April 2007

VOL.80 NO.3 April 2007 $5.00

SAN FRANCISCO MEDICINEJ O U R N A L O F T H E S A N F R A N C I S C O M E D I C A L S O C I E T Y

Innovations in Food and Health

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www.sfms.org April 2007San FranciSco Medicine�

conTenTS

San FranciSco Medicine april 2007 Volume 80, number �innovations in Food and Health

FEATURE ARTICLES

10 Abstinence from Red Wine: Is Abstaining Hazardous to Your Health? ArthurKlatsky,MD

12 The Enlightened Diet DeborahKesten,MPH

14 Providing Effective Nutrition Advice RobertBaron,MD

15 Obesity: A Chemical Connection? SteveHeilig,MPH,andJohnPetersonMyers,PhD

16 A Restaurateur’s Vision Bears Fruit: An Interview with Alice Waters DaveWeich

19 Escape From Nutrition-ism: Michael Pollan’s Rules of Thumb MikeDenney,MD,PhD

20 Nutrition and Food Production: What Role Should the Medical Profession Play? TedSchettler,MD,MPH

22 Stop Diabetes with Diet: Lifestyle Tools for Type II Diabetes Prevention NancyBennett,MS,RD,CDE

24 Nature’s Way: Omega-3s for Cardiovascular Disease PhillipFrost,MD

26 Exploring Unhealthy Eating Habits PatriciaCrawford,DrPH,RD

28 Perspectives in Eating Disorders AdairLook,MD

�0 The Villain in the Obesity Epidemic: Is High-Fructose Corn Syrup the Culprit? LucyCrain,MD

�1 Mercury Update JaneHightower,MD

�2 Improving the City’s Food Systems PaulaJonesandRajivBhatia,MD,MPH

MONTHLY COLUMNS

4 On Your Behalf

7 President’s Message StephenFollansbee,MD

9 Editorial MikeDenney,MD,PhD

�5 Book Review: Fatal Harvest SteveHeilig,MPH

�6 Hospital News

�8 Classified Ads

�9 In Memoriam StephenJ.Askin,MD

Editorial and Advertising offices

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san francisco, CA 94129

phone: 415.561.0850 ext.261

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4San FranciSco MedicineApril 2007 www.sfms.org4San FranciSco MedicineApril 2007 www.sfms.org

on YoUr BeHaLF

April 5, 2007TheSanFranciscoMedicalSociety

TeesupwiththePresidioGolfClub!SFMSmembersareinvitedtoacocktailreceptionat thePresidioGolfClubonThursday,April5, from5:30to7:30p.m.Membersareencouragedtoinvitenonmemberphy-sicianpeersaswell.Getacquaintedwiththisbeautifulfacilityanditsstunningviewswhileenjoyingbeverages,horsd’oeuvres,and the camaraderieof themembers ofSFMS.FormoreinformationortoRSVP,[email protected](415)561-0850extension268byMarch30.Thiseventiscomplimentary,butwedoneedyourRSVP.

May 3, 2007Markyourcalendarsandgetyourclubs

readyfortheSFMS/PresidioGolfClubGolfMixer&“ShortGameClinic”onThursday,May3,from5:30to7:30p.m.TherewillbeaputtingandchippingclinicwiththeClub’sgolfpro,followedbybeveragesandhostedhorsd’oeuvres in theClubhouse.Therewillalsobeano-hostcocktailbar.Additionally,moreinformationaboutthePresidioGolfClub—including a specialmembershipofferexclusivelyformembersoftheSanFranciscoMedicalSociety—willbeavailable.

Membersandnonmembersatalllevelsofskillandinterestareencouragedtoattendthiseveningoffunandfellowship.Membersare especially encouraged to invitenon-memberphysicianpeersaswell.Thecostis$25formembersand$35fornonmembers.IfanonmemberdecidestojoinSFMS,theireventfeewillbeappliedtotheirfirstyear’smembership!

For more information or to RSVP,[email protected] (415)561-0850extension268.RSVPdeadlineisMonday,April30th.

ThissummerlookforthereturnoftheSFMSGalleryMixer,afuneveningofgreat

A sampling of activities and actions of interest to SFMS members

art,terrificrefreshments,andcamaraderiethatwasahitlastyear.

Here’s an opportunity to reach out to fel-low members and help make membership more worthwhile!

SFMShasembarkedonaprogramtomentornewmembers.UponapprovalbytheBoardorExecutiveCommittee,eachnew member is assigned an establishedSFMSmemberasasponsorwhoseprimaryresponsibility is tohelp thenewmemberbecomebetteracquaintedwiththeSocietyanditsbenefits.Sponsorsareexpectedtoconnectatleastoncewiththenewmem-ber socially (overbreakfastor coffee, forexample)andtoinvitethemembertoatleastoneSFMSevent (AnnualDinner,LegislativeDay,Candidate’sNight,Mixer,etc.)duringthecourseoftheirfirstyearofmembership.SponsorswillalsobeaskedtoreporttotheBoardontheresultsoftheirin-teractionwiththenewmember.CurrentlysponsorsaredrawnfromtheSFMSBoardaswellastheExecutiveandMembershipCommittees,butallmembersareencour-agedtoparticipateinthisprogram.ContactTheresePorterintheMembershipDepart-mentat(415)[email protected] formore informationortovolunteer.

Help Grow the San Francisco Medical Society!

Membersreachingouttotheirphysi-cianpeersprovideatremendouslyeffectivewaytogainnewmembers.Ifyourphysicianpeersarenotyetmembers,encouragethemtojoin!

SFMSisalways looking for feedbackfromitsmembers,aswellassuggestionsforhowtomakemembershipmorevaluableandmorefun.ContactTheresePorterintheMembershipDepartmentat(415)[email protected].

notes from the Membership department

april 2007Volume 80, number �

Editor Mike DenneyManaging Editor Amanda DenzCopy Editor Mary VanClayCover Artist Amanda Denz

Editorial Board

Chairman Mike DenneyObituarist Nancy Thomson

SFMS oFFicErS

President Stephen E. FollansbeePresident-Elect Stephen H. FugaroSecretary Michael RokeachTreasurer Charles J. WibbelsmanEditor Mike DenneyImmediate Past President Gordon L. Fung

SFMS Executive Staff

Executive Director Mary Lou LicwinkoDirector of Public Health & Education Steve HeiligDirector of Administration Posi LyonDirector of Membership Therese PorterDirector of Communications Amanda Denz

CMA Trustee Robert J. MargolinAMA Representatives

H. Hugh Vincent, DelegateJudith L. Mates, Alternate Delegate

Stephen Askin Toni Brayer Gordon Fung Erica Goode Gretchen Gooding Shieva Khayam-Bashi

Arthur LyonsTerri Pickering Ricki Pollycove Kathleen Unger Stephen Walsh

Board of directors

Term: Jan 2007-Dec 2009Brian T. Andrews Lucy S. CrainJane M. HightowerDonald C. KittJordan ShlainLily M. TanShannon Udovic-ConstantTerm: Jan 2006-Dec 2008Mei-Ling E. FongThomas H. Lee

Carolyn D. MarRodman S. RogersJohn B. SikorskiPeter W. SullivanJohn I. UmekuboTerm: Jan 2005-Dec 2007Gary L. ChanGeorge A. FourasJeffrey NewmanThomas J. PeitzJohn W. PierceDaniel M. RaybinMichael H. Siu

4San FranciSco MedicineApril 2007 www.sfms.org www.sfms.org April 2007San FranciSco Medicine54San FranciSco MedicineApril 2007 www.sfms.org

national Provider identifier: Seven Steps to implementation

OnlyfivemonthsremainuntiltheNPIcompliancedate—areyoureadytouseyourNPI?Thefollowingstepswillassistyouinyourpreparation:

1.Enumerate:Haveyouapplied foryourNPI(s)?Notonly should individualprovidershaveenumerated,butorganiza-tionsandsubpartsshouldhaveenumeratedalso.

2.Update:Haveyoureceivedyoursoft-wareapplicationupdates,upgrades,and/orchangesrelevanttoNPI?BesurethattheupdatesnotonlyaddresstheHIPAATrans-actionsbutincludetheCMS1500,UB04,and/ordentalclaimformchanges.

3.Communicate:Haveyoucommu-nicatedyourNPI(s) toyourhealthplansandtheotherorganizationsyouworkwith?AllcoveredprovidersmustsharetheirNPIwithotherproviders,healthplans,clearing-houses,andanyentitythatmayneeditforbillingpurposes.

4. Collaborate: Do you know thereadinessofyourtradingpartners(suchashealthplans,TPAs,clearinghouses,etc.)?It’s important toworkwithyour tradingpartnerstoknowtheirreadinesswithNPIandhowitimpactsyou.

5. Test: Have you started testingtheNPI,both internallyandexternally?NotonlydoyouneedtotesttheHIPAATransactions,suchas837Claims,butifyouprocess835RemittanceAdvice,besuretotestthatyoursystemcanprocesstheNPIap-propriately.Also,ifyousubmitpaperclaims,besurethatyou’vetestedthatthedataisbeingprintedinthecorrectfields.

6.Educate:HaveyoueducatedyourstaffontheNPIanditsuse?It’simportantthat staffwhomaybeusing theNPI inday-to-daywork (suchasverificationofeligibility)beawareofitandoftheprovideridentifiersthatitreplaces.

7.Implement:HaveyouimplementedtheNPIintoyourbusinesspractices?Oncetesting is complete, changeswill go intoproduction. Given all the steps above,willyoubereadybyMay23,2007?GototheNPIpageontheCMSwebsiteforall

the helps the practice thrive.$99 per session for SFMS/CMA mem-bers/$85 for secondattendee from sameoffice/$149fornonmembers

Monday,June18,2007Transitioning Your Practice—Retiring, Selling, or Buying a PracticeThis is a not-to-be-missed seminar designed for all physicians who are contemplating retirement, bringing in an associate, joining a practice as an associate, relocating, buying or selling a practice, or changing careers.6–9p.m. (5:45p.m.dinner/registration)$149 forSFMS/CMAmembers/$199 fornonmembers

Friday,October12,2007Customer Service/Front Office Telephone TechniquesThis half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently.9a.m.–12:30p.m.(8:40a.m.registration/continentalbreakfast)$99forSFMS/CMAmembers/$149fornonmembers

Friday,November9,2007“MBA” for Physicians and Office ManagersThis one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management.9a.m.–5p.m.(8:40a.m.registration/con-tinentalbreakfast)$250 forSFMS/CMAmembers/$225 for secondattendee fromsameoffice/$325fornonmembers

CorrectionsIntheDecemberissueofSan Francisco Medicine,

we rananarticlecalled“HealthSavingsAccounts:TheWaveoftheFuture”(bySteveAskin,onpage18).Inthearticle,Dr.AskinmentionsthatthemoneysavedinaHSAcanbewithdrawnafteragesixty-fivewithouttaxorpenalty.Afterfurtherinvestigation,Dr.Askinwouldliketoclarifythatthisisnotcorrect.Infact,themoneycanbewithdrawn,butitissubjecttoregularincometax.

In the January/February issueofSan Francisco Medicine, wereferredtoMarkEspinosaas“PresidentandCEO”ofTheNativeAmericanHealthCenterinthebiofollowinghisarticleonpage13.WewouldliketopointoutthathisjobtitleisactuallyExecutiveDirector.

NPI-related information, www.cms.hhs.gov/NationalProvIdentStand/.

order the 2007 california Physician’s Legal Handbook

Physicians cannoworder the2007California Physician’s Legal Handbook(CPLH). This indispensable manual ispublishedannuallybyCMA’sCenter forLegalAffairsandanswersthelegalquestionsmostfrequentlyaskedbyphysicians.Itcanbepurchasedasaseven-volume,4,500-pageprintedition,aninteractiveCD-ROM,oranonline subscription.Tofindoutmorevisitwww.cmanet.orgorcontactCMA’slegal information lineat (415)[email protected].

SFMS Supports Lawsuit on Mercury Labeling

The SFMS has again joined in anamicusbrieffiledtosupportbetterlabelingofcannedtunaregardingmercurycontentandassociatedhealthrisks.Spurredbygrow-ingresearchonthistopic—includingthatbySFMSboardmemberJaneHightower,MD—acoalitionofhealth groups seekstogiveconsumersbetter informationontherisksofconsumingmercury-ladenfish.TheSFMSdelegationtotheCMAhasalsosuccessfullybroughtpolicyonthisissuetothe CMA and AMA. For information,[email protected].

SFMS Seminar SchedulePlease contact Posi Lyon to register at [email protected] or (415) 561-0850 ex-tension 260.

Friday,May4,2007Managing Up—Masterful Management (for office managers and administrators)9–11a.m.(8:40a.m.registrationandcon-tinentalbreakfast)How to Manage Your Office Manager (for physicians)12:15–1:45p.m.(12p.m.registrationandlunch)These two seminars are designed to help physi-cians and their office managers set expectations, manage change, and design a practice culture

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www.sfms.org April 2007San FranciSco Medicine7

PreSidenT’S MeSSage

i googledthistitleandguesswhat?Igotonly72,100,000results.Iguessmorethanafewpeoplethinkthisistrue.Inthisissueof San Francisco Medicine,thearticleswilladdressvariousin-

novationsintheareaoffoodandhealth.Whilereadersmayask,“Whatcouldbelesscontroversial?”thefactisthatfoodandhealthhavebeentopicsofdebatesincelongbeforemedicine,asweknowit,existed.Ourpatientsoftenpresentuswithalonglistofquestionsregardingfoodandhealth.Theyareworriedaboutdietandcancer,heartdisease,diabetes,Alzheimer’sdisease,depression,andarthritis,justtonameafewconcerns.Buttherelationshipbetweendietandhealthcanbedividedroughlyintotwomajorcategories:preventionandtreatment.Whatdietarychangesorinnovationsarenecessarytopreventdisease?Whatdietarychangesorinnovationshavebeenshowntomodifythecourseofdisease?Asphysicians,whatareourresponsibilitiesintermsofadvisingpatientsondiet?

Wemustlisten.Patientsusuallywanttoknowhowtoproceedwithdietandnutrition;theyareeagerforouradvice.Butfirstwemustlistentotheirconcernsandideas.Thathelpsusframethediscussioninawaythatwillbeusefulforthem.

Wemustnotbetooquicktojudge.Muchoftheinformationthatourpatientsbringtouscomesfromotherpeoplewhosincerelywanttohelp.Ofcoursewecandiscountadvertisementsandpromo-tionsforthe“best”approach,andourpatientsdonotwanttospendexcessiveamountsofmoneybasedonmisleadinginformation.Butalotoftheanecdotalinformationthatourpatientsbringtoourofficesisprovidedbypeoplewhoperceivedabenefitorreadofabenefittoothers.Theyarenotbeingmaliciousorgreedy;theyarejusttryingtohelp.Sowemustbeunderstandingandpatientwithsomeoftheideasandconceptstheybringup.

Wemustbe scientific. I think this issueofSan Francisco Medicine willhelpestablishafoundationforcurrentknowledgeinseveralareas.Weknow,forexample,thatomega-3fattyacidsdonothelppreventcardiacarrhythmias,buttheydohavearoleinlipidmetabolism.Wewilllearnmoreabouttheirroleindepression,sincemanyongoingstudiesareinvestigatingthisissue.

Wemustnotbeafraidorreluctanttoreferpatientswithimpor-tantnutritionneedsorconcernstoexpertsorexpertwebsites—aslongaswehelpthemsiftthroughtheresults.Onarollwithmyresearch,Igoogled“food,dementia”andgot1,260,000results.Inow

“know,”amongotherthings,thatdementiacanbe“prevented”byeatingmoreblueberries,moredarkchocolate,morefish(butreadJaneHightower’sarticleonmercuryinfishfirst!),andbyeatinglessofeverythingelse.Thesearejustafewpointsofviewoutthereincyberspace.Iencouragepatientstobringinsuchresultsoftheirresearchformetoreview,becauseIthinkourscientificbackgroundasphysiciansaffordsus theability to renderexpertopiniononthesematerials.Ourscientificbackgroundteachesusnottoreactimmediatelytoeverynewpieceofinformationoradvice,buttoresearchthecontextoftheresultsandintegratethisinformationintowhatwealreadyknow.

Theseareallwayswecanactas individualdoctorstobestadviseourpatients.ButwealsohavearoletoplayasmembersoftheSanFranciscoMedicalSociety.TheSFMShastakenimportantpublicpositionsintheareaoffoodandnutrition.Weareonrecordasconcernedaboutchildhoodobesityand,undertheguidanceofformerSFMSPresidentDexterLouie,wehaveparticipatedinpro-gramsaddressingtheissue.Wehavesupportedeffortstogethealthyfoodsintotheschools.Wehaveopposedtheuseofantibioticsinanimalhusbandry,underthedirectionofformerSFMSPresidentGeorgeSusens.Wehavesupportedtheregulationandreportingofmercurycontentinfishproducts,undertheguidanceofSFMSExecutiveBoardMemberJaneHightower.IfyouhaveconcernsorideasabouthowSFMScanbemoreproactiveintheseorotherrelatedareas,wewouldliketohearfromyou.

Ifwearegoingtobeinnovativeinourapproachtofoodandhealth,weshouldnotjustbetalkingaboutwhatweeat,butabouthowweeat,howmuchweeat,andwhyweeatthewaywedo.Wearecommittedtoahealthycommunity.Readon,andlearn.Eathappilyandwell!

Dr. Follansbee is the 139th President of the SFMS. An infectious disease specialist, he practices with the Permanente Medical Group. He is Director of Travel Medicine as well as Director of HIV Services at Kaiser San Francisco. He has been Chief of Staff and Director of HIV Research and Treatment at Davies Medical Center, attending physician at S.F. General Hospital, Assistant Director of the Bay Area Consortium of AIDS Providers, and has served on the UCSF clinical faculty.

You Are What You Eat

Stephen Follansbee, MD

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www.sfms.org April 2007San FranciSco Medicine9

deParTMenT TiTLe HereediToriaL

AnancientAustralianaboriginalcreationstorytellsofhowmythicalpeopleatthebeginningoftimehadtosearchforfoodinperpetualdarknessofnight,becausetherewasno

sun.Oneday,atall,grey-featheredBolgastorkhurledtheyolkofanemueggintothesky,whereuponitstrucksomesticksofwoodandburstintoflames,lightingupthebeautyandabundanceoftheearth.Thereafter,Wuriupranili,theSun-Woman,carriedthistorcheasttowestacrosstheheavenseachday,returningthroughatunnelundertheearthatnight.Aftershegatheredfoodassheroseintheskyduringthemorninghours,intheheatofthedayathighnoonWuriupraniliwouldbegintocookforalatercelestialfeast.

Within thisnewdiurnal cycle, the risingof the suneachmorningawakenedTukumbini,theyellow-facedhoney-eater,whowouldthensingoutamelodiousbirdcalltorousetheaboriginessothat,liketheSun-Woman,theywouldgatherfoodinthelightofdayfortheirdinneratsunset.RecognizingTukumbiniasthegodofwisdomandinstruction,Wuriupraniliinspiredhimtoteachthepeoplehowtorecognize,gather,cook,andeathealthy,locally-grown foods thatcontainedguruwari, the sacred life-sustainingessenceoftheearth.

AsinthisissueofSan Francisco Medicinewediscussfoodandhealth—practicaland scientificnutritional ideas suchaseatinghabits, integrativenutrition,eatingdisorders,worldhealth, thebenefitsofwine,environmental foodcontaminants,andspecialdietsforheartdiseaseanddiabetesprevention—wemightpausetoreflectuponthesimple,down-to-earthdietarypracticesandteach-ingsinthemythologyoftheindigenousaborigines,at65,000yearsthelongestcontinuouslyintactlocalcultureintheworld.

Certainly,ifthereisamodern-daypersonificationofWuriu-pranili, itmightbe internationallyacclaimedchef andauthorAliceWaters, inventorofCaliforniacuisine,powerfuladvocateofsustainableagriculture,andfounderofChezPanisserestaurantinBerkeley.Formanyyears,Watersrosewiththedawn,gatheredfresh,organically-grownvegetablesandfruitsfromlocalfarmer’smarkets,spentthedaypreparingandcooking,and,tothedelightofhercustomers,servedadeliciousandimpeccablyhealthyfeastduring theeveningdinnerhours.ShewasnamedBestChef inAmericabyJamesBeardandoneofthetoptenchefsintheworldby Cuisine et Vins de France. Duringthistime,shepublishedeight

booksabouthealthynaturalfoodsandtheirpreparation.Lamentingtheubiquityofprocessedandfastfoods,herfundamentalprinciplehasbeen,“Allowfoodtobewhatitis.”

