1-2

6-8

Breast milk or infant formula (6-8 ounces) Infant cereal (2-4 Tbsp) Crackers (2) or bread (1/2 slice) Fruit or vegetable (2-3 Tbsp) Meat (1-2 Tbsp) or beans (1-2 Tbsp)

3-5 2 1 1-2 1-2

8-12

Breast milk or infant formula (6-8 ounces) Cheese (1/2 ounce) or yogurt (1/2 cup) Infant cereal (2-4 Tbsp), bread (1/2 slice), crackers (2), or pasta (3-4 Tbsp) Fruit or vegetable (3-4 Tbsp) Meat (3-4 Tbsp) or beans (1/4 cup)

3-4 1 2 2-3 2

Afternoon snack: ½ slice dry toast or ½ ounce whole grain toast Evening meal: 2–3 Tbsp mashed sweet potato, 2–3 Tbsp peas Evening snack: 2 Tbsp chopped fruit

Foods to avoid due to choking hazard or contamination:

Popcorn; peanuts; raisins; whole (uncut) grapes; uncut stringy meats; hot dogs; hard raw fruits or vegetables such as apples, baby carrots, or green beans; sticky foods such as nut butters; any other pieces of food that the infant cannot chew that may block the airway; milk not intended specifically for infants, such as nondairy milk alternatives for infants less than 1 year of age; honey; fruit juice before 12 months of age (dilute with water as the child gets older and limit to 4 ounces per day); sugar-containing foods and beverages; foods with added salt; baby food desserts due to the added sugar; commercial baby food with fillers, modified food starch, or preservatives.

Until recently, the American Academy of Pediatrics (AAP) recommended avoiding peanuts for children at high risk of allergies until age three. The AAP now recommends introducing peanuts to infants at about 4–6 months of age in order to help prevent the development of peanut allergy in high-risk infants (according to the March 2018 issue Continued on the following page . . .

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of The NursePractitioner). Research shows the early introduction of egg (4–6 months of age) may decrease the risk of egg allergy. Also, introducing gluten-containing foods at 4–6 months of age, along with continued breastfeeding, may decrease the risk of developing celiac disease, even in some genetically predisposed children.

Follow the Basic Division of Responsibility When Feeding Your Child

Parents are responsible for providing a variety of nutritious foods in three meals and two snacks.

Children are responsible for the amount eaten, or whether any food is eaten at all.

Optional: Preschool-aged children need the same nutritious foods as older kids and adults in order to grow and be healthy. Most 2–3 year olds need to eat about 1,000–1,400 calories a day. A serving size of food is about one-half of an adult serving. They need to learn to eat a variety of foods with limited added sugars for optimal health. An eating plan looks like the following, in 3 meals and 1–3 snacks: • Grains and starches (at least half should be whole grains): 3–5 ounces per day.

• Vegetables: 1–1.5 cups of raw or cooked vegetables.

• Fruit: 1–1.5 cups, preferably fresh, frozen, canned, and dried fruits per day. Limit fruit juice to 4–6 ounces per day. Do not introduce fruit juice before 12 months of age.

• Milk: 2–2.5 cups per day. Whole milk is recommended for children under 2 years of age. Older children can choose lower-fat milk, soy milk, calcium fortified milk alternatives, yogurt, or cheese.

• Protein: 2–4 ounces per day from lean meats, poultry, seafood, eggs, soy products, cooked legumes, unsalted nuts, and nut butters.

• The American Academy of Pediatrics (AAP) states that there is no advantage to introducing solid foods in a particular order and that introducing fruits before vegetables will not lead to a dislike of vegetables.

For more information on serving sizes, check http://www.ChooseMyPlate.gov.

Babies, Toddlers, and Older Children

Tailor this advice according to the individual child’s age and readiness to eat.

• Encourage children to taste at least one bite of a new food, but don’t expect them to eat a whole portion. Children often refuse new foods at least 10 times before finally accepting them.

• Don’t encourage children to eat more than they want to eat, since this may encourage them to override their satiety signals and learn to overeat. Children’s appetites vary depending on several factors, including their growth patterns and activity levels.

• Serve individual finger foods instead of mixed dishes. Children often like to eat foods separately.

• Avoid bribes or gimmicks to get kids to eat. This teaches children that food is an obstacle that they need to overcome in order to get what they want. Dessert should not be used as a reward.

• Keep portions small. Wait for children to ask for more food.

• Kids have small stomachs and need to eat frequently. Serve three meals and two to three small snacks throughout the day but not too close to a meal.

• Don’t allow children to dictate family meals and don’t become a shortorder cook. Kids learn quickly when they have power over adults and will learn to manipulate them over food.

• Eat with your children and model good eating habits. Be sure to make meal time a pleasant experience and avoid discipline or charged conversations at mealtimes.

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• Be sure to cut pieces of foods that may be choking hazards into small pieces. Use small eating utensils and plates, and cups that are age appropriate.

• Avoid serving spicy or strong-tasting foods. Children’s taste buds are very sensitive.

• Make dessert or sweetened beverages “sometimes” foods—limit fruit juices for the first year, then dilute with water.

• Plan meals and prepare food together based on age and skill level. This encourages kids to try new foods that makes eating more fun (http://www.kidseatright.org).

Ages 5–10

Kids should follow the same healthy eating guidelines as adults, which means they should eat a variety of foods from all the food groups, as tolerated. Kids should start the day with a good breakfast. Studies show that breakfast eaters tend to be more alert and have better behavior in school, so they are able to learn better. Calorie and protein needs can be determined based on body weight and height. Younger children generally need smaller portions of foods than older children, but activity level, size, and growth rate determine calorie needs. Specific guidelines can be found in MyPlate for Kids and can help parents offer foods to meet their childrens’ nutrient needs. Diet diversity remains an important part of a healthy diet. Expose infants and older children to a wide variety of healthy foods with a variety of textures and tastes.

