Monday, May 31, 2010
COPD stands for Chronic Obstructive Pulmonary Disease. This condition is usually found after a person has entered a more serious stage. Signs at the time will be shortness of breath, especially with activity and sometimes a chronic cough. Anytime you have cough with phlegm, sputum, gook - see a doctor. It could be acute bronchitis - or chronic. Chronic bronchitis and emphysema are considered to be COPD.
A person with COPD has trouble breathing and this difficulty is not completely resolved with a medicine called a bronchodilator. COPD can lead to significant lung changes - scarring, swelling, mucus entrapment, inflammation, destruction, increased volume and collapse.
The risk factors, in order of most causes to least:
indoor air pollution from heating or cooking with biomass fuels -
coal, straw, dung, wood
work related chemical and gas exposures
infections - esp from the adenoids
gender can play a role as well
All of us lose some amount of lung function over time - we have a lung age that is based on years of life and gender - that lung age is what a lung function test will compare to. COPD is diagnosed through clinical exam and especially through spirometry -
The spirometry test and the diagnosis includes two values. When one blows into this device the first thing it measures is FEVone - or the amount of air you can force out in one second. The second measure is FVC or the amount you can blow out - completely - your total expiration.
The FEVone is divided by the FVC and that score is what defines COPD. If it is less than .70 it can indicate the disease. The second measure determines the stage of COPD. The FEVone is compared to FEVone of people similar to you who are healthy. Having 80% or less of that predicted value is stage one. Having between 50-80% is stage two and so on.
Treatment exists for COPD. The most important thing is to stop any exposure to the cause - tobacco smoke, fuels, chemicals. It is also important to prevent worsening conditions - so disease monitoring and medication management are important.
I am going to stop now. References and links are in the previous post which was linked earlier.
Sunday, May 30, 2010
Cell Phones and Cancer - I would like to be able to tell you that an international study that was completed several years ago and recently published determines the risk of cancer from cell phone use. It does not. There is however, an effort in the United States to try again with a study that will track people going forward, but that will take many years to complete. What should you do in the meantime? I would suggest texting! Also you can use your speaker phone and limit your calls.
Food Companies: I don't know what is worse - what companies try to sell us or what we actually buy. This weekend as I was searching for some simple frozen stir fry vegetables I came upon a well known name brand company that was selling vegetable blends for "immune health" or "vision" or "digestion". Seriously - seriously.
Alli and Xenical: Renewed concerns and label changes for these diet drugs. They are the same drug though one is prescription and the other over the counter. All I can say is what I have always said - eat less - the side effects won't kill you.
Heard on the Street: Literally - I was running this morning and two women went by and I heard one say to the other something about getting a "potato with nothing on it or plainwhite rice. " I thought to myself, WHY? Why not eat cauliflower with lots of seasoning or spaghetti squash with Parmesan cheese? Plain potato - ick...
J&J: Johnson and Johnson is having a real hard time of it these days. Many of their products have been recalled due to problems at the plants where they are manufactured. I saw a headline about a J&J or McNeil staff member stepping down or giving up his bonus- something to that effect - over the recall. I thought, hmmmm.... not so bad when you consider the severe and fatal consequences to associates when this type of thing happens in countries like Japan or China.
Pollution: My Mom and I took a walk along a little park boardwalk at a watershed today. The sign at the trail start indicated how important watersheds were for the environment and that this was one of five that were in Florida. Most of the short walk was pristine - mangrove canopy - clear water. But we also saw
a plastic bottle and a beer can in the water as well as a skittles bag and some other food bag. Really frustrating.
Saturday, May 29, 2010
[with gratitude and thanks to Dr. Stephen Rennard – pulmonary specialist, scientist and professor – he sent me research articles, a book chapter and some email clarifications]
I have worked on this post for some time now. I hope that I can share the important characteristics of the disease, its causes, how it is diagnosed, prevalence, treatment guidelines and maybe USA mortality and morbidity statistics.
