CC Cover finalA-NoBox - Cleveland Clinic · 2013. 12. 20. · summer 2008 Do your genes decide the...

summer 2008

Do your genes decide the size of your jeans?

clevelandclinicmagazine

Bye, fries! Shaping up America’s kids p.20

Pedometer power p.8

A surgical diabetes cure? p.26

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clevelandclinicmagazine contents

Cover photograph: Marge Ely

COVER STORY

12 Do Your Genes Decide the Size of Your Jeans? Somewhat. But you can do a lot to slip into your small-size denims, say experts. At the top of their list: Toss aside poor eating habits and get moving.

FEATURES

20 The Shape of Kids to Come Communities are bringing back P.E., restocking snack machines and selling vegetables on sidewalks to shape up America’s children. The very future of our next generation is at stake. Can we turn around the dangerous trend of our kids’ excess girth?

26 Sweet ResultsWhen the diagnosis is type 2 diabetes, weight-loss surgery may hold the key to a better life—even for people considered “thin” by traditional bariatric standards.

CC PROFILE

9 Getting Real About WellnessMichael Roizen, MD, on why we should stock up on walnuts and make living longer a priority.

volume 5 issue 2 • summer 2008

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contents clevelandclinicmagazine

DEPARTMENTS

clevelandclinic.org/ccm

ADVISORY BOARD

M. Bridget Duffy, MDChief Experience Offi cer, Professional Staff Affairs

Tanya Edwards, MD, MEdDirector, Center for Integrative Medicine

Cynthia GalbinceaExecutive Director, Division of Marketing, Communications and Planning

A. Marc Gillinov, MDThoracic and Cardiovascular Surgery

Grahame Kidd, PhDNeurosciences, Lerner Research Institute

Carol L. MossChairman, Institutional Relations and Development

Ellen Rome, MD, MPHHead, Section of Adolescent Medicine

James Young, MDChairman, Academic Department of Medicine Physician Director, Institutional Relations and Development

EDITORIAL AND DESIGN

Tricia Schellenbach, Managing EditorBarbara Ludwig Coleman, Creative Art DirectorCori Vanchieri, Senior Medical EditorKim Caviness, Senior EditorGinny Reardon, Project ManagerBridget Murray Law, Contributing Editor Glenn Pierce, Art DirectorAli Heck, Photo EditorBrenda Waugh, Production Artist

Editorial, Design and Project Management

Questions, comments and subscription requests:Cleveland Clinic MagazineThe Cleveland Clinic Foundation / AC 322Institutional Relations and Development 9500 Euclid AvenueCleveland, OH [email protected]

Cleveland Clinic Magazine is a biannual publication of The Cleveland Clinic Foundation. Copyright © 2008 Cleveland Clinic. All rights reserved. Reproduction or use without written permission of written or pictorial content in any manner is prohibited. Printed in the United States. The magazine accepts no unsolicited manuscripts, photography or artwork. Cleveland Clinic realizes that individuals would like to learn more about its particular programs, services or developments. At the same time, we fully respect the privacy of our patients. If you no longer wish to receive materials containing this information, please write to us at Cleveland Clinic Magazine, The Cleveland Clinic Foundation/ AC 322, 9500 Euclid Ave., Cleveland, OH 44195. This publication is for informational purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician’s medical assessment and medical judgment. Always consult fi rst with your physician about anything related to your health.

firstword 3 No time to waste in a fi ght against a

growing epidemic

medicinechest 4 On the Road Again

5 Heart Smarts

5 Get the Staple Remover

6 Disparities in Black & White

7 Better Than Counting Sperm

7 Anatomy 101: The Omentum

livinghealthy 8 Step It Up

The power of the pedometer.

diagnosischallenge 10 A Mysterious Malady

Swim instructor Leslie Whitt struggled to stay afl oat until her baffl ing disease was diagnosed and treated.

philanthropia 34 His Favorite Line of Work:

Mindy and Robert E. Rich Jr.

35 Sky-High Healing: The Kelvin and Eleanor Smith Foundation

36 Mission Possible: Diane and Tom Wamberg

37 Making Wellness a Priority: Darlene and James A. Brown Sr.

onthehorizon 40 Rocket Rodent

40 How Could This Cell Harm You?

41 Don’t Bypass the Statins

41 Scar-Free Surgery

asktheexperts 42 Ellen Rome, MD, MPH

Taking Thin Too Far

mystory 44 Working Weight

Sterling P. Shand III set out to lose 100 pounds before fi nishing college. He succeeded … with unforeseen long-term benefi ts.

Cleveland Clinic is proud to support the Forest Stewardship Council. FSC certifi cation helps ensure that the world’s forests are managed in a positive manner: environmentally, socially and economically.

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p.44


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A letter to our

readers from

Delos M. Cosgrove,

MD, CEO

and President

firstword

I see it every day — in the news, on the street, at the office. Americans are alarmingly heavier. How it began is not entirely clear, and how to reverse the trend is even murkier. Two things, however, are certain: The health consequences of an increasingly overweight society are

serious, and we have to do something about it.Conditions associated with being overweight range from

heart disease and diabetes to depression and bone and joint problems. As a physician, I’ve seen the effects on people. Chronic health issues have a big impact on quality of life and can come with substantial financial costs.

I’m painting a dire picture and, indeed, we are facing a challenge. The “simple” equation of “fewer calories con-sumed plus more exercise equals weight loss” — or, more important, well-being — is not so simple. Genetic predisposition, limited access to healthful foods and inad-equate opportunities for exercise can serve as blockades on the road to health. We all have busy lives, and making time to exercise and eat right can be tough. But all of us can take small, manageable steps to overcome these obstacles.

It starts with prevention at a young age. Children are increasingly at risk. In fact, it is here that the statistics are most striking. Thirty years ago, about 5 percent of U.S. children were considered overweight or obese. Today, that figure has more than tripled to 17 percent. Potential causes range from too little active play to too much fast food. But as teachers, parents and even grandparents, we can make a difference by acting as role models, offering support and becoming active alongside our young people — a win-win approach for everyone.

Lifestyle changes don’t have to be monumental. Take the stairs instead of the elevator. Challenge a friend to a game of tennis. Pack a lunch instead of opting for the drive-through. Attend an information session at a local health center. And always work with a primary-care physician.

Cleveland Clinic is trying to do its part to combat this new epidemic. Our physi-cians, researchers and educators are rising to the challenge in inspiring new ways, from pioneering applications for bariatric surgery to developing an elementary-level educational curriculum that encourages anti-obesity behaviors. Close to home, we’ve removed trans-fats from our hospital and food-service menus.

Successfully combating this health crisis will require multiple approaches and a group effort. Together, we can achieve a healthier tomorrow.

No time to waste in a fight against a growing epidemic

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Five StepS to Avoid injury

• Warm up for five minutes before and after your run.

• Stretch within a couple hours after working out.

• If you take time off, ease yourself back into your routine.

• Buy the right shoes at a store that specializes in running shoes.

• Don’t run the same way all the time; switch directions on your daily route.

On the Road Again

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Even as the pain in her knee grew worse month after month, 16-year-old Joanne Berry avoided the doctor. She wanted to keep running — 40 miles a week. Her high school cross country team was headed to the state cham-pionships, and there was no way she was going to miss it.

That attitude is common for runners who visit the Optimal Runners Performance Program at Cleveland Clinic, says physical therapist Amanda

Gordon, MPT. The trick is to understand the psychology of endurance athletes and design a program that they will actually do.

She and her colleagues — including Joanne’s physical therapist, Michele Dierkes, MPT — try not to eliminate running completely, but instead focus on cutting back run-ners’ miles to more manageable distances. Or, if the pain is too severe, as it became for Joanne, who had tendonitis and bursitis in her knee, Ms. Gordon recommends they switch to another sport, such as cycling or swimming. The switch allows athletes to stay in their training mind-sets and get a cardio workout without the injurious stress of running, she says. Then she customizes strength- and flexibility-building programs patients can do on their own.

Most of Ms. Gordon’s patients are serious runners with foot, ankle, knee or hip problems. She puts them through a series of strength and flexibility tests; then,

they hit the treadmill so she can videotape their running biomechanics. The video can reveal injury-causing problems in a runner’s form or point to changes Ms. Gordon’s team can suggest to improve running efficiency. “We show them the video so they can see the problems that we’ve found,” she says.

Sometimes runners just want to improve their times or train for a race, so exer-cise physiologist Heather Nettle, MA, helps them map out an endurance-building plan — often months in advance.

The rehab helps put 80 percent to 90 percent of the program’s injured runners back on the road relatively pain free, Ms. Gordon estimates. It did the trick for

Joanne, who recently ran an 800-meter race just 0.08 seconds off her personal best. — Ian Herbert

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HEART FAILURE AND HEART ATTACK. These distinct cardiac maladies can be managed — even reversed — with early, targeted treatment. But first it helps to know the difference, and the symptoms.

HeArt AttAckKnown medically as myocardial infarction, heart attack refers to heart muscle death usually caused by a blocked blood vessel or spasm that chokes off the blood supply. Symptoms include pain in the chest, back, arms or jaw; shortness of breath; sweating; and nausea.

Physicians immediately treat patients with blood-thinning drugs and may insert balloons and stents to remove clots and open vessels. In certain cases, they may perform immediate bypass surgery to reroute blood around clogged arteries and into the heart. Above all, response to someone having a heart attack must be rapid, says cardiologist Marianela Areces, MD, of Cleveland Clinic in Florida. “The sooner you open the artery, the sooner you may salvage cells that might otherwise die,” she says. “Time is muscle.”

HeArt FAilureIn heart failure, the heart may weaken over time so that it cannot efficiently pump blood around the body, or the heart may become stiff and unable to properly relax. Damage to the heart may stem from previous heart attacks, consistently high blood pressure or even an infection, among other causes.

Symptoms include fatigue, swollen feet and shortness of breath, which are caused by fluid backing up into the lungs. Patients often ascribe such symptoms to old age or just being out of shape. However, the sooner patients recognize the symptoms, the faster they’ll receive potentially life-saving treatment, chiefly drugs that flush out fluids, lower blood pressure and help the heart squeeze harder, says cardiologist Cristiana Scridon, MD, of Cleveland Clinic in Florida. Physicians also advise a low-salt diet to control blood pressure.

In the most severe cases, both heart attack and failure can require heart transplantation or lead to death. With early, targeted treatment, however, these distinct maladies of the heart can be managed — even reversed, says Dr. Areces. “There is much we can do to save this beautiful, yet complex machine,” she says. — Bridget Murray Law

HEAR

T

SmARTSGet the Staple Remover

The name of the proce-dure should be enough to turn people away. But people are trying ear stapling—getting one or

both of their ears stapled—hoping to shed problem pounds, without realizing the potential dangers.

The stapling method is, in some ways, akin to acupuncture, a technique in which thin needles are inserted through the skin at particu-lar points on the body to achieve a beneficial reaction — in this case, to curb cravings. But medical experts warn that stapling is a dangerous choice for losing weight.

“Getting your ear stapled is inviting infection in your cartilage, a very difficult-to-treat area of the body,” warns Tanya Edwards, MD, Medical Director of Cleveland Clinic’s Center for Integrative Medicine. Unlike acupuncture, which relies on very thin needles being well placed in the ear for minutes at a time, ear stapling uses surgical steel staples pierced into the ear’s inner cartilage and typically left in place for weeks or months. It could cause infection in one out of five users, she says. A lack of regulation also means people without medical training may be performing the procedure.

In the meantime, Dr. Edwards notes, studies have shown that when added to a diet and exercise program, acupuncture can help erase an extra 10 or 20 pounds in a year. — Tamar Nordenberg

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Black patients face double trouble when it comes to hardening of the arteries, a risk that increases with age and can lead to heart attacks and strokes. They are more likely than other races to develop the condition in their legs, hips and feet, and, according to a Cleveland Clinic study, they often don’t receive the treat-ments that could prevent the disease and its deadly complications.

More than 8 million Americans have hardening and narrowing of the arteries outside the heart, mainly in the lower extremities. The condition, known as peripheral arterial disease (PAD), is caused by the buildup of cholesterol, fat and other substances in the arteries. Blacks, who are three times more likely to develop PAD than Whites, fare worse with the condition than others for reasons researchers do not completely understand.