A Sample Menu for a Child 5–8 Years of Age Breakfast: ¾–1 cup low-sugar, ready-to-eat cereal; ½ cup low-fat milk or calcium-fortified nondairy beverage; 1 slice whole grain bread; 1 Tbsp nut butter; 1 small/medium banana Lunch: Sandwich with 2 slices whole grain bread, 1 ounce turkey, 1 ounce cheese, 1 Tbsp mustard lettuce, 1 medium apple, 6 baby carrots, water Snack: 1 corn tortilla, 1 ounce cheese, 1 orange Dinner: ½ cup vegetable salad, 1 Tbsp light dressing, 1 ounce baked chicken (no skin), ½ cup steamed rice or quinoa, ½ cup cooked vegetable, ½ cup frozen yogurt (low-fat) Snack: ½ cup blueberries, ½ cup vanilla yogurt (without much added sugar) If you are concerned that your child isn’t eating well, check in with your child’s health care provider and ask for a referral to a registered dietitian/nutritionist.

Resources

The Academy of Nutrition and Dietetics, www.kidseatright.org https://www.choosemyplate.gov https://www.choosemyplate.gov/kids Extension services at major universities

Sonya Angelone, MS, is the owner of a nutrition consulting firm, specializing in the clinical management of inflammatory conditions related to non-immunoglobulin E food sensitivities such as irritable bowel syndrome, migraine, fibromyalgia and arthritis.

Angelone chaired the nutrition committee of the American Heart Association (San Francisco Division) and earned undergraduate and master’s degrees from California State University – San Jose.

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Nutrition

CARDIOVASCULAR DISEASE Where Do We Stand Regarding Cholesterol?

Erica Goode, MD A full evaluation of cholesterol and inflammatory marker status should include total cholesterol, LDL (including particle size Lp(a), HDL, homocysteine, cardiac CRP, and fibrinogen. Much about cholesterol’s importance has been overrated. For example, in the Multiple Risk Factor Intervention Trial (MRFIT) involving 362,000 men, for those with low (<140 mg/dL) total cholesterol levels, the annual death rate from CAD = <1/1,000. Among those with cholesterol of 300 mg/dL, annual death rate was 2/1,000, not statistically different. So what other factors keep the heart healthy?

Total fat is not the culprit. The type of fat makes a difference, as does a switch to a much higher intake of fruits, vegetables, some dairy, eggs, fish, seeds, nuts, and whole grains. The specifics are noted in the Universal Diet plan.

Foods and supplements that can help with cardiovascular disease include those discussed below.

Anti-inflammatory foods Crucifers such as cabbage, kale, cauliflower, and Brussels sprouts reduce the body’s production of prostaglandins; broccoli contains sulforaphane, which can repair heart vessels. It activates antioxidant enzymes and reduces cardiac events, especially in women. Broccoli also limits LDL oxidation and prevents cholesterol attachment to arterial walls.

Organic strawberries contain ellagic acid, which markedly reduces free radical levels. They also contain flavonoids, which lower the levels of cyclooxygenase, which leads to atherosclerosis.

Blueberries, strawberries, plums, apples, and cherries all offer good oxygen radical absorbance capacity (known as ORAC levels). Raw blueberries also contain resveratrol, stabilizing telomeres of cell DNA, thus maintaining the normal function of cells.

Apples—especially the skins—contain quercetin (free radicals), thus preventing LDL oxidation. Flavonoids inhibit blood clot formation. They lower cholesterol production due to high levels of soluble and insoluble fiber.

Kiwis are high in vitamin C, which neutralizes free radicals.

They also contain arginine, which helps maintain healthy blood vessels.

Grapefruit in particular—but also other citrus fruits—contains pectin, which lowers cholesterol. HDL also rises with regular citrus intake.

Spinach contains high levels of antioxidants and folate, the latter being especially good at lowering homocysteine, which can damage arterial endothelium. Kale, Swiss chard, and mustard greens can have a similar effect.

Asparagus is a source of folate and vitamin B6. Both lower WWW.SFMMS.ORG

homocysteine levels.

Orange and yellow winter squashes contain high levels of lutein, zeaxanthin, and beta carotene. All are antioxidants. They also contain potassium and omega 3s, which can stabilize heart rhythm.

Avocado contains monounsaturated fats. This lowers LDL and triglycerides, and it raises HDL cholesterol. Avocado also increases levels of other carotenoids, especially beta carotene and lycopene from other fruits and vegetables eaten concurrently.

Legumes (a variety of beans), can protect the heart due to their high fiber content and antioxidants. They lower cholesterol, protect blood vessels, and lower blood sugar levels.

Beans contain eight different phenols with antioxidant properties; levels are especially rich in pinto, small red, and kidney beans. Bean phenols are extremely good antioxidants. Black beans contain anthocyanins (as do grapes).

Dark chocolate (70% or higher) contains flavonoids, capable of lowering cholesterol. Its anti-inflammatory content lowers CRP.

Nutritional effects on heart disease Substances that directly affect blood vessel flexibility and plaque buildup include the following: Beans, due to good folate content, can repair damaged blood vessels. Folate improves homocysteine levels through its antioxidant capacity.

Lycopene from tomatoes prevents LDL oxidation, thus preventing atherosclerosis. Tomatoes are helpful cooked or raw.

Onions, if eaten regularly, reduce heart disease by about half.

Pumpkin seeds and other high-magnesium sources relax arterial walls due to their effect on smooth muscle. Heart rhythm is improved and hypertension better controlled. Magnesium is also found in high amounts in figs, nuts, beans, leafy greens.

High–vitamin C foods repair arterial damage from atherosclerosis, improve vessel circulation, and lower the risk of clotting.

Atherosclerosis is markedly reduced if the individual emphasizes foods high in lycopene, especially watermelon, tomatoes, and other red and pink foods (papaya, pink grapefruit).

High-fiber foods contain antioxidants that protect cells by maintaining good levels of nitrous oxide (NO). NO dilates blood vessels and lowers blood pressure. It can reduce clots and prevent atherosclerosis.

Some oils (corn, soy, sunflower, and canola oils) reduce NO production. This can be reversed by high-fiber foods, including ground flax meal, and other high-fiber contributors.

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Oat fiber and other whole grains containing folate also lower homocysteine levels, clots, and cholesterol deposition in blood vessel plaque.