Extendingouraboriginalmyth,wemightvisualizeamodernTukumbini,onetocarryforwardthisearthbounddietaryphilosophywithwisdom,teaching,andintellectualfervor.ThatmightwellbeBerkeleyprofessorMichaelPollan,directoroftheKnightPrograminScienceandEnvironmentalJournalism,who,AliceWatershassaid,“foragesintheovergrowthofourschizophrenicfoodculture”and“isthekindofteacherweallwishwehad,onewhotriggersthelittleexplosionsofinsightthatchangethewayweeat.”Pollanhasrecentlypublishedtwobooksaboutfoodandnutrition,The Botany of DesireandThe Omnivore’s Dilemma,inwhichheelucidatesthepowerfulconnectednessofhumanbeingswiththeplantworldanddescribeshowthecurrentpoliciesandpracticesofthemodernfoodindustryimpactnegativelyupontheeatinghabits,nutrition,andhealthofAmericans.

BothAliceWatersandMichaelPollanadvocatemorebasicand intuitivewaysof eating. Inanarticleon foodandhealthpublishedinThe New York Times Magazine onJanuary28,2007,Pollandiscussestheprocessofwhathecallsnutritionism,theer-roneousbeliefthatthescientificstudyofindividualcomponents,nutrientsratherthanfood,canoffersolidconclusionsaboutwhattoeatorwhatsupplementstotake.Hesaysthatnutrition-ism,withitsinabilitytoaddressthecomplexityandwholenessofthehumanrelationshiptofood,hasledtotheoppositeofhealth—toobesity,diabetes,heartdisease,andmalnutrition.Focusinguponfood,notjustindividualnutrients,Pollanconvincinglyarguesthatwewouldbebetteroffeatingthewayourgrandparents,great-grandparents,andgreat-greatgrandparentstaughtustoeat.

Thus,bothWatersandPollanaskforareturntomoretra-ditionalwaystorecognize,gather,cook,andeathealthy,locally-grownfood.Theyacknowledgethe intimateandcomplexcon-nectionofhumanbeingstotheirplanet.Yes,overthesethousandsofyears,thesacredlife-givingessenceoftheearth,the guruwari, remainswithusinthespiritsofWuriupranili,theSun-Woman,andTukumbini,theteacher.

Mike Denney, MD, PhD

Wuriupranili and Tukumbini


innoVaTionS inFood and HeaLTH

Abstinence from Red WineIs Abstaining Hazardous to Your Health?

Arthur Klatsky, MD

IIdiabetesmellitus.Thus,fortotalmortal-ity,thecompositeisaJ-shapedcurve,withlowest riskamongdrinkerswhotake<3drinksperday,andhighestriskfromnumer-ousconditionsamongheavydrinkers.ThelowermortalityriskoflighterdrinkersisduemostlytolessCAD.

Lightdrinkershaveabout30percentlowerCADmortalityriskandanapproxi-mately10percentlowertotalmortalityrisk

(Klatsky 2003). Consistency in studies,relativespecificityofbenefitforCAD,andplausiblebiologicalmechanisms forpro-tectionbyalcoholagainstCADsupportacausalprotectiveeffect.Someearlierstudieswereunable to separateex-drinkers fromlifelongabstainersortocontrolforbaselineCADrisk.Skepticshaverepeatedlycitedthisproblemas theexplanationof spuri-ousbenefit reallydue topriormovementofhigh-riskpersonsintothenondrinkingreferencegroup(Shaper,Wannamethee,and Walker 1988) (Fillmore, Kerr, andStockwell2006).This“sickquitter”hypoth-esishasbeenrefutedbyanumberofstudies,includingKPanalyses.Studiesthatseparateex-drinkersfromlifelongabstainersorcon-trolforbaselineCADriskalsoconsistentlyshowthatdrinkershave lowerCADriskthan lifelongabstainers.Although therehavebeennorandomized,controlledtrialsofCADoutcomeevents,manyepidemiolo-

H ardlyamonthgoesbywithouttheappearanceofa researchfindingsuggestingthatdrinkingredwine

isgoodforyou.Themediapublicityisnevernuancedorsubtle,sotheheadlinesblare.Hereareseveralrecentones:“Procyanidin-richred wines reduceheartattackandmor-tality,” “Resveratrol,a red wine ingredient, improveshealthandsurvivalinmiceonahigh-fatdiet,”and“Cabernet sauvignon red winereducestheriskofAlzheimer’sdisease.”With thehintofgreater longevity,whatnonred-winedrinkerwouldn’tfeelpressuretostartaredwinehabit?Whatpersonoversixty-fiveyearsoldwouldn’tconsideralife-stylechangethatpromisedalowerchanceofAlzheimer’s?Thepublichasheardtheim-pliedmessage.A60 MinutesTVbroadcast(CBS,Nov.17,1991)attributedlowerheartattackriskinFrancepartiallytoredwine.Thisexplanationofthe“FrenchParadox”(lowcoronarydiseasedeath ratedespiterelativelyunfavorablelifestylehabits)hasbecomewidelyknown.RedwinesalesintheU.S.skyrocketedinthe1990sandremainhigh.InarecentKaiserPermanente(KP)survey,80percentofthoseinterviewedhadheardofpresumedbenefitfromalcoholandhalfofthesevolunteeredthatthiswastrueonlyofredwine(Klatskyetal2003).

Socialandmedicalharmfromheavierdrinkinghasbeenevidentformillennia,buttheconceptofasafedrinkinglimitwasalsoaccepted.Perhapsbetterthan“safe”istheword“sensible,”sincenolevelisabsolutelysafe for all persons. Modern populationcohortstudiesconfirmtheincreasedrisksofheavydrinking,definedas>3standard-sizeddrinksperday(Corraoetal2004).Thesamestudies showthat light tomoderatedrinkershavelowerrisksofcoronaryarterydisease(CAD),ischemicstroke,andtype

gistsnowfeelthatthereislittledoubtthatalcoholexerts aprotectiveeffect againstCAD(Klatsky1992)(Klatsky,Friedman,andArmstrong2003).

Plausiblebiologicalmechanisms forCAD protection by alcohol start withhigher levels of protective high-densitylipoprotein(HDL)cholesterolindrinkers(DreonandKrauss1997).Theevidencefor this effect of alcohol is compelling.SeveralanalysesindifferentcohortsshowthatHDLeffectexplainsabout50percentof the alcohol-CADbenefit.This is aneffect of alcohol,without specificity forwine.Antithromboticeffects, less specifi-callyanalcoholeffect,arealsosupportedby substantial data (Zakhari 1999).Lessestablishedmechanisms forCADbenefitof alcohol include improvedendothelialfunctionandreducedinsulinresistance.Theevidencethatmechanismsofbenefithavetodowithethylalcoholmeans thatanynonalcohol-relatedbenefitfromaspecificbeveragetype,suchasredwine,wouldbeadditionaltothatfromalcohol.

Supportforthehypothesisthatwinemaybemorebeneficialthanliquororbeerisoftwomajortypes.Thefirstconsistsofinternationalcomparisons showing lowerCADmortalityinwine-drinkingcountries(e.g.,France)thanincountrieswherebeeror distilled spirits are the preponderantalcoholicbeverages (Rimmet al 1996).Called ecological studies, these analysesrelatemeanconsumptiondatatoaggregatemortality.Sincetraitsofindividualsarenotinvolved, theseecological studiesarenotwellcontrolled forconfoundingexplana-tions.Thesecondtypeofevidence,thetypefrequentlyreceivingmediahyperbole,isthepresenceofpotentiallybeneficialnonalco-holcompoundsinwine(BooyseandParks

“Hardly a month goes by without the appearance of a research finding suggesting that drinking red wine is good for you.”


2001).Usually foundmoreconcentratedin redwine, these substances aremostlyphenoliccompoundswithantioxidantandantithromboticproperties.Sinceoxidationoflow-densitylipoprotein(LDL)cholesterolisanintegralpartofdevelopmentofathero-scleroticplaques,itfollows that anti-oxidantcompoundsinthedietrepresentan appealing hy-pothesisforbenefit.Dietsrichinnaturalantioxidants seemto be associatedwithbetterhealthoutcomes,althoughtrialsofantioxidantsupplementationhavebeendisappointing.Manyfeelthatredwinecouldbeconsideredafermentedfoodbeveragewithbeneficialantioxidantingredients.

Epidemiologicstudieswithdataaboutspecificbeveragetypesarefewerinnumberthan those that deal with total alcoholconsumption.Theydonotconsistentlyandconvincingly support specific additionalbenefitfromwine.Importantinthisregardaregood studies inbeer-drinkingpopula-tions showingapparent substantialCADprotection by that beverage (Keil et al1997).AseriesofstudiesinDenmarkshowthatwinedrinkershavelowerriskoftotalmortality,cancer,andstroke,buttheDan-ishinvestigatorspointoutthat,comparedtobeer/liquordrinkers,winedrinkershaveahealthierdrinkingamountandpattern(Gronbaek2004).TheDanishwinedrink-erssmokeless,exercisemore,eathealthierdiets,havehigher socioeconomic status,andscorehigheronintelligencetests.Itiswellknownthatinepidemiologicstudies,“healthy”traitstendtoclusterinthesameindividuals.Inobservationalstudies,theremaybe residual confoundingbyuncon-trolledorincompletelycontrolledtraits.KPstudiesshowevidenceofCADbenefitfromeachmajorbeverage type,withapparentbenefitgreatestforwine,nextforbeer,andleast for spirits (Klatsky,Armstrong,andFreidman1997).Importantly,theapparenteffectwasthesameforwhitewineasforredwine.AsinDenmark,ourCaliforniawinedrinkershadthehealthiestlifestylehabits.

Winehasbeencalled the“beverageofmoderation.”Tosomeextentthisseemstrue inDenmarkand inCalifornia,bothofwhich include substantialnumbersofpersonsthatdrinkeachbeveragetype.Yetincountriesinwhichwinedrinkingprepon-

derates,mostheavydrinkersdrink theprevalent, usuallyinexpensive bev-erage. Resultantwine-induced pa-thologies includelivercirrhosis, sys-temichypertension,cardiomyopathy,andperipheralneu-ropathy (Klatsky

2002).Organdamagefromchronicheavydrinkingisrelatedprimarilytolifetimeethylalcohol intake,not beverage choice. Intheappropriateculturalmilieu,somewinedrinkersreadilyprogresstoheavydrinking.In theU.S., for lowcost somealcoholicschoosewine.Thepejorativeterm“wino”arosebecauseaproportionofdown-and-outalcoholicsdrinkcheap fortifiedwineorjugwine.

TheacceptanceofthespecificbenefitsofredwineforCADinvolvesinterpretivestretchingof thedata.For example, thetrulyfascinatingresveratrol-longevitystoryinvolvesup-regulationofageneticsystem(thesirtuingenes)thatinfluencemetabolicprocessespromotinglongevity(Bauretal2006).Resveratrolhas thiseffectandhasshown the ability to increase longevityinseveralspecies.Extrapolationfromthedoses used in themousestudytohu-mansindicatesthata comparable hu-manresveratroldosefrom drinking redwinewouldinvolve>1,000 glasses perday,hardlyapracti-calproposition. Intheoligomericprocyanidins(OPC)report,correlationsweredonebetweenOPCcon-tentofwinesandlongevityinseveralareas,withthefindingthatbothwerehighestincertainareasofFranceandSardinia(Corderetal2006).Foundlargelyingrapeseeds,the

OPCsaresaidbytheauthorstobethewinepolyphenolswiththestrongestendothelialrelaxant effect.These analyseswerenotcontrolledforotherpotentialconfounders;intheviewofthiscommentator,thesedatadonotsuggestthatwinedrinkerswoulddowellbyswitchingtoSardinianwines.TheAlzheimer’sreportwasanothermousestudy(Wangetal2006).

Inviewofthemajorhealthproblemsofheavierdrinking, there are legitimateconcerns about anymedical advice thatencouragesdrinking.Althoughitislikelythatfewheavyimbibersdrinktoimprovetheirhealth,theconcernsarebaseduponthe fear that somepersonsmightnotbeable tohandle theknowledgeofbenefitresponsibly,andmightdeliberatelyor in-advertently indulge inheavierdrinking.Advicetopersonswhoarealreadyheavydrinkersneedsnorisk/benefitindividualiza-tion.Sincenothinginthemedicalliteraturejustifiesheavierdrinkingandincreasedriskspredominate, allheavierdrinkers shouldreduceintakeorabstain.

Theadviceproblemcanbeamelio-ratedbyindividualizationofadvicetolightdrinkersandabstainers,takingintoaccountrisk/benefitfactorssuchasage,sex,andper-sonalandfamilyhistoryofproblemdrink-ingversusriskofCAD,certaincancers,orother illnesses (Klatsky2004).Advice todrinkmustbeweighedverycarefully fornondrinkers.Abstainersusuallyhaveavalidreasonforabstinence.AlcoholdrinkingisnotatornearthetopofthelistofwaystoreduceCADrisk;itcomeswellaftersmok-ingavoidance,properdietandexercise,and

attentiontolipids,hypertension,dia-betes,andobesity.

However, thecase that lighterd r i n k i n g i n ahealthypatternhashealthbenefitshasbecome compel-ling.Thus it is as

inappropriateforpublichealthofficialstopromote general abstinenceas to advisetheentirepopulationtodrink.Mostadultsalready are established light-moderatedrinkers.Exceptforspecialreasons,anes-

“In view of the major health problems of heavier drinking, there are legitimate concerns about any medical advice that encourages drinking.”

“However, the case that lighter drinking in a healthy pattern has health benefits has become compelling.”

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The Enlightened DietAsking the Right Questions to Achieve Integrative Nutrition

Deborah Kesten, MPH

I’vebeenponderingthisquestionsincegraduate schoolwhen, in the eighties, Iworkedasthenutritionspecialistwithpio-neeringphysicianDeanOrnish,M.D.,andcolleagues,whodemonstratedthatlifestylechanges—stress management (yoga andmeditation); ano-fat-added,plant-baseddiet; group support; and exercise—mayreduceriskfactorslinkedtoheartdisease,suchashighcholesterollevels,highbloodpressure, andbeingoverweight. I beganto realize that thebiologicaland techni-calexaminationofnutrients—measuringandanalyzingcalories,fats,carbohydrates,protein,vitamins,andminerals—isjustonepartof the foodandnutrition story; thatfood isa four-partgift thatnourishesnotonlyphysicalhealthbutalsoourspiritual,emotional,andsocialwell-being.

The Missing ingredientSometimesyouhavetogobackward

before you can move forward. I got myfirstclueaboutmissing“nutrients” inourmeals inNewDelhi, India,where IhadbeeninvitedtopresentaworkshopattheFirstInternationalConferenceonLifestyleandHealth.OneofthepresenterswasK.L.Chopra,fatherandmentorofdoctorandwriterDeepakChopra.Afterhis lecture,I interviewedDr.Chopra foramagazinearticleIwasplanningtowriteaboutyogaanddiet.Whathesaidwastochangemyviewoffoodforever:“Pranaisthevitallifeforceoftheuniverse,thecosmicforce,anditgoesintoyou,intome,withfood.Whenyoucookwithlove,youtransfertheloveintothefoodanditismetabolized.Informerdays[basedontheHinduscripture,theBhagavad Gita],thetraditionwasforthemothertocookthefoodwithloveandthenfeedittothechildren;onlythenwouldsheeat.”

E ven though we count calories,watchourweight, andfigure fatgrams,Americansare the fattest

peopleintheworld.Perhapswe’veforgot-tenthatfoodismorethananamalgamofnutrients.Alongwithhealingusphysically,itenhancesemotions,satisfiesthesoul,andconnectsus toothersand to themysteryoflife.

WhenIlectureaboutoptimaleating,thequestionI’maskedmost frequently isaboutthedietdujour.Manywanttoknowwhat’sbest:Isitthezone?Eatrightforyourtype?WhatdoIthinkaboutOrnish(highcarbohydrate/lowfat)vs.Atkins(highpro-tein/highfat)?WhichdoIchoose?

The simple answer is that I don’tchoose.Rather,Ibelievewe’reaskingthewrongquestion,sowe’regettingthewronganswer—andongoingweightgain.Letmeexplain.Given thatAmericanchildren,teens,andadultsaremoreoverweightthaneverbefore(80percentofadultsoveragetwenty-fiveareeitherobeseoroverweight,upfrom58percentin1983),it’snaturalthatwhenwethinkaboutnutrition,wefocusonweightandfat,bothinfoodandourbodies.Wegoondiets,analyzeandobsessaboutfood,turntoitasanenemyorfriend,eattoomuch,eattoolittle,worryaboutit,avoidit,craveit,revereit,orbelievethataparticularnutrientwillmagicallymeltthepounds.Yetdespiteallofourconscientiousattentiontofoodandtheincredibleadvanceswe’vemadeinnutritionalscience,notonlyareourwaistlinescontinuingto increase, so, too,aremostfood-linkedailments.Fromhighbloodpressure,heartdisease,anddiabetestocancer,osteoarthritis, anddepression,excesspoundsareanever-risingthreattoourhealthandwell-being.Sowe’re leftwondering,what’sgonewrong?

Was it reallypossible to infuse foodwith lovingconsciousness?Fascinatedbythepossibility, Ibegana search throughthemajorworldreligions(suchasJudaism,Christianity,Islam,Buddhism,andHindu-ism)andculturaltraditions(suchasyogicnutrition,theJapanesechanoyu (wayoftea),NativeAmericanfoodbeliefs,andAfricanAmerican soul food) for their teachingsaboutfood.

I learned thatour spiritualancestorsrelatedtofoodasmorethanjustsustenanceforthebody.Forinstance,Judaism’sdietarylawsaredesignedtohonorthesanctityoflifethatisinbothanimal-andplant-basedfoods;Christianshonorthedivinethroughthebreadandwine(orgrapejuice)ofHolyCommunion;AfricanAmericanscelebratefood,life,andfriendshipbyspicingsoulfoodwithlove;yogiseat,inpart,tocommunewith food’s life-givingqualities;Muslimshonorfoodforitsdivineessence;Buddhistspursueenlightenmentbybringingamedita-tiveawarenesstofood;theChineseusefoodtocommunicatewithancientancestorsandgods;andtheJapaneseturntoteaceremo-niestorenewthespirit.

integrative nutrition: The Four Facets of Food

Notonlydovirtuallyallreligionsandculturaltraditionsencouragecookingwithlove,theyalsoseemtointegrateintuitivelyand instinctivelywhatmodern research-ersarebeginningtoconjecture:thatfoodempowersus tohealmultidimensionally.Inotherwords,wemayuseourincrediblehumanconsciousnessandfoodinfourways:to prevent or reverse physical ailments(biologicalnutrition);experiencethefood-moodconnection(psychologicalnutrition);reunitewiththespiritualmeaningoffood

12San FranciSco MedicineApril 2007 www.sfms.org www.sfms.org April 2007San FranciSco Medicine1�12San FranciSco MedicineApril 2007 www.sfms.org

(spiritual nutrition); and return to ourheritage(socialnutrition).Recognizingallfourfacetsoffoodallowsustopayattentiontotheconnectionsbetweenfoodandbody,foodandmind,foodandsoul,andfoodandsocialwell-being.Whenwedothis,wegainanew focus foroptimaldietary self-care,whichIdescribeasintegrativenutrition.

Thepracticeof integrativenutritionisbothnewandold. It isbasedonthreeworldviewsabout foodanddiet:Westernnutritional science,which focusesonnu-trientsandphysicalhealth;Easternheal-ingsystemsthatincludenutrition,suchastraditionalChinesemedicine,Ayurveda,andTibetanmedicine;andtimelesslifestylewisdomgleaned fromworld religionsandculturaltraditions.Ultimately,integrativenutritionisnotonlyaboutwhattoeatbutalsoabouthowtoeatforbetterhealth.Itistheessenceoftheenlighteneddiet.

Six elements of enlightened eating

Tobeenlightened,according to thedictionary, is tobe“freed fromignoranceandmisinformation.”Toenlighten is toilluminate and furnishwith spiritual in-sight.EnlightenedEatingmeans turningto science to freeourselves fromdietarymisinformationand to spiritual traditiontoinfusemealswithmeaningandlove.Togetanideaofwhatsuchacomprehensiveapproachmeans,herearethesixnutritionaltruthsof theenlighteneddiet thathavenourishedhumankindformillennia,withexamplesofstate-of-the-artsciencethatarebeginningtoverifyfood’smultidimensionalpowertoheal.

1. Unite with others through food. Food,eating,anddininghavealways

beenintimatelyinterwovenwithourrela-tionships.Intribesandclansandthroughritualsandcelebrations,connectingwithothersthroughfoodisoursociallegacy,arefugewherememoriesreside,anourishingworldwhereintraditionsendure.

Oneofthefirststudiestodemonstratethelinkbetweenasociallysupportivediningenvironmentandhealthandwell-beingwaspublishedintheJune16,1951,issueofthemedicaljournalThe Lancet.ThestudywasconductedbyBritishnutritionistElsieM.