A team led by Telly Meadows, MD, a cardiologist at Cleveland Clinic, wanted answers. The researchers compared the medical histories of 236 Blacks with PAD to 1,810 Whites with the condition.

A greater proportion of Blacks had been diagnosed with several other health condi-tions that raised their risk for developing PAD, including high cholesterol, high blood pressure, diabetes and obesity. Yet they were less likely to be taking aspirin, cholesterol-lowering drugs or other medications that can keep these conditions in check and prevent PAD, according to the results reported at the American Heart Association’s 2007 Scientific Sessions.

“This study is important. It highlights some of the existing ethnic disparities in the treat-ment of patients with PAD,” Dr. Meadows says.

Although it doesn’t shed light on why Blacks are less likely to receive treatment, the study suggests doctors need to be more vigilant in assessing PAD risk factors in their Black patients. And those with PAD should “take an active initiative in their own health,” says Dr. Meadows, checking with their physician to make sure their risk factors, such as blood pressure and cholesterol, are within normal range or are being adequately controlled with appropriate therapies. — Steve Mitchell

Disparities in Black & White

keep it movingregular exercise, eating to

lower cholesterol levels and

smoking cessation are key

to halting peripheral arterial

disease’s (paD’s) progres-

sion and reducing risk for

stroke, heart attack and limb

amputation. medications may

be needed to control blood

pressure, cholesterol, blood

clotting and calf pain caused

by narrowing and harden-

ing of the arteries in the leg.

When all else fails, stents can

be surgically inserted into the

arteries to keep them open

and prevent blockage.

Source: American Heart Association

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Better Than Counting

Sperm“We don’t know why you can’t conceive” is devastating news for a couple trying to have a baby. For the past 50 years, testing for male infertility — looking at a semen sample and counting the sperm — has been too basic to offer much helpful information.

Two new tests, refined for diagnostic use by Cleveland Clinic scientists, are providing the kind of detail that makes pregnancy a possibility.

These new tests “go beyond semen analysis to look at how the sperm functions at the level of its DNA,” explains Edmund Sabanegh, MD, Director of the Center for Male Fertility at Cleveland Clinic’s Glickman Urological and Kidney Institute.

If the tests show a high number of molecules called free radi-cals (which can damage sperm cells) and there is a high amount of damage to the sperm DNA, Dr. Sabanegh looks for causes, such as enlarged veins in the scrotum (called varicoceles) or an undi-agnosed urinary tract infection. The former can be repaired with surgery; the latter requires antibiotics.

parenthood prohibitors1/3 MaLe INferTILITy 1/3 feMaLe INferTILITy 1/3 INferTILITy TrouBLeS IN BoTH parTNerS, or uNkNowN cauSeS

AnAtomy 101: tHe omentumIt’s an oddly named, unfamiliar organ. And if allowed to collect

excess fat, it can be dangerous to your health. The omentum is a

blanket of internal abdominal fat that rests on top of the intes-

tines and attaches to the stomach and small intestine. A healthy

omentum is transparent and lacelike. A fat-filled omentum is thick

and opaque, giving that unsightly “beer belly” its bulge. A fatty

omentum can quickly provoke bad cholesterol levels to rise and

block the hormone insulin from keeping blood sugar in check.

Diet and exercise can return a flabby omentum to its former

healthy self.

The omentum has its benefits. It contains germ-fighting cells

that battle infections in the abdomen. Surgeons have been known

to use the omentum as a kind of biological duct tape. Sections

of omentum are “taped” over cuts in the gastrointestinal tract, for

example, to help them heal. — cori Vanchieri

Dr. Sabanegh recently worked with a couple who could not conceive even though the man’s semen analysis was normal. The new tests showed that his semen had an elevated level of sperm-damaging free radicals. The man was treated with antibiotics and antioxidant vitamins C and E, which reduce free radicals. The couple is expecting a baby this summer.

Ashok Agarwal, PhD, Director of the Andrology Laboratory and Director of Research at the Reproductive Research Center at Cleveland Clinic, worked with Dr. Sabanegh to develop these tests, preparing them for use in a clinical setting. “We standardized them for use in human semen samples, developed quality-control guide-lines and determined cutoffs for normal and abnormal results.”

Explains Dr. Sabanegh, “These tests are extremely helpful when we are not sure what is causing a couple’s infertility,” which is the case for about 15 percent to 20 percent of infertile couples. Before these tests were available, he says, “we were missing some opportu-nities to identify and remedy problems.” — christine Theisen

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livinghealthy

The message to lose big and fast is everywhere: Trim 10 pounds in two weeks. Drop a dress size in a month.

Step It Up

To avoid fast-fix failure, a better approach might be simply walking more each day — with the help of a pedometer. Clip on one of these pager-sized gadgets that track daily steps, and you’ll more likely achieve slow, steady weight loss, according to several new studies.

“People need goals and plans to guide them on weight loss. That’s where the pedometer comes in,” explains exercise physiologist Gordon Blackburn, PhD, of Cleveland Clinic’s Heart and Vascular Institute. “If I want to do a thousand more steps today than yesterday, the pedometer gives me immediate feedback. That’s a powerful motivator.”

And though a thousand steps may sound as tough as three hours on the treadmill, it’s really just a few extra blocks, says Dr. Blackburn.

Pedometer Power Proof of pedometers’ benefits comes from an analysis of 26 studies, published in the Journal of the American Medical Association in November 2007: Among almost 3,000 research participants, those who wore the devices daily and used them longest lowered their body mass index, exercised more and dropped their blood pressure the most.

The reduction in blood pressure was especially significant — enough to lower stroke and heart disease risk considerably. “These were mostly small studies over 18 weeks, on average,” says lead author Dena M. Bravata, MD, MS, of Stanford University School of Medicine, who notes that the reduction over time could be even larger.

In line with the findings, an analysis of nine studies lasting up to a year found pedom-eter wearers lost an average of five pounds in a year. The analysis, involving 307 partici-pants, appeared in the January/February issue of Annals of Family Medicine.

SteP CheCking Of course, your pedometer only works when you add steps. In Dr. Bravata’s analysis, pedometer wearers walked more than they did pre-pedometer — an extra 2,000 to 2,500 steps, or about one mile, each day.

Those who set daily goals and recorded how well they met them increased their steps the most. Many experts suggest that pedometer packers aim for 10,000 steps a day, or five miles. But that might seem daunting to some, says Cleveland Clinic’s Dr. Blackburn. He recommends starting with small, realistic goals. “Look at where you are today and go up incrementally from there,” he says.

Some critics say too much is made of pedometers and that people who use them are more motivated to lose weight in the first place. That may be so, says Dr. Bravata, but a pedometer provides instant health feedback that, she speculates, could spur weight-loss motivation beyond just walking more.

“You might say, ‘I’m not walking as much as I should today. I’ll skip that cookie with lunch.’ Just by wearing it, you’re more likely to change your health behaviors in general.” — Bridget Murray Law

walk on BuyReady to try a pedometer,

but not sure where to start?

Step out with these tips from

the experts:

•don’t blow your budget.

If you like bells and whistles

like calorie and heart-rate

monitoring, you’ll spend

more than $20. But all you

really need is reliable step

counting, available for less.

•invest in a cover. It’s worth

spending a tad extra on this

feature; coverless models

tend to reset themselves if

bumped, erasing your hard-

earned steps.

•wear it on your waistband.

Center it over your knee for

an accurate reading.

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ccprofile

Getting Real About WellnessMichael Roizen, MD, began getting through to his patients when he adopted the label “anti-aging expert.” He co-founded RealAge.com, which has taught millions how to calculate their body’s age — for better or worse. Here’s what “Dr. Mike,” as he’s known on Oprah and PBS specials, has to say about living healthier and younger.

What is an “anti-aging” expert? It’s someone who motivates you to adopt the preventive measures within your control to help you live with a higher quality of life and less risk of death and disability at any age. You see, like any physician, I found a whole bunch of my patients just didn’t pay attention to what I said. They wouldn’t fill prescriptions or take their drugs reliably, for example. So, since almost everyone understands the concept of age, I found the idea of making yourself younger to be really motivating.

What is a person’s “real age”? RealAge is the actual age of your body, as opposed to your calendar age. Your RealAge can be many years older or younger based on your habits. You can control your genes to a much greater degree than any of us thought possible.

How so? Studies have shown that there are 148 factors, from continuing your education to how often you floss, that slow your rate of aging. I’ve adopted 145 of them. However, I don’t get enough sleep some-times, and I have more stress in my life than I should. And third, since I am a guy, I don’t take hormone therapy, which makes the RealAge of certain people younger at specific times.

So how old are you, really? I am 61 calendar years of age, and my RealAge is around 42.

You must have perfect eating habits to maintain that kind of RealAge. Do you allow yourself any food vices? People might say my food vice is coffee, but coffee is healthy, so I don’t consider that a vice — rather a joy. I do love walnuts, and I carry little packs with me. They are high in antioxidants and omega-3 fatty acid, which protect the heart.

When your chronological age begins creeping up on you, how do make yourself feel younger? Get on an exercise bike or walk. It is almost paradoxical: You feel tired so you don’t want to exercise, but if you get up and move you are energized.

I hear you play squash to relax. How can such an intense sport be relaxing? With squash you have to focus on the ball every second, or you’ll get hit with it. It seems like an intense activity, but in fact it is totally relaxing, because you can’t think of anything else.

People always say they’re too busy to exercise or do healthy things. How can they make the time? First, you say, “I am a priority; I am worth it.” So you resolve to exercise X amount of time. Or, you say, “As soon as I get up and go the bathroom, the next thing I am going to do after washing my hands is to floss my teeth for two minutes.” It is just a matter of doing small steps that make a big difference.

What is the weirdest health question you’ve gotten? There have been so many. We did a “poop show” on Oprah, and we got every question you could possibly think of. People were asking, “My poop is this color or this shape on Tuesdays, but this shape on Fridays or this fre-quency; what does that mean?” — Interview by Dennis Meredith

dr. roizen, an internist and anesthesiologist, is Cleveland Clinic’s Chief Wellness Officer.

realage is the actual age of your body, as opposed to your calendar age. your realage can be many years older or younger based on your habits.

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diagnosischallenge

“I started to feel really ill and really tired. The other swim teacher said I didn’t look good. I stumbled back to my cabin and when I got there, I passed out on some clothes on the floor.”

Counselors fetched the camp nurse. “They couldn’t get a pulse on me.”

The nurse found Ms. Whitt’s blood sugar was one-third of normal and gave her dextrose to raise her sugar level and bring her back to consciousness.

The sophomore in psychology and nutrition at Case Western Reserve University in Cleveland didn’t know it, but she was about to embark on a six-month journey from doctor to doctor in search of answers.

“My primary-care physician examined me and told me I had dumping syndrome,” Ms. Whitt recalls. “She said I ate too much sugar that morning and that my body dumped all that sugar into my blood, and my body produced all this insulin to make me go so low.” But Ms. Whitt had not been eating sweets.

Another episode sent her to the emergency room, where she received diagnosis number 2: classic hypogly-cemia, in which blood sugar drops abnormally low. She went on a diet of six meals a day to keep her blood sugar even throughout the day, and returned to the camp.

Despite sticking with the food plan, Ms. Whitt’s blood sugar kept dipping to abnormal levels. “A whole slew of other symptoms started: nausea and vomiting, and not just fatigue, but extreme sleepiness to the point where I wanted to sleep all day. I had severe muscle weakness, cramping and pain in my legs, my joints ached and I had severe headaches. I started to get a red,

Leslie Whitt nearly died on June 27, 2007; she’d just turned 19. The energetic blonde teen, who had been a competitive swimmer in high school in her hometown of Bethel, Ohio, was teaching a swimming class for kids with special needs at Camp Sky Ranch in Boone, N.C.

A Mysterious Malady

bumpy rash on my face. My hair was falling out in clumps.”

At the end of summer, Ms. Whitt returned home. “My parents noticed a very big change in me. They said I looked lifeless, that I didn’t have anything left in me. And I started sleeping 18 hours out of a 24-hour day.”

Doctors proposed two more diagnoses: depression (#3) and anorexia nervosa (#4), because she had sud-den and severe weight loss, dropping from 150 pounds to 125 pounds on her 5-foot-10-inch frame.

“The first thing doctors asked me was, ‘Do you see a psychiatrist?’” she recalls.