Omega 3s, DHA and EPA, are best found in cold-water fish. These substances thin blood; repair arterial wall damage; keep arteries flexible; and reduce prostaglandin, leukotriene, and thromboxane production, lowering the risk of clot production. Safe fish, free of high mercury levels, include Pacific wild-caught salmon, herring, mackerel, cod, sardines, and, to a lesser extent, shrimp, oysters, scallops, and trout. Chunk tuna from Costco (Wild Planet brand) is best.

Finally, ground flax meal, at approximately 2 Tbsp. per day, contains alpha linolenic acid, ALA, which lowers cholesterol. It reduces levels of apolipoprotein A-1 and B, both being more harmful than elevated LDL. Several types of nuts dilate blood vessels and lower blood pressure. Their arginine content provides this benefit. They also contain vitamin E, which reduces arterial inflammation and inhibits cholesterol oxidation.

Almonds, peanuts, pecans, and walnuts are among these, as are macadamia nuts (though less affordable). Peanuts also contain resveratrol.

Eggs, including yolks, can be eaten three times per week. They increase HDL cholesterol and large-particle LDL. Red wine contains resveratrol and powerful antioxidants. Red wine grapes are crushed whole, and much of the flavonoid content is right beneath the skin, thus getting into the fresh juice a high level of antioxidants.

Foods known to lower cholesterol and raise HDL Carrots reduce cholesterol when eaten daily.

Garlic lowers LDL levels. It's also among the foods that reduce blood clotting.

Olive oil should be extra virgin, ideally from California. Olive oil labeled as Italian may be Tunisian, with lower quality control standards. If shipped to Italy, pressed, and kept for six months, it can be labeled Italian. Olive oil contains polyphenols, which have excellent cardiovascular effects, as well as anti-coagulating and anti-inflammatory effects.

Soy contains isoflavones and lowers LDL levels while increasing HDL. Coffee is beneficial, as is black tea and particularly green tea, with its immune-enhancing enzymes, moodenhancing qualities, and platelet-activating factor (due to its level of flavonoids).

Capsaicin from peppers is good in preventing thromboembolism as well as lowering cholesterol and triglycerides.

Ginger can lower the incidence of new blood clots.

Finally, cinnamon is spectacular at lowering inflammation. The cinnamaldehyde content stimulates NO release, which lowers blood vessel resistance.

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DOJ certifies CURES: Physicians must check database prior to prescribing effective October 2, 2018 The California Department of Justice (DOJ) has certified that as of April 2, 2018, the Controlled Substance Utilization and Evaluation System (CURES) –California’s prescription drug monitoring database – is ready for statewide use. The certification starts a six-month implementation period for the duty to consult requirements enacted by the Legislature in SB 482 (Lara, 2016).

Effective October 2, 2018, physicians must consult CURES prior to prescribing Schedule II, III or IV controlled substances to a patient for the first time and at least once every four months thereafter if that substance remains part of the patient’s treatment. Physicians must consult CURES no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient.

This law provides, however, that the requirement to consult CURES would not apply if doing so would result in the patient’s inability to obtain a prescription in a timely manner and adversely impact the patient’s conditions so long as the quantity of the controlled substance does not exceed a five-day supply.

Physicians are also not held to this duty to consult when prescribing controlled substances to patients who are: • Admitted to a facility for use while on the premises; • In the emergency department of a general acute care hospital, so long as the quantity of the controlled substance does not exceed a seven-day supply; • As part of a surgical procedure in a clinic, outpatient setting, health facility or dental office, so long as the quantity of the controlled substance does not exceed a five-day supply; or • Receiving hospice care.

In addition, there are exceptions to the duty to consult when access to CURES is not reasonably possible, CURES is not operational or the database cannot be accessed because of technological limitations that are beyond the control of the physician.

As of July 1, 2016, the law mandates that all California licensed physicians authorized to prescribe scheduled drugs and registered with the Drug Enforcement Administration be registered to access CURES. https://cures. doj.ca.gov/registration/confirmEmailPnDRegistration.xhtml For more information on CURES and the upcoming duty to consult, see CMA On-Call document #3212,“California’s Prescription Drug Monitoring Program: The Controlled Substance Utilization Review and Evaluation System (CURES)” or visit the DOJ’s website and CURES user guide: https://oag. ca.gov/sites/all/files/agweb/pdfs/pdmp/cures-2.0-user-guide.pdf CMA will continue to provide educational resources and work with the DOJ to ensure a smooth implementation of the new requirement.

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Nutrition

THE UNIVERSAL DIET A Nutritional Plan for Health and Wellness Erica Goode, MD The Universal Diet is largely vegetarian, with occasional fish (wild, unendangered, caught sustainably) and lean poultry, dairy, and eggs (free range from organic farms practicing humane methods).

It incorporates elements of the Mediterranean Diet; the DASH Diet (rather than the 2015 federal Dietary Guidelines); Diet for a Small Planet; Laurel’s Kitchen; Michael Jacobson’s Nutrition Action newsletter; the 2010 article in this journal, reflecting the wisdom of Marion Nestle, PhD; and presentations at the American College of Nutrition Conference on Nutrition and Cancer, held in November 2017 in Alexandria, Virginia.

On p. 11 of this issue, Dr. Neal Barnard, president of the Physicians Committee for Responsible Medicine, makes a strong case for a vegan diet. This is laudable from an animal rights perspective and for its environmental benefits. But for the needs of some human populations, including small children, athletes, pregnant and nursing women, and both sexes post andropause and menopause, a strong case may be made for higher levels of complete protein. This is true for patients with severe wounds or burns as well.

Detailed information regarding supplements and an emphasis on particular foods relevant to different health topics will be found in articles on cardiovascular and metabolic issues; eye and oral health, cancer, obesity, and optimal aging; and non-inflammatory digestive issues. What is known about maintenance of a healthy microbiome is discussed in multiple articles.

The Universal Diet/Health Plan: Adults

The main elements are as follows: Eggs, several per week Vegetables, 8–10 types per day Seeds and nuts, 1–2 servings per day Fruit, 2–3 servings per day whole fruits (tubers, rice, other whole grains) Legumes, 1–2 servings per day (winter vegetables, squash Dairy (including fermented), 2–3 servings per day Choose all organic foods. If financially impossible, adhere as much as possible to avoidance of the “Dirty Dozen” worst possible choices of fresh fruits and vegetables in terms of pesticide contamination.