WiddowsonjustafterWorldWarII.WhenshearrivedattwoorphanagesinGermany,shedecidedtotakeayeartostudytheef-fectsofservingsof foodonthechildren’sweightandheightgain.Whensheassessedtheresults,shelearnedthatsomechildrenthrived—regardless of whether they re-ceivedequaloradditionalfood.TheenigmawassolvedwhenWiddowsonrealizedthatastrictcaretakerchosemealtimetoadmin-isterpublicrebukesandtoridiculecertainchildren.Thosewhoweredisciplineddur-ingmealtimegainedtheleastweightandstature, regardlessof their caloric intake.Theimplication:Dininginapleasant,sup-portiveatmospheremayimprovephysicalandemotionalwell-being.

2. Be aware of feelings before, during, and after eating.

Byusingtheirownmindsandbodiesaslaboratoriesthousandsofyearsago,ancientyogis(calledrishis)createdafoodphiloso-phy(annayoga)withfeelingsatitscore.Inessence,theylearnedthatparticularfoodshadsattvic,orcalming,qualitiesthatwerebelievedtoenhancedeepmeditationandencouragemind-bodyequilibrium.

Inthe1970s,MassachusettsInstituteofTechnology(MIT)researcherJudithWurt-man,Ph.D., confirmed inherhigh-techlaboratorywhatancientrishishaddiscov-eredcenturiesbefore:Carbohydrate-dense,plant-basedfoods(fruits,vegetables,grains,etc.)doindeedcalmandrelaxthemind-body.Whatisthemechanism?Whenyouconsumecarbohydrate-dense foods (suchaspotatoesandrice),thehormoneinsulinisreleasedinthepancreas.Inturn,aminoacids from thebloodstreamareabsorbedintothebody—allexceptone:tryptophan;instead,itfloodsthebrain,whereitiscon-vertedintosoothingserotonin,anaturallyoccurringhormonethatpromotesafeelingofcalmandrelaxation,whichmakesmedi-tatingeasier.

3. Bring moment-to-moment nonjudgmen-tal awareness to each aspect of the meal.

“Contemplating our food for a fewsecondsbeforeeating,andeatinginmind-fulness,canbringusmuchhappiness,”writesBuddhistThichNhatHanh inPeace Is Every Step.Indeed,itmayalsomakeadif-

ferencetohealthandwell-being.WhenMeyerFriedman,M.D.—there-

searcherwhogaveustheterm“TypeAper-sonality”—andcolleaguesfedasuper-highfatsnacktobothtime-urgent,angry,hostileTypeAsandmoremindful,mellowTypeBs,andthenmagnifiedphotographsofthetinyvesselsinthewhitesoftheparticipants’eyes,theycouldactuallyseethecapillariesofTypeAsbecomingclogged,aphenom-enonthatDr.Friedmancalled“sludging.”TheTypeBs’capillariesremainedrelativelyclear.Suchresultssuggestthatifyouhappentoconsumehigh-fatfoodsbutyoudosoinacalm,relaxed,presentframeofmind,you’relesslikelytoclogyourvessels,andyourriskofheartdiseasemaybelower.

4. Be grateful for food and its origins—from the heart.

Tohavesuchanattitudeofgratitude,tobe trulygrateful for the life thatbothplant-andanimal-basedfoodsgavesothatyoumay thrive,mayenhancebothyourhealthandyourappetite.

Groundbreakingresearchbymyhus-band,LarryScherwitz,Ph.D., publishedinPsychosomatic Medicine, suggestsa linkbetweenexcessiveself-involvement(mea-suredbythefrequentuseofpronounsI, me, my, andmine)andincreasedthreatofheartdisease.Theantidote:“Eachtimeyoueat,focusonthefoodandmealinsteadofonyourself,”saysScherwitz.“Itmaymakeyoulesspronetoheartdisease.”

5. Unite with the divine by flavoring food with love.

Whether it’s Communion or soulfood,virtuallyeveryreligiousandculturaltraditionhasacorebeliefthatfoodcanbetransformedbylove.

Themessagethatfoodcouldbespiri-tuallyimbuedwasbroughthometomebyLeonardLaskow,M.D.,authorofHealing with Love.Dr.Laskow’smethodof infus-ing liquids and foodwith loving energyconsistedoffoursteps,whichhedescribesas: intentionality,heart focus, letting inthe light, and food infusion. After the“infusion,”people can smell and taste adifferenceinthe“loved”versus“unloved”nourishment.Hundredsofstudiesontheex-

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f ew topics in medical practicereceivemoreattentioninthelaymedia thannutrition.Eachweek

bringsnewinformationabouttheadvan-tages anddisadvantagesof specificdiets,foods,andnutrients.Patientsareconfusedandphysiciansareillpreparedtoprovidedefinitiveanswers.

Atthesametime,patientsandphysi-ciansarefullyawarethatwhatweeathasamajorimpactonourriskofdevelopingalonglistofchronicillnesses.Andasphysi-cians,allofusshouldbeawarethatchangesindietprovideapowerfulpotentialtoolformanagementofthesesameillnesses.

Thequestionis,whatlevelofevidenceisneededinordertoprovidepatientswithsensiblenutritionadvice?Thecomplexityofnutritionalsciencehasmadeitdifficulttodesignandimplementdefinitiverandom-izedtrials.Ontheotherhand,observationalstudieshaveoftenprovidedmisleadingin-formation.Weareforcedtounderstandthestrengthsandweaknessesoftheevidencethatwehaveandcombineitwithahealthydoseofbiologiccommonsense.

Whatdoweknow?Mostconvincingly,weknowthatweeattoomanycalories.TheincreaseinoverweightandobesityintheUnitedStatesandagrowinglistofotherna-tionsclearlyprovidesnoidentifiablehealthbenefit (with theexceptionof increasedbonemineraldensity).Infact,theUnitedStatesispoisedtoreversebeneficialhealthtrendsforthefirsttimeinhistory.Debat-ingtheidealbodymassindexforoptimalhealth,theexactimpactofobesityonmor-tality,andwhetherobesityisagreaterthreattohealththantobaccoarealldistractionsfromthebasicpoint:There isnohealthadvantagetobeingobese.

We know that we are not active

enough.Alllinesofevidencesupporttheconcept thatdecreasedphysical activityisassociatedwithweightgainandthatin-creasedphysicalfitness(atanybodyweight)improveshealthoutcomes.

Weknowthatwedonoteatenoughplantfoods.Vegetablesandfruitsshouldbethebackboneofeverydiet.Currentdietaryguidelines recommendnine servingsperday foradultswho require2,000caloriesperday.

Finally,weknowthatweeatwaytoomuchoutofbags,boxes,andcans.High-calorie snack foods, convenience foods,andbeveragesaredirectlyrelatedtoourin-creasedweightandtoourreducedvegetableandfruitconsumption.

AsMarionNestlewrites inWhat to Eat (NorthPointPress2006), thebasicprinciplesof agooddiet canbe summa-rizedinfifteenwords:eatless,movemore,eatlotsoffruitsandvegetables,goeasyonjunkfoods.

Manipulating MacronutrientsAsubstantialamountofrecentnutri-

tionalsciencehasbeendevotedtodefiningthe optimal balance of macronutrients

(fat, carbohydrates, andprotein) in thediet.Effortsover the last severaldecadestodemonstrate substantialhealthadvan-tagesof a low-fatdiethavebeen largelynegative.Reducing fatwithout reducingtotal calorieshas littledirect impactonhealthoutcomes.Forexample,therecentWomen’sHealthInitiativeclinicaltrialoflow-fatdiets showedno improvement inweight,breast cancer, coloncancer, anyandallothercancers,cardiovasculardisease,oranyandallcausesofdeath.Similarly,studiesevaluatingcarbohydraterestriction,particularlyforweightloss,havealsoshowednoclearadvantagesovermoretraditional“balanced”diets.

Morerecentstudieshave focusedonMediterranean-stylediets,emphasizingtheroleof “good fatsandgoodcarbs” ratherthanarestrictionofeither.Theevidencesupportingthisapproachisasstrongasany.Thebottom line,however, is this:Totalcaloriestrumpmacronutrientcomposition.Formost clinical circumstances, e.g., forhealthpromotion,diseaseprevention,andtreatmentofmostchronicillnesses,calorierestriction(withaconcurrent increase inphysicalfitness)willhavegreater impactonhealthoutcomesthanchangesinmac-ronutrientcomposition.

Supplementing MicronutrientsFew areas of nutrition have been

subject tomore study, including a largenumber of excellent randomized trials,thanmicronutrient(vitaminandmineral)supplementation. Observational studieshave longsuggestedthat individualswhoconsumegreateramountsofavarietyofvi-taminsandminerals(particularlythosewithantioxidantactivityandthoseinvolvedinhomocysteinemetabolism)had improved

Providing Effective Nutrition AdviceIntegrating Evidence-Based Medicine, Common Sense, and Social Activism

Robert Baron, MD

“Each week brings new information about the advantages and disadvantages of specific diets, foods, and nutrients. Patients are confused and physicians are ill prepared to provide definitive answers.”


OBESiTY: A CHEMiCAl COnnECTiOn? Steve Heilig, MPH, and John Peterson Myers, PhD

healthoutcomes.Dozensof randomizedtrials,however,haveconvincinglydem-onstrated theopposite. For example,noimprovementinclinicaloutcomescanbeidentifiedfromsupplementationwithanti-oxidantsupplementsorwithavarietyofB-vitaminsupplements.Thisliteratureshouldprovide futurecaution for thosedrawingprematureconclusionsfromobservationalstudiesofdietandnutrition.

Whathasbeenestablishedisthatvita-minandmineralsupplementscanpreventvitaminandmineraldeficiencies.Patientswith inadequate vitamin and mineralintakes should take simplemultivitaminand mineral supplements. For example,individualswithinadequatedietary folateintakeneedfolatesupplementationduringtheir reproductiveyears.Similarly, thosewithinadequatedietarycalciumintakewilllikelybenefitfromcalciumsupplementsdur-ingtimesofbonedevelopment.Providinglevelsofmicronutrientsgreaterthanthoseneededforadequacyisnotonlyunproventobeeffective,butinmanycasesisproventobeineffective.

Making dietary and Physical activity changes

Unfortunately,knowingwhattorec-ommendtopatientsisonlyoneaspectofthebattleforgoodnutritionandphysical

fitness.Powerfulcommercialinfluencesinboththefoodindustryandthoseindustriesthateffectphysicalactivitymakeadheringtorecommendedbehaviorsextremelydif-ficult.Patientsmustmakesubstantialeffortsjusttomaintaintheircurrentweightandleveloffitness.Makingchangesthatleadtoweight reductionand improvedfitnessrequirenear-heroicmeasures.

Randomized trials,however,demon-stratethatbotheatingandexercisebehaviorcanbechanged.Althoughthemeanimpactisoftenmodest,approximatelyone-quarterofpatientsdemonstratemore significantchanges.TheNationalWeightControlRegistrysuggeststhatsuchchangescanbemaintainedforthelongterm.Patientswhoareabletoloseweightandkeepitoffcon-tinuetoeatlow-caloriediets(approximately1,400caloriesperday),exercisemoderatelyforapproximatelyonehourperday,andmonitortheirweightregularly.

Physicians must become skilled inteachingbehavior-change techniques topatientswhoare ready tomakechanges.Usefulskillsincludegoal-setting,self-moni-toring,stimuluscontrol,andcognitiveskills.Workingcloselywithdieticians,psycholo-gists,andotherskilledprofessionals ises-sential.Studiesthathavemostconvincinglyachievedbehaviorchange,suchastheDia-betesPreventionProgram,haveusedvery

intensiveinterventionsincludingmultiplevisitswithnonphysicianproviders.

Butphysicianswill alsoneed tobe-come activists to change our food andexerciseenvironment.Radicalchangesinhow food isproduced, transported, sold,andpurchased,andhowourtimeisspentintransportationandatschool,work,andleisureactivitieswillbenecessarytoachievethenutritionandphysicalactivityoutcomesthatwedesire.

Robert B. Baron, MD, MS, is a Professor of Medicine, Associate Dean for Graduate and Continuing Medical Education, and Vice Divi-sion Chief of the Division of General Internal Medicine at the University of California, San Francisco (UCSF). A practicing internist for more than twenty years, he has been recognized as one of “America’s Top Doctors” and as one of the “Outstanding Primary Care Physicians in the U.S.” In addition to his practice in primary care, he maintains a special interest in nutri-

tion and manage-ment of obesity. He founded and continues to di-rect the UCSF Weight Manage-ment Program.

Oneofthemoreinterestingdevelop-inglinesofresearchintheetiologyoftheobesityanddiabetesepidemicsfocusesonthepossibleroleofindustrialchemicals—pollutants—on metabolism, endocrinefunction,andconditionssuchasdiabetes.Thislineofinquiryhasacceleratedinjustthepastfewyears,withagrowingliteratureindicatingthatsomeofthechemicalswidelyfoundinhumanbodiescandisruptnormaldevelopmentandfunction.Thechemicalsinquestionenterourbodiesviafood,water,air,andinutero.Bothanimalandhumanstudies are finding some striking leadswhenlookingatchemicalswidelypresentinourbodiesatconcentrationssimilartothose studied.Most recent among theseare a rodent study that found that fetal

exposure todiethylstilbestrol (DES)canleadtogrotesqueobesityinadultmice.Inhumans, studiesof pesticide compoundsandPCBsindicatedalinkwithincreasedinsulin resistance, aswell as interactingwithexistingobesitytoincreasetheriskoftypeIIdiabetes.AlinkbetweenPCBsandconfirmeddiagnoseddiabeteswasfoundinwomeninanotherrecentstudy.

Mostrecently,inMarchastudyfoundalinkbetweenphthalates,aclassofchemicalsoftenfoundinplasticsandothercommonproducts,andobesityanddiabetesinmen.Spurred by the widely observed severedeclines in spermcountand testosteronelevelsalsolinkedtothesechemicals—theresearchers hypothesize that phthalatesare likely just apartof themutifactorial

picture,which includes thewidelyknownissuesofdiet,lackofexercise,foodindustrypractices,socioeconomicstatus,andsoon.They tested their prediction using datafromtheCDCand found thepredictionconfirmedbystatisticalanalysis.Thisonestudywithhumansleavesmuchtobedone,buttheirfindingsarealsoconsistentwithagrowingconsensusandpredictionsgoingbackwelloveradecadethatsomewidelyused and present chemicals can act asendocrinedisruptersviaotherpathwaysatconcentrationsfarbelowearliersuspected,and that widely accepted standards ofrisk assessment and regulation do notaddresssuchfactors.Formoreinformationseewww.ourstolenfuture.org and www.healthandenvironment.org.



A Restaurateur’s Vision Bears FruitExcerpts from an Interview with Alice Waters

Dave Weich

Well, for quite awhile. i appreciate it a lot more looking back. i know so many families now that don’t cook, that might only sit at the table together on holidays or special occasions.

Waters: I’m sortof shockedby that.Mywholepurposenowistotrytoeducatepeo-pleabouttherelationshipoffoodtocultureandfoodtoagriculture.Wereallyneedto

beengagedinthatprocessandbringourchildrenintothewholeexperience.It’saroundthetableandinthepreparationoffoodthatwelearnaboutourselvesandabouttheworld.

Right now in thiscountrywe’rebeingedu-catedby fast-foodvalues.Unconsciously or con-sciously,that’swhat’shap-pening,andthey’regivingaverystrongmessage:thatitdoesn’tmatterwhetherwe eat hamburgers andhotdogseverydayoftheweek; it doesn’t matter

whetheryousitatthetablebyyourself,orifyoueatinthecarandjustthrowthestuffinthegarbage.Foodshouldbecheapand labor shouldbecheapandeverythingshouldbethesamenomatterwhereyougo;whether it’saMcDonald’sinGermanyoroneinCalifornia,itshouldbethesame.Andthismessageisdestroyingculturesaroundtheworld.Needlesstosay,agriculturegoeswithit.

Weneedtocometosomeconscious-nessaboutfood,andrightaway.

buythemfromlocal,organicsuppliers.It’salsoapointofview.I’mtryingtobringyouaroundthetabletoeatwithyourfriends.That’showIthinkofeating.

Growing up in new Jersey, your family had a garden, right? Did you sit around the table together to eat? What were meals like in your home?

Waters:At that time, in thefifties, youhadtositatthetable;thatwasjustpartofgrowingup.Ididn’tknowanyfamiliesthatdidn’tgatheratthetable.Andevenifthefoodwasnotbrilliant,itwasnutritious,andwehadthatexchangegoingon.

My mother was a great cook, but what she’s known for is the duration of her meals.

Waters:Youmeanyouhad tobe thereseveralhours?

i n2001,thirtyyearsafteritsfoundingbyAliceWaters,ChezPanissewasnamedthebestrestaurantinAmericabyGour-

met magazine.Theprecociousupstarts inBerkeleyhavecertainlycomealongway.Onopeningnightin1971,thestaffoftherestaurant thatwould changeAmericancuisineboastedanearlycomplete lackofindustryexperience.

No single factorcanexplain the re-markablesuccessofChezPanisse,butnearthetopof any listwouldbe thestaff’s early recognitionthat thebest foodcomesfromthefreshest,highest-quality local ingredients.Ifthatseemslikeanobvi-ous statement in 2007,American foodies haveWaterstothank.AsRussParsonsnoted intheLos Angeles Times, “There isprobablynorestauranteurinAmericawhohasdonemoreforthefarmer’smar-ketmovementthanAliceWaters.”

The followingare ex-cerpts froman interviewwithAliceWa-ters.

Dave Weich: Your books aren’t entirely about how to prepare food. They’re also about where to find it, how to know when it’s ripe, and so forth.

Alice Waters:That’swhat’sreallyimpor-tant: thatpeopleknowwhat’s in season,whatitlookslikewhenit’sripe,whatthedifferentvarietiesareandwhattheyeachtastelike,andthereasonthatweneedto


Eating with the fullest pleasure—plea-sure, that is, that does not depend on ignorance—is perhaps the most profound enactment of our connection with the world.

Waters:It’sfantastic.

Still, there’s quite a movement toward organic agriculture and local ingredients right now. it’s not just you screaming out in the wilderness.

Waters:Thereisabigmovement,butbigcomparedtobig—it’sverysmallwhenyou’retalkingaboutoneortwopercentoffoodthatisorganicallygrown.It’sahugeincrease,butit’snothingincomparisontofastfood.

i worked for about twelve years in restaurants, but i never understood how delicious a tomato could be until i went to a tasting at a farmer’s market.

Waters:Iwentyesterdaytoonedowntown.WhenIfindsomethingsthatI’venotseenbefore,I’malwayskindofthrilled.Ifoundthisredgarlic,avarietyofgarlicthatIhadn’tseen. I’magarlicprofessional, youcouldsay,butIhadn’tseenthisbeautifulvarietywithlittlemaroon...almoststripesgoingaround.Splendid.IhavetwoheadsthatIboughtandI’mtakinghome.Thatwasathrillforme.

And I loved the woman who hadsalads.Shehad thisblack,woodenbowlwhereallthegreensweremixedjustlikeit

wouldcometoyourtable—whatawonder-fulpresentation!Imetaguy,Ken,whohasanartisanbreadcompany;he’sdoingallofhisbreadwithorganicflour.Iwasimpressedwiththat.IalsometElizabethMontesofSahagún,whohadsuchbeautifulhandmadechocolates.

Iwasdelighted that therewas thatkindofsophisticationandlifeaboutthings.Therewerehundredsofpeoplethere.That’swhatmarketsneed;theyneedalotofbuyerstoencouragethefarmerstocomein.

Elsewhere you’ve spoken about organic produce in major supermarkets; it’s great to have organic food out there, basically, but yet if it’s not being handled correctly or if it’s not fresh, it’s only giving people the wrong ideas about organic farming.

Waters: It’swonderful that youcangetsomeof the fruits,particularly,but Ifindthatalotofthemaren’tlocal.It’snotgrownforshelflife.Ifit’sperishableatall,it’sim-mediatelydamaged.Theberries,evensaladgreens...theyjustcan’tbekeptlikethat.Andyou’repayingmoreforthembecauseyou’repayingthemiddleman.

Talk about the Edible Schoolyard project.

Waters:It’saprojectinaschoolinBerke-ley—MartinLutherKingJr.MiddleSchool,withaboutathousandkids.Andit’sanideaforacurriculumthatcouldbeputineveryschoolinthiscountry, frompreschoolall

thewaythroughcollege.Thepurposeistoengagekidsinthegrowing,thecooking,andtheeatingoftheirschoollunchesasawayofteachingthemveryimportantvalues.Ifwedon’tlearntobecomestewardsoftheland,ifwedon’tunderstandwhereourfoodcomesfrom,we’reheadedforenvironmentaldisaster.

i feel that i had a very good public school education, but never during those years was i offered the opportunity to learn about gardening or the cultivation of food. That seems so strange in hindsight.