There are still things that I do not understand – mostly because of the highly technical material I read which did increase my vocabulary when it did not overwhelm me. There came a point when I had to admit, I really did NOT have to know ALL of those details to do my job or write this blog.
I do think that this was somewhat harder to process than the information related to heart disease and smoking which I shared back in February. With regard to the heart, there is endothelial damage and with the lungs it is mostly epithelial. This helps me to recognize the difference better – epithelial is tissue and organ cells – like the lungs and endothelial has to do with blood vessels!
So let me begin:
COPD stands for Chronic Obstructive Pulmonary Disease and is included in the CLRD category of the leading causes of death. It is the fourth leading cause of death in the USA after heart disease, cancer and stroke. In the world, it can be THE leading cause of death in low income countries.
The established definition of COPD is as follows:
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles and gases. (book chapter -see end notes)
There are two main diseases in this disease categorization – chronic bronchitis and emphysema. I have at times been confused with regard to where asthma fits in. The main difference between COPD and asthma is irreversibility. Both diseases involve an obstructed airway, but most often asthma will respond with a complete reversal with a medicine referred to as a bronchodilator. In other words, a medicine that opens the airways. Probably because, in mild to moderate asthma, the airways are blocked from muscle spasms, not damage and once those passage ways are relaxed, normal breathing can resume.
There is a respected global non profit organization or consortium that includes the USA’s NHLBI and NHI as well as the WHO. The entity is called GOLD for Global Initiative for Chronic Obstructive Lung Disease. GOLD has clinical practice guideline for identifying, preventing and treating COPD. Most of the research literature on COPD will refer to the GOLD standards for identification and treatment. For that reason, they should be noted. These signs and symptoms below are clinical indicators of disease, however, it is protocol that a person with them be considered as having COPD with a lung function test to confirm. Significantly, a person who does not have the signs but has been exposed to risk factors such as chemicals, dust and tobacco smoke should also be evaluated.
The signs are:
Shortness of breath or feelings of breathlessness often referred to as dyspnea
Chronic cough (may come and go and may not produce any phlegm)
Chronic sputum production (any time this occurs it is a WARNING for COPD)
The risk factors are:
Tobacco smoke (the number one cause of COPD and possibly the cause of 50% of all cases)
Exposure to dust and chemicals on the job (occupational exposure)
Smoke from home cooking or heating, especially in some countries where biomass fuels, such as coal, wood, straw and animal dung are used.
Risks that may be less common or more likely to be synergistic include:
Gender, genes, infections, outdoor air pollution, asthma and being poor or living in an impoverished nation.
The lung function test and the parameters for diagnosis are spirometry and FEV1/FVC.
Let me explain. The spirometer is a device that the patient blows into and it provides the clinician with a reading. There are specifics on how one inhales and exhales or blows for the test, but they are not necessary here. The letters stand for Forced Expired Volume in one second and Forced Vital Capacity. COPD as defined by the GOLD standards, has four stages. The stages are based on the FEV1/FVC score. All stages have FEV1/FVC less than .70 and then they have an additional predicted value of the FEV1 which is diagnostic.
1- Mild - the persons FEV1 is 80% or more of what similar persons (without disease) would score. There may be no other signs and a person may not complain. It is very important then that providers know about the risk factors and DO use the spirometer in said patients to catch the disease early and treat accordingly.
2- Moderate- the FEV1 is now between 50 and 80 % of predicted and shortness of breath is more common, especially when the person is active. There may be cough with sputum or discharge and this is when a patient often seeks help.
3- Severe – the patient’s air flow is limited further and the value is below 50% of predicted but above 30%. Now a person’s health quality and activities of daily living are adversely affected.
4- Very severe- the patient has significant obstruction and a predicted FEV1 of less than 30 or less than 50 with other complications, such as acute respiratory failure. This stage can have many exacerbations or worsening for the person and can be life threatening.