In fact, three years earlier, she had been diagnosed with depression and had controlled that problem.

She felt tired all the time ... Her hair was falling out in clumps ...

“ My parents noticed a very big change in me. They said I looked lifeless, that I didn’t have anything left in me.”


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She found a new family doctor and a neurologist. CT scans and MRIs ruled out a tumor. But the neurologist thought Ms. Whitt might have migraines (diagnosis #5) and possibly narcolepsy (#6), sudden, uncontrol-lable urges to sleep. She received medications for both.

Ms. Whitt was increasingly frail. Walking the mile from Alpha Phi sorority house to campus was a strug-gle. She could barely carry her books and purse.

The situation was snowballing and nothing was helping. She had to cut her course load.

“In October,” she says, “my parents and I decided to take matters into our own hands.”

She started fresh with a Cleveland Clinic internist, Shobha Jagadeesh, MD. The doctor felt there was an underlying condition causing the blood sugar problems.

Endocrinologist Byron Hoogwerf, MD, and Dr. Jagadeesh suspected metabolic disease, a condition caused by the accumulation of poisons produced natu-rally in the body. They referred Ms. Whitt to Cleveland Clinic pediatric neurologist Bruce H. Cohen, MD, who specializes in metabolic disorders.

Based on the strange symptoms, Dr. Cohen’s hunch was that Ms. Whitt had a metabolic condition affecting her mitochondria, the energy generator of the cell that

converts nutrients into energy. The condition prevents the body from properly burning fats for energy, and sugar gets used up more quickly. As a result, the body turns on itself and creates potentially deadly compounds.

Dr. Cohen took blood and urine samples along with a skin biopsy. The test results confirmed Dr. Cohen’s diagnosis of mitochondrial disease. Ms. Whitt had unburned fats in her blood and urine, suggesting a classic disorder of energy metabolism.

This metabolic defect can be deadly, but if recog-nized, Dr. Cohen says, it can be fully treated with diet and riboflavin, or vitamin B2. “Once you order the right tests, it’s pretty easy to know.”

Ms. Whitt remembers the relief of finally having a diagnosis and treatment. “My mom and I cried for probably an hour.”

Today, Ms. Whitt is on a new low-fat, low-protein, high-carbohydrate diet that provides a steady, easy-to-handle flow of food — six small meals a day. She also takes high-dose riboflavin, which boosts the mito-chondrial machinery. The diet is challenging, but she’s started feeling better. She is back in class full-time, walking to campus from the sorority house — books and purse in hand. — Howard Wolinsky

Her blood sugar dropped abnormally low ... And she suddenly lost 25 pounds ...

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TK

Does your DNA decide the size of your jeans?

blue genes


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John Kirwan, PhD, was baffled. While conducting a study on diabetes risk, he expected his study’s older, overweight participants to become healthier after 12 weeks of supervised exercise. What he didn’t expect was that a handful of people would virtually erase their diabetes risk — slashing it by 90 percent — with a simple hour of daily exercise.

What was different, he asked, about this small group of people? Was it diet? Was it good genes? After examining and rejecting several explanations, Dr. Kirwan and his research team at Cleveland Clinic’s Lerner Research Institute decided to examine what people were eating. At the study’s start, participants were all teetering dangerously close to developing type 2 diabetes, a major risk of being overweight. They had been told to stick with their normal diet and to record what they ate in a food diary. When the researchers compared food diaries, they were amazed at what they found.

By Kar yn Hede Photography by Marge Ely

blue genesSomewhat. But you can do a lot to take control of your long-term health and weight, such as reaching for an apple and taking a walk.


14 “The ones who had improved 90 percent had changed their food selection over the course of the study,” he says. “They had shifted to a low-glycemic diet,” which is lower in “white” carbs, processed and sugary foods. While the goal of the study was to reverse prediabetes, the participants also lost weight. Genetic predisposition was trumped by diet and exercise.

Over the past decade, researchers have begun to identify genes that play a part in establishing our body weight and the risks that go along with being overweight and obese. But should overweight people feel resigned to their fate?

No, say doctors who study obesity. With the exception of a few rare conditions, most of us can control our weight within a range that is in part determined by our genetic makeup. And Dr. Kirwan’s study points to exercise and the foods we eat as key to reaching the healthiest weight possible.

Looking for a ProbLem gene About 20 genes likely play some role in weight gain, according to Claude Bouchard, PhD, an obesity researcher and Executive Director of the Pennington Biomedical Research Institute, Baton Rouge, La. Yet, “the epidemic of obesity is not driven primarily by our genes,” he says. “It’s driven by the environment. We have, hid-den in our genes, a predisposition that does not become manifest until the environment changes, until it becomes obesogenic like it has today.”

Lots of genes can contribute to weight gain, and it takes the combined effect of those genes, along with that obesogenic lifestyle — a shorthand term for a set of factors, such as low levels of physical activity and high-carbohydrate diets — that produce

IN tHE lAtE 1970S, 47% of U.S. ADUltS wErE ovErwEIgHt; toDAy, 66% ArE.increasing numbers of overweight people. And those increases are indeed dramatic.

In the late 1970s, 47 percent of U.S. adults were overweight; today, 66 percent are. Obesity among adults has more than doubled, from 15 percent to 33 percent, according to the Centers for Disease Control and Prevention (CDC). During the same period, incidence of type 2 diabetes, the form closely associated with obesity, has surged. About 20 percent of people over age 60 have type 2 diabetes, according to the CDC, resulting in annual medical costs of $92 billion and growing.

In the past year, Dr. Bouchard says, one gene variation has risen above the rest as a “strong player” in the average person’s weight troubles. That gene, called FTO, appears to be the first to predis-pose people to gain weight regardless of other risk factors.

In 2007, three independent groups studying the FTO gene in tens of thousands of people in the United States and Europe came to the same conclusion: People with a specific variation of FTO are two-thirds more likely to be obese — carrying an aver-age of 8 additional pounds — than those without the variation. Indeed, when Bouchard and his colleagues reexamined genetic evidence from the Quebec Family Study, a research project that looked for obesity genes, they confirmed that FTO contributes to obesity. However, the gene is linked with obesity among only Whites. Studies among Asians have so far shown no association with obesity; results among Blacks are mixed.

The gene appears to be particularly active in the areas of the brain that control appetite and energy expenditure, but it is unknown whether its activity reprograms the appetite center of the brain or changes how the brain responds to signals of fullness from the body.


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IN tHE lAtE 1970S, 47% of U.S. ADUltS wErE ovErwEIgHt; toDAy, 66% ArE.

What is it about a low-glycemic diet that helped the overweight study participants of Cleveland Clinic’s John Kirwan, PhD, lose weight and turn their backs on diabetes?

fifty-four million people in the United States have prediabetes, according to the American Diabetes Association, and most of them don’t know it. the warning signs include elevated blood sugar, high blood pressure and excess weight. Prediabetes is part of a vicious cycle that, left unchecked, can lead directly to type 2 diabetes and all its risks for early death, says Dr. Kirwan.

the cycle begins at mealtime. A high-glycemic or high-carbohydrate meal, one that contains what are often called the “whites” — white bread and rice, pasta and sugary drinks — quickly releases sugars into the bloodstream, resulting in a spike in insulin, the hormone that helps regulate blood sugar levels. A low-glycemic meal, which releases sugars into the bloodstream more slowly over a longer time, requires less insulin. the so-called high-glycemic meals — think processed and fast foods — have become the U.S. norm, and doctors say these wild swings in blood sugar and insulin levels contribute to the body losing its ability to respond to insulin — a hallmark oftype 2 diabetes.


What is it about a low-glycemic diet that helped the overweight study participants of Cleveland Clinic’s John Kirwan, PhD, lose weight and turn their backs on diabetes?

fifty-four million people in the United States have prediabetes, according to the American Diabetes Association, and most of them don’t know it. the warning signs include elevated blood sugar, high blood pressure and excess weight. Prediabetes is part of a vicious cycle that, left unchecked, can lead directly to type 2

the cycle begins at mealtime. A high-glycemic or high-carbohydrate meal, one that contains what are often called

glycemic meals — think processed and fast foods — have become the U.S. norm, and doctors say these wild swings

white outcould A low-glyceMic dieT Be THe Key To weigHT loss?

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Dr. Bouchard points out that the gene appears to have its strongest effect in people who don’t exercise. In January 2008, researchers from Denmark reported in the journal Diabetes that carriers of the high-risk version of the gene who were inactive weighed about 5 pounds more than those with the high-risk version who exercised more than one hour per week.

“We are far from genetic determinism here,” says Dr. Bouchard. “People who exercise from time to time [more than one hour per week] appear to have some protection from the effects of the FTO gene.”

Genetics certainly is one of the underlying factors that drives weight gain, says Cleveland Clinic’s Dr. Kirwan. And excess weight is definitely a risk factor for debilitating health conditions such as diabetes and heart disease, he says. But not all fat is created equal.

Doctors have known for years that between two people who are 5 feet 6 inches tall and weigh 200 pounds, the one who carries most of that weight around the middle, like an apple, is at higher risk for all kinds of ailments, including heart disease and diabe-tes, than the one who carries the weight around the hips, like a pear. Doctors are beginning to understand why it’s healthier to be a pear with fat at the hips than an apple with fat around the internal organs.

“It is really the visceral fat, the deep fat that deposits around internal organs such as the liver, that causes the problem,” says Dr. Kirwan. Detailed measurements of body fat among his study participants, taken with sophisticated CT scanning techniques, revealed that those with the strongest reductions in diabetes risk had lost visceral fat. He has launched a study to test whether

combining exercise and low-glycemic meals can help more people trim the visceral fat and reverse course on the road to type 2 diabetes.

fat taLksFat is more than unsightly ripples on the back of our thighs or stubborn love handles. It is not just an inert blob. Fat can com-municate. The cells that store and release fat produce small mol-ecules that influence our organs and even our brain. That’s right, our fat is talking back to us.

Scientists have identified dozens of molecules, such as a protein called rbp4, produced by fat. Proteins such as rbp4 send signals to distant organs that change our metabolism, says

Are your pArenTs’ wAisTlines your geneTic desTiny? gENES Do PlAy A PArt IN EStABlISHINg BoDy wEIgHt, BUt ovErwEIgHt PEoPlE Do Not HAvE to rESIgN tHEMSElvES to AN UNHEAltHy fAtE, SAy oBESIty ExPErtS.

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Dr. Kirwan. The levels of some of these appear to be influenced by our genes, but others can change quite dramatically depend-ing on what we eat or how active we are during the day.

To understand why visceral fat seems to be linked to dia-betes, Dr. Kirwan went to Cleveland Clinic’s bariatric surgery group to obtain samples of visceral fat removed from patients during gastric bypass surgery. Comparing the proteins produced in the fat cells of patients with and without diabetes, Dr. Kirwan found higher levels of rbp4 in the visceral fat of the obese patients with diabetes. While doctors don’t yet know rbp4’s exact role, it is clear that these fat-associated proteins influence the body’s response to the foods we eat and contribute to diabetes.

Lean genesWe all know people who seem to indulge in whatever foods they want, never set foot on a treadmill and yet stay lean and healthy. Joseph Nadeau, PhD, a geneticist collaborator of Dr. Kirwan’s at Case Western Reserve University in Cleveland, wants to know what makes those people so genetically blessed. He is studying the genetics of health in search of genes that can protect us from gaining weight and becoming diabetic.

“We’ve learned from studying mice that there are some variations of genes that will protect against disease,” says Dr. Nadeau. “We often focus on the individuals with disease, and that’s important, but at the same time our observations tell us that there are genetic solutions. How is it that your friends who eat all the time get to stay

Are your pArenTs’ wAisTlines your geneTic desTiny? gENES Do PlAy A PArt IN EStABlISHINg BoDy wEIgHt, BUt ovErwEIgHt PEoPlE Do Not HAvE to rESIgN tHEMSElvES to AN UNHEAltHy fAtE, SAy oBESIty ExPErtS.


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ur bodies are home to tens of trillions of bacteria that inhabit our 25- to 30-foot-long gut, our food digestion factory. Although they

do a lot of good — easing our digestion and keeping us healthy — some of these minuscule factory workers can make us sick — or even fat, according to recent studies.