Waters:Doesn’tit?Maybeitwasthoughtthatyoulearnedthatathome.It’sjustnotpartofbiologyandnutrition,whichareconsideredseriousthings.Butthisotherstuffisnotserious.It’sthoughtnottobeessential,butit’sfundamentaltoourlives.

Fundamental to our lives?

Waters:Yes.Weeateveryday,andifwedoitinawaythatdoesn’trecognizevalue,it’scontributingtothedestructionofourcultureandofagriculture.Butifit’sdonewithfocusandcare,itcanbeawonderfulthing.Itchangesthequalityofyourlife.

Editor’s Note: This interview was re-printed with permission from Powells.com, an independent Internet seller of used, new, and out-of-print books. It can be found, in its full length, at www.powells.com.

tablishedlight-moderatedrinkerataverageorgreater thanaverageCADrisk shouldnotbe advised to abstain.Studieshaveshownthatthisappliestothosewithandwithoutpre-existentCAD,hypertension,anddiabetes.Mostmedication-alcoholin-teractionsaredocumentedonlywithheavyalcoholintake;thisshouldnotbetooreadilygeneralizedtoaprohibitionofallalcoholforthesepatients.

Butwhatabouttheissueofabstinencefromredwine in the titleof thisarticle?Theshortansweristhatthequestionofad-ditionalbenefitfromnonalcoholingredients

isunresolved.Redwine isobviouslyfineforthelight-moderatedrinkerwhoprefersit,butthescientificknowledgeoffersinsuf-ficientbasisforurgingthemanorwomanwhoprefers anotherbeverage to switch.MostoftheCADbenefitderivesfromethylalcohol.Ifsmallamountsaretakenintheoptimalpattern, slowlyandwith food, itislikelythatbeer,liquor,whitewine,andredwinewouldhavefairlysimilarbenefit.Mostmoderatedrinkersaremoreinterestedinthesensorypleasuresandrelaxingeffectthan inhealthbenefit.Onehopes thatthenumberofpeoplewhodrinkredwine

whentheywouldprefersomethingelseisnottoolarge.

Arthur L. Klatsky, MD, is a Senior Con-sultant in Cardiology and Adjunct Investigator for the Division of Research at Kaiser Perma-nente in Oakland. This article was reprinted with permission from The Permanente Press. It originally appeared in ThePermanenteJournal2007 spring, 11(2):86-8, ©2007 The Permanente Press. A full list of references is available on our website, www.sfms.org.

Red Wine Continued from Page 11...

www.sfms.org April 2007 San FranciSco Medicine19


Escape from Nutrition-ismMichael Pollan’s Rules of Thumb for Healthy Eating

Mike Denney

i nperhaps themost compelling, elo-quent, andcomprehensivearticleonfoodandhealtheverwritten,which

appearedinThe New York Times MagazineonJanuary28,2007,MichaelPollan,authorofThe Botany of DesireandThe Omnivore’s Dilemma,takesonthegovernment,thefoodindustry,andagriculture,allofwhichhavecontributed towhathecallsnutritionism, thedistortionofcommonsense,taste,andtraditionbyturningoureatinghabitsintoapseudoscience.Pollanskewerstheconceptofprocessedfoodswithsuchperspicaciouscomments as, “It’s a lot easier to slap ahealthclaimonaboxofsugarycerealthanonacarrot”and“Ahealthclaimonafoodproduct isagood indication that it’snotreallyfood”and“MedicineislearninghowtokeepalivethepeoplewhomtheWesterndietismakingsick.”

Pollanbeginshisarticle,entitledUn-happy Meals,with the simple statements:“Eatfood.Nottoomuch.Mostlyplants.”This,he says “is,moreor less, the shortanswertothesupposedlyincrediblycom-plicatedandconfusingquestionofwhatwehumansshouldeatinordertobemaximallyhealthy.”Afterconvincinglycontradictingthebasicassumptionsofthereductivesci-enceofnutrients,Pollanoffersguidelinesonhowwemightescapethedeleteriouseffectsofthemoderndiet.Hesays,“Trythesefew(flagrantlyunscientific) rules of thumb,collected in thecourseofmynutritional

odyssey,andseeiftheydon’tatleastpointusintherightdirection.”

1.EatFood.Though inourcurrentstateofconfusion,thisismucheasiersaidthandone.So,trythis:Don’t eat anything your great-great-grandmother wouldn’t recog-nize as food.

2.Avoideventhosefoodproductsthatcomebearinghealthclaims.They’reapttobeheavilyprocessed, and theclaimsareoftendubiousatbest.

3.Especiallyavoidfoodproductscon-tainingingredientsthatarea)unfamiliar,b)unpronounceable,c)morethanfiveinnumber—or that contain high-fructosecornsyrup.

4.Getoutofthesupermarketwheneverpossible.Youwon’tfindanyhigh-fructosecornsyrupatthefarmer’smarket;youalsowon’tfindfoodharvestedlongagoandfaraway.Whatyouwillfindarefreshwholefoods picked at the peak of nutritionalquality.Preciselythekindoffoodyourgreat-great-grandmotherwouldhaverecognizedasfood.

5.Paymore,eat less.TheAmericanfood systemhas foracenturydevoted itsenergiesandpoliciestoincreasingquantityandreducingprice,nottoimprovingqual-ity.There’snoescapingthefactthatbetterfood—measured by taste or nutritionalquality (whichoftencorrespond)—costsmore,becauseithasbeengrownorraisedlessintensivelyandwithmorecare.

6.Eatmostlyplants,especiallyleaves.Scientistmaydisagreeonwhat’s sogoodabout plants—the antioxidants? Fiber?Omega-3s?—buttheydoagreethatthey’reprobablyreallygoodforyouandcertainlycan’thurt.Also,byeatingaplant-baseddiet,you’llbeconsumingfarfewercalories.

7.Eatmore like theFrench.Or theJapanese.Or theItalians.Or theGreeks.Confoundingfactorsaside,peoplewhoeataccordingtotherulesofatraditionalfoodculturearegenerallyhealthierthanweare.Any traditionaldietwilldo: If itweren’tahealthydiet, thepeoplewho follow itwouldn’tstillbearound.

8.Cook.Andifyoucan,plantagarden.Totakepartintheintricateandendlesslyinterestingprocessesofproviding foroursustenanceisthesurestwaytoescapethecultureoffastfoodandthevaluesimplicitinit:thatfoodshouldbecheapandeasy;thatfoodisfuelandnotcommunion.

9.Eat likeanomnivore.Try toaddnewspecies,notjustnewfoods,toyourdiet.Thegreaterthediversityofspeciesyoueat,themore likelyyouare tocoverallyournutritionalbases.

The full text of Michael Pollan’s exten-sive article can be found at www.nytimes.com/2007/01/28/magazine/28nutritionism.t.html.



Nutrition and Food ProductionWhat Role Should the Medical Profession Play?

Ted Schettler, MD, MPH

nutritional Quality of FoodDespite significant advances in the

nutritional sciences,manypeopledonoteat a healthy diet. The composition offoodandthenatureoftheAmericandietareinlargepartaresultoffoodproduction,distribution,andmarketinginterests,whichareoverwhelminglybasedonproductsforlargecommoditymarkets.Highlyprocessedfoodthat iscalorie richandnutritionallypoor is promoted, especially to children(Nestle2006).

Manyfoodanalystsandhealthprofes-sionalsnotewithconcerntheprevalenceof obesity, diabetes,heart disease, food-borneillnesses, somekindsofcancerandbirthdefects,dementia,andotherhealthconditionsthatarelinkedtowhatweeataswellasthefoodproductionanddistribu-tionsystemmoregenerally.Thesediseasescausesuffering,areincreasinglyexpensivetotreat,andareobvioustargetsforpreventivemeasures.

Confinedanimalfeedlotsarejustoneexampleoftherelationshipbetweenfoodproduction systems and nutrition. Beefcattlethatare largelyraisedoncorninafeedlot and routinely treatedwith anti-biotics and hormones reach marketablesizemorequickly thanpasturedanimals.Butthefatcompositionofthemeatofthecorn-fedanimalscontainsamuchhigherratioof omega-6 toomega-3 fatty acidsthangrass-fedcounterparts(Wood1999).Industrial poultry production has had asimilarimpactonchicken.Today’stypicaldiet in theU.S.hasa farhigher ratioofomega-6s:omega-3sthanfiftytoahundredyearsago,directlycontributingtocancer,heartdisease, arthritis,obesity, cognitivedecline,and, inall likelihood,numerousotherdiseases(Allport2006).

smallproducers fordifferentiatedmarkets(Kirschenmann2005).

Increasingconcentrationofpeopleinlargeurbancentershas ledtoredesignoffoodproductionsystemsanddevelopmentofcomplextransportationsystemstobringfoodtolocalmarkets.Today,foodtypicallytravels1,500milesfromfarmtofork,a25percent increase since1980.Timedelays

duetotransportoverlongdistancesincreaseopportunitiesforcontaminationandlossofnutrients.Theentiresystemisincreasinglydependentonfossilfuelsfortransportation,mechanizedfarmingofcropsandlivestock,andpetrochemicalpesticides.

Many foodproducts aredesigned tomeet theneedsof today’s industrialagri-culturalsystem,withefficiency,durability,andmarketabilityasdrivers.Consequently,thenutritionalqualityoffoodoftensuffers,while the enormous environmental andsocial impactsofhow it is producedarelargelyacceptedasthecostofdoingbusi-nessinthisway.

f ewtopicsareas fundamentalandcrosscuttingas food.Meeting thebasicneed fornourishment is of

greatinteresttoaverylarge,diversewebofpeople,organizations,andinstitutions.Theybringtheperspectivesoffarming,nutrition,publichealth,spirituality,clinicalmedicine,economics,labor,ecosystemhealth,familyandcommunity,immigrationpolicy,justice,landuse,national security,pleasure, andconvenience.Thisisalookfromtheper-spectiveofthehealthcaresystem.Weknowthatwhatweeatisamajordeterminantofdeathanddisease.Thehealthcaresectorhasanobviousinterestandresponsibility.Itcouldbeamongtheleadersinpromotinghealthyfoodandhealthyagriculture.

Thequalityofnutritionandthecon-taminants in foodaffectconsumersmostdirectly,buttheentireagriculturalsystemhas numerous indirect impacts as well.Dominant formsof agriculturalpracticesareoftenenormouslydestructive,causingsoil erosion; desertification; salinization;soil,water,andairpollution;habitatloss;diminishedbiodiversityand soil fertility;geneticcontamination;andsocialandeco-nomicdisruption.Theseareveryrealpublichealth concerns in the dynamic, richlyinterconnected,wholebioticcommunitieswherepeoplelive.

Food Production and distribution in the U.S.

In recentdecades in theU.S.,withsome geographical variations, food ag-riculturehas seendecliningnumbers ofmidsized farms; increasingconcentrationof large, industrial, vertically-integratedagricultural systems producing for largecommoditymarkets (e.g.,corn, soybeans,sugar, pork, beef); and some increase in

“What we eat is a major determinant of death and disease. The health care sector has an obvious interest and responsibility and it could be among the leaders in promoting healthy food and healthy agriculture.”


standingalsoplacesmedicalethicswithinanexpandedframeworkofbioethics.Anyviable systemofethicsmustpreserve theecosystems fromwhich itarisesand thatsustainit(Elliott1997,Pierce2004).Thatis,therulesofethicsmustconformtotherulesofnature.Bioethicsandmedicalethicsneedtoseekamoreunifiedecologicalmoralframework.Thehealthcare systemhasaparticular responsibility toaddress today’secological realitiesbecauseof itsmission,itsopportunities,andthesizeofitsecologi-calfootprint.Areformulatedbioethicandmedicalethicwillseebeneficence,nonmal-feasance,andjusticenotonlythroughtheeyesofthepatientandhealthcareprovider,butalsofromtheperspectiveoftheentirecommunityandthenaturalenvironment.

Proposed goals for Health care institutions•Adopt foodprocurementpolicies thatprovide nutritionally improved food forpatients, staff, visitors, and the generalpublic.•Adopt foodprocurementpolicies thatsupport foodproduction systems thatareecologically sound, economicallyviable,sociallyresponsible,andmorallyfeasible.•Adopt foodprocurementpolicies thatreflectanecologicalunderstandingofthedependenceofhumanhealthonhealthyecosystemsandthathelppromotesustain-ableagriculturalpractices.

expected Benefits for Health care institutions •Healthpromotionanddiseasereduction•Reduceduseofnontherapeuticantibioticsin foodproductionwithdecreasedriskofantibiotic-resistantorganisms•Reducedpesticideuse;reducedpesticideexposures to farmworkers, communities,consumers,andwildlife• Reduced ecological impacts of foodproduction•Improvedsocialandeconomicconditionsinfood-producingcommunities•Improvedhospital-communityrelations

Ted Schettler, MD, MPH, is the science director of the Science and Environmental Health Network. A full list of references is available on our website, www.sfms.org.

thathormonesarepresentinsurfacewatersatconcentrationsthataresufficienttoalterfishreproductionanddevelopment(Soto2004, Orlando 2004). Organic arsenic,usedas a growthpromoter in swineandchickenproduction,notonlycontaminatesthemeatwitharsenicatlevelsofconcern(Lasky2004)but also isdischarged intothe environment when animal manureis spreadonto the land.Once in soilorsediments,organicarsenicisconvertedtoitsmore toxic inorganic form,making itwater-solubleandallowingittoseepintosurfaceandgroundwaterultimatelyusedfordrinking(Gabarino2003).Becauseofadenseconcentrationofanimalsinarela-tivelysmallspace,CAFOsarealsoasourceofnoxiousairborneemissionsfrommanurelagoonsthatmakepeoplesick.

Pesticide runoff and air emissionsfromagriculturaloperationscontaminatewaterways, rainwater, and air (USGS1999).Drinkingwater in theMidwest iscontaminatedwithatrazineduringseasonsofherbicideuse(U.S.EPA),andairmoni-toring inCalifornia shows thatpesticidedriftfromsprayingoperationsexposesfarmcommunities to unsafe levels (PesticideActionNetwork,2006).Wildlifestudiesinthefieldandinthelaboratoryshowadverseimpactsatcurrentlevelsofexposure.

a role for the Health care System

Hospitalsandhealthcaresystemscanplayan important leadership role inad-dressingeachoftheseconcerns.Hospitalsroutinely feedpatients, staff,visitors,andthegeneralpublic,affordingaperfectop-portunitytodirectlyinfluencehealthanddiseaseriskaswellastomodeldietarypat-ternstoothers.Thisisreminiscentoftheimportantrolethathospitalsplayedinthe1980swith the adoptionofno-smokingpoliciesasademonstrationofanimportantpublichealth intervention.By adoptingfoodprocurementpoliciesthatshowanun-derstandingthatthequalityofnutritionandfoodproductionsystemsmatter,healthcareinstitutionsalsorecognizetheinextricablelinksbetweenindividual,public,andeco-systemhealth,orwhatmightbecollectivelycalled“ecologicalhealth.”

Anethicaldimension to thisunder-

antibiotic UseIndustrial agricultural systems that

producepoultry,swine,beef,andfarmedfishroutinelyuselargeamountsofantibioticsasgrowthpromotersratherthanaspharmaceu-ticalagentstotreatidentifieddisease.Moreantibioticsareusedinagriculturalproduc-tionthaninclinicalmedicine.Theroutineuseofantibioticsasgrowthpromoters inanimalhusbandrycontributessubstantiallytoantibioticresistanceinbacteriathatarehumanpathogens(Wegener2003).

Pesticide UseTheannualuseofhundredsofmil-

lionsofpoundsofinsecticides,herbicides,andfungicidesinfoodproductiondirectlyleads to significantpopulationwide, farm-worker, and farm-community exposures,oftenexceedingestablished“safety”limits.It increases risk of some malignancies,neurodegenerativediseases, asthma, andbirthdefects (OntarioCollegeofFamilyPhysicians2004).

Foodborne infectious illnesses Foodborne infectiousagentsareesti-

matedtocauseseventy-sixmillionillnesses,325,000hospitalizations,and5,200deathsin theUnitedStates eachyear.Knownpathogensaccount foranestimated four-teenmillion illnesses,60,000hospitaliza-tions,and1,800deathsannually(CDC).Inadditiontobacterialandviralvectors,bovinespongiformencephalopathy(“madcow”disease)isagrowingconcernintheU.S. Its spreaddependson feedingprac-tices inwhichanimals thatmayendupinthefoodsupplyarefedanimalproductscontaminatedwith theprion responsibleforthedisease.Thesepracticesareunder-going extensive modification followingtheidentificationofaninfectedanimalinWashingtonin2003.

environmental Health consider-ations

Confined animal feedlot operations(CAFOs)andotherlargeindustrialfarmsare point sources for runoff of growthpromoterssuchasarsenic,hormones,andantibiotics into local surfacewaters, andin somecases intogroundwater (USGS2003).StudiesofrunofffromCAFOsshow



Stop Diabetes with DietLifestyle Tools for Type II Diabetes Prevention

Nancy Bennett, MS, RD, CDE

lifestyle interventions,notdietary restric-tions;and,tothisauthor’sknowledge,nooneever successfully“thought” theirwaytoleanness,thoughtheiractionshaveleadthemthere.

Therefore, focusing interventionsonthose key, simple, actionable steps thatleadtoleannessishelpfulindirectingourpatients’effortstoloseweightandmaintainaleanerweight.

Onevery realistic andpractical ap-proachtohelpingourpatientslowertheircalorieintakeandloseweightistogivethemspecificexamplesofhowsmallsubstitutionsinfoodchoicescanleadtolargelossesofweightovertime.Forexample,sprinklingatablespoonoftoastedalmondsonsautéedgreenbeans insteadofone tablespoonofmeltedbuttersavesseventycaloriesaday.Notonlydoes thisdailyaction translateintoaseven-poundweightlossperyear,itlowersthepatient’ssaturatedfatintakeaswell.Asmanyoftheseclientsareatahigherriskforheartdisease,smalltipslikethiscanhelp themtranslate themessage“eat lesssaturatedfat”intorealistic,practicalactionstheycantakeonaconsistentbasis.Inotherwords, the behavior becomes a lifestylechange rather thana “diet.”The sidebarontheopposingpagelistsotherpracticalsubstitutionsforcommonfoodchoicesthathelptolowertheintakeofcalories,refinedcarbohydrates,andsaturatedfat.

Americaisthelandofplenty,andourgrowingwaistlinesaretheconsequenceofeatinglargeportions.Feelingsatiatedwithsmallerportions is achallenge formany.Fortunately,certainfoodchoiceshavebeenproven topromote the feelingof fullnesswhile lowering thecaloricdensityof themeal.

BarbaraRolls,aprofessorofnutritionat

escalatingtrendsindiabetesandprofoundlyimpactthefutureofAmerica’shealth.

TheDiabetesPreventionTrial(DPP),completedin2001,demonstratedthatalossof7%to10%bodyweightandanincrease

of150minutesofweek-ly activity decreasesthe risk for develop-ing diabetes by 58%.TheFinnishDiabetesPrevention Programduplicatedtheseresultsand found that suchlifestyle interventionprogramscanproducelasting results. Those

who received lifestyle interventionwereshowntohavemaintaineda58%lowerriskfordevelopingdiabetesfouryearsafterthestudyinterval.

ResearchersattheUniversityofColo-radoHealthSciencesCenteranalyzedtheDPPresultsandtherelativecontributionsofchanges indiet,physicalactivity, andweight loss to the reduction indiabetesincidence.Theyfoundthatweightlosswasmoststronglyassociatedwithlowerdiabetesincidence,comparedtodietand/orphysicalactivity.Onaverage,therewasa16%reduc-tionindiabetesriskperkilogramweightloss(Hamman2006).

Thoughthisresearchisindeedprom-isingas far as averting this loomingepi-demic, losing weight—and maintainingthatloss—isnoeasymatter.Simplyeatingfewercaloriesthanoneburnsiseasiersaidthandone.Manyahealthprofessionalhasstruggled right alongsidepatients in thisarena.

Itmightbehelpfultofocusinterven-tionsonthosebehaviorsthatleadtolean-ness.Afterall,theabovestudiesfocuson

T henumberofAmericanswithdia-betesorpre-diabetesisstaggering.There are currently20.8million

personswithdiabetes,18.7ofwhomhavetypeIIdiabetes.AccordingtoaNationalInstitutesofHealthesti-mate,thereareanother54 million Americanswith pre-diabetes, de-finedbyimpairedfastingglucose (IFG) or im-pairedglucosetolerance(IGT). Some 20% to34%ofthosewithIFGwill go on to developTypeIIdiabetesinfivetosixyears;thosewithbothIFGandIGThavea38%to65%chanceofdevelopingdiabetesinthesametimeinterval.