So as you can see, the spirometry is the standard method for diagnosing COPD and for staging its course. There are other diagnostic tests and imaging that can be used to get more details on disease. Those can be explored elsewhere.
The absolute most important thing to be done at ANY stage and immediately is to STOP the exposure to the toxicant. In other words, stop smoking. In the USA and several other countries work exposures are limited – for instance, some chemicals are banned and some regulations require masks and ventilation. Coal miners are a group that continues to have work exposure that can lead to COPD as well as Black Lung. In some countries, however, no occupational safe guards exists and there are no other options for heating and cooking – this is a significant health threat to those individuals. Outdoor pollution is less a threat to cause COPD, but may lead to exacerbations of illness.
Do NOTE: We all lose a certain amount of our lung function as we age and thus the FEV1 predicted value difference can show the acceleration especially in smokers. Smoking cessation (quitting) can prevent progression of emphysema only in its earliest stages. But cessation always improves treatment outcomes. A person who quits smoking by age 30, in at least one clinical trial, shows no difference in lung aging than a healthy non smoker! (if they do not already have disease)
Treatment includes oral medications,(pills or inhalations) and most often does not include nebulizors. The standard pharmacotherapy includes bronchodilators of two types as well as long and short acting ones. In other words, a person can take a daily formulation of a bronchodilator and then use a short acting one as needed or in crisis. Other meds used, especially in later stages, include inhaled glucocorticosteroids and then systemic steroids. Treatment can include the use of oxygen therapy as well – as needed or at night, or continuous. Oxygen use is based on the person’s oxygen and carbon dioxide levels. People with COPD are especially encouraged to be vaccinated against the flu and less strongly pneumonia. Lung volume reduction, lung transplants and other invasive surgeries can also be performed.
____________ A little pause to note that I have far more information that is needed for a blog post – And I have three more things to cover______________
Prevalence is the term used to describe the number of persons living with a disease at a certain time point – like now or when the statistic was last available. This is different than incidence, which is the number of new cases, usually offered by year or projected into a decade. The prevalence will differ by nation. I have to say that there is a concern in the scientific community that the prevalence is grossly UNDER estimated based on the fact that spirometry is NOT used and that many persons with the disease are not unidentified at the earlier stages. For that reason it is better to tell you the differences as offered in a Lancet journal article forwarded to me by Dr. Rennard. The chart offered there has cases per 100,000 persons and includes only stage 2 or higher COPD. There is a gender difference sometimes extreme sometimes slight. The highest prevalence is noted in South Africa which is probably related to home fuels and the lowest is in Mexico which I speculate has a low smoking rate. The USA is center left – i.e. closer to South Africa than Mexico and for some reason the UK is not on that chart. The USA is one of only a handful of countries where the rates in women is higher than men. For a look into the mortality rates of COPD in the USA please view this MMWR from the CDC.
The differences between chronic bronchitis and emphysema are significant. I am afraid that if I try to offer much detail I may make mistakes – and I have read and read and read in an attempt to grasp this fully.
Chronic bronchitis has to do with a buildup of mucus in the lungs. Certain cells in the tissue will react to irritants and cause mucus secretion which under normal circumstances will help to clear out toxic or irritating substances. The bronchial tubes swell also and this mucus and swelling makes the airways smaller. This is now the lungs are obstructed. Chronic bronchitis is the type of COPD that is associated with coughing and sputum. It can also be exacerbated by a virus or bacterial infection.
Emphysema is noted for being the disease in which the alveoli or little air sacs are destroyed. There is a lot that goes on with both diseases that leads to oxidant stress, inflammation, scarring and dysfunction. As the lungs lose elasticity in emphysema and air sacs are destroyed, the lungs have more volume – but that is a negative thing. There is a treatment, rather invasive, to remove the damaged lung and it is called Lung Volume Reduction Surgery. People with emphysema sometimes describe their breathlessness as feeling like they are drowning. The lungs do not fully expand or relax and normal breathing is compromised.