Heavy people harbor a different population of gut microbes than thin people, according to scientists at washington University in St. louis. And those differ-ences matter, as explained by their studies in mice. when the researchers intro-duced the bacteria from obese mice into the guts of mice raised in a germ-free

environment, the mice gained more weight than when they received bacteria from slender mice. the researchers weren’t able to say how or why, but the gut microbes

were altering the amount of stored fat — the bugs from the rotund creatures turned formerly trim rodents into candidates for a diet program.

“Establishing a link between gut microbes and weight gain was a ‘eureka’ moment in science,” says John Kirwan, PhD, of Cleveland Clinic’s lerner research Institute. “the discovery

is likely to drive further research into how different types of microbes contribute to obesity and metabolic diseases such as type 2 diabetes that are associated with being overweight.”

there may be good news for the unwitting victims of mischie-vous microbes: yogurt. A study by a Swiss research team suggests it may be possible to reduce fat storage by eating certain yogurts and fermented milk products containing the do-gooder bugs — probiotics. Some yogurts with probiotics are already available, marketed as digestion helpers. Now researchers are trying to formulate specific mixes of probiotics to help people gain or lose weight, as needed.

Jeremy Nicholson, PhD, of Imperial College, london, and his collaborators there and at Nestle research Center, lausanne, Switzerland, replaced normal mouse gut bugs with human microbes and then gave the mice probiotic drinks. with probiotics, the mice absorbed less fat from their meals. the findings, reported in the January 2008 issue of the journal Molecular Systems Biology, suggest that probiotics could transform those microbe-fattened washington University mice back to their former svelte selves. People too? If confirmed in people, Dr. Nicholson thinks it may be possible to create functional foods that help us reprogram our microbial workforce. However, he notes, probiotics make some people ill, and the ratio of various probiotic components will need to be carefully controlled before they can safely be given to people.

“the potential to bring body weight to a healthy level by eating specific foods that alter the gut’s microbe population is an exciting prospect,” says Dr. Kirwan, “and one that is likely to be embraced by millions of over-weight Americans.”

the Inside StoryAre gut bugs making you fat?

there may be good news for the unwitting victims of mischievous microbes: yogurt.


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lean? What genes are involved, and how do they do what they do?”Dr. Nadeau is working with researchers in Wisconsin and San

Diego to study the genetics of healthy elderly people with an eye toward finding health-promoting genes. “We hope to take advan-tage of this kind of genetic information to tip the genetic balance in a good way that benefits people,” he says.

Even people who feel they have been dealt a bad genetic hand when it comes to gaining weight can improve their odds of stay-ing healthy by building and maintaining muscle. Standard advice encourages people to focus on calorie-burning exercises such as run-ning or biking. But as we age, we lose muscle mass each year even if we continue fat-burning aerobic activity. Studies show people who work out regularly with weights gain less of the dangerous abdomi-nal fat and maintain more muscle as they age. And weight training appears to keep even overweight people from gaining abdominal fat.

Researchers at the University of Pennsylvania recently com-pleted a two-year study of 164 overweight and obese women between ages 25 and 44 and showed that those who lifted weights twice a week lost a moderate amount of weight, while the non-weight lifters lost none. More important, the researchers reported in the September 2007 issue of the American Journal of Clinical Nutrition, although both groups gained some abdominal fat, the weight lifters added only 7 percent fat to their midsections, while those who didn’t lift weights experienced a 21 percent gain in abdominal fat — the worst kind.

Boston University researcher Ken Walsh, PhD, has been study-ing the link between losing muscle mass after age 50 and gaining dangerous abdominal fat. He says the importance of the type of muscle we use to lift objects and maintain our core body strength is only now becoming clear.

“If you poll average 50-year-olds who go to a gym, they would say that ‘I’m in good shape. I jog, I play tennis,’ but if you mea-sure their grip strength, it is probably being drastically reduced,” says Dr. Walsh. They may be doing aerobic exercise, but without strength training, their muscle mass and strength is declining.

The good news is: “You can get muscle back with weight train-ing,” he says. “And, you don’t have to become a body builder.”

What all these studies boil down to, says Dr. Bouchard, is “what your mother always told you: Eat right and get some exercise.” n

fAt IS MorE tHAN UNSIgHtly rIPPlES oN tHE BACK of oUr tHIgHS or StUBBorN lovE HANDlES. It IS Not JUSt AN INErt BloB. fAt CAN CoMMUNICAtE.

karyn Hede is a freelance science and medical writer whose work has

appeared in Science Magazine, The Scientist, and other publications.


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“Obesity is where nature meets nurture,” says Ellen Rome, MD, MPH, Cleveland Clinic’s Head of Adolescent Medicine. For children in 21st century America, that meeting is a high-speed collision. In the 1970s, about 5 percent of U.S. children were considered overweight or obese. That fi gure has more than tripled to 17 percent.

Nature, or our genetics, equipped us with a taste for fat and sugar to encourage us to pack away calories for the lean times. Nurture — or, more broadly, society — offers us nearly unlimited food and plenty of excuses to sit still.

Children are caught in the intersection.

The Shape of Kids The Shape of Kids The Shape to Comeof Kids to Comeof Kids

From bringing back P.E. and restocking snack machines with healthy treats to selling vegetables on sidewalks, communities are stepping up to the

challenge of shaping up America’s kids. If they lose this junior battle of the bulge, the very

future of our children’s health is at risk.By Brian Vastag


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The Shape of Kids The Shape of Kids The Shape


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Consider 12-year-old Jacob Kelly, a sixth-grader from Parma, Ohio. With an overweight parent, he began life already at risk of becoming overweight himself. By age 11, he weighed almost 190 pounds, 40 pounds above his ideal weight. The extra weight slowed his basketball and football game. And it discouraged him. “He just hated to look down at the scale and see that number,” says Jacob’s mother, Michelle.

The equation that has added up to those discouraging scale readings for Jacob and the other 9.2 million overweight school-age kids is simple: too many calories in and too few calories out. But the solutions, experts say, are complex and will require huge commitments from families, health systems, schools, communi-ties and policymakers.

Epidemiologists worry that today’s heavy kids will face weighty health consequences down the road. The incidence of type 2 diabetes — once a disease of adults — has soared tenfold among children and teens in the past two decades. Overweight and obese children also may experience fatty liver disease, bone and joint problems, sleep disorders and depression.

One research group estimates that by 2035, today’s childhood obesity epidemic could cause an extra 100,000 cases of heart dis-ease. Other research suggests that by 2050 the childhood obesity epidemic, left unchecked, will shave two to five years off the aver-age life expectancy in the United States. That could wipe out half of the 10 years we’ve gained since 1950.

Many communities — and the federal government — are taking action. In 2005, Cleveland Clinic launched the Fit Youth program, which teaches kids and their parents healthy habits. Likewise, in doctors’ offices across the country, physicians are spending more time encouraging parents and children to eat better and exercise more.

Nationwide, schools are feeling the pressure to improve their menus, food marketers are being reined in and legislators are attempting to mandate more physical activity during school.

“You can’t just tackle the problem in the pediatrician’s office,” says Dr. Rome. “You need to work together on solutions in the home, at school, in the communities.”

How DiD it Happen?The childhood obesity epidemic ballooned between 1980 and 2000, according to national surveys conducted by the Centers for Disease Control and Prevention (CDC). But the CDC’s William H. Dietz, MD, PhD, Director of the Division of Nutrition, Physical Activity and Obesity, says getting a handle on causes is tricky. “I’m often asked, ‘What’s changed?’ And the answer is: ‘Everything.’ ”

On the intake side of the equation, children eat more processed, calorie-heavy foods now. They eat more restaurant food and drink more sugar-sweetened beverages, both sodas and juices. In short, much of the food problem can be boiled down to one measure: calorie density. Today’s processed foods pack many more calories per ounce, on average, than home-cooked or unprocessed foods that were much more popular just a generation ago.

On the physical activity half of the equation, “there are just as many changes, but they’re subtler,” Dr. Dietz says. Fewer kids walk to school, participation in physical education classes has dropped, and many schools have eliminated recess. And then

On a typical day in California,half of teens eat fast food, two-thirds drink soda — yet just one-quarter eat five or more servings of fruits and vegetables.

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DeFininG

there’s “screen time,” the term adopted by researchers for col-lective TV and movie viewing, video game playing and computer use. According to the American Academy of Pediatrics (AAP), kids bask in the glow of screens for about fi ve hours a day. (The group recommends no more than two hours a day.) That’s about one-third of the waking day spent immobile.

Every single factor may play a small role, experts say, but col-lectively, the shifting eating and behavior patterns have bred a generation of overweight and obese kids.

Understanding the root of the problem isn’t enough, though. “It doesn’t tell us what we need to do to effectively control the epidemic,” says Dr. Dietz.

HeLpinG CHiLDRen one BY oneThe AAP recently published updated guidelines for obesity assessment and treatment beginning at age 2. The guidelines advocate a “staged” approach to weight management for chil-dren, starting with fi rm advice for the family, then offering struc-tured programs like Fit Youth. Finally, as last resorts for those who can’t lose the weight, the guidelines call for use of medica-tion, an extreme low-carbohydrate diet or weight-loss surgery.

While data on the long-term effectiveness of these interven-tions is still trickling in, Dr. Dietz says, “this problem is so signifi cant that we’ve got to move forward despite the lack of proven interventions. For that, we have to act on the best available evidence rather than the best possible evidence.”

At Cleveland Clinic’s Independence Family Health Center on a Wednesday evening, pediatric psychologist Eileen Kennedy, PhD, dietitian Jill Fisher and exercise physiologist Beth Sprogis coach 10 overweight kids and their parents on eating better and moving more. “Our focus is on the healthy changes they can keep going for the rest of their lives,” says Dr. Kennedy, who developed the 10-week Fit Youth program.

“I think there’s this misperception that you have to change every-thing all at once,” says pediatric psychologist Margaret Richards, PhD, who is developing Fit Youth at Cleveland Clinic’s main campus. We encourage families to make small changes. They’re more likely to stick with them.” For instance, she advises families to switch to lower-fat milk. And instead of telling kids to exercise every day, which will probably foster some resistance, she starts by suggesting they take the stairs to her offi ce instead of the elevator.

CHiLDHooD oBeSitY DeFininG CHiLDHooD oBeSitY DeFininGIn children, overweight and obesity statistics are usually grouped together. Physicians defi ne “over-weight” or “obesity” in children and adolescents as a body mass index (BMI) higher than 95 percent of children of the same age and gender. BMI is a ratio of weight to surface area. Children with a BMI between the 85th and 95th percentiles are considered at risk for being overweight or obese. In late teens and adults, a BMI above 30 is considered obese.

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Kids are moving less:

In 1969, 42% of kids walked or biked to school; in 2001, that number dropped to:

16%Children who exercise vigorously at least 3 times a week:

1 in 5Elementary schools with daily recess:

68%Elementary schools with daily physical education:

4%Elementary schools with physical education 3 times per week:

14%Middle schools with physical education three times per week:

15%High schools with physical education three times per week:

3%Daily screen time (TV, computer, video games):

5 hours Sources: Centers for Disease Control and Prevention, American Academy of Pediatrics, American Heart Association


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Paying attention to food is another big message. “We’re get-ting them to think about food choices, what their thoughts and feelings are as they eat, to slow down eating, to make it more of a choice,” Dr. Kennedy says.

For Jacob Kelly, who attended Fit Youth with his mom last year, better choices meant portion control. First, the family bought smaller plates. Then, instead of putting food on the table, where Jacob can easily grab seconds and thirds, mom Michelle keeps the food in the kitchen and dishes out single servings. In addi-tion, instead of making poor lunch choices at school, Jacob brown-bags it every day — a sandwich, low-fat chips, fruit and a 100-calorie cake pack.

“A whole lot depends on the families,” says Dr. Kennedy. “Their support is essential, especially for the younger kids.”

It’s working for Jacob, who’s cut his previous 2,400-calorie daily diet almost in half. At 26 pounds below his peak, he’s a lot swifter on the basketball court now. “I liked learning about the food labels. It helped me understand not to go overboard with sugar or calories,” Jacob says.

Caitlyn Rice says she “never exercised at all” before attending Fit Youth in 2006. Now, once or twice a week, the 13-year-old goes to the recreation center to take a dance class and work out with her father, Norman, who has lost weight to control his type 2 dia-betes. “I wanted to be a role model for my daughter,” he says. Like Jacob, Caitlyn has lost 26 pounds.