Sample Day on the Universal Diet

Breakfast: A one-egg omelet,* with sautéed green peppers, chives, and dill; coffee or tea (green or black); fresh berries, melon, and pomegranate seeds* Lunch (can be brought from home): A large green salad with garbanzo beans, herbs, olive oil dressing; parmesan cheese; fresh fruit (1–2 tangerines)* WWW.SFMMS.ORG

4 p.m. snack: Apple and string cheese* Dinner: Vegetarian lasagna or spinach casserole* with ricotta, feta filling and filo wrap;*salad with avocado; Esalen or other dense, whole grain bread* with hummus; 2–3 oz. red wine, organic when possible *Pre-prepared the previous night or, for casseroles, soups, etc., on the prior weekend A 12-hour break from eating overnight, after dinner, allows for mild ketosis in the morning, ample sleep, and clearing of toxins from brain and other cells.

Food Types

Dairy: 1–2% milk; kefir, yogurt; cottage cheese, ricotta, other lower-fat cheeses; quark. Eat plain with fresh fruit or flavored with stevia and vanilla if desired.

Starches: Moderate amounts of whole grain bread; tubers, peas, corn, corn tortillas; unusual items such as sunchokes; pasta, cereals (McCann’s steel-cut oatmeal, for example); brown, Himalayan, or Lundberg’s rices. California rice is best among U.S.-grown rices (much of the rice produced near the Mississippi is, sadly, burdened by pesticides and heavy metals). Koda Farms Japanese short-grain brown rice is an example; 365 brand wild rice and all Lundberg multigrain rice types are from California.

Water should be filtered (otherwise, worldwide, it contains plastic particles). Use a Brita or other filter, then store the filtered water in a stainless steel teapot (for coffee, tea) and glass pitcher in refrigerator. This keeps the water from undue contact with the plastic Brita container.

Cooking oil should be olive oil (the best is from California— Frantoia or McEvoy’s, for example). Much Italian olive oil comes from questionable olives from Tunisia; if bottled and kept in Italy for six months, it can be labeled as Italian. Occasionally, you may want to use walnut, sesame, truffle, almond, or other oils.

More organic wines are better tasting than in the past. These are found at Whole Foods, Berkeley Bowl, some specialty wine and grocery stores. Red wine, due to its resveratrol content, is preferred. Japanese sake is an acceptable alternative.

Searing poultry and fish isn’t good. Best to pan saute items at a lower heat in oil and add capers, dill, parsley, and other seasonings during cooking. Baking, braising, and boiling items are fine.

For soup bases, use 1-quart boxes of organic chicken bone broth or stock, or vegetable broth. If canned soup is desired, use Amy’s, which has a plastic-free can liner. Buy sauces and condiments in glass.

For families with children, occasional gingerbread with nuts, oatmeal cookies, or peanut butter cookies may be added to Continued on the following page . . .

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the diet. Banana or pumpkin bread with walnuts, poached pears, apple crisp with extra walnuts, baked apples, etc., would be satisfying and healthy dessert choices. Brown rice pudding or apple, peach, or berry crisp with added nuts might be reserved for weekends.

Supplements

Vitamin D3: 2–4 drops (one drop = 1000 IU). These are better absorbed than capsules. This is not necessary for people living +/15 degrees from the equator. (Assuming exposure to some midday sun to arms, legs on most days). Take drops with food containing 5–10 grams fat for best absorption.

Omega 3 fats: These should come from 2–3 servings (4 oz. cooked) of higher-fat fish.

Lysine: Take 1,000 mg. capsules in wintertime. This may help reduce the onset of colds, flu, or parainfluenza; it is alsogood for those with a history of HSV-I or -II. If symptoms of either begin, ramp up lysine intake to 2 grams morning and evening.

Vitamin C: For vitamin C beyond that found in the normal diet, to respond to early phases of cold or flu, use buffered EsterC, 500– 1,000 mg., 3 times daily with food. (Read more on vitamin C in the article on cancer.)

Probiotics: I favor Klaire Labs Ther-Biotics, a mixture of 25 million CFUs, with 12 most common adult probiotics. These are kept refrigerated in transit and at home. They are primarily to be used if a recent severe illness has led to antibiotic use. They, and

saccharomyces boulardii, should be used for about a month during and after antibiotic use.

The multiple benefits of food phytonutrients, from lutein to sulforaphanes, will be discussed in individual articles.

Optimal aging needs for men and women are largely served by the above principles, plus added emphasis on exercise throughout life and especially at andropause/menopause. This should include brisk walking 5–6 times per week plus exercises for arm and vertebral spine strength and stretching.

Specifics for an optimal pediatric diet, probiotics, and a pitch for a school breakfast program, pre-K through high school, will be discussed by Sonya Angelone, RD, in her article on pediatric nutrition, “How to Feed a Child.” She will urge that schools adopt a sugar-free policy on campuses in all public and charter schools.

Children need breakfast, a later start date for classes in adolescence (9 a.m. would be ideal), and a vigorous exercise program for optimal alertness and learning.

References 1. Lappé, Frances. Diet for a Small Planet, the first widely researched and published book for the public (with recipes). Ballentine Books. 1971.

2. Robertson, Laurel. Laurel’s Kitchen. Nilgiri Press. 1973.

NUTRITION AND MIGRAINES Interventions to Lessen or Prevent Migraine Headaches Erica Goode, MD Migraine headaches can be severely debilitating, necessitating days off school or work, especially if they recur monthly in conjunction with the PMS phase of a menstruating woman’s cycles. They are common, affecting approximately 15% of women and 6%of men. They are unilateral, throbbing, and often severe. They are frequently preceded byphotophobia or phonophobia, nausea, and vomiting. At their worst, a temporary hemiparalysis can occur.

Many interventions including Dolovent, ergot alkaloids, or other medications may lessen or abolish these headaches, especially if taken preventively.

These include: CoQ10, 150–300 mg per day. It functions as an antioxidant and for cellular energy production.

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Magnesium, 100–200 twice daily. This mineral is often low if the diet is suboptimal. Magnesium facilitates smooth muscle activity in nerves and arteries, both of which play a role in migraines.