TheNIHpaintsadirepictureforthehealthoffuturegenerationsinthiscountry.Theypredict thatone-thirdof all thosebornintheyear2000willdevelopdiabetesintheirlifetimes.Asdiabetesistheleadingcauseofblindness,amputations,andkidneyfailure,itisimperativethathealth-promot-inginterventionsbeginearlyandcontinuethroughoutthepatient’slifetimeifuntoldlevelsofsufferingarebeaverted.

As this threat to America’s publichealth is fueledby theobesityepidemic,theseinterventionsneedtobedirectedatstemmingthetidalwaveofobesity.EightypercentoftypeIIdiabetesiscausedbyobe-sityand,accordingtotheNationalHealthandNutritionSurveyof2003–2004,cur-rentlyone-thirdofAmericansareobeseandanotherone-thirdareoverweight.

Thoughthesefactsaregrim,thereisasliverofhopeonthehorizon.Researchershave shown that small losses inweight,coupledwith activity, can reverse these

“America is the land of plenty, and our growing waistlines are the consequence of eating large portions.”

22San FranciSco MedicineApril 2007 www.sfms.org www.sfms.org April 2007San FranciSco Medicine2�22San FranciSco MedicineApril 2007 www.sfms.org

PennStateUniversity,hasshownthatthosewhobeginmealswithsaladsand/orbroth-basedsoupseatfewercaloriespermeal,and,moreimportantly,theydonotcompensatebyeatingmorelateronintheday.Suggest-ingsoupisawell-receivedmessageforthosewhocomplainthattheycannotfeelfullwithsmallerportionsoffood.

Another action step that promotessatietywith smallerportions is tochoosefoods that requirechewing, suchas fruitsandvegetables.Thoughresearchtellsusittakestwentyminutesforgastrichormonesto signal satiety in thebrain,most findeating slowly adifficult behavior tode-velop.Choosingfoodsthatdemandalotofchewingaidsinslowingdownthespeedinwhichpeopleeat.Whole-grainbreadsforsandwichesatlunchandapplesfordessert(inlieuofsofterfoodssuchassandwichrollsandraisins)notonlyhelpboostsatietybutincreaseyourpatient’ssolublefiberintakeaswell.Solublefiber fromwholegrains,fruits,andvegetablesslowsgastricempty-ing,whichpromotessatiety.Solublefiberhasalsobeenshowntoflattenpostprandialglucose curves, lower insulin levels, anddecreaselow-densitylipoproteins.

Anotherbehaviorthatpromotessatiety

withmealsistheinclusionofleanproteinwitheverymealorsnack.Proteinandfatdelaygastricemptyingandgivemealsorsnacks“stayingpower.”Twosuchfoodsthatareperfectforquickmealsonthegoarewal-nutsanddry-roastededamame.Thesefoodsarealsogoodsourcesofomega-3fattyacids,whichhavebeenshowntoreducechronicinflammation.However,thoughthesefoodsaredeliciousandhealthychoices,theycanbeaconcentratedsourceofcalories.Expe-riencehasshownthathandingpatientsaquarter-cupcontainercanhelpthemlimittheirportionstoalevelthatdoesnotinter-ferewithweightlossefforts.

Finally, encourage your patients tosurround themselveswithhealthy foods.Thosewhoarehungrywilleatfoodsthatareavailable.Weliveinaseaoffast-foodchainsandconveniencemarketsfilledwithhigh-fat,high-fructosefoods,sosuggesttoyourpatientsthattheycarrysomehealthysnackswith themtoworkor school.Setthemupforsuccessbysuggestingafewofthesnackandmealideasinthesidebar.

Last,butnot least,promoteactivity.Simplyadding two thousand stepsadaycan lead toa ten-poundweight loss inayear.Apedometerisaninexpensivetoolin

choices for Losing Weight

Substitutingonefoodforanotherisagreatwaytosubtractfatandcaloriesfromyourdietwithout feeling thedeprivationandsufferingcommonlyassociatedwiththefamousfour-letterworddiet.

Considerthis:Everytencaloriesyousubtract eachday fromyournormal fareresults in one pound of weight loss peryear. Subtracting one hundred caloriesperdayresultsintenpoundsperyearand250caloriesperdayresultsintwenty-fivepounds lostperyear. Imagine, losing twopoundseverymonthjustbychoosingonefoodoveranother!

Thefoodsbelowlisttheircaloriecon-tentinparentheses;seeiftherearen’tafewideasyoucanrealisticallyincorporateintoyourdaily life.Whoknows,youjustmaychooseyourwaytoleannessanddropyourriskfordiabetestoo!

Substitute These Foods… Breakfast

2oz.whole-milkcheese(220)4oz.sausage(432) ¼C.raisins(120) ¾C.granola(375)

lunchQuarter-pounder(530) 3oz.hamburger(244) 3oz.bologna(270) 1largecroissant(231) 1C.creamofbroccolisoup(234)

Snacks1C.fruit-flavoredyogurt(232) Flourtortilla(115) 3oz.potatochips(330) Doveicecreambar(260) 15Triscuits(280)

Dinner4Tbsp.bluecheesedressing(308)6oz.steak(344) 1C.rice(266) 4Tbsp.butter(400) 2Tbsp.hollandaisesauce(200)

helpingpatientsmonitorandincreasetheiractivitylevels.Increasedactivitynotonlyhelpspatientsburnmorecalories, it alsohelpsdecreasetheinsulinresistancethatisattheverycoreofthisdisease.

Health professionals play a pivotalroleinshapingthehealthoffuturegenera-tions.Wehaveanopportunitytoshowthatsimple,realisticactionscanhelppeopleloseweightandlowertheirriskofdevelopingdiabetes.Ifweshareourperceptionofdiabe-tesaspreventable,wewillbegintohelpourpatientsliveinthesolutionand,perhaps,stemthetideofthiswretcheddisease.

“let history be the final judge of our deeds.”—John F. Kennedy

Nancy Bennett, MS, RD, CDE, is a consulting nutritionist and the principal author of Enlightening Choices. Her company pro-vides nutrition consultations for a number of health care agencies, medical clinics, private physicians, corporations, and individuals within the San Francisco Bay Area. She earned her bachelor’s of science degree in Nutrition from the University of California at Berkeley in 1976, her master’s in Nutritional Science from the University of Bridgeport in 1992, and her Certificate of Diabetes Education in 2000.

With These Foods…

2oz.LaughingCowreduced-fatcheese(70)4oz.Canadianbacon(180)½C.grapes(57)1C.KashiGoLeancereal(140)

Grilledchickensandwich(310)3oz.grilledchicken(140)3oz.ham(90)2slicesryebread(140)1C.minestrone(82)

1C.sugar-freeyogurt(90)Corntortilla(67)3C.popcorn,air-popped(90)2DoveMiniaturebars(100)16WheatThins(140)

4Tbsp.lightbalsamicvinaigrette(200)6oz.chickenbreast(200)1mediumpotato(140)4Tbsp.sourcream(120)2Tbsp.parmesancheese(50)



Nature’s WayOmega-3s for Cardiovascular Disease

Phillip Frost, MD

andn-3fattyacidsarethemostfavorablelipid-loweringinterventionswithreducedriskofoverallandcardiacmortality.Anypotentreductionincardiacmortalityfromfibratesisoffsetbyanincreasedriskofdeathfromnoncardiovascularcauses.”

In the editorial accompanying theWang review, it is stated, “In total, theevidenceindicatesthatincreasedconsump-tionofthen-3fattyacidsEPAandDHA,eitherthroughfishorsupplementsorboth,reduced the rates of all-causemortality,myocardialinfarction,andsuddencardiacdeath.” Important is thatnoorvery fewcomplicationsofsupplementswereencoun-tered(Deckelbaum2006).

TheNIHconvenedaworkinggrouponfutureclinicalresearchdirectionsonomega-3 fatty acids and cardiovascular disease(CVD)onJune2,2004.Theyconcludedthatthebodyofevidenceisconsistentwiththehypothesisthatintakeofomega-3fattyacidsreducedCVDbutthatadefinitivetrialisneeded(NIH2004).

ThereisrecenttrialdatafromJapannow that thefive-year JapanEPALipidInterventionsStudy(JELIS)hasbeenpre-sented.Subjectswitha total cholesterol>250 mg./dL were recruited, 14,981 inprimarypreventionand3,664 in second-arypreventionarms.Allwererandomizedto low-dose statin(10mg.pravastatinor5mg.simvastatin)orlow-dosestatinplusEPA(1800mg.daily) in a randomized,open-label,blindedendpointtrial.Primaryendpointwasdefinedasmajor coronaryevents: suddendeath, fatal andnonfatalMI,andunstableanginaincludinghospi-talizationfordocumentedischemiceventandangioplasty/stentingorcoronaryarterybypassgrafting.Atmeanfollow-upoffourto sixyears, therewasa significant19%

(Siscovick1995).ThisresultwasechoedinthePhysician’sHealthStudyconductedinapparentlyhealthymen.Ninety-fourmeninwhomsuddendeathoccurredasthefirstmanifestationofCHDwerematchedwith184controls.Ascomparedwithmenwhosebloodlevelsoflong-chainn-3FFAswereinthe lowestquartile, therelativeriskofsuddendeathwassignificantlylowerinthethirdquartile(adjustedrelativerisk[RR]was0.28)andloweryetinthefourthquartile(RR0.19)(Albert2002).

TheGISSI-PrevenzioneInvestigatorsrecruited11,234subjectswhohadsurvivedarecent(<3months)myocardialinfarction(MI)andwererandomlyassignedsupple-mentsofn-3FFAs1g,vitaminE,both,orneitherfor3.5years.Primaryendpointwascombineddeath,nonfatalMI,andstroke.Resultswereprovidedintwo-wayandfour-wayanalyses,respectively.Treatmentwithn-3FFAs,butnotvitaminE,significantlyloweredriskofprimaryendpoint(RRde-crease10%and15%).Benefitwasattrib-utedtodecreaseinriskofdeath(14%and20%)andcardiovasculardeath(17%and30%)(GISSI1999).

The relationshipbetweenn-3 fattyacids(EPA+DHA)intakeandcardiovas-culardiseasehasbeen reviewed recently(He2004,Studer2005,Wang2006).TheHereviewlookedataccumulatedevidenceonfishconsumptionandCHDmortalityandconcluded, “ThepooledmultivariaterelativerisksforCHDmortalitywere0.89(95%CI,0.79to1.01)forfishintakeonetothreetimespermonth,0.85(95%CI0.76to0.96)foronceperweek,0.77(95%CI0.66to0.89)fortwotofourtimesperweek,and0.62(95%CI0.46to0.82)forfiveormoretimesperweek.”

TheStuderreviewconcluded,“Statin

N aturenotonlyprovideshumansafulllistofnutrientstoforestallchronicdisease(ifwechosetoeat

themhabitually)butstocksthelipidologist’stoolchestwithofferingstothwartcardio-vasculardisease.

SincetheappreciationthattheGreen-landInuithadalowmortalityfromChronicHeartDisease (CHD)despiteadiet richinfat,themarineomega-3fattyacids(n-3FFAs)havebeen studied in theclinicalarena.Eicosapentaenoicacid (EPA)anddocosahexaenoicacid (DHA),C-20andC-22, respectively, are products of mi-croalgae,areessential fattyacids,andareconcentrated inmarineanimals.DHAisproducedcommercially frommicroalgaeand isFDA-approved for infant formula.EPAandDHAinfishandinconcentrateshavebeenstudiedtogetherandascompo-nents.EPAandDHAnotonlyprovokelipoproteinconcentrationsbuthaveotherpotentialhealthbenefits.

recent observationsMultiplestudiessuggestthathigherin-

takeofthemarinen-3fattyacidsinthedietreducetheriskofsuddendeath.InSeattle,a totalof334casepatientswithprimarycardiacarrestattendedbyparamedicswerestudied,alongwith493population-basedcontrol cases. Diethistories were takenfromspousesandbloodspecimenscollectedfromcases(n=82)andcontrols(n=108).Comparedtonofishintake,anintakeof5.5gofn-3FFAspermonthwasassociatedwitha50%reductioninriskofprimarycar-diacarrest.Comparedwitharedbloodcell(RBC)n-3FFAlevelof3.3%oftotalFFAs(lowestquartile),anRBCn-3FFAsof5.0%oftotalFFAswasassociatedwitha70%re-ductionintheriskofprimarycardiacarrest


lower event rate in theEPAplus statincomparedwithstatinalone.Thiswastrueinbothstrata,but insubgroupanalysis itwassignificantonlyinthesecondarystrata(Koba2006).

The Lipidologist’s PerspectiveEarlydatasuggestedthatnormalizing

bloodcholesterolandassociatedlipoproteinabnormalitieswas likely to reduceCVDevents and total mortality. History hasproventhistobethecase.

Thequestionnowishowtoachievelipidgoals.Toaninvestigatoractiveinstud-iesofdietandsingletherapeuticagents,itbecameevidentthatcombinationregimenswouldberequiredinmostcasestoachievegoals.TheATPIIIupdatedgoalsforhigh-risk individuals are an LDL cholesterol(well)below70andnon-HDLcholesterol(againwell)below100mg./dL.Normaliz-ingHDLcholesterolisimportant(Grundy2004).CommonlipoproteinabnormalitiesincludenotonlyelevatedLDLbutelevatedVLDL (surrogate triglycerides) and lowHDL.Whilemosttherapeuticregimensarestatin-based,weneedeffective,safestatincombinations.N-3fattyacidsclearlysteptotheplate.EPA+DHApredominatelylower the triglyceride-rich lipoproteins.In a blinded comparison of gemfibrozil1,200mg.with3,225mg.EPA+DHAinhypertriglyceridemicsubjects,bothagentsloweredtotalcholesterol,triglycerides,andVLDLandraisedHDLsimilarly.LDLcho-lesterolincreasewasattributablelargelytoanincreaseinthelessdenseLDLsubspecies (Stalenhoff2000). Intermsof lipoproteinresponse,wecan think of n-3 fatty acids asnature’sfibratebut,asnotedabove,with additional attributes. Theresponse to statin,EPA+DHA,andcombinationshasbeenstudiedand the lipoprotein response tocombinationisadditive(Contacos1993). Importantly, there havebeennoassociatedsideeffectswithn-3FFAs+statin,andspecificallynoincreasedriskofthemyopathysyndrome,whichisaconcernwiththestatinfibratecombination.

Ihavebeenusing thiscom-binationaspartofmyarmamen-

tarium since 1994, as have many otherlipidologists. It is particularly useful forpatientswith type IIdiabeteswhere theprimary lipoproteinabnormality includeselevatedVLDLandassociatedlowHDL.

an illustrative caseSixty-five-year-old sedentarywoman

referredforlipidmanagementin1990(cur-rentage82).Pasthistory:TypeIIdiabetesmellitus,1984.Intervalhistory:Subsequentdiagnosisofanginapectoris,resolvedwithdiabetes, lipidmanagement.PE:Shewasobese(BMI37.7),normotensive.Weightunchangedoverintervalseventeenyears.

Clinical course:She failedefforts tocontroldiabeteswithdietandsulfonylureas.Afteryearsofdiscussion,sheacquiescedinfall1993toinitiatinginsulintherapy,firstNPHandthen70/30bid.Diabetesregimenexpandedwiththeadditionofmetforminin fall1995,andpioglitazone in summer2004.

In reviewing individual values andpooleddatapresentedinthechartbelow,thelipidsclearlytracktothecombinedlipidregimen(n-3fattyacids[EPA+DHA]3.0g.plus simvastatin40mg.) anddiabetescontrol.

The long-chain omega-3 fatty ac-idsEPAandDHAare likely toprotectagainst CVD by lipid independent andlipiddependentmechanisms(Din2004).Lowdose(about1g.ofEPAplusDHA)consumedasfishorsupplementsisassoci-atedwithreducedsuddendeathandtotal

mortality.Higherdosageregimens(about3–4g.)leadtoreducedVLDLcholesterolandtriglycerides,amodestincreaseinHDLcholesterol,and,onoccasion, increase inLDLcholesterol,aresponsesimilartothatobserved with the fibrate drug class. Incontradistinctiontothefibrates,therearenoknowndruginteractionswiththen-3fattyacids,andspecificallynoincreasedriskofthemyopathysyndromewhenprescribedwith statins.Also incontradistinction tothefibrates,studiestodatedemonstratenotonly reducedcardiaceventsbut reducedtotalmortality.Then-3FFAsarevaluableagentsusedincombinationlipidperturbingregimens.

Dr. Frost is a Clinical Professor in the Department of Medicine, Cardiovascular Research Institute (CVRI) at UCSF. He at-tended UCLA School of Medicine, interned in New York City, and completed his medical residency at Stanford University. After two years in the USPHS, he was an NIH Special Fellow in Metabolism CVRI, UCSF. He has been an active clinical investigator since 1969. He currently sees patients with lipid disorders at the UCSF Lipid Clinic and in his private prac-tice. He can be reached with questions at [email protected] or by telephone at (415) 673-2241. A full list of references is available on our website, www.sfms.org.

Date Total Cholesterol

Triglycerides HDlCholesterol

non-HDlCholesterol

HbA1c lipidRegimen

1990 319(287-373)

616(554-786)

35(35-35)

286(252-337)

10.8(9.8-11.6)

None

1991 to 1993

376(223-540)

988(356-2086)

36(33-40)

269(193-343)

12.2(9.6-14.1)

Gemfibrozil1,200

1993 to 1996

293(256-332)

422(174-637)

36(27-42)

254(220-299)

9.9(8.1-11.2)

Gemfibrozil1,200

1996 to 2001

187(160-258)

213(171-328)

42(37-45)

145(120-221)

8(6.9-8.7)

EPA+DHA3g.Simvastatin20

2001 to 2004

161(126-224)

204(115-278)

42(34-49)

118(96-185)

7.4(6.5-8.3)


2004 to 2007

151(137-165)

118(87-141)

56(53-60)

95(84-108)

6.4(5.8-6.5)


Data are mean values and range in mg./dL or for HbA1c percent.

Lipids—HbA1c—Lipid Regimen



Exploring Unhealthy Eating HabitsA Longitudinal Study of Eating Behavior in Girls

Patricia Crawford, DrPH, RD

approximatelyequalnumbersofblackandwhitegirls,withawiderangeinhouseholdincomeandparentaleducationwithineachracialgroup.Thestudywasremarkableinitsveryhighretentionrate;89percentoftheoriginalcohortwasmeasuredinthetenth

yearoffollow-up.D u r i n g t h e

courseoftheNGHSstudy,wemeasuredthe girls and col-lected informationontheirdietaryandphysicalactivitypat-terns eachyear forten years. To oursurprise, nearly aquarterofthewhitegirls (22 percent)

andnearly a thirdof theblackgirls (31percent) were overweight (BMI > 85thpercentile)atagesnineandtenwhentheywere initiallyenrolled in the study.Thiswasadoublingoftheratefromthepreviousdecade,asmeasuredbytheCDC’sNationalHealthandNutritionExaminationSurvey.Atagesnineteenandtwenty,41percentofthewhitegirlsand57percentoftheAfricanAmericangirlswereoverweight.Whilerateswentup for bothblack andwhitegirls,theabsoluteincreasewasconsiderablyhigherforblackgirls.

Usingourwealthof annualNGHSstudydataondietaryandphysicalactivitypatterns,wewereabletoexaminewhetherchildren’sfoodandactivityenvironmentsvariedbyraceandwhetherthevariationsmightcontribute todifferingpatternsofweightgaininthetwogroupsofgirls.Whatkindsof changes in children’s food andactivityenvironmentsdidwesee,andwhatracialdifferencesdidweobserve?

T henumberofoverweightchildrenintheUnitedStatestodayisassoci-atedwithanunprecedentedrisein

typeIIdiabetes.Consequently,thereisanexpectationthatmanychildrenborntodaywillhaveshorterlifespansthantheirpar-ents. Today’s chil-drenarethreetofourtimesmorelikelytobeoverweight thanchildrenthirtyyearsago, and rates areparticularlyhighforAfrican Americanyouth.TheNHLBI(National Heart,Lung, and BloodInstitute) Growthand Health Study,thelargeststudyofAfrican-Americangirls’healtheverconducted, canprovidenewinsightsintothisphenomenonandcanhelpusunderstandhowchangingpatternsofnu-tritionandphysicalactivitysincethe1970smaycontributetothealarmingincreasesinchildhoodobesity.

