Thursday, October 27, 2011

Healthy Eats

You are what you eat. I’m guessing you’ve heard this cliche before. But have you thought about what it means and whether it’s true? Surely, “You are what you eat,” doesn’t mean that later today I’ll morph into a frosted doughnut with Halloween sprinkles. What it does mean is that my body is built, mostly, on nutrients I consume. There are, of course, exceptions – women are born with all of the (non-surrogate) eggs they will have for their lives and medical devices do not use diet to sustain themselves. Tooth enamel and cerebral cortex neurons stay constant but, other than that, our bodies undergo constant turnover. And, as we all know, the substrate for that turnover is what we eat (so, if you had a turnover for breakfast, that turnover is used for turnover). And even those things in our bodies that are not directly the result of diet are affected by it. Your teeth, for example, are highly sensitive to the food you eat and its sugar content. So, food matters – and food quality affects health. But, eating well is expensive, right?

Consider a recently published University of Washington study that examined the cost of eating a diet compliant with the federal Dietary Guidelines for Americans, 2010 – which recommends increased dietary quantities of vitamin D, calcium, dietary fiber and potassium and less sugar and saturated fat. Using a survey to assess eating habits and then tallying retail prices at Seattle-area food suppliers, the study team tabulated the estimated dollars needed to get enough of some key nutrients, such as potassium. Based in part on the fact that such nutrients are plentiful in fresh produce and hard to find elsewhere, the researchers reported that meeting the guidelines would add to food costs. In fact, for one nutrient (potassium), an additional $380 was needed per person per year to meet recommended guidelines. On the other hand, for every 1% increase in dietary calories obtained from sugar and saturated fat, study subjects saved approximately $26 (sugar) to $102 (saturated fat) per person per year. Based on these findings, the authors concluded that, “Improving the American diet will require additional guidance for consumers, especially those with little budget flexibility, and new policies to increase the availability and reduce the cost of healthful foods.”

This study certainly has limitations in terms of its scope and methods (including the fact that the calories and costs were estimated rather than directly observed), but it nonetheless supports the conventional wisdom that you have to be rich to eat a healthy diet. I argue, however, (and I’m not alone in this) that conventional wisdom is simply not true on this point. It is, of course, a lot easier to be a healthy eater if you have a fat wallet, but it’s certainly possible without one. And while I agree with the basic tenet of AB 581(declaring access to healthy food items a basic human right), I don’t think this issue should be left to legislation alone. For example, here is a quick recipe of tips for economic and nutritious eating.

Recipe for Eating Well on a Tight Budget.

·      Mix the following into your routine
o   Two parts buying local, fresh and in-season when possible.
o   Three cups planning nutritious meals that can be re-served another night.
o   One part frequent thick and hearty soups (these will cut back the urge to splurge).
o   Three carts of buying generic and in bulk and freezing perishables.
o   Six tablespoons of reading food labels. You’ll be shocked at all the added sodium.
·      Cook this mixture slowly in a reduction sauce dedicated to cutting back on unrefined sugar, saturated fat and expensive and unnecessary vitamin supplements.
·      Finish with three thimbles of nutrition education.

It is in the finishing that the most enduring benefit will be found Рfor you and your family. In particular, we could be doing a much better job of teaching our children about food and nutrients and creating a life-long appreciation for their importance. As a father who delivers sprinkled doughnuts home on a bi-weekly basis, I am likely more delinquent on this point than many in Marin. So, for parents like me a great place to start the schooling saut̩ is at the North Bay Discovery Day. On November 5th, in an event sponsored by The Buck Institute, over 50 exhibitors will gather at Infineon Raceway, all tasked with helping to make science fun and accessible for kids.

Among the exhibitors is accomplished chef Ted Smith, founder of Kids Cooking for Life (KCL) which is a community program that focuses on educating children on food, cooking and (big bonus!) table manners.

The KCL exhibit (in partnership with Kaiser Permanente) on Discovery Day is called a “Whole Grain Adventure” and will feature fun and games (including a Fiber Race) and deliver the message “that whole grains (and the fiber they contain) are an essential ingredient of a healthful diet.”

Ted Smith writes, “I strongly believe that you don't have to be wealthy to eat healthy. What I’ve learned as an owner-operator of restaurants in Chicago for over 23 years (and having served over 18 million customers) is this: fruits and vegetables are a lot cheaper than meat, seafood and poultry! And fruit and vegetables is where you find healthy eating.”

And don’t worry, a diet rich in produce will not turn you into a turnip.

For more info about Discover Day check out

Monday, October 3, 2011

The Good, The Bad, The Ugly (Marin IJ)