During Fit Youth sessions, Dr. Kennedy helps the kids develop lists of alternatives to eating. “So many kids use the kitchen as their default,” says the psychologist. “When they’re upset, they go to the kitchen. Bored, go to the kitchen. Great day at school, same thing. We’re trying to shift them so the kitchen is not the first choice.”

In the Fit Youth program, sessions are grouped by age — one session for 7- to 12-year-olds and one for teenagers. In both, peer support is vital, says Dr. Kennedy. And if children are being teased or bullied at school or on the playground, they use a role-playing game to learn how to cope.

Cleveland Clinic is expanding Fit Youth, now in its fourth year, to make it available to a greater number of families. Families pay $200 for the program, much less than its true cost. Few insurance plans pay for such programs — a barrier to combating childhood obesity, according to many experts.

Dr. Kennedy has begun collecting follow-up data on Fit Youth graduates. She says about three-quarters of participants lose some weight, and the average weight loss during the 10-week pro-gram is in the 4- to 5-pound range. A few, like Jacob and Caitlyn, lose more. More important, participants learn sustainable, healthy habits.

Fast Fact:

teens are eating moreof the wrong stuffTeenagers eat more than in the 1970s:

125 more calories each day

Teenagers drink more soda than in the 1970s:

137% more soda each day Too few high schoolers eat the recommended five or more daily servings of fruits and vegetables:

1 in 5 eat enough fruits and veggies

1970s 4%

Today 19%

Percentage of kids ages 6–11 considered overweight or obese:


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Communities and entrepreneurs are getting inventive to give kids a fi ghting chance to shape up.

Toy developers have designed devices that let kids earn points to spend in their virtual play worlds by going for a walk or taking a bike ride. TV-monitoring devices let kids punch in a code to get the screen time they’re allotted. Time up, power off. A two-year study published in March comparing kids ages 4 to 7 who were overweight—half of whom had their screen time curtailed with the moni-tor and half who did not—showed that the kids whose screen time was restricted by the monitor cut their screen time by 17.5 hours per week and lost weight.

New York City, the fi rst U.S. city to ban trans fats from restaurants, is bringing fruits and vegetables to the streets of its low-income neighborhoods. The City Council is creating 1,000 new permits for street vendors who ex-clusively sell fresh fruits and vegetables in neighborhoods where the Health Department has found consumption of fresh produce is low.

Fourth- and fi fth-graders in Lakewood, Ohio, a suburb of Cleveland, receive body mass index (BMI) “report cards,” which are sent to parents with health recommen-dations. Cleveland Clinic researchers are tracking BMI and academic performance, driven by the theory that better nutrition equals better grades.

“We think good nutrition plays a role in academic per-formance, student conduct and community well-being,” explains Cleveland Clinic’s Ellen Rome, MD, MPH. “Ideally , we can prevent obesity and, when it’s identifi ed, get families the resources to help them change.”

CReatiVeCHanGeCReatiVeCHanGeCReatiVe“I defi nitely look at how many calories are in stuff now,” says

Caitlyn. “I try to get fruit and vegetables in every day. My snacks are usually just carrots, and before the program it was sugary snacks, mostly.”

MoRe GLoBaL CHanGeSBut for all its individual successes, Fit Youth and similar pro-grams can help only a handful of kids and families at a time. To really stanch the epidemic, sweeping societal changes are needed, argue Drs. Dietz and Rome. “In my perfect world,” says Dr. Rome, “healthy foods would be as inexpensive as fast foods. A dinner of salmon, rice pilaf, broccoli and fresh fruit would be as inexpensive and as accessible as mac and cheese.”

There are promising signs that big changes are under way — and short-term results are being achieved. In recent years, the federal government has launched an array of community-based initiatives to combat childhood obesity. More and more schools are lowering the fat content of school lunches, according to the CDC. For instance, in 2000, 23 percent of school districts banned junk food sales during breakfast and lunch. By 2006, close to 40 percent of districts had such bans. French fries are on the way out, too: In 2006, 19 percent of high schools offered fried potatoes, down from 40 percent in 2000. A few school districts, including Boston’s, have also banned soda and juice from vending machines; Boston students now drink 17 percent less soda than they did before the ban. Still, 64 percent of school dis-tricts receive a cut of on-site soft drink sales, according to the CDC, making that habit hard for schools to give up.

Food makers and advertisers are feeling the pressure, too. After the federal government released new nutrition guidelines in 2005, Kraft Foods Inc., agreed to stop targeting children with advertisements for foods like cookies and sugary drinks. And in 2006, Disney pledged that its characters would no longer endorse fast food chains or high-fat, low-nutrient packaged foods. Now the face of Disney’s newest princess, Enchanted’s Giselle, is used to boost the appeal of a 5-pound bag of Granny Smith apples.

In 2007, the nonprofi t Robert Wood Johnson Foundation jumped into the fray with a large commitment: $500 million over fi ve years to improve access to healthy foods and to increase outdoor play and exercise opportunities, especially in poor sections of cities where childhood obesity rates climbed above national averages. And a number of pending federal laws would mandate healthier foods and more opportunities for physical activity at schools. For instance, an add-on to the No Child Left Behind Act would encourage school districts to offer more physical education classes. The bill, called FIT Kids, would provide extra physical education training for teachers and require schools to report to the federal government — and par-ents — how much physical activity students get each week. The bill has not yet made it to the fl oor of Congress for a vote.

The experts say there’s no time to waste. “If we teach kids how to get healthy and make lifestyle changes when they’re younger,” says Dr. Richards, “we can prevent so many long-term illnesses for these kids. The more programs we can put in place, the better.” ■

Brian Vastag, a former staff reporter for JAMA and Science News, is

a Washington, D.C.-based freelance writer for U.S. News & World Report

and other outlets.


26At age 37, Rahele Malança — the mother of an

infant, a toddler and two teenage stepchildren — was over-

whelmed. And her full house was not the problem.

“I was having a lot of trouble controlling my type 2 diabe-

tes. I had tried all the insulins, all sorts of different things,

to no avail,” she says. “Not only was I getting worse, I was

putting on weight with all these medications and feeling

very, very sick.”

Speaking from her home in Geneva, Switzerland, Ms.

Malança describes the struggles that led her to a new —

and experimental — treatment for diabetes. “I started

developing other problems — high blood pressure, high

cholesterol,” Ms. Malança says. “I didn’t have a very positive

outlook on the future.”

Desperately searching for alternatives via the Internet,

she learned about the possibility of weight-loss, or bariatric,

surgery for her diabetes. Her primary care provider brought

it up as well, while cautioning that it was still under study

and would be considered an experimental treatment.

When the diagnosis is type 2 diabetes, weight-loss surgery may hold the key to a better life, even for people considered “thin” by traditional bariatric standards.

By Tracie L. Thompson Photography by Justin Hession

ResuLTssweeT

Rahele Malança, right,

had bariatric surgery

for her type 2 diabetes,

even though she

was far less than 100

pounds overweight—

the usual cut-off.


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ResuLTssweeT


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Traditional bariatric surgery guidelines require patients to weigh at least 100 pounds more than their ideal body weight and have a body mass index (BMI) of at least 40. At 5 feet 2 inches tall and 176 pounds, Ms. Malança had a BMI of 32. Although she was overweight, she did not meet the criteria for surgery.

Excess weight and type 2, or adult-onset, diabetes go hand in hand, though. More than 80 percent of people who are diagnosed with type 2 diabetes are overweight, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Bariatric surgery has been shown to be effective for weight loss. And studies in severely obese patients have shown benefits for obesity-related diseases such as diabetes.

Now, researchers are exploring whether bariat-ric surgery is a safe, effective alternative for people with diabetes who, like Ms. Malança, don’t have an extreme amount of weight to lose. Is type 2 diabetes itself a good enough reason to consider

bariatric surgery? Many physicians, including specialists at the Cleveland Clinic, think it may well be. And now they are doing a long-term study to weigh the benefits for diabetic patients against the risks that come with surgery.

A Difficult DiseAseDiabetes is a disease in which levels of glucose, or sugar, in the blood are too high. The hormone insulin helps move glucose out of the blood and into cells to make energy. In type 2 diabetes, the body loses its ability to move sugar out of the bloodstream, because it doesn’t make enough insulin and doesn’t use it well. This chronic condition, considered incurable, affects more than 20 million Americans and routinely leads to amputations, kidney failure, blindness and death from cardiovascular disease.

So, in January, when Australian researchers reported in the Journal of the American Medical Association that weight-loss surgery had erased

Ms. Malança prepares a fresh

salad with 3-year-old son Kidane

and nanny Nadine McDonald.

Opposite page: With no more

diabetes, and 50 pounds lighter,

Ms. Malança has happily had to

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all signs of diabetes in patients with mild to moderate obesity, the media, the public and physicians took note.

“It’s very exciting, because we’ve always told patients that diabetes is a chronic, progressive disease with no cure, and that, most likely, at some point they will be on insulin treatment,” says Sangeeta Kashyap, MD, a Cleveland Clinic endocri-nologist and diabetes treatment researcher.

“Now,” says Dr. Kashyap, “I can actually say that there is a possible treatment that could resolve the diabetes and prevent some complica-

tions associated with diabetes, like high choles-terol and high blood pressure.”

The Australian team tracked patients with an initial BMI of 30 to 40 for at least two years. They found that diabetes remission — with all signs of the disease disappearing — occurred in 73 percent of the surgery patients, compared with only 13 percent of patients who received conven-tional medication therapy.

With this and other studies, support for bariatric surgery for diabetes is mounting. It helps that the risks from bariatric surgery are now far lower than most people realize, says Stacy Brethauer, MD, a Cleveland Clinic surgeon specializing in bariatric procedures. “The mortality rates for modern gas-tric bypass procedures, which are done primarily

laparoscopically (through a few small incisions) by experienced surgeons, have gone down signifi-cantly over the last decade, even as the number of procedures has dramatically increased.”

Both epidemiologic studies and controlled trials indicate that ongoing obesity is more dangerous for patients than having surgery to correct their condition. Swedish researchers recently looked at long-term results of an obser-vational study of 4,000 obese individuals, half of whom had undergone bariatric surgery and half of whom received conventional, nonsurgical

treatment for obesity. At the 10-year mark, the surgically treated patients were 23 percent less likely to have died, according to a 2007 report in The New England Journal of Medicine.

The patients in the Swedish study who under-went gastric bypass also lost, and kept off, about 25 percent of their weight, while conventional treatment patients lost only 2 percent of their weight over the years. The surgery patients did substantially better in terms of prevention of new diabetes and resolution of existing diabetes. They even experienced a 92 percent reduction in diabetes-related deaths.

Many physicians, medical organizations and insurance companies are waiting for long-term results of randomized trials before they will

“ Not having to think about what you eat and how it affects your blood sugar, not having to take injec-tions, not having to test your blood all the time and then seeing these numbers no matter how many units of insulin you use, not being hungry all the time because you’re taking all this insulin.”

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recommend or cover bariatric surgeries for people on the lighter end of obese, generally considered a BMI of about 30. But specialists in the field are very optimistic based on what they’ve seen in studies to date.

“Right now, bariatric surgery is the only tool we have to alter the course of diabetes,” says Dr. Brethauer. “Medical management alone,” he notes, “is not effective in controlling the majority of long-term complications related to diabetes.”

The accumulating studies make clear that major, long-term weight loss is incred-ibly difficult without surgery, according to an editorial accompanying the report of the Australian study in the Jan. 23, 2008 Journal of the American Medical Association. The authors, David Cummings, MD, and David Flum, MD, of the University of Washington, Seattle, go a step further, adding that the insights gained by these studies of surgery for diabetes “may be the most profound since the discovery of insulin.”

compAring ApproAchesDrs. Kashyap and Brethauer, along with Philip Schauer, MD, are helping to determine the long-term future of surgery for diabetes as co-investigators in a randomized trial under way at Cleveland Clinic, sponsored by manufacturers of blood glucose monitors and bariatric surgery supplies.

Called STAMPEDE (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently), the study will track 150 patients with diabetes who are mild to moderately obese for at least five years to compare the results of two types of surgery and medical care.