There are treatment options beyond the medications or procedures listed above which include controlled coughing and controlled breathing – these are actual physical techniques learned by the patient.
Of utmost important with regard to health quality is returning the patient to a level of functioning that is independent and retains quality. In that regard, as indicated in the book chapter written by Shapiro, Reilly and Rennard , “exercise conditioning is the single most important aspect of rehabilitation and has been repeatedly shown to improve exercise capacity and endurance….as with any exercise program, gains in conditioning are lost if the exercise program is stopped.” Read that last part again people – that applies to ALL of us.
There is so much more to know about this disease. You can take this free course on it if you like – you can visit the website of GOLD – you can review the articles I have read and you can view this website recommended by Dr. Rennard.
The articles are:
The natural history of chronic airflow obstruction revisited. Am J Crit Care Med Vol 180 pp. 3-10, 2009
At A Glance outpatient management resource for COPD. GOLD Report 2009.
COPD: the dangerous underestimate of 15%. The Lancet. April 15,2006.
Global burden of COPD: risk factors, prevalence and future trends. The Lancet, Vol 370. September 1, 2007.
Chapter 39 (book title unknown -personal correspondence) Chronic Bronchitis and Emphysema, Shapiro, Reilly and Rennard. Current.
Friday, May 28, 2010
So - let me share with you a video that will enable you to make some very yummy and still calorie moderate pizza bagels :) Enjoy
Thursday, May 27, 2010
My sister then took a turn and educated ME and I must share with you now.
She said that a similar though not quite as serious tactic occurs with olive oil. Most know that olive oil is considered one of the heart healthy or health promoting oils which contain the good monounsaturated fat. The type that we SHOULD consume - in moderation and in place of saturated fats. You might also know that great chefs and nutrition experts recommended EVOO - or extra virgin olive oil. BTW, my sister, and I believe her, said that the EEVOO is just a gimmick - there is no extra extra in reality.
My sister has been to Italy - as have I and many people in my family, but she went to a place where they make the olive oil. This is what happens- They harvest the olives and then press them so the wonderful heart healthy oil is released. They capture this oil. It is a beautiful greenish color. This very first press - a cold press - is the extra virgin product, or EVOO. Then the producers press those same olives again, also a cold press and that is virgin olive oil - a bit lighter in color - perhaps milder - still quite good for you. Well, alas, even in Italy we have to get out every last drop of something before casting it aside. Yes, it is the bottom of the barrel so to speak, the opposite of cream of the crop - the residue. My sister said that the olives are so "spent" at this point that they must be HEATED to extract the last of the oil, the lightest in color - and least aromatic. It is said to have the least amount of antioxidants and it is NOT the recommended choice (per the mayo clinic and others we should be consuming EVOO or VOO)- but the companies label it LIGHT and people buy it because they think what? Light as in less calories? Better taste? Heck, they probably even charge more for it - just to be sure you will think it is better. It is not. Extra virgin olive oil is the right one to buy.
Take home message - light can be misleading - read the label for the truth - sometimes it's really there.
Remember also that cooking olive oil can break down the very properties that are healthful so topping food with it is the better idea.
Wednesday, May 26, 2010
This type of information could be used to support the legislation for point of ordering or point of purchase - nutrient information. I use information like this to inform my decisions on where to eat out and how to order when I do. I offer the information below to address eating out on my website:
When eating your meals away from home there are a few things that you can do to keep them low in fat and calories. The main thing to do is stay in control! It is no secret that restaurant foods are served in abundance with excess calories mostly from fats and sugars. The American Heart Association is one of many organizations that offer advice on how to dine out and stay healthy. Weight Watchers is another place where you can get trusted advice.
See online menus before you choose a restaurant or before you go to a restaurant someone else has chosen. If you already know what you are going to order you can overcome some of the temptations.