In1987,duringtheperiodofsoaringpediatricobesityrates,andinresponsetorapidincreasesinratesofobesityandheartdisease inAfricanAmericanwomen,theNationalHeart,Lung,andBloodInstituteoftheNationalInstitutesofHealthfundedthe ten-yearNHLBIGrowthandHealthStudy(NGHS)tolookatthedevelopmentofobesityandcardiovasculardisease(CVD)risk factors inblackandwhitegirls.Par-ticipantswereselectedfromContraCostaCounty, California; Cincinnati, Ohio;andWashington,D.C.NGHSrecruitedmorethan2,300girls,agesnineandten,atschools(inCaliforniaandOhio)andfromalargeHMO(inD.C.).Thestudyenrolled

First,weobservedfrequentconsump-tionoffoodfromfast-foodrestaurantsbyallchildren.Thisagreeswithotheranalysesshowingthatbothchildrenandadolescentsareobtaining lessof their energy intakeathomethaninearliereras,andmoreatrestaurantsand fast-foodoutlets.Portionsizeshaveincreased,andpatronsareoftenencouragedtopurchasemealsthatcontainmorecalories through“value”marketingor“supersizing.”Further,fastfoodandres-taurantfoodsaretypicallycaloricallydense,nutrient-poor, andhighlypalatable, andfrequentpatronagehasbeenassociatedwithdietshighinfatandcalories.Childrenwhoateatfast-foodestablishmentstwoormoretimesaweekweremorelikelytoincreasetheirrelativeBMI(bodymassindex)thanthosewhopatronized fast-foodestablish-mentsonceaweekorless.

We found that fast-food intake rosewithincreasingageingirlsofbothraces,butacrossallages,fromninetonineteen,blackgirls consumed fast foodmore frequentlythandidwhitegirls.

Second,weobservedhighconsump-tionofsweetenedbeverages.Inbothblackandwhitegirls,consumptionincreasedwithage.Further, of all beverages consumed,increasedsodaconsumptionpredictedthegreatestincreaseinBMI.Thismaybeinpartaresultofdifficultiesinphysiologicalcom-pensationforenergyconsumedasaliquidcomparedtoasolid,andinpartaresultoftherelationbetweenconsumptionofsodaandothereatinghabits.Ateachannualvisit,blackgirlsconsumed lessmilk thanwhitegirls,andtheincreasedrateofsodaconsumption throughout childhoodwasgreateramongblackgirlsthanwhitegirls.

Apartfromthesefrequentlydiscusseddietmarkers,what aboutoverall dietary

“Today’s children are three to four times more likely to be overweight than children thirty years ago, and rates are particularly high for African American youth.”


quality?Dietarypatterns of eatingwereexaminedusingclusteranalysistoclassifyindividualgirlsintodiscretepatternsoverthe tenyearsof theNGHSstudy.Eightpatternswereidentified:fourforwhitegirlsandfourforblackgirls.Onlyonecouldbeclassifiedasa“healthypattern,”anditwasfollowedbyonlywhitegirls.Only6percentofthegirlsinNGHShaddietsclassifiedas“healthy.”Further,thehealthypatternwastheonlypatternassociatedwithasmallerincrease inadiposityover thechildhoodyears.Onaverage,morethantwo-thirdsofthegirlsatanygivenagewerenotmeetingdietary fat recommendations,withwhitegirlsonly somewhatmore likely tomeettheguidelines.Further,nearlyhalfof allgirlshaddietsbelowrecommendedlevelsinvitaminsAandC,calcium,iron,andzinc.

Wefoundthatblackgirlsweremorethan twiceas likelyaswhitegirls to fre-quentlyengage ina spectrumofweight-relatedeatingpractices, includingeatingwhilewatchingTV, eatingwhiledoinghomework, skippingmeals, eating in thebedroom, eating when not hungry, andeating snacks.Formostof thebehaviors,girlswho frequentlypracticedabehaviorhadhighercaloricintakescomparedwiththosewhopracticeditinfrequently.

Althoughthelikelihoodofagirlfre-quentlyengaging in some,butnotall,oftheseeatingpracticesdecreasedwithanincreaseinparents’incomeandeducationlevel,evenwhencontrollingforsocioeco-nomic status (SES),blackgirls remainedmore likely to engage in these eatingbehaviorsthanwhitegirls.Infact,NGHSwasthefirsttoreportthattherelationship

betweenSESandweightdifferedforblackandwhitegirls.Bothlowhouseholdincomeandparentaleducationareriskfactorsforpediatricoverweightinwhitegirls,butnosuchassociationwasfoundforblackgirls.

TheNGHSalsodocumentedadra-maticdeclineinleisuretimephysicalactiv-ityinbothblackandwhitegirlsfromagesninetotwenty,butthedeclineforAfricanAmericangirlswasgreater.Adirectasso-ciationbetweenhoursofTVviewingandincreasesinBMIwasobserved.Wedocu-mentedaveragedailytelevisiontimeof3.6hoursperdayforwhitegirlsagedninetotencomparedwith5.2hoursperdayforblackgirls.Theimpactoftelevisionviewingmaybemoresignificantthanvideogameplaying,because itcanreduceenergyexpenditureandincreaseenergyintake:TVinfluencesthetypeandamountoffoodsconsumedbyviewingchildren.Atypicalchildwatchesabout40,000commercialsonTVeachyear,anumberthathasdoubledduringtheyearsthathaveseenalargeincreaseintherateofpediatricoverweight.Infocusgroupsthatwehaveconducted,mothersreportknow-ingwhattofeedchildren,butnotknowinghowtogetchildrentoeatthehealthyfoods.Mothersreportthattheirmessagestotheirchildrenareunderminedbyever-presentadsforfastfoodsandjunkfoods.Furthermore,televisionprogrammingmarketedprimarilytoAfricanAmericanshassignificantlymorefoodandbeverageadsandadvertisementsforunhealthfulfoodsthangeneralmarketprogramming.

Overweight inbothblackandwhitegirls in theNGHS study increaseddra-maticallyfromninetotenyearsofageto

nineteentotwentyyearsofage.Changesinnutritionalpatternsareclearlyimplicatedamongthereasonsforthischange.How-ever,werecognizethatobservedincreasesinpediatricobesityarenotcausedbypeopletakinglesspersonalresponsibilityfortheirwell-being,butratherbyprofoundchangesintheworldaroundus.Itbehoovesallofus—healthprofessionals,parents,andciti-zens—toadvocatenotonlyforanenviron-mentsafefromimminentdanger,butalsoanenvironmentsafe fromriskofchronicdisease.Ournation’seconomicandsocialenvironmentmustsupportpeopleintheiractionstowardachievingandmaintaininghealthylifestyles.Withoutthis,wewillallpaythefuturecostsforconditionsthataretheconsequencesofanoverweightsociety.In thewordsofoneexpert, “If youhavemalaria,youdraintheswamp.Ifyouhavedeathontheroads,youimposeseatbelts.…”Ifyouhaveobesity,youcreatehealthierfoodandactivityenvironments.

Patricia Crawford, DrPH, RD, is Ad-junct Professor in the School of Public Health and the Department of Nutritional Sciences and Toxicology at the University of California, Berkeley. She is Codirector of the Center for Weight and Health and is a Cooperative Exten-sion Nutrition Specialist. Dr. Crawford has led seminal studies in the longitudinal development of obesity and is currently Principle Investiga-tor on studies exploring environmental, family, and policy approaches to childhood obesity. She is widely published, serves on several advisory boards, and is a consultant on numerous col-laborative projects.

28San FranciSco MedicineApril 2007 www.sfms.org


Perspectives in Eating DisordersWhat Physicians Should Know

Adair Look, MD

perday.Lessimmediatebutequallydamaging

effectsofeatingdisordersareexemplifiedby“Alyssa,”a twenty-seven-year-oldwomanwithaneatingdisorder.Sinceagetwelve,Alyssahasrestrictedcaloriesandexcessivelyexercised.Duringherfirstyearoflawschool,herweightdecreasedto92%ofher idealbodyweight(twentypoundsundernormalweightforher),andshesustainedafemoralneck fracture.Shewasable tonormalizeherweightoverthenexttwoyears,butshethenbeganexcessivelyexercisingagainandfracturedthemetatarsalsinherleftfoot.Shesuffersfromfemaleathletictriad:disorderedeating,amenorrhea,andosteoporosis.Threeto66%offemaleathletesareaffected,ac-cordingtoYeager(1993).

Theamenorrhea ishypothalamic innature. During extreme stress, whetherphysiologicor psychiatric, thehypotha-lamic-pituitary-adrenalaxisisactivatedtostopunnecessarybodilyfunctions,resultingincessationofreproductivefunction.Itisintendedtobea“protectivemechanism”of thebody, a reaction to stress. In fact,increaseinstresscausesincreaseinamenor-rheain100%ofprisonerspriortoexecution,as found by Chrousos (1998). In 2005,Abrahamshowedthatamenorrheaisalsofoundin24%ofpatientswithEDNOSand15%ofpatientswithbulimia.

Osteoporosis,thethirdaspectoffemaleathletictriad,commonlyleadstobonefrac-tures,asseeninthefemoralneckfractureAlyssasustained.Anorexicpatientsoftencite the fact thatweight-bearingexerciseleadstoincreaseinbonedensity.However,excessiveweight-bearingexerciseleadstodecreaseinbonemineraldensity,andosteo-porosisoftenpersistsafterweightrestorationoccursandhormonallevelsnormalize.

so shecontinued thebehaviordespite itsinconvenienceanditseffectonherbreath.Sarah’seatingdisorder, rumination, is farmoreprevalentthanmosttreatersareaware.Kjelsasshowsinhis2004articlethat3%ofyoungwomenhaveAN,8%haveBN,andabout14%meetcriteriaforEDNOS.O’Brien (1995) and Fairburn (1984)showedthat17%to33%ofpatientswithBNengageinruminationatsometimeintheirhistory.

Regardlessofthecommonalityofthepresentingsymptoms,theimmediatecon-cernsintreatingeating-disorderedpatientsinclude refeeding syndrome, metabolicabnormalities, andcardiacabnormalities.Refeeding syndromeoccurswhenunder-weightpatientshave starved themselvesto the extent that their cardiac tissuehas atrophied, andwhen theyare givenincreasedfluids and solids, their cardiaccapacitybecomesoverloaded.Thisresultsindependentedema,tachycardia,increasedjugularvenouspressure,andcardiacrhythmabnormalities.

Metabolic abnormalities can in facthelp diagnose eating disorders, as seenwith“Kay.”Kay,athirty-year-oldwoman,presented with low body weight and alowpotassiumandhighCO2,thoughshedeniedvomitingtodecreasecaloricintake.Asalivaryamylasewasdrawnandprovedelevated, indicating repeated vomiting.Onceconfrontedwiththeresults,Kaywasabletoadmittopurginguptotwelvetimes

E mily,” a twenty-year-old collegestudent, came to treatment justafterhavingattemptedsuicideby

overdosingonoldpainmedications shefoundinherparents’bathroom.Sheadmit-tedthat,beforetheattempt,shehadbecomedespondentoverherunstoppableneedtochewlargequantitiesoffoodandspititoutwithouteverswallowinganyofit.Shewaswasting away,nowcarryingonly eightypoundsonherfive-foot,five-inch frame.Emilyhadbeenchewingandspittingoutherfoodasawaytosootheherselfsincethesixthgradebuthadneverbeenabletotellanyonebecause shewas tooembarrassed.“Whoeverheardofsomethingsogross?Icouldn’ttellanyone!”shestated.

Emilyisoneofapproximatelyfivemil-lionpeopleintheUnitedStateswhosufferfromaneatingdisorder,whilemanymoresufferfromdisorderedeatingthatbordersonafull-fledgeddisorder.Inaddition,eatingdisorderscarrythehighestmortalityriskofanypsychiatricillness.Patientsoftencometotreatmentforreasonsseeminglyunrelatedto theireatingdisorders.Although thereisoverlap in symptomotology,eatingdis-ordersarecurrentlycategorizedintothreedistinctdiagnoses:anorexianervosa(AN),bulimianervosa(BN),andeatingdisordernototherwise specified(EDNOS).Manypatients,likeEmily,donotfitneatlyintothesecategories.

“Sarah”was forty-twowhenshepre-sented to her internist with a concernforchronichalitosis.Afteranexhaustivemedicalworkup,Sarahfinallyadmittedtoregurgitatingherfoodtwotothreetimesperday.Afterherdivorcetenyearsprior,shebeganregurgitatingherfoodfromstress.Shewelcomeditssoothingeffectandthefactthatitmadeherweighteasiertomanage,

“

“Patients often come to treatment for reasons seemingly unrelated to their eating disorders.”

www.sfms.org April 2007San FranciSco Medicine2928San FranciSco MedicineApril 2007 www.sfms.org

Mooddisordersarecommonineating-disorderedpatients,withcomorbidAxisIdiagnoses in73%ofpatientswithANandin60%ofpatientswithBN(Herzog1992).Recentresearchhasfocusedontheconnectionbetweeneatingdisordersandmood,showingthatserotoninisinvolvedinmodulating impulsivity,obsessionality,mood,andappetite.Patientswithbulimiashowadecreaseinnaturallyoccurringsero-toninandadecreasereactivitytoserotonin.Patientswithanorexiaalsoshowadecreasein serotonin activity and reactivity, buttheselevelsincreaseafterweightrecoveryhasbeenachieved.“Pamela”wasunabletokeepherweightaboveonehundredpounds,despitebeingfivefoot,nineinchestall.Shewas alsoprofoundlydepressedandoftencontemplatedsuicide.ShewaseventuallyabletoincreaseherbodyweightbecauseherpsychopharmacologistexplainedthatSSRIsdonotworkaseffectivelyonunderweightpeopleandthataminimumbodyweightmustbeachievedforfulleffecttooccur.

Treatmentof eatingdisorders isdif-ficult.However, it ismosteffectivewhenusingamultidisciplinarytreatmentteamin-cludingapsychopharmacologist,atherapist,

anutritionist,andaprimarycarephysician.There are currently limitedpsychophar-macologicinterventionsforthetreatmentof eatingdisorders. Fluoxitinehas beenshowntodecreasetheurgestobingeandtopurge,ashavedesipramineandimipramine(Becker1998).Topamaxhasbeenshowntodecreasetheurgeaswell,butithastheworrisomesideeffectofweightloss(Hedges2003).Anorexiahasbeenmoredifficulttotreatbothpharmacologicallyandtherapeu-tically.Antipsychoticshavebeguntoshowpromisewithabnormalorinaccuratebodyimageissues,butnothinghasbeenshowntotreattheunderweightstateofanorexia.Cognitivebehaviortherapyhasproventobeeffective in improvingtheoutcomeofpatientswithBNbutnotwithAN.

Eating disorders carry with them astigmatizationthatmakespatientsashamedofandsecretiveabouttheirbehavior.Onetactic toengage them in treatment is toisolatetheirillnessasaforceoutsideoftheirperson.“Angel”calledhereatingdisorder“theit”andgraduallybegantoconceptualizeitasanentityuntoitself.Shewasabletoac-ceptthesupportofhertreatmentteamwiththeunderstandingthat“theit”wasstronger

thananyonememberoftheteam—butthattogether,sheandhertreaterswerestronger.Angelwasintreatmentforseventeenyearsbefore shecouldeatoutwithher family.Sheiswellversedinthehighrelapserateofpatientswitheatingdisorders,buthercommittedrelationshipwithhertreatmentteamhaskeptheralivethroughthreeICUstaysandtwosuicideattempts.

Often the triumphsofworkingwitheating-disorderedpatientsarefoundinthesmall steps they achieve, suchas eatingmorethanonethousandcaloriesforsevendays straight.Atother times the rewardsaremoreremarkable:Afterelevenyearsofamenorrhea,Alyssarecentlygavebirthtoherfirstchild.

Adair Look, MD, is an Attending Psy-chiatrist in the Women’s Health department of California Pacific Medical Center.

changeofconsciousnessinplantsandfoodhavebeenpublished,suchasintheclassic,The Secret Life of PlantsbyPeterTompkinsandChristopherBird.Other researchbyBernard Grad, PhD, also suggests thatplantsandfoodsomehowsenseandrespondtoverbal andnonverbal communicationfromhumans.Indeed,Gradhasbeenabletodemonstratethatplantsfeda“cared-for”solutionofwaterthrived.Hisconclusion:“Ifaperson’smoodcouldinfluencea…solu-tion…itseemednaturaltoassumethatacook’smoodcouldinfluencethequalityoffoodpreparedforameal.”

6. Eat fresh whole food in its natural state as often as possible.

Virtually every world religion andculturaltraditionencourageseatingfresh,whole foods.For instance,when I inter-viewedHamidAlgar,Ph.D.,professorofIslamicStudiesattheUniversityofCali-

fornia,Berkeley,hesaid,“Fastfoodisthespiritualantithesis[ofthedietarytenetsoftheQur’an].”Thismeansthatby“treatingfoodasan industrialartifact that is con-sumedwithoutanydevotionalcontext”istonegatethatfoodisadivinegift.

Manyofusarepartofavast,uncon-trolledexperiment in “industrial”eating.Thedata is clear thatconsuming lotsofprocessed,high-fat foods thathavebeendepletedofmanybeneficialnutrientscon-tributestoobesityandrelatedailments.

an experiment in True nourishment

Thesixelementsof theenlighteneddiet area templatenotonly forwhat toeatandhowtoeatbutalsohowto live:consciously,filledwithasenseofwonderinherentinthealchemicalunionbetweenhumanbeingsand food.This integrationofnutritionalscienceandspiritisanongo-

ingprocess,a real-worldexperiment thatis resplendent with possibilities in howtonourisheveryaspectofourbeingeachtimeweeat.

Deborah Kesten, MPH, is the award-winning author of FeedingtheBody,Nour-ishing theSoul(Conari Press, 1997) and TheHealingSecretsofFood (New World Library, 2001). A pioneer in the field of integra-tive nutrition, she has worked as the nutrition specialist with Dean Ornish, M.D., on his first clinical trial for reversing heart disease. Kesten has presented workshops and participated in research internationally and was honored as “a healer for the new millennium” by HealthyLiving magazine. She and her husband, Larry Scherwitz, live in Northern California.

This article was first published in Spiritual-ity & Health magazine, winter 2003, www.spiritualityhealth.com.

The Enlightened Diet Continued from Page 13...

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A Villain in the Obesity EpedemicIs High-Fructose Corn Syrup the Culprit?

Lucy Crain, MD

itsuseisincreasing.High-fructosecornsyrup isproduced

bymillingcorntocornstarch,thenfurtherprocessing the corn starch to yield cornsyrup,whichisalmostpureglucose.Enzymesarethenaddedtochangetheglucoseintofructose.Theprocess is complexand re-quiresnumerousenzymaticadditions,alongwithothersugars,inmultiplestagestobreakdownthesugarchainsandconvertthemtofructoseandglucose.ThisyieldsHFCS90(90percentfructose).Theothercommonformulations,notedabove,areproducedbycombiningtheHFCSwithdesiredpropor-tionsof100percentglucosecornsyrup.

Brayandassociatesnotethatthediges-tionandmetabolismoffructoseisdifferentfromthatofglucose,withhepaticmetabo-lismof fructose favoringnew lipogenesis.Fructose(unlikeglucose)doesnotenhanceleptinproductionorstimulateinsulinsecre-tion, suggesting thatdietary fructosemaycontributetoweightgain.

Canesugarisessentiallypuresucrose,adisaccharide,equallyconsistingoffructoseandglucose.Incontrasttofructose,glucoseabsorptionandmetabolismisdependentoninsulinstimulationtoeffectthetransportmechanismand trigger insulin receptors.Leptinreleaseisstimulatedbyinsulinandisknowntoinhibitfoodintakeandlessenhungerandgainsinbodyfat.

Whilethereisaprovocativetemporalassociation of HFCS with the growingepidemicsofobesityandtypeIIdiabetes,there are confounding covariables thatmake it difficult to label this food anddrinksweetenerastheprimeculpritintheepidemics.Possibletaxationonitsinclusioninfoodsandbeveragesmaybetheonlylogi-calmeanstodecreaseoreliminateitsuse

in foodsanddrinks.(It isclear thathighU.S.sugartariffsandimportquotasmakedomesticallygrown,corn-basedsweetenersmoreeconomicallyadvantageous.)