It is important that the study is focused on patients who would not ordinarily be candidates for bariatric surgery. Current guidelines from the National Institutes of Health state that the sur-gery should be reserved for patients with a BMI of at least 40 or, alternatively, a BMI between 35 and 39 with a serious obesity-related health problem, like diabetes.

A person who is 5 foot 4 inches tall with a BMI of 40 weighs around 230 pounds. For someone who’s 5 foot 10, a BMI of 40 is 275 pounds.

Meanwhile, notes Dr. Kashyap, “the average BMI for people with diabetes in this country is about 31 to 32 with most of the fat distribution in the belly.” A typical 5-foot-4-inch person with dia-betes with a BMI of 31 would weigh 180 pounds, but he or she would not be eligible for bariatric surgery unless she gained another 25 pounds.

In the STAMPEDE study, each participant will be randomly assigned to one of three groups.

“ If you can’t eat properly afterward and follow the guidelines, do the exercise and all the other things, in about five years it would be pointless.”

Ms. Malança takes time to exercise in her office, and she often runs with a personal trainer.

besity is clearly a major cause of diabetes: People with a BMI of 30 or higher are five times more likely to have type 2 diabetes than those with a BMI of 25 or less, according to the National Institute of Diabetes and Digestive and Kidney Diseases. But researchers are still trying to figure out why weight gain and diabetes are so intimately linked.

An early, significant step is prediabetic insulin resistance, a condition in which the patient’s body does not properly

use insulin — the hormone that converts blood sugar into energy for cells. At first, the pancreas responds by making more insulin, but eventually loses its ability to deliver enough in response to meals. That’s when an external source of insulin, often daily shots, becomes necessary.

But why does insulin resistance develop as people put on weight? Harvard researchers have found that obesity causes stress in a system of membranes in the cell called the endoplasmic reticulum (ER), which reacts by suppressing insulin production.

Some observers have likened the ER to a factory that gets overwhelmed with orders. When there are too many nutrients for the ER to process, it sends out SOS signals that instruct cells to slow down their insulin production. Beyond these tantalizing insights, however, the process remains unclear.

Equally obscure is the reason for the finding that some types of bariatric sur-gery cause diabetes to disappear almost immediately after surgery — and long before the patient loses any weight.

One important clue is that this response occurs only in procedures that bypass the upper section of the small intestines for weight loss as opposed to procedures that reduce the size of the stomach with banding or stapling. Laparoscopic adjustable gastric banding (LAGB) takes a solely “restrictive” approach to weight loss with banding to shrink the size of the stomach. The Roux-en-Y procedure is a combination that bypasses the upper small intestine and restricts the size of the stomach.

One theory is that the upper small intestines may actually be the source of impaired glucose regulation in people with diabetes. Thus, surgically bypassing this section of the digestive tract skirts the problem area and cures the diabetes.

Sangeeta Kashyap, MD, of the Cleveland Clinic is among the research-ers looking at the surgery’s effect on incretins, a type of hormone in the gut that boosts release of insulin. After surgery, incretin levels seem to return to normal, and the body’s insulin can once again handle the blood’s sugar load after a meal.

“What that means is that it is a gut-related phenomenon: When you eat, there are certain factors that are being produced that stimulate the pancreas to make insulin,” says Dr. Kashyap. “This incretin effect is one of the major path-ways by which we think this Roux-en-Y procedure restores pancreatic function and reverses diabetes, and that is what we are currently studying.”

One group will undergo the most common form of bariatric surgery in the United States, a laparoscopic procedure known as a Roux-en-Y gastric bypass. Others will receive laparoscopic sleeve gastrectomies, a newer type of surgical procedure. The third group will be treated with advanced medical therapy, including oral medi-cations and injectable insulin. All of the surgical patients also will receive follow-up care with diabetes drugs as needed.

In Roux-en-Y gastric bypass, the type of surgery Ms. Malança had in 2007 at Cleveland Clinic, the stomach is reduced in size with surgi-cal staples and then connected directly to the middle section of the small intestine, bypassing most of the stomach and the upper intestine.

The sleeve gastrectomy, comparatively, involves the removal of about 75 percent of the stomach, leaving a narrow tube of stomach that limits food intake. Outside of the study, Cleve-land Clinic surgeons use the sleeve gastrec-tomy as a first-stage procedure for higher-risk patients — people with higher BMIs or heart problems who can’t tolerate a longer operation.

“These patients lose about half of their extra weight in the first one to two years, and then we re-evaluate them to see if they’re able to toler-ate the second stage, which is conversion of the sleeve to a gastric bypass,” says Dr. Brethauer.

In the STAMPEDE trial, Cleveland Clinic researchers will be studying whether the sleeve gastrectomy can work as a stand-alone proce-dure that strikes the right balance of safety and benefits for diabetes patients with lower BMIs.

The Australian researchers tested a different form of bariatric surgery known as laparoscopic adjustable gastric banding (LAGB). A plastic band with an adjustable inner lining is placed around the top of the stomach, and, over time, the band is tightened by filling the lining with saline through a port. This creates progressively more restriction for the patient and effectively decreases the amount of food the patient’s stom-ach can comfortably hold.

The LAGB procedure is commonly available in the United States, but is used less often than the Roux-en-Y gastric bypass. With the LAGB procedure, diabetes remission does not occur until the pounds have come off. For Roux-en-Y gastric bypass, however, diabetes remission occurs quickly, even before substantial weight loss, according to previous studies. The body may be recovering from diabetes through mecha-nisms separate from the weight loss. What those mechanisms are is one of several questions researchers are trying to answer.

Two Medical Mysteries

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Why Obesity Causes Diabetes and How Surgery Cures It



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like A teenAgerOutside of the STAMPEDE trial, relatively few Cleveland Clinic patients have had bar-iatric surgery as a treatment for diabetes, as opposed to obesity. Most insurers won’t cover the surgery for diabe-tes, and the cost for a bypass procedure, hospitalization and six months of follow-up care is around $30,000.

But for Rahele Malança, the treatment was covered by health insurance from the International Organization for Migration, which employs her husband as an international civil servant.

There were limited options for bariatric surgery in Swit-zerland: One medical center rejected Ms. Malança because her BMI was below 40; she rejected the second because of its limited experience with the surgery. Her research kept pointing her to the Cleveland Clinic program. So she packed up her family—her parents, her husband and four children—for a weeklong trip to Cleveland.

She reserved the right to bow out until the last moment, but

went ahead with the Roux-en-Y gastric bypass based on a thorough presurgical evaluation and the reassuring manner of Dr. Schauer, her surgeon and the director of Cleveland Clinic’s Bariatric and Metabolic Institute.

The results were “fantastic,” says Ms. Malança, who has lost 50 pounds.

“I went into the hospital using 130 units of insulin a day, and four days later I came out without having to use any at all.” Her experi-ence is not unusual, according to Dr. Brethauer: “Many of our gastric bypass patients, especially those with early diabetes, leave the hospital on no medicine for their diabetes and basically

never have to return to their medication after their bypass.”

Six months after surgery, the improvement in Ms. Malança’s quality of life is “really stagger-ing,” she says. “Not having to think about what you eat and how it affects your blood sugar, not having to take injections, not having to test your blood all the time and then seeing these num-bers no matter how many units of insulin you use, not being hungry all the time because you’re taking all this insulin.”

No more pills for her blood pressure or diabetes either. But life isn’t a walk in the park. She can’t eat much sugar, dairy or pork without experiencing what is known as “dumping syndrome,” a common problem for bypass patients whereby food moves too quickly through the gastrointestinal system and causes nausea, weakness, sweating, faint-ness and sometimes diarrhea.

She is also on a lifelong regimen of daily multivitamins, iron, calcium and B12 supple-ments to counteract the nutritional deficiencies that occur when food bypasses a large portion of the small intestine, where most nutrients and calories are absorbed in the normal digestive process. In earlier studies, anemia and osteo-porosis developed in up to one-third of patients after bariatric surgery if they did not take recom-mended iron, B12 and calcium supplements. These nutritional deficiencies are correctable if patients follow doctors’ orders.

“We do see patients with bone problems because they haven’t adequately taken their calcium or vitamin D,” says Dr. Kashyap.

Patients also can undermine the benefits of surgery through a return to poor eating hab-its. Indeed, that’s why physicians describe the results of bariatric surgery as a remission of dia-betes rather than a cure. “If these patients were to gain their weight back, then their diabetes would likely come back,” notes Dr. Brethauer.

Rahele Malança says that’s why she wouldn’t recommend the surgery for people who aren’t pre-pared to change their lives. “If you can’t eat prop-erly afterward and follow the guidelines, do the exercise and all the other things, in about five years it would be pointless,” she says. But the choice was right for her: “It’s made me a different person. Just this evening my mom said, ‘You know, it’s funny, you look like you did when you were a teenager.’ I really have that vibrancy again.” n

“ It’s made me a different person. Just this evening my mom said, ‘You know, it’s funny, you look like you did when you were a teenager.’ I really have that vibrancy again.”

tracie thompson is a San Francisco-based writer and

editor who specializes in medical and legal issues. In our

winter issue, she wrote about anesthesia awareness.

Do you take better care of this body…

than your own?

Schedule your 50,000-mile checkup at Cleveland Clinic today.

In just one day, our Executive Health experts will have you on the road to better health.

For more information or to make your appointment, visit www.clevelandclinic.org/executivehealth,

or call 800.223.2273 ext. 45707.

Exh-AD.indd 1 5/30/08 11:00:32 AM


34

philanthropia

When Robert E. Rich Jr. was asked three years ago by Cleveland Clinic CEO and President Delos “Toby” Cosgrove, MD, to head Cleveland Clinic’s $1.25 billion philanthropic campaign, he wasn’t sure what his answer would be.

“I was 63 and I thought, ‘Do I really need this at this time of my life?’”

Those feelings were fleeting, Mr. Rich says. “I have never gotten so much satisfaction as with this cam-

paign,” he says. “For a lot of people, the ‘ask’ is hard. For me, it’s a joy because I like to help people give back to the institution or doctor or medical system that might have saved their lives.”

The campaign, which is called Today’s Innovations, Tomor-row’s Healthcare, is now close to approaching its goal.

Mr. Rich is Chairman of Rich Products Corp., the largest fam-ily-owned frozen food manufacturer in the country. He and his wife, Mindy Rich, Vice Chairman of Rich Products Corp., and their family recently contributed $5 million to establish a Chief Execu-tive Chair at Cleveland Clinic, with Dr. Cosgrove as the first chair holder. The gift also is intended to attract additional support for the new chair. Mr. Rich says he is aiming for $20 million.

“We have been looking for just the right thing that we could do on behalf of our family to help Cleveland Clinic,” Mr. Rich says. “The idea for a CEO chair is a natural. Whoever is in that chair sees a lot of oppor-tunities that require financial support, and speed is of the essence. The new chair might supplement a new program or new technology or could be used to reward exemplary service, for example.”

Mr. Rich and Dr. Cosgrove are “longtime pals” who belonged to the same fraternity at Williams College in Massachusetts. But that is not what drives Mr. Rich to help Cleveland Clinic.

“Our lives went their own, separate ways when he went to the University of Virginia, to Vietnam, and then to Massachusetts General,” he says.

“I began running the family business. I was selling chocolate éclairs while he was out there saving lives.”

Eventually, Mr. Rich says, “our lives came back together when my mother was having open heart surgery. I knew of Toby and the exceptional things he was doing, and this was an awakening for

me of what it was all about. I came on the [Cleveland Clinic] board because of Toby, but the work I’m doing now is far beyond our friendship. I’m doing this for the institution.”

In fact, Mr. Rich and his family are longtime philanthropists. “That was how I was raised, and I’ve always felt fortunate. Giving back is very important to me.”

Mr. Rich also is an avid fisherman and author who couples his love of fishing with his focus on philanthropy in his most recent book, The Fishing Club: Brothers and Sisters of the Angle, published by Lyons Press in 2006.

Proceeds from the book, which profiles men and women who fish and includes a chapter on Dr. Cosgrove, go to the favorite charities of those he interviewed.

He sees a connection between his love of fishing and his work as Campaign Chairman. “I’ve found my life’s larger work doing this job,” he says. “Every day is my best fishing day.” — Elaine DeRosa

His Favorite Line of Work“ For a lot of people, the ‘ask’ is hard. For me, it’s a joy because I like to help people give back to the institution ...”

Mindy and Robert E. Rich Jr.