Vitamin D3, 2,000 IU or more. This definitely helps, although the mechanism of action has not been defined.

Riboflavin, 25 mg. twice daily.

5-HTP (5-hydroxytryptophan). This is a precursor of serotonin; it boosts mood and cellular communication.

Melatonin, beginning with 1–2 mg. an hour before sleep and perhaps increasing to 3–5 mg. Taken nightly for three months, this can decrease adult migraine severity or incidence by about 80%.

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Nutrition

OBESITY, ANTIBIOTICS, AND THE HUMAN MICROBIOME How the Modern Diet and Antibiotics Have Impacted Americans’ Gut Health Erica Goode, MD It is clear that over the last 50 years, America has seen a huge increase in concentrated, low- fiber, high-fat, salty, sugary, and protein-manufactured foods. Initially,

this seemed the culprit in our obesity problem and in associated deleterious effects on the body: weight gain, high blood sugar, high cholesterol, and liver function abnormalities. Abnormal behavior, decline in sexual performance, and an appetite shift toward continued intake of these nutrient-depleted foods is the result. (I saw a chunky, middle-aged fellow leaving CVS yesterday; a Monster Energy four-pack, potato chips, SweeTarts, and a frozen ice cream cone were his only purchases. He unwrapped the cone as he left.) The best description of this: the decade-old Supersize Me film, whose subject became exhausted, irascible, and increasingly overweight, with labs to match.

In 1900–1919, the average calorie level available in the U.S. food supply was 3,400 (for a very active, mostly rural population); this rose to 3,600 in 1990–1999; and to 3,900 by 2004. Beginning in 1975, the prevalence of obesity increased sharply, and since use of antibiotics and calorie intake both rose, we cannot discount either as the root cause.

Heavily lobbied refined foods certainly play a major role in the alarming increase in national overweight and obesity. However, antibiotics may be a major, hidden player, since it is more evident over time that antibiotics are an important contributor to this problem. Even those of us who pride ourselves on growing and buying only organic fruits and vegetables can be chronically exposed to other sources of antibiotics. Two parallel sets of studies are compelling and demonstrate evidence for rising levels of antibiotics being introduced into our food, especially in CAFO (concentrated animal feeding operations) of beef, pork, and chicken. In 2011, 13.5 million kg. of antibiotics were used for food-producing animals; human use was 25% of that level.

There has been a mild decline in this practice, but more laws must be passed to control such use. In general, this would also lead to more humane treatment of these animals. The trend is difficult to buck, since beginning in 1946, baby chicks were shown to gain weight better if their feed was laced with a chlortetracycline mash.

In 1950, a mixture of vitamin B12 and streptomycin lead to a 40% increase in the final weight in pigs. Since the 1960s, scientists have voiced increasing alarm that this could lead to antibiotic resistance and sometimes allergies in humans; the concern regarding weight is a recent observation (G. Ternac first proposed this possible association in 2004).

An insidious problem is the variety of environmental sources of antibiotics, from rivers, especially those downstream from agricultural operations, to plants either watered from these rivers or “enriched” with manure from CAFO animals. Commercially grown corn, lettuce, potatoes, carrots, scallions, and cabbage have been found to contain various antibiotic residues, as have fruit orchards watered with antibiotic-contaminated water. Other sources can be aquaculture (shrimp and fish farms) and unintentional water conWWW.SFMMS.ORG

tamination from hospital effluents and discarded drugs.

Gut microbiota can be identified through 16S rDNA clone libraries, with primers and sequencing of the inserts. Then 16S rDNA V6 pyrosequencing is performed with standard protocols. The Sanger technique sequences at the phylum, class, order, and genus levels.

Although there are limitations to using this method, since primer coverage may underestimate microbial diversity, the comparative conclusions still hold.

A number of studies have shown that normal-weight adult humans share a distinct pattern of microbial species, altered from that profile seen in overweight and obese individuals.

Further, with a dramatic loss of weight (such as that seen in bariatric surgery), the pattern of gut flora returns to a more normal state.

A well-functioning microbiome benefits the host in multiple ways. It manufactures vitamin K, B vitamins, and some amino acids; maintains a healthy mucosa; and, through digestion, hosts several species that ferment dietary polysaccharides to produce SCFAs (short-chain fatty acids), leading to an added 80–200 calories per day for that human host. However, in the obese individual, rodent or human, dysbiosis has recently been reviewed by Harris, Kassis, et al. For individuals homozygous for the (ObOb) leptin gene, the researchers found that there was a 50% reduction in the microbiome Bacteroidetes population, with a contrasting increase in Firmicutes. The normal weight individual generally had a high level of ample Bacteroidetes, but the subfamily Prevotellaceae was more prevalent in the obese.

Three other families, Actinobacteria Coriobacteriaceae; Erysipelotrichaceae (a Firmicute), and the Proteobacteria Alcaligenaceae were all more prevalent in the obese. Of interest, formula-fed infants also develop a prominence of Coriobacteriaceae in their microbiome.

In general, obese individuals have a very different microbial community than normal weight individuals, and bariatric surgery (RYGB) alters the intestinal microbial community in a unique way—more toward normal. Gastric sleeve bariatric surgery, being more physiologically toward normal gut function, also shows a different but significant reversion to a normal weight microbiome profile. If the program works closely with the individual to adopt more normal (albeit more soft-cooked or liquified intake in some cases) and slower eating practices, this is likely the best long-term nutritional and weight control plan for the obese (>/= 35 BMI) individual.

Normal weight humans have no microbiome Methanobrevibacter (methanogen) species, and most post-bariatric surgery patients are devoid of this bacteria. But in the obese, we see more Archaea methanogens, whereby the H2 produced by some bacteria transferred to methanogens, both in cow ruContinued on the following page . . .

APRIL/MAY 2018 SAN FRANCISCO MARIN MEDICINE

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men and in humans. Methanogens are H2 consumers, but with this syntrophic partnership with the H2 producers, we see an increase in host energy extraction from normally indigestible polysaccharides, in the form of SCFA calories absorbed across the intestinal epithelium. These SCFAs include formate, propionate, butyrate, and lactate, all of which convert to acetate, which is then transferred to the host as increased calories.