You may have noticed that vaccines are back in the news. In fact, the last few weeks have brought several related stories, which as a vaccine advocate, I would categorize as the Good, the Bad and the Ugly (yes, vaccines and Clint Eastwood movies do have something in common!) These developments can be summarized as 1) Good; rotavirus vaccine benefits children and public health, 2) Bad; pertussis (whooping cough) vaccine wears off sooner than previously thought (after about three years) and 3) Ugly; the Human papillomavirus (HPV) vaccine was blindsided by hearsay from a U.S. presidential candidate. More plot details below…
Good: Rotavirus vaccine decreases health costs
Have you heard of rotavirus? As a medical student studying for the boards, I had trouble remembering what type of infection this bug caused until I learned the mnemonic R-O-T-A, which stands for “right out the a@*&#.” That pretty much sums it up. Rotavirus is a leading cause of diarrhea, especially in children under the age of five. Tens of thousands of kids visit emergency departments each year because of rotavirus (which can cause life-threatening dehydration), and thousands more will require hospitalization for re-hydration. According to the CDC, just five years ago, rotavirus was responsible (annually) for approximately 55,000 to 70,000 hospitalizations and 20 to 60 deaths among young children. Even in mild cases, rotavirus is a bummer for everyone involved, except, that is, for the diaper industry.
The good news is that there are now two licensed vaccines against rotavirus (RotaTeq and Rotarix) and recent evidence suggests that they are working well. In the September 22nd issue of the New England Journal of Medicine (NEJM), researchers from the CDC reported the results of a 2001-2009 study comparing pre- and post-vaccination outcomes. Their results suggest that the vaccine (first widely available in 2007) resulted in an approximately one-half reduction in diarrhea-related ED visits and hospitalizations. Furthermore, the researchers calculated that the vaccine had likely prevented over 20,000 hospitalizations a year since 2007, resulting in a health care cost savings of over $90 million a year. I think you’ll agree; that’s a public health benefit we shouldn’t be flushing away.
Bad (well, not totally bad): Pertussis vaccine wears off earlier than thought
Hopefully by now everyone knows that we are in the midst of a pertussis (whooping cough) epidemic – one in which (quite regrettably) Marin County has led the way. This epidemic is multi-factorial – it is due in part to natural disease fluctuation, but also related to significant rates of personal belief exemptions (PBEs) for vaccines and waning immunity in older kids and adults. We have suspected for some time that the typical schedule of acellular pertussis vaccination (in older kids and adults) does not provide adequate protection and very recent (and still unpublished) evidence from the 2010 pertussis outbreak seems to confirm this. Dr. David Witt (infectious disease) and Dr. Paul Katz (pediatrics) from San Rafael Kaiser Permanente recently studied over 15,000 kids under the age of 18 in Marin County and identified 132 confirmed cases of pertussis. Their preliminary results, presented two weeks ago at the American Society for Microbiology in Chicago, suggest several important trends; 1) vaccinated children (age 2-18) are less likely to get whooping cough than unvaccinated ones, 2) younger children (age 2-7) who are vaccinated are well protected against disease and 3) older kids (with a peak around age 12), even if vaccinated, are very susceptible. In fact, the risk for 12-year olds is approximately ten times higher than for 2-7 year olds. This, then, seems to be good justification for the idea of a pertussis booster shot (as now required by state law AB 354) for 7th-12th graders. Fortunately, and this is where the bad news is not really so bad, Marin County seems to be doing very well with these boosters. According to public health officer, Dr. Jason Eberhart-Phillips, “We are nearly there to full compliance in Marin at this time. Local education officials understand and value the health and well-being of their students! “

Ugly: The HPV vaccine flap
Genital warts are not a pleasant topic. Especially when you consider that the causative virus (HPV) is a major risk factor for cervical cancer. Cervical cancer is nasty, even for cancer, and it kills young women. If you have any doubt about how horrible this cancer can be, consider this description of metastatic disease from The Immortal life of Henrietta Lacks by Rebecca Skloot… “Henrietta’s body was almost entirely taken over by tumors. They’d grown on her diaphragm, her bladder and her lungs. They’d blocked her intestines and made her belly swell like it was six months pregnant.” Fortunately, HPV immunization offers significant protection (70% or so) against cervical cancer in addition to genital warts. But despite its well-documented safety (over 35 million doses given worldwide), the context of the topic (teenagers having sex) has fueled some political pushback.

On September 13, the day after a GOP presidential candidates debate, Michelle Bachmann claimed on several media outlets that the HPV vaccine was hazardous and could cause “mental retardation.” Later, Bachman told Matt Lauer on the “Today” show that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk." As it turns out, these statements were based, not on fact, but on a single anecdotal account from a woman who had talked to Bachmann at a campaign event. This sort of   “a person I knew had a…” approach to public health is not healthy. In fact, this tact by a public figure was so egregious that Dr. Arthur Caplan of the University of Pennsylvania Center for Bioethics, challenged Bachmann – offering her $10,000 of his own money (to be given to a charity of her choice) if she could, in Caplan’s words, “produce a person within a week who had been made ‘retarded’ by the HPV vaccine, and if that claim could be verified by three doctors.” It’s been several weeks now and Caplan’s challenge remains unanswered. I asked Dr. Caplan to summarize his opinion of the situation:

He says, “Bachmann decided to base her campaign on an anti-vaccination platform. To do so she had to claim that vaccines like the HPV vaccine to prevent cervical cancer are dangerous.  Her willingness to throw away women's lives for political gain is not only unworthy of a Presidential candidate it is morally despicable.”
“As a recent study in NEJM on vaccines against rotavirus demonstrated,” Caplan continues, “vaccines remain our best response to lethal and disabling diseases in children and adults. By continuing to allow politicians, celebrities and crackpots to spew utter nonsense about vaccine dangers the medical, scientific and media communities are complicit in compromising the health of the public both in the U.S. and worldwide.  Vaccines do have risks as do every other health intervention from alternative medicine, to aspirin, to anesthesia.  But, vaccines are among the safest and most effective tools we have to fight dread diseases.  The public should know that and hopefully my challenge to Bachmann will help make that happen.”
Ugly situation indeed, but if it results in a better understanding of vaccines, including their minimal risk in the face of major benefits, it will lead to a prettier picture of public health.