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Soon patients will have the opportunity to retreat from their hospital room and expe-rience the outdoors’ calming effect 254 feet above street

level. The rooftop of the new Sydell and Arnold Miller Family Pavilion will be designed for visitors to relax and enjoy a spectacular view.

Overlooking the hospital’s entrance reflection pool, The Kelvin and Eleanor Smith Rooftop Garden will offer a tranquil environment for patients and visitors. When Ellen Stirn Mavec recently toured the rooftop garden, she was overwhelmed by its panoramic view and imagined its great potential for re-energizing patients and their families.

Ms. Stirn Mavec, President of The Kelvin and Eleanor Smith Foundation, donated $1 million on behalf of the foundation to name The Kelvin and Eleanor Smith Rooftop Garden. The gift adds to the foundation’s $1 million donation in 2004 to support the Heart and Vascular Institute, rated No. 1 in heart care by U.S. News & World Report.

“What a wonderful opportunity, to go to the rooftop, feel the breeze and see the blue sky, and also experience a 360-degree view of Cleveland with Lake Erie, Cleveland’s cityscape and the arts and cultural amenities at University Circle. I’m sure there are few hospitals around the world that can offer such a special loca-tion for their patients,” Ms. Stirn Mavec says.

She is confident her nature-enthusiast grandparents, the late Eleanor and Kelvin Smith, would be honored to support a unique outdoor space at Cleveland Clinic where patients will have a chance to retreat from their hospital rooms.

“My grandparents would be very proud they were able to give to such a forward-thinking and helpful organization as Cleveland

Clinic and contribute to a place where people can experience nature and feel better from within,” Ms. Stirn Mavec says.

She imagines her grandparents would want lots of wonderfully scented flowers intermingled with the outdoor tables and furniture that will be available for patients and their families to enjoy food and conversation among a comfortable, serene environment.

Ms. Stirn Mavec recounts her grandmother’s love for gardening, remembering her lush garden filled with manicured and uniquely scented flowers, such as roses and dahlias, her grandmother’s favorites.

Kelvin Smith, a chemist, also had a great appreciation of nature. Ms. Stirn Mavec remembers her grand father encouraging the family to always closely observe their surroundings.

“We would look at the trees and listen to the birds and know their names; look under the rocks and know the names of the newts living beneath; look at rock formations and know how they were created. My grandfather had a love of nature and a true appreciation for all living things that he passed on to us,” Ms. Stirn Mavec says.

The Kelvin and Eleanor Smith Foundation supports major Northeast Ohio institutions that align with arts and culture, the environment, education, health and human services and economic development.

“The foundation truly believes in supporting excellence. Cleveland Clinic is just the embodiment of that, and, with Dr. Toby Cosgrove at the helm, we feel honored and delighted we can be of support to him as well,” Ms. Stirn Mavec says. The foun-dation, she says, wants to help keep the Cleveland Clinic engine going to keep Northeast Ohio going. — Natalie Sobonya

Sky-High HealingThe Kelvin and Eleanor Smith Foundation

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philanthropia

Tom and Diane Wamberg begin each day with a lofty goal: Change the world.

“My philosophy is that there are a lot of things in this world that can and should be done, and while we can’t get to all of them, there’s a lot we can do,” says

Mr. Wamberg, who is Chief Executive Officer of Clark & Wamberg, LLC, a private equity firm. He adds, “We have the ability in this country to make a difference if we want to.”

That philosophy has been ingrained in the Wambergs’ seven children. “We’ve taught our children CTW — change the world — and their daily mission is to further that goal.”

Mr. Wamberg leads by example through extensive philan-thropic activities, which include support for the American Cancer Society, Alzheimer’s research and Cleveland Clinic.

“It’s the giveback that’s important to us,” says Mr. Wamberg. “It’s something you want to instill in your children.”

Championing education and research is particularly important to the Wambergs, who recently gave $1.5 million to endow a chair in stroke research at Cleveland Clinic. Endowed chairs provide ongoing support for the activities of the physician or researcher who holds the chair.

The gift will have a direct impact, says Richard Rudick, MD, Vice Chairman of Research and Development for Cleveland Clinic’s Neurological Institute.

“Stroke is one of the leading causes of death and disability in the world,” says Dr. Rudick. “The generous commitment by Tom and Diane Wamberg to create an endowed chair in stroke research will enable us to recruit a world leader in stroke research to the Neurological Institute.”

The Wambergs, who reside in Barrington Hills, Ill., as well as Naples, Fla., have roots in the Cleveland area. Both grew up on the west side of the city, and Mr. Wamberg is an alumnus of Baldwin-Wallace College.

It was a personal experience, though, not the family’s Ohio ties, that inspired his gift. “My mother suffered a stroke,” says Mr. Wamberg, who is a member of Cleveland Clinic’s Board of Trust-ees. “She was treated in the Chicago area and had quality medical care. But, ultimately, she lost many capabilities. We wanted to

help other families because we’ve seen firsthand how debilitat-ing stroke can be.” He saw promise in Cleveland Clinic’s research program and wanted to support a top-quality organization. Mr. Wamberg says he is pleased to have partnered with Cleveland Clinic, a healthcare organization that he says is in a position to make a global difference.

“Over the years, I’ve become more familiar with the Clinic and its mission,” says Mr. Wamberg. “It’s making a difference right now. We wanted to be involved with an organization that is chang-ing the world.” — Tricia Schellenbach

Mission Possible“ We wanted to be involved with an organization that is changing the world.”

Diane and Tom Wamberg

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Maintaining a healthy lifestyle is a habit like any other, says James A. Brown Sr.

“Good habits are just as easy to stick with as bad habits,” says the President of Classic Auto Group, which has dealerships in Northeast Ohio. “Once you

start exercising and eating right, you can’t stand not to do it.”The trick is getting started, says Mr. Brown, who went through

his own transformation years ago. “Like many, I was uneducated,” he says. “I smoked and consumed alcohol for many years until I was forced to say, ‘What’s going on here?’”

For him, education was key. Now, Mr. Brown — who exercises regularly and eschews unhealthy behaviors — is educating others. It starts, he says, with his 800 employees. He warns them against what he calls “the three vices”: smoking, alcohol and fattening food. Mr. Brown has generously sent those who’ve needed care to specialized programs. On a daily basis, he stresses preventive healthcare, which, he points out, can be expensive for employers to provide.

That’s why he and his wife, Darlene Brown, recently made a substantial gift to Cleveland Clinic’s new Wellness Institute, for which Mr. Brown has agreed to serve on a volunteer leadership board. Their hope is that a dedicated focus on wellness will bring to light the importance of everyday health habits through pro-grams that educate individual patients, as well as the community.

The Browns are also hoping their support of wellness at Cleve-land Clinic will ultimately lead to a program that will expand affordable preventive healthcare options for businesses. While Cleveland Clinic already offers preventive health services for executives, Mr. Brown wants to see more employers like himself able to offer preventive care plans to their general workforce.

“Healthcare costs are an increasing issue for businesses,” notes Richard Lang, MD, MPH, who is Vice Chairman of the Well-ness Institute and has been Mr. Brown’s physician for 10 years. “Because of this, we’re seeing a shift toward thinking about how to prevent cost escalation. That starts with wellness.”

Dr. Lang, who also leads the Executive Health program, empha-sizes the importance of making positive choices at home and at work. He also shares the Browns’ interest in wellness education

and “getting the message out,” which will be a focus of the Well-ness Institute.

“Many people simply don’t understand,” says Mr. Brown, “and they need to be educated. Cleveland Clinic is going to do that. As far as I’m concerned, Cleveland Clinic will be a world leader in wellness, just as they are in many other areas.”

“Jim Brown has always had an interest in looking forward,” says Dr. Lang. “The Wellness Institute is a new enterprise at Cleveland Clinic, and the Browns are supporting that in a very meaningful way.” — Tricia Schellenbach

Making Wellness a PriorityDarlene and James A. Brown Sr.

The friends featured in Philanthropia are transforming the future

of medicine through Today’s Innovations, Tomorrow’s Healthcare:

Campaign for Cleveland Clinic. Campaign support of patient care,

research, education and a campus master plan will have a direct

and beneficial impact on the health and well-being of patients for

generations to come. Learn more at clevelandclinic.org/giving.

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MOVING HEALTHCARE

At Cleveland Clinic, we’re opening the doors to the future of healthcare. This fall, we’ll introduce two new buildings that will further enhance our abilities to provide leading patient care, research and education. To keep advancing, we need your support — because the help you give now will make a difference in the care we give in the future.

FORWARDTo support the campaign for Cleveland Clinic, please visitclevelandclinic.org/giving.

CLE-006 Philan Ad v3 PRO.indd 1 6/10/08 11:57:40 AM


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onthehorizon

These mice are nonstop action. They can run nearly four miles without stopping. The 2-week-old pups will jump around while trying to nurse. And the mice, genetically engineered by a team of researchers from Cleveland Clinic and Case Western Reserve University, live and

breed much longer than other mice. The researchers — including Richard W. Hanson, PhD, Parvin

Hakimi and Satish C. Kalhan, MD — changed a gene in the mice so they would overproduce an enzyme called PEPCK in muscle. The enzyme helps the body make a sugar called glucose. It’s typi-cally found at high levels in the liver and kidney, but at low levels in muscle.

“We wanted to find out what PEPCK was doing in muscle,” says Dr. Hanson, who has spent 40 years studying the enzyme. He is at Case Western Reserve University School of Medicine and is an adjunct member of Cleveland Clinic’s Lerner Research Insti-tute. Dr. Kalhan is a researcher at the Lerner Research Institute, along with John Kirwan, PhD, who contributed to the report. The researchers want to find out if this single enzyme might hold some valuable information for overall health.

PEPCK mice can run twice as fast as other mice: about three-quarters of a mile in an hour. Normal mice can run only about one-tenth of a mile before needing a rest, but these PEPCK mice can run for hours, covering nearly four miles. That’s like a human running at about 8 miles an hour for 29 hours, without a break.

“We didn’t think aging would be a factor in this study,” Dr. Hanson says. But PEPCK mice live more than 50 percent longer than other mice and reproduce well into old age. “We had one reproduce when it was nearly 3 years old!” he says. “That’s like an 80-year-old woman giving birth.”

PEPCK mice eat more than normal mice, but are much leaner. Sounds like heaven, right? Can the results be applied to humans? Not a good idea, say the researchers. Besides being hyperactive, PEPCK mice are aggressive and anxious.

“I don’t think it’s possible or ethical to do this in humans,” Dr. Hanson says. “The people wouldn’t be able to sit still. And the world is full of aggressive people already.”

Still, the researchers hope to find out how one enzyme could cause all these changes. Dr. Kirwan, specifically, plans to study how the mice are protected against obesity and whether they also are less likely to get type 2 diabetes.

Says Dr. Kirwan, “These mice will help us to better understand what a change in one gene can do and what the implications are for treating chronic disease.” — Nancy Volkers

White blood cells called monocytes, such as the one shown here with a blue

nucleus, are the cleanup crew of the bloodstream. They float along, responding at

sites of injury, infection and inflammation. Their presence, however, isn’t always

helpful. When inflammation becomes a chronic condition, such as hardening of

the arteries, also known as atherosclerosis, these white blood cells can cause more

damage by irritating the site and producing additional fatty plaque buildup. Scien-

tists at Cleveland Clinic’s Lerner Research Institute are studying an enzyme that

controls monocytes’ response to tissue injury with the hope of putting the brakes

on their detrimental contributions to chronic inflammation. — Tricia Schellenbach

How could this cell harm you?

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Don’t Bypass the StatinsI

t may be a good idea to follow that bypass surgery with a dose of statins to protect against stroke, according to a study by Cleveland Clinic researchers.

Formally known as coronary artery bypass grafting (CABG), this surgical procedure restores normal blood fl ow to the

heart by “bypassing” one or more blocked coronary arteries, usually with veins from the patient’s leg. However, postoperative stroke affects up to 5 percent of patients undergoing bypass sur-gery and is a catastrophic and costly complication that physicians and patients would love to avoid.

Statins, such as atorvastatin calcium (Lipitor™) and simvasta-tin (Zocor™), are widely used to lower cholesterol, especially LDL (or “lousy”) cholesterol levels, to reduce risk for heart attack or stroke in patients who are not undergoing surgery.