With RYGB surgical weight loss, there is a large increase in the proportion of the Enterobacteriaceae Gammaproteobacteria, a decrease in Firmicutes, and a loss of methanogens. This is thought to occur for several reasons. First, the small gastric remnant, exposed to much less acid and pepsin, likely favors the aerobic Gammaproteobacteria over obligate anaerobes— the Firmicute Clostridium species. Second, with a shortened small bowel, there is more dissolved O2, some of which arrives at the colon, thus affecting the decline in methanogens. Third, the bypass of the upper small bowel, with its maximal nutrient absorptive capacity, might also relocate some of its predominant Enterobacteria to the large intestine, along with rapid transit of nutrients to the colon. Finally, due to the altered, shortened absorptive gut surface transmitted by the nutrients, there is simply less time for uptake of nutrients.

At some point, the microbiomes of those obese individuals undergoing gastric sleeve (the preferred means of bariatric surgery) who become relatively normal in weight will be characterized. With either surgery, these individuals should also adapt to a healthier eating pattern, which in itself fosters a more health-promoting microbial colony.

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Celebrating 150 Years of Physician Advocacy and Camaraderie

The gala was attended by 22 Past Presidents of SFMMS!

150th Anniversary Celebration & Gala Planning Committee Chair Rob Margolin, MD, and Robin Harris.

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2018 SFMMS President John Maa, MD, delivers his President’s Message.

More than 200 physicians, leaders in the medical community, and their guests joined SFMMS for an extraordinary 150th Anniversary Celebration & Gala on March 15, 2018, recognizing an important milestone in the organization’s history. Held at the St. Francis Yacht Club, the event marked SFMMS’s sesquicentennial as the only physician association that advocates for physicians across all specialties and modes of practice in San Francisco and Marin.

Attendees were able to network with colleagues, meet SFMMS and community leaders, and take in breathtaking views of the San Francisco Bay. Guests were also treated to the musical stylings of acoustic guitarist Kevin Ayers and were able to take photos in an elegant photo booth during a lively reception.

The festivities continued with a seated dinner and formal program that celebrated SFMMS’s rich history, its members, and their contributions to the local medical community. Recognition included SFMMS’s 150th Anniversary, the many volunteers who have served the SFMMS, and the 20th anniversary of SFMMS Executive Director/CEO Mary Lou Licwinko. Immediate Past President Dr. Man-Kit Leung was acknowledged for his contributions to the medical society, and a tribute was provided for two SFMMS members who attained 50-Year Membership status: Dr. Chuck Fischer from Marin and Dr. David Smith from San Francisco.

The evening’s program continued with inspirational remarks by 2018 SFMMS President Dr. John Maa and the premiere of a commemorative video highlighting the many advocacy achievements of the medical society over the years. The video may be viewed at http://bit. ly/2IDUOgO. The program concluded with a motivational and galvanizing speech by featured speaker Dr. Sandra Hernández, President and CEO of the California Health Care Foundation, and recent Governor-appointee to the Board of Covered California. Dr. Hernández spoke about her professional journey, sharing moments along the way that inspired her to leave clinical medicine and become a strong advocate for access to health care. She spoke about the importance of building bridges to improve access, what lies ahead for health care reform, and encouraged SFMMS members to stay involved in helping to make positive changes.

SFMMS would like to thank our members; sponsors; and special guests Assembly members David Chiu and Phil Ting, Senator Scott Weiner, Board of Equalization Member Fiona Ma, Marin Board of Supervisors President Damon Connolly, and CMA President Dr. Ted Mazer for their support of the event and of SFMMS. Special thanks also go to SFMMS Associate Executive Director Erin Henke and the members of the 150th Anniversary Celebration & Gala Planning Committee for organizing a truly memorable evening.

SAN FRANCISCO MARIN MEDICINE APRIL/MAY 2018 WWW.SFMMS.ORG

From left, SFMMS Board Liaison Shannon Udovic-Constant, MD; Senator Scott Wiener; Immediate Past President Man-Kit Leung, MD; President John Maa, MD; Executive Director/CEO Mary Lou Licwinko; Board Liaison Rob Margolin, MD; Board of Equalization Member Fiona Ma; Alex Walker; and Assemblymember Phil Ting.

SFMMS President John Maa, MD, presents Immediate Past President Man-Kit Leung, MD, with a certificate of appreciation for his service.

Room with a view.

WWW.SFMMS.ORG

Executive Director/CEO Mary Lou Licwinko accepts a proclamation from Mawuli Tugbenyoh of the Mayor’s Office declaring March 15, 2018, “San Francisco Marin Medical Society Day.”

Medical students enjoying the gala.

APRIL/MAY 2018 SAN FRANCISCO MARIN MEDICINE

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Fifty-year members Chuck Fischer, MD (left), and David Smith, MD (middle), with John Maa, MD (right).

Congratulations Fifty-Year Members!

Presenting Sponsor Mechanics Bank representatives John Osborn (left), and Martha Cifuentes (right), award a check to Tracey Hessell, MD (center), for the Marin Community Clinics.

Charles T. Fischer, MD | Dr. Charles (Chuck) Fischer retired

from his private internal medicine practice, San Rafael Medical Group, in 2002 after 35 years. He then served as a volunteer physician for Rotacare Clinic for the uninsured in San Rafael from 2003– 2015. Dr. Fischer completed his undergraduate degree at Denison University in Ohio and received his medical degree from the University of Cincinnati College of Medicine in 1961. He completed his residency training at the University of Oregon, and then served in the U.S. Army from 1966–1968. Dr. Fischer was president of the Marin Independent Physician Association from 1988–98. In addition to his volunteer work with the Rotacare Clinic, he participated as a Volunteer Physician with Faith in Practice, making annual trips to Guatemala between 2004–2013. Dr. Fischer is married with four children and four grandchildren, and in addition to spending time with family, he enjoys travel, photography, reading, and sailing.

David E. Smith, MD | Dr. David Smith is a living legend in the

San Francisco Bay Area and beyond, having been a foundational figure confronting addiction in our society. Born and raised in Bakersfield, he came to UC Berkeley and then to UCSF for medical school.