Try these Tricks – Ask for your food to be cooked without oil, fat or butter. Not so brave? Ask that it be cooked with very little OFB. Or ask for the sauce to be served on the side. Ask for your fish to be broiled or grilled. If your food comes soaked in oil, dab it with a napkin and remove 100s of extra calories. My favorite meals to order out are grilled tilapia or mahi mahi and steamed vegetables. I always tell them not to add OFB. When at an Asian restaurant I ask for shrimp with mixed vegetables steamed with sauce on the side. Often my meal comes in a bamboo basket and is the envy of everyone at the table! I also will order grilled or broiled fish or shrimp on a bed of lettuce and tomato. (make sure you ask what comes on the salad – leave the cheese and croutons behind) A great dressing is balsamic vinegar – not a vinaigrette, just the vinegar. Or bring along your own Walden’s Farms near calorie free dressing.
Be assertive (it’s your money and your body!) – but be nice. I always tell the server that I have special dietary issues, or allergies and it is OKAY if the chef can’t do what I want, I have a plan B. I would rather they say they cannot do it, then to serve me something swimming in butter. I also tip generously when my meal is as I requested.
With regard to the USA Today article, they reported on the Center for Science in the Public Interest's report on extremes in eating. Here is the link to the actual report from CSPI – it really is enough to make you sick – really sick.
Tuesday, May 25, 2010
When the media began reporting tarball findings in the Florida Keys I paid attention. I live very near to the Gulf Coast shore in Sarasota Florida. I think all of us would expect that the tarballs were some manifestation of the oil that is spewing from the Deepwater Horizon site. I was surprised to hear that the tarballs found were NOT from that spill. That made me question my whole notion of the tarball.
A tarball is indeed a remnant of an oil spill. NOAA - National Oceanic and Atmospheric Administration- explains it very well and to summarize, the oil that escapes from tankers or wells will go through many changes brought about by the elements, time, temperature and the like. The oil begins as one big mass and while some lighter components of the oil will evaporate and some will break down, the majority is spread out into smaller pools of oil. This occurs from the tide and wind and even the temperature of the air and water. The division continues over time and tarballs result. They can be as big as a small plate or the size of a marble or pea. Often they will become hard on the outside but remain sticky inside. A tarball that becomes crusty like that, like a toasted marshmallow NOAA says, is said to be weathered. (the balls should be avoided and can cause irritation to peoples skin if you see any you should call the Joint Information Center at 251-445-8965.)
If the tarballs are NOT from the Deepwater Horizon explosion - where are they from? There is actually a test that can be performed to get the "fingerprint" of the tarball and link it back to a previous spill. The ocean is vast and wells exist off many lands while tankers sail the waters world wide.
Yesterday I was saddened to read of the marine life in the Louisiana marshes. Pelicans who cannot fly because their wings are oil coated. I always feel the strongest angst when animals and very young children suffer so- especially due to NO ACTION on their part. The fish and sea fowl, the mammals of the deep - innocents. The worst part is that we cannot tell them what happened - we cannot explain to them why they cannot fly or why their young may die.
I wish there were no tarballs. To read more about them click here.
Monday, May 24, 2010
What has been less challenged is the deleterious effect of saturated fat in red meat, especially in regards to heart disease. A study recently published in the journal of the American Heart Association found that consumption of red meat itself did not correlate to new cases of coronary heart disease. However, there WAS a significant relationship between processed meats and heart disease and possibly diabetes as well. The concern is related to both nitrates and sodium. A high salt diet, especially as it can lead to hypertension, is damaging to artery walls and that damage - inflammation for example, can lead to plaque buildup. Processed meats include lunch meat, bacon and sausage. What did not bear out as a risk factor was eating a steak for example. However, saturated fat does increase caloric density. For that reason, serving size and frequency of consumption must be moderated. The serving size is 3-4 ounces and the frequency is just a few days a week at most. Saturated fat is a problem as is overconsumption of any nutrient which can lead to obesity and the host of problems that involves.