“Generally, any of the people going into bypass already have strong indications for being on statins,” says cardiologist Matthew Becker, MD, who led the study. However, prescrib-ing statins after bypass surgery is not standard procedure. Dr.

The belly button might be good for more than collecting lint. By entering a single, small incision through the navel, a Cleveland Clinic surgeon is taking laparoscopic surgery to a new level. Typi-cally in laparoscopic surgery — also called band-aid or pinhole surgery — a telescopic rod con-nected to a video camera, or laparoscope, is inserted through a small incision in the abdomen. Three to fi ve additional small cuts are used as “ports” to insert instruments to remove a kidney,

for example, or to repair the urinary tract. Patients can often return home the same day.Cleveland Clinic urological surgeon Jihad H. Kaouk, MD, is now performing these procedures

through a single port that holds both the camera and the instruments. Dr. Kaouk is one of a handful of surgeons across the nation, including Cleveland Clinic’s Mihir Desai, MD, who are pioneering single-port laparoscopy.

Patients are reporting less discomfort and faster recovery compared with those undergoing traditional laparoscopy. “Many patients also like the fact that the belly button hides the incision site,” he adds.

The surgery is more challenging than traditional laparoscopy because the surgeon has less freedom of movement with all instruments using the same entry point. Specially designed fl exible instruments help to overcome that limitation. “For certain procedures, patients considered for laparoscopic surgery may also be candidates for the single-port procedure,” Dr. Kaouk says, “as long as they did not have multiple major surgeries to the abdomen and are not morbidly obese” — conditions that limit visibility and movement inside the abdomen. As the fl exible instruments become more refi ned and readily available and more surgeons become familiar with the procedure, Dr. Kaouk says single-port laparoscopy will become widely available. — Laura Bonetta

SCAR-FREE SURGERY

Becker and colleagues in Cardiovascular Medicine reviewed charts of all patients who had undergone their fi rst bypass at Cleveland Clinic between 1993 and 2005. After excluding patients who went into surgery with complicating cardiovas-cular factors such as clotting, the researchers evaluated 1,000 charts with information on cholesterol values or statin use.

“People prescribed postsurgical statins had signifi cantly lower LDL, associated with reduced stroke in the year following their bypass surgery,” Dr. Becker explains. The lower the LDL level, the greater the protection. “The people who saw the greatest benefi t were those whose LDL levels were below 70 — considered ultralow,” he adds.

Dr. Becker emphasizes that his study results are meant to be “thought-provoking and hypothesis-generating, but a large prospective, randomized and blinded trial is needed to make pre-scribing statins standard practice after bypass surgery to confi rm the benefi t seen in our study.” — Christine Theisen

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he belly button might be good for more than collecting lint. By entering a single, small incision through the navel, a Cleveland Clinic surgeon is taking laparoscopic surgery to a new level. Typi-cally in laparoscopic surgery — also called band-aid or pinhole surgery — a telescopic rod con-nected to a video camera, or laparoscope, is inserted through a small incision in the abdomen. Three to fi ve additional small cuts are used as “ports” to insert instruments to remove a kidney,

through a single port that holds both the camera and the instruments. Dr. Kaouk is one of a handful of

Patients are reporting less discomfort and faster recovery compared with those undergoing traditional

The surgery is more challenging than traditional laparoscopy because the surgeon has less freedom of movement with all instruments using the same entry point. Specially designed fl exible instruments help to overcome that limitation. “For certain procedures, patients considered for laparoscopic surgery may also be candidates for the single-port procedure,” Dr. Kaouk says, “as long as they did not have multiple

movement inside the abdomen. As the fl exible instruments become more refi ned and readily available

SCAR-FREE SURGERY


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asktheexperts

Ellen Rome, MD, MPH, says eating disorders are affecting younger and increasingly diverse patients.

Taking Thin Too Far

We’ve been hearing about eating disorders for a long time. Has any new information surfaced?

We’ve learned a few things. Eating disorders are an equal-opportunity illness, affecting girls and boys from all races and walks of life. We no longer think of eating disorders as a condition limited to white, upper-middle-class, adolescent girls. We’re seeing a greater prevalence in boys, and, overall, we’re recognizing it in younger and younger children. My youngest patient was a 5-year-old with classic bulimia that began at 3.

Eating disorders generally bring to mind poor body image and low self-esteem. Is it possible for someone as young as 3 to have poor body image?

For patients this young, the eating disorder is more of an unhealthful way of managing stress. The child turns to, for example, vomiting to relieve stress, which isn’t a great strategy. But, yes, younger and younger children are being affected by behaviors such as weight-related teasing. We’re seeing negative effects in children as young as 5.

Are eating disorders physically harder on very young children?

Physical problems occur more quickly in younger kids because they’re growing. Delays in diagnosis can be particularly damaging. We see cognitive difficulties, stunting of final height, osteoporosis, even sudden cardiac death.

Ellen Rome, MD, MPH, Associate Chief of Staff and Section

Head for Adolescent Medicine at Cleveland Clinic, is a noted

expert on eating disorders, childhood obesity and teenage

pregnancy prevention.


43

TK

What are the medical complications for older children and adults?

They’re similar. When the body is starved, the heart muscle can break down, putting the patient at risk for sudden cardiac death. We also worry about “refeeding syndrome,” a life-threatening heart condition that can occur when the patient begins to eat again without adequate supervision. Bone loss is another complication, and the only real treatment is weight gain. There’s also hair loss and dental erosion from intentional vomiting. Brain func-tion, interestingly, remains preserved for some time. The gastrointestinal issues — early full-ness, bloating, constipation — are usually most distressing for patients. Convincing people that they’re at medical risk, though, is not easy.

Childhood obesity is an epidemic. Is there a risk of becoming hyper-vigilant about children’s weight and pushing them toward eating disorders?

Prevention of one should never lead to the other. That’s why families, schools and com-munities need to be so mindful of extinguish-ing weight-related teasing. Many programs targeting youth are designed to prevent both, and educators, clinicians, school nurses and all those in contact with our kids need to watch for “weighty words” that could trigger abnormal eating attitudes and behaviors, or engender hopelessness in those already overweight.

How can families help? Making it normal to sit down together and talk at the end of a day builds connections. Ann Landers or “Dear Abby” talk about the “special plate.” All the people at the table have to say something nice about the person who gets the “special plate” that day. Siblings will comment that they didn’t even know their brother liked them, and it can be a real ego builder to have people consciously saying nice things to each other.

Today’s younger kids are so tech-savvy. How do online communities factor into eating disorders?

There are sites out there described as “pro-ana” or “pro-mia” that promote anorexia and bulimia as lifestyles, not diseases. Kid-friendly social technology can be supportive for young people or, in this case, it can be devastating.

Are there any new treatments?

Not really “new,” no. But the Maudsley Method is increasingly being recognized as useful. It combines a medical team with group work and family support for young people who need to relearn how to eat. The family is coached on how to take control of meals, and kids are often happier with less choice. In the old days, we used to promote a “parent-ectomy,” removing the parental influence. But we now recognize that families will have a lifetime involvement in eating habits and need to be part of the solution.

Are there any other similarities between the severely obese and the severely underweight?

Both groups may have low self-esteem and are feeling the impact of poor food choices and behaviors. Both must sustain change in small, manageable steps. But not everyone who is obese or underweight has an eating disorder. Treating everyone as an individual is the key.

Besides the obvious, are there any differences in these two conditions?

It’s easier to treat an eating disorder than it is to treat morbid obesity. If a patient is 200 pounds overweight, losing 10 pounds a year is not going to feel like it is making a significant differ-ence fast enough. But if a patient is 25 pounds underweight, gaining 10 pounds a year can make a significant positive impact. Prevention of both illnesses, though, is even easier. — Tricia Schellenbachg

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mystory

Sterling P. Shand III, a native of Akron, Ohio,is graduating from John Carroll University, just outside of Cleveland.

Working Weight

BY STERLING P. SHAND III, as told to Cleveland Clinic Magazine

I was a junior in college, thinking about start-ing my career. I read an article in a business ethics class about how people who are less attractive experi-ence prejudice in the business world. Although I’m not a lazy person by any stretch, I was worried I’d be perceived as lazy because of my obesity. It was hard to visualize myself as a successful businessman, while being overweight. It was May 2007, and I real-ized I had time before graduation to slim down, but I needed to get busy. I weighed 315 pounds.

My parents suggested I check out Cleve-land Clinic. I was interested in surgery, but my insurance required that I go on a moni-tored diet for six months before they would approve surgery. A nutritionist gave me an eating plan that would work with my body. I focused on eating more protein and cut-ting way back on carbs. But I didn’t deprive

myself. That’s when diets don’t work.I began taking a prescription to curb my appetite so I could

stick to the diet and develop a healthy pattern of behavior. The prescription mandates that I get checked every two weeks, so a doctor monitors my weight and blood pressure.

I was reaching my goal every month. The whole process was pretty easy. I am a goal-oriented person — not obsessive, but driven. I made up my mind, telling myself: I know what I want, and it’s not food. I want a healthy body.

I’m down to 203 pounds, and I’m 5 feet 11 inches. I’d like to get to 185–190. That’s not too low. There’s still meat on these bones.

I had to be strict for the fi rst few months to develop a taste for good things. It took me about three months to really appreciate healthier food. Double cheeseburgers are addictive. But I came to realize I didn’t want to give in to my cravings. I wanted to get to my goal, which forced me to eat good foods. Eating fruits and veg-etables instead of fast food leaves me feeling so much better inside. Now I eat a little bit and realize I’m full. An appetizer is enough. Eating has become much more about taste than quantity.

I live off campus, so I can control what comes into my house. My fridge has lots of cheese — regular cheese, not that awful non-fat cheese. Lots of meat, chicken. The fruit and vegetable drawers are full. I drink lots of water, and I have about fi ve cases of diet soda in there. I snack on pretzels and peanut butter.

I started slowly with exercise. First, I took the stairs when I could. I used a pedometer and aimed for 10,000 steps a day. After

a few months, walking wasn’t cutting it. The weight was coming off more slowly than when I started, so I started jogging. Now, I can run three miles, fi ve miles easy. And I feel great afterward. About fi ve months into it, they had me do more weight lifting to build my muscle back up.

Every day, people ask me for advice. I tell them, “First, you have to make up your mind you want to do this.” You have to cut down on carbs, though you’re allowed to have spaghetti once in a while. Don’t make it painful or you’ll give in. You don’t want it to be a chore. It’s a life.

This has agreed with my body so well. My doctors say I’m one of the few nonsurgical patients to lose this much weight, so my results aren’t typical. I just don’t get that hungry. If I get hungry, I eat a little. And I can stay under 2,000 calories a day. You have to weigh yourself every day. To see the weight going down feels good. It can be easy to gain back, though. I’m reminded when I look at my driver’s license photo. When I get “carded,” the expression on their faces is quite amusing. They always ask if it’s really me.

It’s paying off in many ways. I get a different kind of attention from girls. Now they say I’m a handsome dude.

And, just before winter break, I got a job with a local company that develops shopping centers. My new look gives me a confi -dence I don’t think I would have had if I still resembled the photo on my license. G

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needed to get busy. I weighed 315 pounds.

land Clinic. I was interested in surgery, but my insurance required that I go on a moni-tored diet for six months before they would approve surgery. A nutritionist gave me an eating plan that would work with my body. I focused on eating more protein and cut-ting way back on carbs. But I didn’t deprive

myself. That’s when diets don’t work.I began taking a prescription to curb my appetite so I could

stick to the diet and develop a healthy pattern of behavior. The prescription mandates that I get checked every two weeks, so a doctor monitors my weight and blood pressure.

I was reaching my goal every month. The whole process was pretty easy. I am a goal-oriented person — not obsessive, but

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These are the hands of the future.

The hands of University School graduate Toby Manders, Class of 2008. A bright young man with

clear direction and just one of this year’s 96 graduating seniors, all of whom we are very proud. His year-long project with Cleveland Clinic, under the direction of Dr. Damir Janigro and a team of international researchers, studied the effects of common anti-inflammatory drugs in the prevention of seizures in epileptic patients following a stroke.

The result of his hard work in and out of the classroom has him calling Columbia University his home away from home for at least the next four years. We believe in Toby’s commitment and personal pursuit and know that the best plan for tomorrow rests in the hands of people like Toby and his classmates — today.

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