Dr. Smith opened the Haight-Ashbury Free Clinic during 1967’s “Summer of Love.” In the 40 years he headed the clinics, over one million patients were seen, and the free clinic movement spread around the nation. He has served as guest editor of the SFMMS journal and co-chaired the San Francisco Addiction Summit, cosponsored by the SFMMS last year and again this June. Dr. Smith is a Past-President of the American Society of Addiction Medicine.

He has been awarded the University of California Medal of Honor, the UCSF Chancellor’s Award, and countless other recognitions. He embodies the principle under which he founded his clinic half a century ago: “Health care is a right, not a privilege.”

Featured speaker Sandra Hernández, MD, delivers an inspirational speech.

SFMMS President John Maa, MD, with President-Elect Kimberly Newell Green, MD.

All photos courtesy of Ginger Tree Photography. All rights reserved.

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SAN FRANCISCO MARIN MEDICINE APRIL/MAY 2018 WWW.SFMMS.ORG

FIREARM VIOLENCE PREVENTION How Physicians Can Educate and Change Behaviors Related to Firearm Violence CMA Resource Center The United States continues to struggle with an epidemic of firearm violence. In 2015, there were 34,997 deaths in the U.S. caused by firearms, with firearm-related suicide deaths outnumbering firearm-related homicides by a large margin. Suicide was the tenth leading cause of death in 2015, and firearms accounted for almost half of those deaths, with older white men at the highest risk.1,2 Homicide is the leading cause of death for male and female African Americans aged 10–34 years, and firearmrelated homicide is highest among young African American men.3 When combined, suicide and homicide were the fourth leading causes of years of potential life lost in the U.S. in 2015, and they accounted for the second and third leading causes of death, respectively, among adolescents and young adults.4 Mass shootings account for a small percentage of the firearm violence deaths, yet they result in unnecessary morbidity and mortality and capture the attention of the media and the public.

The economic burden of firearm death and injury is substantial, reaching $229 billion in aggregate costs and representing about 1.4% of the U.S. gross domestic product.5 As a result, in 2017, the California Medical Association (CMA) convened the Firearm Violence Prevention Technical Advisory Committee (TAC), composed of physician experts. The TAC performed a comprehensive review and analysis of existing CMA policy, epidemiological data, and current scientific research and developed a CMA position statement on the prevention of firearm violence (adopted by the CMA Board of Trustees on July 28, 2017). Through the TAC’s work, the CMA has identified several opportunities and resources that may aid physicians in addressing firearm violence as a public health issue: Take the pledge. Make a commitment to ask your patients about firearms when, in your judgment, it is appropriate, and follow through with support and resources to keep patients safe. Click here to see what you can do, as physicians, to help stop firearms violence.

Educate yourself and your patients. Expanded education and training are needed to improve clinician familiarity with the benefits and risks of firearm ownership, safety practices, and communication with pa-

tients about firearm violence. There is a growing body of literature and resources available to initiate patient discussions and support patient education on firearm safety and storage, including best practices to reduce injuries, deaths, and psychological trauma related to firearm use:

Yes, You Can: Physicians, Patients, and Firearms6 Preventing Gun Violence: Moving from Crisis to Action7 Firearm Violence and Its Prevention: From Scientific Evidence to Effective Policy8 Gun Violence—Risk, Consequences, and Prevention9

Support research. The suppression of firearm research has stripped federal and state funding for data surveillance, research, and analysis, and has prevented the advancement of evidence-based policies as benefiting other major public health issues.

Recognize warning signs and respond appropriately to patients with mental illness. They are at higher risk for suicide and for being a victim of violence. Access to firearms is associated with increased suicide risk.

Understand the physician’s legal obligations to report.Physicians should know their legal obligations for reporting specified medical conditions and the clinical interventions that might restrict a patient’s ability to own or possess a firearm.

• CMA ON-CALL #3667: “Psychiatric Inpatients: Reporting Firearms Prohibition” • CMA ON-CALL #3653: “Reporting Injuries by a Deadly Weapon, Criminal Act, Health Facility Neglect, or Emergency Department Violence” For more information, visit: www.cmanet.org/resource-library/ detail/?item=psychiatric-inpatients-reporting-firearms. A full list of references is available online, www.sfmms.org.

MEDICAL COMMUNITY NEWS Kaiser Permanente Maria Ansari, MD

Nutrition plays a key role in overall health, highlighted by the fact that 80% of chronic disease is attributable to lifestyle factors, including diet. For the first time, Kaiser Permanente has a Culinary Medicine Program, which includes healthy cooking classes to empower people to improve their health, and a dedicated physician/chef administering the program, Linda Shiue, MD. Dr. Shiue, who has practiced internal medicine since 2001, has been teaching healthy cooking classes for six years. She received a Certificate in Plant-Based Nutrition from Cornell University and completed a Certificate in Culinary Arts at San Francisco Cooking School in 2016. As the Director of Culinary Medicine for the medical center, Dr. Shiue is responsible for providing a hands-on healthy cooking program called “The Thrive Kitchen.” This monthly class, held at the Kaiser Permanente Mission Bay Medical OfWWW.SFMMS.ORG

fices, is open to members, physicians, staff, and the community. She also hosts “Lunch with Linda,” a monthly cooking class for physician colleagues. In 2009, Dr. Shiue began her food blog, SpiceboxTravels.com, which shares recipes for health-supportive, globally inspired cuisine, with an emphasis on plant-based ingredients. Dr. Shiue worked with medical center leadership to develop her program in San Francisco. “I wanted institutional support to do what I’ve been doing for so many years, and Kaiser Permanente’s focus on prevention made it easy to implement this new program.”

Dr. Shiue brought Kaiser Permanente San Francisco in as an inaugural member of the Teaching Kitchen Collaborative of the Harvard School of Public Health and the Culinary Institute of America. The collaborative confirms that integrating a wellness and prevention program with evidenced-based nutritional information is in both the medical establishment’s and patients’ best interests.

For more information about Dr. Shiue’s classes, go to https://www.facebook. com/thedoctorsspicebox or email sfhealthed@kp.org.