Take home message is that though red meat intake may not be as severe a threat as once thought, it is still something that should be moderated.
The research was one that reviewed over 20 other studies for outcomes based on the food histories of the persons involved. It is not a controlled experiment or clinical trial so the force of the conclusion is somewhat diluted. You can see the abstract of the study here.
Remember also that the AHA has many great resources on its website, including guidance to prevent heart disease in what it calls the Simple Seven.
Sunday, May 23, 2010
One Nation Overweight: That is the title of the CNBC special that aired last week and encores tonight at ten. I have not had a chance to view it, but it is on my list. Tonight of course is also the series finale of LOST - of which I am a fan. Here is a link about the CNBC special in case you are interested. You should be interested.
Avandia Troubles: Avandia, also known as rosiglitazone, is a drug used for the management of diabetes. It is a drug that, when working properly, would make a diabetics system respond more effectively to existing or endogenous insulin. The drug has come under fire in the last year or two because there are cardiovascular risk factors that some - including the advocacy group Public Citizen - find far too severe and frequent for comfort. I agree that the drug should not be used and agree with the assertion that there are safer medicines that are effective. The EU has not banned its use, nor has the USA - however, the FDA has requested additional trials on the drug - which others have also spoke out against. Interestingly, there is a lack of volunteers and at least one site has had to stop their study. It caught my attention as it was my career affiliated WFU School of Medicine.
Beef Costs: HMM - Fast food restaurants are said to be pushing chicken these days. Not so much for your health unfortunately but because beef prices are rising and chicken prices are not. Reading in the WSJ this week, companies expressed reluctance at raising the price of burgers so instead they were promoting chicken and other menu items in the hopes that customers would not order as many burgers. What caught my attention was a discrepancy between lean and not lean beef. I imagine that 90% lean beef or hamburger was more expensive than 50% lean to begin with - still the extra extra lean is now up less of a percentage than the 50% which, again according to the WSJ, is at its highest since 1995.
Nicorette Mini Lozenge: Goodness talk about confusion. The first is that the commercial seen on TV for this product is ridiculous. I make this claim based on the fact that the few people I have surveyed who have seen it, did NOT know what the message or the product was. One of my "smokers" explained it to me - but other "smokers" whom I explained it to said that they did not get it until just that minute when I explained it. So you can see the commercial on line - fairly I saw it only once on TV and missed the start. [If you do NOT immediately know what is being sold - somebody wasted a lot of money. Seriously - are you ever NOT sure what Cialis and Viagra commercials are about?] Anyway, I went to the Nicorette Mini Lozenge website where I became more confused. The website claims that it is the first lozenge from Nicorette - technically true - the standard nicotine lozenge is Commit. GlaxoSmithKline, however, produces BOTH. So why is it a mini lozenge? I thought it would be a smaller dose, but the website only notes the 2 and 4 mg versions - same as Commit. I guess they just encase the nicotine in a smaller lozenge. Weird. I recall that on the commercial the quitter tossed back the lozenges like they were a bunch of Chicklets. That would not be good. I should watch this commercial again. BTW, I emailed a GSK representative on Friday - so we will see what he has to say. [ah yes, I did review the ad - and I didn't miss the beginning after all - but now I do notice that the guy only flips one lozenge into his mouth - good to know] ALSO - I am not saying that nicotine replacement therapy doesn't work - it does help many people to quit.
Fewer isn't Less: Sorry - I know I have said it before but it was on my little notepad so I am compelled. I must have heard the commercial again this week- for Alleve. Just because you take a medicine less times a day ( or in fewer pills) does NOT mean you are taking in less medicine. And it is always WISE to take the smallest possible dose that is effective for your issue. I just want you to think about that when your hear that two pills of one drug is less than four of another. The drug mentioned here lasts 12 hours, not four - that is true - but the two pills are possibly a higher dose of medicine..