So,what is thispossiblyunnatural,ultra-sweet high-fructose corn syrup, of

whichtheaverageAmerican con-sumed19.2kg.perin2004(versus20kg.of sugar), justthirty years afterit was developedandpromptly in-cluded in manyprocessed foods,

sodabeverages,andotherfooditemsintheUnitedStates? (TheaverageAustralianconsumed56.2kgofsugarin2002).HFCSincludesagroupofcornsyrupsthathaveundergoneenzymaticprocessing inordertoincreasetheirfructosecontent,thenaremixedwithglucoseorpurecornsyrupinvaryingamounts.Forexample,HFCS90is approximately90percent fructoseand10percentglucoseandismostcommonlyusedinbakedgoods.HFCS55ismostcom-monlyusedinsoftdrinks,andHFCS42(42percentfructoseand58percentglucose)ismostoftenusedinsportsdrinks.Theprocessfor enzymaticconversionofd-glucose tod-fructosewasoriginallydevelopedbyU.S.scientistsRichardMarshallandEarlKoolin1957andsubsequentlyrefinedbyJapaneseresearchersinthe1970s,beforewidespreadintroduction into U.S. food production(MarshallandKool1957).Thisprovidedmajoreconomicadvantages for thecornmarketintheU.S.,wherethepriceofsugaris artificiallyhigher than itsglobalprice.HFCSis rarelyused inEuropeandotherpartsoftheworld,exceptforJapan,where

i n2006,theCenterforScienceinthePublic Interest (CSPI) threatened alawsuit against Cadbury Schweppes

forfalselyadvertising7Upas“allnatural,”citing that itcontainshigh-fructosecornsyrup (HFCS). Although the FederalDrugAdministra-tionhasnodefini-tionof “natural,”CSPI c la imedthat HFCS wasnot natural, dueto the significantamountofprocess-inganduseofoneor more geneti-callymodifiedenzymesrequiredtoproduceit.CadburySchweppesannouncedinJanu-ary2007thatitwouldceasedescribing7Upas“allnatural.”

Since the 2004 publication by Dr.GeorgeBrayandassociatesof anarticlesuggestingacausalassociationofHFCSintheobesityepidemic,ongoingcontroversycontinues about the roleplayedby thisubiquitous sweetener. Dr. Bray and hiscoauthorsnotedthattheconsumptionofHFCS increased more than a thousandpercentbetween1970and1990,exceed-ingchanges in intakeof anyother foodorfoodgroup(Bray,Neilson,andPopkin2004).Others argue that increased foodanddrinkportionsizesandAmericanlife-stylechanges,suchasmorefastfoodsandeatingout,decreasedexercise, andmorecomputerandvideotimeversussportsoroutdooractivities,alsohaveetiologicroles.EagertodiscountanycausalroleofHFCS,theU.S.FarmandCornRefiners lobbieshavepointedtoincreasingratesofobesityanddiabetesincountriessuchasMexico,whereHFCSisnotacommoningredient Continued on Page 33...

“Consumption of HFCS increased more than a thousand percent between 1970 and 1990, exceeding changes in intake of any other food or food group.”

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Mercury UpdateWhere Things Stand as of April 2007

Jane Hightower, MD

T heissueofmercurypollutioncon-tinuestobringuslivelydiscussionspitting health impacts against

economicones.TheAmericanMedicalAs-sociation(AMA),asaresultofaresolutionbroughtbytheIllinoisdelegation,recentlyaddressedthecurrentstateofmercurypollu-tion.Itidentifiedthechlor-alkalimanufac-turingindustry(whichproduceschlorine)asoneofthechemicalindustriesthatwasstillcontinuingtodumpmercuryintotheenvironment.Whilefifty-threeplants intheUSAhadchanged toanon-mercurysystem,nineplantsineightstatesstillhadnot.TheseHg-cell plants emitMercury(Hg)intotheairandwater,andtheircon-taminationresultsintheaccumulationofmercuryandsubsequentmethylmercuryinthesurroundingfishandotherwildlife.Inrecentyears,sixty-fivetonsofmercurywasunaccounted for by theseplants,whichprompteda2003EPAstatementdeclar-ing,“Thefateofallthemercuryconsumedatmercury-cellchlor-alkaliplantsremainssomewhatofanenigma.”Theindustry,inturn,claimedtheremaindermercurywascontainedonsitewithinthemanufacturinginfrastructureandprocessingequipment.

TheAMAaddressed theCleanAirMercuryRuleinitsreportaswell,statingthatthetradingofairpollutantsthatthegovernmentwasusingasamercurypollu-tioncontrolmethodwaspotentiallyharmfulforvulnerablepopulations,andthattherulethatwascurrentlyinplacebyourgovern-mentwas inconsistentwith theAMA’shealth-protectiveapproachtoairpollution.Intheend,theAMAurgedstategovern-mentstobeproactiveinprotectingcitizensfromharmfulmercuryemissions,andforthereductioninmercuryuseinmanufacturingwheneverpossible. It recommended in-

creasedvigilance,monitoring,andtrackingofmercuryuseandemissionsinchlor-alkalifacilitiesthatusemercuryinthemanufactur-ingprocesses.Lastly,theAMAencouragedtheU.S.governmenttoassumealeadershiproleinreducingtheglobalmercuryburdenand work towardpromotingbinding,health-protectiveinternationalstan-dards (AmericanMedical Associa-tion2006).

Thefederally-fundedWomen,In-fants,andChildrenprogram (WIC)had a recent vic-tory.Thisprogramgivesvouchers for thepurchaseof selectfooditemstopregnantornursingmothers,toincludetwenty-fourouncesofalbacoretunapermonth.Thewomenpreviouslyhadnoothernondairyproteinoptionsintheprogram.Quietly,onAugust7,2006,theFederalRegisterannouncedaproposedrulethatstated,“foreaseofadministrationbyStateagencies,toaccommodatepartici-pantpreferences,andtominimizeintakeofmercury,thisproposedrulewouldauthorizethefollowingvarietiesofcannedfish—lighttuna,salmon,andsardines.”Italsoproposedtoraisetheamountofcannedfishallowedtothirtyouncespermonth.Thepurchaseofalbacoretunawasnolongerallowedwiththe federalgovernmentvoucher (FederalRegister2006).

InFebruaryof2006Ipublishedapaperontheprevalenceofelevatedmercurylevelsin thebloodofAsians,Pacific Islanders,andNativeAmericans,otherwiseknownas“Other”bytheCentersforDiseaseControl

(CDC).AlthoughtheCDChadbeenusingthisgroup’sdataforthefinalanalysisandin-terpretationofourUnitedStatespopulationasawhole,thecategoryitselfwasnoten-teredintothetablesoftheirreports.WhiletheU.S.populationasawholehadtheprev-

alence of 5.66%being over 5.8mcg/LHgintheirblood,the“Other”groupwas16.59%over (Hightower2006).

It is still un-clear why theCDC leaves the“Other”groupoffoftheirtables,butforCalifornia,itis

especially important. In the2000UnitedStatesCensus,4.1millionpeopleidentifiedthemselvesasNativeAmericanorAlaskanNative;12.5millionidentifiedthemselvesasAsianorPacificIslander,with51percentresiding in theWest.ThisbecomesevenmoreimportantforourongoingCaliforniaProposition65courtbattleoverwhetherthemercuryadvisoryshouldbeplacednearoroncansofalbacoretuna.Thetunaindustryhasconvincedthejudgeinthecase,throughless-than-credible evidence by industryexperts,thatmethylmercurywas“naturallyoccurring”inthefish,whichgavethemabreakunder the statute.Also, the judgeallowedaterrificamountofwateringdownthrough“averaging”ofdata,tothepointofallowingtheaveragealbacoremercurylevelstobeaveragedwiththeaveragechunklightmercury levels (albacorehas three timesmoremercury thanchunk light).As forthehumandatathatisnowavailabletothe

Continued on Page 33...Continued on Page 33...

“The AMA encouraged the U.S. government to assume a leadership role in reducing the global mercury burden and work toward promoting binding, health-protective international standards.”



Improving the City’s Food SystemA Public-Private Partnership Works toward a Healthier San Francisco

Paula Jones and Rajiv Bhatia, MD, MPH

toensurethatlow-incomeSanFranciscanscanuse their food stampbenefitsatSanFrancisco’sfarmer’smarkets.

Anotherpriority focusareahasbeenthequalityof food inpublic schools. In2003, SFUSD’s Student Nutrition andPhysicalActivityCommitteedevelopedanutritionpolicythatincludedhigh-prioritypilotprogramsaimedatimprovingtheuti-lizationandqualityoftheschoolmealpro-gram.SFUSD,withthesupportofseveralcommitteemembers,hassubsequentlypi-lotedmanyinnovativeprograms,includingtheGrab’n’Gobreakfastanddailyofferingsoffruitbars,andithasdevelopedamodelWellnessPolicy.ThroughapartnershipwithTheFruitGuys,alocallyownedpro-ducecompany,SFUSDstudentshavehadaccesstoorganicandsustainablyproducedfruitthroughtheschoolbreakfastandlunchprogram.In2006,SFUSDwontheCon-gressionalVictoryagainstHungerAwardforitsworktoimproveschoolmeals.

TheDepartmentofChildren,YouthandtheirFamilies(DCYF)hasalsoprovidedleadershiptoensurethatduringthesummermonths,SanFrancisco’s school childrenhavehealthymealsintheirneighborhoods.During the school year, approximately21,000schoolchildreneatfreelunchesatschool,whileduringthesummermonths,onlyabout5,000childrenparticipate inthe federally sponsored Summer FoodServiceProgramoperatedthroughneigh-borhoodorganizations.DCYF,alongwiththeSanFranciscoFoodBankandmanyothercommunitypartners,hasfocusedonthreeareas:enlistingmoreneighborhoodorganizations to participate, developingmarketing informationto informparents,andincludingmorevarietiesofsummerfruitintheprogram.

gardens,schoolgardens,farmer’smarkets,andregionalagriculture.Foodsystemsac-torsareworkingtogetherthroughadiversearrayofothercollaborations,suchastheSanFranciscoUnifiedSchoolDistrictStudent

NutritionandPhysicalActivityCommit-tee,theBoardofSupervisor’sFoodSecurityTaskForce,theGreenSchoolyardAlliance,andtheShapeUpCoalition.

Onekey goal sharedbymany foodsystemsstakeholdershasbeento increasetheamountandqualityof foodresourcesforthecity’smostvulnerablefamilies.Forexample,approximately40,000SanFrancis-cansareeligibleforbutnotenrolledintheFoodStampProgram—themostwidelyusedfederalnutritionsupportprogram.Lastfall,theSanFranciscoHumanServiceAgency,workinginconjunctionwiththeFoodSe-curityTaskForce,wasawarded$1millionbytheUSDAtoimprovefoodstampaccessinSanFrancisco.SanFranciscoFoodSys-tems,inpartnershipwiththeSanFranciscoDepartmentofPublicHealth (SFDPH)HumanServiceAgency,workedwithlo-calfarmer’smarketstoimplementsystems

l ikemanyurbancenters,SanFran-ciscofacessignificantchallengestocreatingandmaintainingahealthy

food system forall residents.Hungerandfoodinsecurityareontherise,andthereisanever-growingdemandforfoodpantriesandother formsofemergency foodassis-tance.Atthesametime,theoverabundanceof cheap foodof lownutritionalqualitycontributestoanepidemicofobesity,dia-betes,andotherdiet-relateddiseases.SanFranciscotakesprideinitshigh-qualityandethnicallydiverse restaurants, butmanyresidentsalsolackaffordable,healthyfoodoptionsintheirownneighborhoods.Withfederaland statebudgets tightening,SanFranciscoriskscutstocrucialfederalnutri-tionprogramsthatserveourmostvulnerableresidents.Additionally,our foodchoiceshaveresultedinenvironmentalissues,in-cludingairandwaterpollutionfromfoodproduction,distribution, andprocessing;pesticideexposure;hazardstofarmworkers;andthelossofCalifornia’sfarmlands.

San Franciscans recognize that allthese food issuesare linked togetherandthattheyaresignificantforpublichealth,socialjustice,andecologicalsustainability.Theseproblemsalsorequireworkingacrosstraditional sectors,usinga systems-basedapproach.Asa result,manygovernmentagencies,community-basedorganizations,residents,andbusinessesarenowaimingtoharnesstheircollectivepowertofindmulti-objectivesolutionsateverypotentiallevelofaction.In2005,inanactionconsistentwiththis systemsapproach, theSanFranciscoFoodAlliancepublishedtheSan Francisco Collaborative Food System Assessment toprovideabaselinepictureofSanFrancisco’sfoodsystemthatincludesretailers,distribu-tors,federalnutritionprograms,community

“Hunger and food insecurity are on the rise, and, at the same time, the overabundance of cheap food of low nutritional quality contributes to an epidemic of obesity, diabetes, and other diet-related diseases.”

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Work toprovidehealthier food re-sources at the neighborhood level hasalsoenlisted smallbusinesses.TheGoodNeighborProjectinBayviewHuntersPointisacollectiveeffortbyLiteracyforEnviron-mentalJustice,theSFDPH,theDepartmentoftheEnvironment,andtheMayor’sOfficeofEconomicDevelopment, joiningwithSanFranciscoCommunityPower,RainbowGrocery, and theSanFranciscoProduceTerminal.This collectivehasworked tosupport small business byproviding thenecessaryrefrigeration,in-storemarketingmaterials,andbrandingtoencourageshop-perstopurchasehealthierfoods.Therearenow several Good Neighbor merchantsinBayview,includingSuperSaveandtheBayviewHuntersPointFarmer’sMarket.In2006,AssemblymemberMarkLenousedtheseprogramsasmodelsinlegislationthatcreatedastatewide“HealthyPurchase”pilotprogramtogivecornerstoreownersinlow-incomeareasassistanceinprovidingfreshfruitsandvegetablestotheircustomers.

Thefocusonvulnerablepopulations,schools,andneighborhoodsisnowtricklinguptocitylevel.Anexampleofacitywide

foodsystemsactionisthe2006SustainableFoodPolicybySanFranciscoDepartmentofPublicHealth.ThispolicyrequiresSFDPHtoincreasetheamountoflocal,sustainablefoodsofferedbycontractorsandservedinthe public hospitals and at departmentevents.ThisSFDPHpolicywillultimatelyserveasthefoundationforacitywidesus-tainable-foodpurchasingpolicy.

Othercitywide strategies to improveour food systemwill requireattention toland-use planning, in order to supportneighborhood supermarketsandcommu-nitygardens,andtofiscalmechanismstosupporthealthychoices.Thereisnoshort-ageofideas,andSanFranciscoisanidealenvironment to supportexperimentationandinnovation.

SupportforSanFrancisco’slocaleffortsandmorelong-lastingchangesinregionalandnationwidefoodsystemsalsorequiresattentiontofederalpolicy.Forexample,the2007U.S.FarmBillauthorizeshundredsofbillionsofdollarsinspendingandaffectsthequalityoffoodineverycity.Fortunately,thebroadparticipationinfoodsystemseffortshasledtoawarenessonthepartofCitylead-

ersoftheimpactoffederalpolicy,andSanFranciscohasbegunadvocatingforchangesintheFarmBill.Theseeffortscallonthefederalgovernmenttoprotectandenhancefederalnutritionprograms,supportregionalfruit andvegetable growers, and supportecologically sustainable farmingpractices.Establishingacoherentandhealthy foodsysteminaglobaleconomyisadauntingtask,buteffective solutionscanbe foundbyworkingacrosssectorswithgovernmentagencies, communityorganizations, andbusinesses.Usingafoodsystemsapproach,wehopeSanFranciscowillhelppointthewayforward.

Paula Jones is the Director of San Fran-cisco Food Systems at the SFDPH, and Rajiv Bhatia, MD, MPH, is the Director of Oc-cupational and Environmental Health at the SFDPH.

court,thejudgedecidedthataratstudyfrom1980representedthe“bestquality”andthatityieldedthelowestNoObservableEffectLevel(NOEL) forhumans. Inthis study,sixteenpregnant ratsweregivenvaryingdosesofmethylmercuryduring fourdaysofgestation.The subsequenteightypupswerethenputthroughaseriesoftests,toincludepressingleverstoobtainfood.Isawnowhereinthispaperthattheratsweretry-ingtogetintoPrinceton.TheFaroesandnoweventheSeychelleshaveseenadverseeffectsonthehumanfetus,buttheindustryarguedaboutwhat“type”ofstudiescouldbeallowedunderthestatute.Itwasacompli-catedmessandisnowonappeal(Hightower2006,thePeoplevs.theStateofCalifornia2006,Bornhausen1980).

Allinall,ourProposition65statuteseemstobetheretoprotectthe“ordinary”or “average”consumer.According to theNationalHealthandNutritionExamina-tionSurvey (NHANES)data,notonly

butisprobablyprematureuntilandunlessfutureresearchconvincinglyestablishesitscausalrole.SelectiveeliminationofHFCSfromanyone’sdiet ischallenging,as it iscontained in almost all U.S.-producedprocessedorpreparedfoodsandisdifficulttoavoidifoneeatsout.Cautiousreadingof labelsofany frozen,baked,orcannedgoods to prevent consumption of itemscontainingHFCSisencouraged,alongwithexercise,well-balancedmeals,andhealthylifestyles.

Lucy Crain, MD, MPH, FAAP, is a member of the SFMS Board of Directors and a First Five San Francisco County Commis-sioner. She is Past President of the California District of the American Academy of Pediatrics and a former member of the national Board of Directors of the AAP. Since her retirement from full-time pediatric practice and teaching at UCSF, Dr. Crain continues to teach at UCSF as a member of the voluntary clinical faculty and consults at Lucile Packard Children’s Hospital at Stanford in the Child Development Clinic. Mel Heyman, MD, also contributed to this article. Dr. Heyman is Chief of Pediatric Gas-troenterolgy at UCSF. A full list of references is available on our website at www.sfms.org.

Mercury Update Continued from Page 31...

High-Fructose Continued from Page 30...

do coastal people have higher mercurylevelsthaninlandpeoplebecauseoftheirincreasedfishconsumption,wealsohavethe“Other”peopleinhighernumbers.Our“ordinary”inCaliforniaisnotthe“ordinary”ofNebraska.

Asforfishconsumptioninadults,bothmenandwomen,thecurrentadviceisthattwothree-ounceservingsoronesix-ounceservingperweekiswherethebenefitsout-weightherisk,butuptotwelveouncesisac-ceptableifthefisharelowincontaminants(Mozaffarian2006).

Jane Hightower, MD, specializes in

internal medicine at California Pacific Medi-cal Center in San Francisco and has done extensive research on mercury exposure from fish in adults. She is a member of the San Francisco Medical Society and currently serves on the SFMS Board of Directors. A full list of references is available on our website at www.sfms.org.

�4San FranciSco MedicineApril 2007 www.sfms.org

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beans,fruits,coffee,dairyproducts,meats—younameit—arecontaminatedwithunnecessary levelsofpesticides, antibiotics andotherdangerouschemicals.Theamountandtypesoffertilizersused,whichundeniablyhaveincreasedfarmyieldsinthepast,arewastefulandvastlypolluting.Water,anincreasinglyscarcenecessity—“Itisnotamatterof‘if’butratherofwhentheWest’swaterresourceswillbecompletelydepleted”—issquanderedandpollutedaswell.

Industrialagriculturealsokillsoffnatureitself,fromthebiodiversityofplantsneededtomaintainhealthysoiltothebirdsandbeesthathelppollinatecrops.Andvast levelsofhumanstarvationandmalnutritionpersistdespitethemuch-vauntedgreenrevolution,whichwassupposedto solve thatemotionallyungraspable tragedy. In fact, the suffering isworsening:“Since1950,aboutone-thirdofAmericancroppedlandhasbeenabandonedbecauseofproblemswithsoilerosion.”

Thesefailures,theseauthorshold,arebothtechnologicalandeco-nomic.Quickfixeslikegeneticallyengineered,orGE,foodandirradiationareshowntobechimeraswithhugerisks,whichgovernmentwatchdogsrefusetoinvestigatefully,letaloneregulate:“TheFDA’sresponsetothepotentialtoxicityproblemwithGEfoodswas,andcontinuestobe,toignoreit.”

Patentingofseedsandgenesforprofitpromisesmorestarvationthansolutions.Overall,thecorporatetakeoverofagriculturesacrificesfoodqual-ityandsafetytophantomefficiency,thesmallerfarmertobankruptcyanddespair,andthehealthandsurvivalofmillionstothebottomline.

Gloomy?Yes.Unappetizing?Yesagain.But theprovokingofourgag reflex is intentional. “FatalHarvest”aims foroutrage,even in theotherwiseunconcernedaffluentgourmand:Thelossofchoicesinfoodsishammeredhomeoverandoveragainwithastonishingillustrationsofallthevarietiesoffruitsandvegetableswearenowdeniedbecauseof“ef-ficient”modernfarming.

Thesolutions?Moreorganicfarming,localcontrolanda“naturalsystems”agriculture thatworksby“emphasizingNature’swisdomoverhumancleverness,”asfarmerandprofessorWesJacksonarguesinperhapsthemostimportantpracticalcontributionherein.Manyothers,includinglocalluminariessuchaschefAliceWatersandAnuradhaMittalfromthepioneeringthinktankFoodFirst,offersupportingevidenceandperspec-tives.Thechangestheyurgewillbevastlydifficulttoeffect,morebecauseofpoliticalobstacles thananyotherhurdles.Butwhere is theremoreimportantaneed?