APRIL/MAY 2018 SAN FRANCISCO MARIN MEDICINE

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GOLD SPONSOR

SILVER SPONSORS

BRONZE SPONSORS Keystone Sponsors

1868 2018

Anniversary Celebration &

Please join the San Francisco Marin Medical Society as we gratefully acknowledgethe support of these dedicated partners:

Sponsors

Organizational

Individual

PRESENTING SPONSOR

Lawrence Cheung, MD Man-Kit Leung, MD John Maa, MD David Werdegar, MD

Champion Sponsors

Actify Neurotherapies Peter Bretan, Jr., MD A. L. Nella & Company LLP Eduardo Dolhun, MD Chinese Hospital Staff StevenMedical Fugaro, MD Robert Margolin, Marin General Hospital MD Shannon Udovic-Constant, MD

Sponsors

SFMMS would like to thank Saint Francis Memorial Hospital, UCSF Mt. Zion, and Hospice by the Bay for providing meeting space for SFMMS meetings;

Keystone Sponsors

Champion Sponsors

Practice Management & Liability Consultants providing a gift for our Medical Student / for Resident Sponsors Ambassador Sponsors

Lawrence Cheung, MD Man-Kit Leung, MD John Maa, MD David Werdegar, MD

Peter Bretan, Jr., MD Eduardo Dolhun, MD Steven Fugaro, MD Robert Margolin, MD Shannon Udovic-Constant, MD

featured Harvey forMD making the St.Goode, Francis Michael Kwok, MD speaker; and Dr. Robert Erica MD Yacht Club Donald Abrams, Keith Loring, MD Roger Eng, MD available for our 150th Anniversary Celebration & Gala.

SFMMS sincerely thanks Jason Nau, MD Stephen MD Kimdelegation, Newell Green,board, MD Michael Scahill, MD every member who has served on an Follansbee, SFMMS committee, George A. Fouras, MD Michael Scahill, MD Monique task Schaulis, force,MD or other volunteerGordon body—you are the soulCharles of the Wibbelsman, medical society.

Fung, MD MD Jeff Stevenson, MD

PLATINUM SPONSORS

Saint Francis Memorial Hospital

GOLD SPONSOR

St. Mary’s Medical Center

SFMMS would like to thank Saint Francis Memorial Hospital, UCSF Mt. Zion, and Hospice by the Bay for providing meeting space for SFMMS meetings; Practice Management & Liability Consultants for providing a gift for our featured speaker; and Dr. Robert Harvey for making the St. Francis Yacht Club available for our 150th Anniversary Celebration & Gala. SFMMS sincerely thanks every member who has served on an SFMMS committee, delegation, board, task force, or other volunteer body—you are the soul of the medical society.

SILVER SPONSORS

A very special thanks to the 150th Anniversary Celebration & Gala Planning Committee: Rob Margolin, MD—Chair Irina deFischer, MD Steve Heilig Erin Henke Man-Kit Leung, MD

Mary Lou Licwinko Keith Loring, MD John Maa, MD Kimberly Newell Green, MD Monique Schaulis, MD

BRONZE SPONSORS Actify Neurotherapies A. L. Nella & Company LLP Chinese Hospital Medical Staff Marin General Hospital

Individual

Sponsors

Keystone Sponsors

Champion Sponsors

Ambassador Sponsors

Medical Student / Resident Sponsors

Lawrence Cheung, MD Man-Kit Leung, MD John Maa, MD David Werdegar, MD

Peter Bretan, Jr., MD Eduardo Dolhun, MD Steven Fugaro, MD Robert Margolin, MD Shannon Udovic-Constant, MD

Michael Kwok, MD Jason Nau, MD Michael Scahill, MD Monique Schaulis, MD Jeff Stevenson, MD

Donald Abrams, MD Roger Eng, MD Stephen Follansbee, MD George A. Fouras, MD Gordon Fung, MD

SFMMS would like to thank Saint Francis Memorial Hospital, UCSF Mt. Zion, and Hospice by the Bay for providing meeting space for SFMMS meetings; Practice Management & Liability Consultants for providing a gift for our featured speaker; and Dr. Robert Harvey for making the St. Francis Yacht Club available for our 150th Anniversary Celebration & Gala. SFMMS sincerely thanks every member who has served on an SFMMS committee, delegation, board, task force, or other volunteer body—you are the soul of the medical society.

A very special thanks to the 150th Anniversary Celebration & Gala Planning Committee:

UPCOMING EVENTS Rob Margolin, MD—Chair Irina deFischer, MD Steve Heilig Erin Henke Man-Kit Leung, MD

30th Annual Western States Regional Conference on Physicians’ Well-Being

Wednesday, May 23, 2018 | 8:00am-4:15pm UC Riverside Extension Center, 1200 University Avenue, Riverside, CA | Presentations at this one-day CME conference include Legal & Legislative Hot Topics, Visit http://bit.ly/2EJNBbO for more information or to register.

SFMMS Addiction Summit: Annual David E. Smith, MD Symposium

Friday, June 1, 2018 | 8:30am-5:30pm UCSF Mission Bay Conference Center, 1675 Owens Street, San Francisco | Join us for an action-oriented forum with leading multidisciplinary faculty covering opiates, psychedelic medicine, legal marijuana, advances in addiction medicine and primary care, and Marin & SF problems and responses. To register, or for more information, visit www.drsmithsymposium.com.

Annual Meeting of the AMA House of Delegates

June 9-13, 2018 Hyatt Regency Chicago, IL | Officials and members gather to elect officers and address policy at the AMA Annual Meeting in Chicago. Visit https://www. ama-assn.org/events/annual-meeting-ama-house-delegates.

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Erica Goode, MD Keith Loring, MD Kim Newell Green, MD Michael Scahill, MD Charles Wibbelsman, MD

Mary Lou Licwinko Keith Loring, MD John Maa, MD Kimberly Newell Green, MD Monique Schaulis, MD

ASPC 2018: Congress on Cardiovascular Disease Prevention

June 27-29, 2018 Hyatt Regency Tamaya Resort, New Mexico | The American Society for Preventive Cardiology (ASPC) is holding the 2018 CVD Prevention Congress featuring innovative education, ground-breaking science and interactive discussions with top prevention experts. For more information, visit https://www. aspconline.org/congress2018/.

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