This book review originally appeared in the SanFranciscoChronicle.

Fatal Harvest:The Tragedy of Industrial AgricultureEditedbyAndrewKimbrellISLAND;396Pages;$75,$45PAPERBACK

There’snothingmorefundamentalthanfood,andaffluentAmeri-canshavemoreof it,withmorevariety tochoose from, thananyoneinhistory.Buthowmanyofusknowwhereourfoodwas

actuallyproduced,bywhom,andwithwhatresourcesandadditives?Howdoesthepathfrommodernfarmtokitchenaffectpeopleandtheplanet?

“FatalHarvest”isahugeworkthataddressesthosesweepingquestions.Itisabeautiful,photo-laden,51/2-poundtreatisethatmightbecalledacoffee-tablebook—if thecontentweren’t sodisturbing.Evenacasualbrowserofthesepagesiswarnedtothinktwiceabouteatingordrinkingmuchofwhatissoldasfoodnowadays.Itisanencyclopediaofwhat’sgonewrongwithhowweprovidefoodinthemodernworld.

“Weeatourdailybreadwithoutbeingconsciousofthemassivelossoftopsoil,diversity,andfarmcommunitiesinvolvedinitsproduction,”writeseditorAndrewKimbrell.“Wehappilymunchonhamburgerswithoutathoughttotheforestandprairiebeingdestroyedforcattlegrazingortheimmensecrueltyintheraisingandslaughteringoftheanimals.Motherscontinuetoprodtheirchildrentoeattheirvegetables,unawareofthepesti-cidepoisoningofourwaters,farmworkers,andwildlifethatisinvolved.”

Iftheseunappetizingchargessoundmostly likeenvironmental is-sues,theyare,buttheyhaveseldombeenpresentedassuch.FarmerandphilosopherWendellBerrywrote the still-classic agricultural critique“TheUnsettlingofAmerica”in1977,andhisnewessaysbookendthisvolume.Hearguesthattheenvironmentalistagenda“hasrarelyincludedtheeconomicsoflanduse,withoutwhichtheconservationeffortbecomesalmostinevitablylongonsentimentandshortonpracticality.”

Inotherwords,savingwilderness,howeverimportant,isnotenough.WhatBerryandthemanyauthorssaywemustconserve,andrevitalize,isthesmaller,decentralizedfarm,whichwasthenormuntilthepastcenturyofindustrializationandconsolidation.Butisthisvisionrealistic?Yes,saytheseauthors,forit’sessentialtothehealthandwelfareofnotonlyhumansbutalllifeaswell.“Agrassrootspublicmovementfororganic,ecological,andhumanefoodisnowchallengingthedecades-longhegemonyofthecorporate,industrialmodel,”Kimbrellnotes.Hethenturnstheexamina-tionofthatmodelovertothreedozenauthorsfromdiversebackgroundswho,inaggregate,presentadevastating,perhapsoverwhelmingcritiqueofmodern“farming.”Theattacksrangefromthosebasedonabstractconceptstopresentationsoftechnicalalternatives.

Readerswillconfrontconvincingevidencethatmanyofthepromisesofmoderntechnologicalfarminghavenotbeenfulfilled,andinfacthavebeencounterproductiveinmanyways.Ourfoods—vegetables,nuts,grains,

Steve Heilig, MPH

What’s Gone Wrong with How We Produce Food?

Book reVieW


CPMCDamian Augustyn, MD

KaiserRobert Mithun, MD

TheDepartmentofUrologyhelditsFirstAnnualUrologyUpdateonSaturday,February10,2007,at theMandarinOrientalHotel indowntownSanFrancisco.Attendedbyurolo-giststhroughouttheSutterHealthSystem,theprogramaddressedthelatestcutting-edgethera-pies,innovativesurgicaltechniques,andpracticemanagementupdates.

TheDepartmentofOrthopaedicSurgeryisproudtopresent“HotTopics inSurgeryoftheShoulder,Elbow,andHand”onFriday,July27,2007,attheMiyakoHotelinSanFrancisco.Aninternationallyrecognizedfacultywillcoveravarietyof topics, includingmanagementofshoulderosteoarthritis in the youngpatient,“reverse”totalshoulderreplacement,optionsfortreatmentoflargeandmassiverotatorcufftears,managementofthestiffelbow,managementofnonunionsandradialnervepalsyinthehumerus,andtheuseofpyrocarbonimplantsinthehand.Our guest speakerwill beDr.Wayne “Buzz”Burkhead,currentPresidentof theAmericanAssociationofShoulderandElbowSurgeons.Formore information,pleasecontactBeverlyHooverat(415)600-6484.

PleasesavethedatefortheSecondAnnualCPMCPediatricHospitalistMedicineConfer-ence.Thistwo-dayconferencewilltakeplaceOctober25–26,2007,attheSirFrancisDrakeHotelinSanFrancisco.

IncorporatinghealthyfoodpracticesintothecultureoftheSanFranciscoMedicalCenterisoneoftheexplicitgoalsofKaiserPermanente’sComprehensive Food Policy. As professedin thevision statementof thepolicy, “KaiserPermanenteaspires to improve thehealthofourmembers,employees,ourcommunities,andtheenvironmentbyincreasingaccesstofresh,healthyfoodinandaroundourKaiserPerma-nente facilities.Wewillpromoteagriculturalpracticesthatareecologicallysound,economi-callyviable,andsociallyresponsiblebythewaywepurchasefood.”

Launchedinfall2005,theHealthyPicksprogramhassuccessfullyconverted50percentoftheregionalvendingmachineitemstohealthychoices,includingfreshfruit,driedfruitswith-outadded sugar, green teadrinks, andwater.Subsequently,Kaiserexpanded theproject tohospitalcafeteriasandinpatientmenus,andithasrecentlybegunusingfresh,seasonalproducefromsmall,localfarmsinpatients’meals.AllnewfoodcontractsarealignedwiththephilosophyandpracticedetailedinKaiser’sNationalFoodPurchasingandLabelingGuidelines.Wheneverpossible,theorganizationwillchoosetocontractwiththosevendorswhobuyfromlocallyownedandoperatedfarmsandbusinessesthatsupplyseasonalandfreshproducts.Weendeavortopur-chaseUSDAOrganic,FairTrade,FoodAlliance,ProtectedHarvest,orotherthirdparty-certifiedfoodfromourvendors.

Additionally,severalKaiserfacilitieshostweekly farmer’smarkets, easily accessible tomembers,physicians,andstaff.Thevendorsofferproduceandotherproducts fromasmallgeo-graphicarea,whichallowsfortheleastamountofenvironmentalimpact.Nutritionandmedi-cine,onceviewedbythemedicalcommunityasverydistantcousins,arenowcommonlyheldbymanydisciplinesasbeingequallyintegraltogoodhealthandoverallwell-being.

HoSPiTaL neWSSt.Luke’s

Jerome Franz, MD

MarchatSt.Luke’swasdedicatedtothereductionofmedicationerrors.Afterlastyear’sreport by the Institute of Medicine on thenumberofinjuriessufferedinthiscountryfrommedications,andinlinewithJCAHO’snewre-quirements,St.Luke’s—likemosthospitals—haslaunchedamajorefforttochangeourways.TheDirectorofPharmacy,JohnQaqundah,hasledtheprogram,holdingin-servicesforallclinicalemployees,presentingaGrandRoundsonmedi-cationerrors,anddiscussingthenewpolicywiththemedicalstaffat“DoctorTalk.”Hedeservesmuchcreditforhispersistence.

Acknowledgingourroleasthefourthcam-pusofCPMC,themedicalstaffleadershipatSt.Luke’shasenteredintoastrongpartnershipwithadministrationtoensureafutureforhealthcareSouthofMarket.Thekeyisbuildingpracticesofprimaryandspecialtycarethatwillcontinuetothrive,evenifweareultimatelyforcedtocloseacutecareduetoseismicrequirements.Butwehavenotyet givenuphope forourhospital,whosemissionandrichhistoryofprovidingcaretoanunderservedpopulationhasinspiredourcareers.Moreinfuturecolumns.

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TheSanFranciscoMedicalSocietyoffersmultipleadvertisingoppor-tunitiesrangingfromfull-page,4-colordisplayadstoclassifiedadswithdiscountedratesformembers.PleasecontactAmandaDenzformoreinformation,(415)[email protected].

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SaintFrancisGuido Gores, MD

ThisspringbringsappointmentchangestoSaintFrancisMemorialHospital,andthiswillbemylastcolumnasChiefofStaff.ThenomineeformysuccessorisWadeAubry,MD,whowillauthorthiscolumnmovingforward.Dr.AubryisanendocrinologistandinternistandisalongtimememberoftheSFMHstaff.HeisanAssociateClinicalProfessorofMedicineatUCSFandaformerSeniorVice-PresidentandChiefMedicalOfficerforBlueShieldofCalifornia.Forthepastseveralyears,hehasservedastheChairmanoftheSaintFrancisIRB.Dr.AubryisalsocoauthoroftherecentlypublishedFalse Hope: Bone Mar-row Transplantation for Breast Cancer (OxfordUniversityPress,2007).

NomineeforSecretary/TreasurerisfamilypractitionerPatriciaGalamba,MD.Dr.GalambaisMedicalDirectoroftheSFMHPalliativeCareProgramandaTrusteeoftheBoardaswellasChairoftheBioethicsCommittee.NomineesforMedicalExecutiveCommitteeMembersatLargeareRonaldValmassy,DPM;GiffordLeoung,MD;PhillipPiccinnini,MD;andPeterTeng,MD.Wewelcomethemtotheirnewpositions.

AtSaintFrancisMemorialHospital, in-novationinnutritionandfoodwasthesubjectof a recentGrandRounds.The speakerwasformerstaffmemberMelinaJampolis,MD,whospokeabouthealthyeating,dietfads,nutritionalfacts,theglycemicfoodindex,andtheroleofmetabolism.Dr. Jampolis servesasDiscoveryNetworkFitTV’sDietDoctorandistheauthoroftherecentlypublishedbookNo-Time-to-Lose Diet: The Busy Person’s Guide to Permanent Weight Loss(NelsonBooks,2007).

Iwillbereturningtofull-timepatientcareandthepracticeofmedicine.AsIstepdown,I’dliketothankmycolleaguesforalltheirhardworkandcooperationduringmytenure.It’sbeenapleasureworkingwithyouall.

St.Mary’sKenneth Mills, MD

UCSFRonald Miller, MD

Inarecentarticlein The New York Times, writerMichaelPollanexamineddietsandthehistoryofdietaryscienceinAmerica.Hecon-cludedthatdespitealltheproposedinnovationsindietaryrecommendations,verylittleactuallyseemstobemakinganysignificantdifferencetothehealthofAmericans.InPollan’sarticle,hediscussednutritionism—an ideology inwhichthekeytounderstandingfoodsisafocusontheindividualnutrients.This ideologyhasdrivenmuchofdietresearch,bothcurrentlyandinthepast.Unfortunately,studyingnutrientsindividu-allydoesnotaccountforothereffects,suchastheconcurrentinfluenceofothernutrients,lifestylefactors,orevenculturalandbiologicalfactors.

AccordingtoPollan,theWesterndietweAmericanshavebecomeaccustomedtohasasurfeitofmeatsandprocessed foods,with lotsofaddedsugarsandfats.Whataremissingarethe fruits andvegetables.Nutritionism takesthisWesterndietasagivenandsimplytriestomodifyitbytellingpeopletoeatmoreofthisnutrient(suchas“wholegrains”)andlessofthatnutrient(suchassaturatedfats).Afterdecadesofnutrient-basedadvice,obesityanddiabetesareontherise.TheWesterndietisglamorous,and17,000newfoodproductsareintroducedeveryyear.Americansnowfind themselves relyingonscience,journalism,andmarketingtohelpdecidewhat toeat.Pollan says that therearesimpler solutions to thisproblem.Amonghissuggestions are:don’t eat anything that yourgreat-great-grandmotherwouldn’t recognizeasfood;andavoidfoodsthatbearhealthclaims,sincetheyareusuallyheavilyprocessed.

AtSt.Mary’s,wetrytoprovidemealsthatarebothenjoyable andnutritious.Wedon’tfollow fads.Eating in amanner that is bothhealthyand realistic canbeconfusing, givenall theconflictingadvice.AtSt.Mary’s,ourregistereddietitiansandNutritionServicesstaffhelpsortitallout.

UCSFwelcomes the arrival of thefirstmemberofa teamthat isdeveloping thefirstheadacheclinicintheWestwithaninpatientcomponentfordiagnosisandtreatment.

Assistant Professor Abraham Nagy hasbegunseeingpatients,andinthecomingmonthshewillbejoinedbyotherneurologists,fellows,residents,nurses,andsupportstaff.HecomestoUCSFfromtheHeadacheGroupattheInstituteofNeurology,UniversityCollegeofLondon,QueenSquare.

LeadingtheteamwillbePeterJ.Goadsby,MD,PhD,whowill arriveatUCSFMedicalCenterinthenextfewmonths.RoundingouttheteamofattendingswillbeManjitS.Matharu,MB,ChB,MCRP,whowasaclinicalfellowwithGoadsbyandNagy.

“Ourgoalistoprovideconsultationfortheworstoftheworst,”Nagysays.“Thegoalisnottoprovidecontinuingcare,buttogivepatientsthetools,whichmayincludemedicationorlifestylechanges,todealwiththeirheadaches.”

Thereareplanstobeginclinicaltrialsaswellasbasicresearch,oncetheentireteamishere.“Morepeoplesufferfromheadachesthanthosewhosufferfromdiabetesandheartdiseasecombined,”Nagysays.“While[headaches]maynotbetreatedasseriouslyassomeotherafflic-tions,wehavetorememberadaywithamigraineisadayapersonisnotabletofunction.”

Nagy is currently seeingpatients in theoutpatientclinicat400Parnassus,butwhentheentireteamisassembled,itsmemberswillbeseeinginpatientsandoutpatientsatMt.Zion.Forappointments,calltheNeurologyClinicat(415)353-2273.

HoSPiTaL neWS


Americans tend to be overweight, andunfortunatelyveteransarenoexception.KarenArnold,MA,RD,ChiefoftheNutritionandFoodServiceatSFVAMC,acknowledgesthat73percentofveteransareoverweightandnearlyathirdareobese.Inresponse,bodymassindex(BMI)isnowroutinelycalculatedforeverynewpatientatSFVAMedicalCenterandcommu-nityoutpatientclinics.VeteranswithelevatedBMIsarereferredthroughtheVA’selectronicmedicalrecordssystemtoappropriateweight-lossinterventions.Tomeetthedemand,newclasses,individual counseling, and ongoing supportgroupshavebeenformed.

Medical Center inpatient meals havebeenmodified tomeetcurrentguidelinesandrecommendations for good nutrition. Goalsincludelimitingfattonomorethan30percentof calories, increasingmonounsaturated fats,eliminating trans fats, and reducing sodiumlevels to less thanthreegramsperday.Mealsalsoincludemorefiberthanbefore,withlargerportionsofvegetablesand100percentwholewheatbreadandrolls.

VA nursing home care is transitioningtoresident-centeredcare,whichpromotestheidea that thenursinghome is the resident’shome,whatever the lengthof stay.Dietarily,thismeansmorechoice,flexibilityofmealtimes,andliberalizeddiets.

TheVAemployeecafeteria switched totransfat-freecookingoilinmid-2006.Employeescanfindnoontimehealthycookingdemonstra-tionsand information tablescoveringcurrentnutritionandhealth topics.Topromoteem-ployeehealthandwellness,therearenoontimewalks,“MovetoMusic”programs,andafter-workyogaclasses.

TheSFVAMCNutritionandFoodServiceisdevelopingpartnershipswithlocalsmallfarmstobringfresh,locallygrownproducetoitsmenusandtosupportlocalagriculture.

VeteransDiana Nicoll, MD,

PhD, MPA

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in MeMoriaM

robert a. Major, Md

Dr.MajorwasborninHearne,Texas,onDecember20,1920,anddiedatPaloAltoonJanuary11,2007.Heispredeceasedbyhisparents,MaggardKeyMajorandLetaAllenMajor,andhisbrothers,AlexanderDavidMajor,MD,MillardHollandMajor,andJohnWilliamMajor,MD.

BobgraduatedfromBowieHighSchool(Bowie,Texas)in1936;hegraduatedfromTexasA&Min1938.HismedicaleducationwasatBaylorMedicalSchoolinDallasTexas,graduatinginMay,1942.HejoinedtheArmyMedicalCorpsandwassenttoEuropeinJuly,1944,withtheFifthAuxiliarySurgicalGroupfromTexas,landingonUtahBeachinAugust.Heworkedasananesthesiologistandassistantsurgeon,servinginfieldhospitalsinHolland,Belgium,France,andGermanyaspartofGeneralPatton’sNinthArmy.HewasdischargedinMay1946asMajorMajor.

BackinTexas,Bobwentintopracticewithhisphysicianbrothers,DavidandJohn.TheypracticedinNoconaatanewhospitalbuiltforthembytheirparents;theyhadalargeandsuccessfulpracticethere.However,in1956,Dr.MajormadeabigmovewesttoopenapracticeinSanFranciscoonTaravalStreet.Inthatsameyear,hemarriedPatriciaCarson,whowastobehiswifeofmorethanfiftyyears.BobcontinuedtopracticeoutofhisTaravalStreetofficeuntilhisretirementafewyearsago.HewasonstaffatSt.Luke’sHospital,CaliforniaPacificMedicalCenter,andSt.Mary’sHospital.HewasactiveatSt.Luke’s,wherehewaswellknownasanex-cellentclinicianandsurgicalassistant.Withhisoutgoingpersonalityandsenseofhumor,hehadmanyfriends.WhenheattendedhospitalpartieswearingapairofTexanboots,hecouldbethelifeoftheparty.Heseemedtothoroughlyenjoycaringforhispatients,butherecentlyrequestedthesewordsonhistombstone:“He’sNotonCallAnymore.”

HisaffiliationsincludedmembershipintheAmericanMedicalAs-

sociation,AmericanAcademyofGeneralPractice,AmericanAcademyofFamilyPhysicians,andAmericanBoardofFamilyMedicine.HewasdirectoroftheCaliforniaAcademyofFamilyPractice,editoroftheGP Journal forsixyears,AssistantClinicalProfessoratUCSF,andAssistantClinicalProfessoratStanford.

ruben e. Montes, Md

RubenE.Montes,Jr.,aneurologistandDirectoroftheStrokeCenteratKaiserPermanenteofSanFrancisco,diedathomeonJanuary17,2007,attheageof41.Hewasalsoaprominentfigureskatingjudge,followingasuccessfulcareerincompetitivefigureskating.Dr.Montesissurvivedbyhispartneroftwelveyears,DavidLewis;hisparents,RubenMontes,Sr.,andMaryMontes;andhis sisters,MarisaMontesandDr.MarisolMontesOrtiz.

Dr.MontescompletedhisearlyschoolingintheMontereyareawherehegrewup,finishinghighschoolattheRobertLouisStevensonSchool.HeattendedDartmouthCollegeandgraduatedfromU.C.atBerkeleywithabachelor’sdegreeinbiology.HismedicalschoolwasUCSF;hecompletedamedical/neurologyresidencyatStanfordandaneurologyfellowshipatHarvard.HethenbeganpracticeinneurologyatKaiserandwasappointedDirectoroftheStrokeCenter.

YoungRubenbeganiceskatingatageten,and,givenhisloveofthe sport,becamequiteproficient.Heenteredcompetitionsandwongoldmedalsinsinglesaswellaspairscompetitions.Afterheretiredfromcompetitionhebecameaskatingjudge,quicklyrisingtobecomeaU.S.nationalandinternationaljudgeandthefirstjudgeofthePuertoRicanFigureSkatingAssociation.

Stephen J. Askin, MD

BC/BE Internist sought for highly respected established multi-specialty group practice. Thriving outpatient practice with some inpatient responsibilities. Minimal call of 1:10 and four day workweek allows balance of work and lifestyle. Excellent support staff and full business office maximizes your time in providing patient care. Site offers full lab, x-ray, ultrasound, digital mammography, DEXA, treadmill and Holters. Very flexible vacation and generous CME, medical and 401(k) plan. Portland is a fantastic city with multiple cultural activities, outdoor recreation and within a short drive to the rugged coast or mountains. Practice medicine as you envision in a well compensated fee for service practice. Please respond by March 31, 2007. Contact Dr. James Johnson at [email protected] or fax resume to 503-382-7706.

Broadway Medical Clinic, LLPPortland, Oregon

Sutter Health offers a wide variety of practice styles, geographies, and life styles.

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April 2007

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