Saturday, May 22, 2010
The FDA requested information on these kits at about the same time which, thank goodness, got the attention of the company big wigs who decided to wait before putting the products on their shelves.
The tests, which are saliva tests, cost about 20 to 30 dollars to purchase, but the actual diagnostics and results could cost an additional 80 to 250 according to an article written by J Corbett Dooren in the WSJ.
The tests might supply a person with information on genetic risk for disease, on passing on diseases through procreation (you know the whole blue eye, brown eye recessive gene thing!) and possibly, information on which type of disease a person has – in order for tailored medications to be prescribed. That last one is definitely one you would ask your oncologist to order and review – it isn’t the best do it yourself idea you might have! I believe I did a blog post on this new form of tailored treatment – but it is far from mainstream and no provider is going to tailor your treatment based on a home test.
Otherwise, there are genetic counselors for family planning and for goodness sakes; your risk for disease is almost always based on environment and your interaction with it. When the President’s Cancer Panel report came out recently both within the text and in publicly aired discussions among experts , it was said that 1 percent of disease is solely based on genes. It is almost always a multifactorial disease process. No matter what test you take or what kind of faith you want to put into it – taking care of yourself through healthful eating and near daily exercise is the MOST effective way to prevent disease (along with protective factors, like not smoking, avoiding pollution, wearing sunscreen etc). Is it a 100% guarantee against any disease – NO – but the thing is, the side effects – sore muscles from time to time and angst at passing over cupcakes and chips most days – well , that ain’t NOTHING compared to the side effects associated with pills, fad diets, supplements and the like.
The FDA is reviewing these products to verify accuracy and to make sure that the marketing by the companies is accurate. The house panel is rightfully concerned about the data. The Health Insurance Portability and Accountability Act, usually referred to as HIPAA, became law in order to protect the medical records of persons and I imagine the government is concerned with personal identity and the un chartered waters of DNA collection as well as the protection of health information.
Friday, May 21, 2010
I think the reasons that these veggies come out so well is either because of their innate properties or the spices and such I use to cook them. There is this food idea or concept out there called umami - I believe. It refers to a food's savoriness and the foods that have the most umami properties are also satiating ones.
Think mushrooms, Parmesan cheese, tomatoes, soy based foods or Asian foods. I am adding green beans and brussels sprouts because they hit the same spot for me. So these veggies are my favorites for their nutritional make up - high nutrient, low calories and / or also for their umami flair.
Roasted green or yellow beans
Roasted or Baked brussels sprouts
Yellow, green, orange and red bell peppers
Here is the link which provides video cooking ideas for some of these veggies...
Thursday, May 20, 2010
RE: Today's post and title:
The motive may not be the purest, but in the end, with one possible exception, it doesn't matter. I am referring to an 80 member food industry coalition that has formed in response to growing restrictions or suggestions of restriction with regard to the content of our foods and point of purchase nutrition information.
The industry group is called the Healthy Weight Commitment Foundation. The goal of this group is to reduce the amount of calories in their products by 1.5 trillion. Yes, that is right - trillions of calories. They hope to accomplish this by the year 2015 with substantial progress towards that goal by 2012. The Foundation includes a few of my favorite companies - favorite in that I often purchase their products - General Mills, Kraft, Kellogg, Coca-Cola, Red Lobster and PepsiCo.
Our national obesity reduction program is the Let's Move initiative begun and managed by Michelle Obama. Many nonprofit groups have joined the first lady's program and the Healthy Weight Commitment Foundation has made a pledge to these groups to contribute by reducing the amount of calories in their foods. The Let's Move program calls from calorie reduction - through less fat and sugar, but also encourages an increase in nutrients.
I was very happy to see in the press release and on its website, the involvement of the Robert Wood Johnson Foundation. They will be responsible for evaluation of the program. Please read their statement here.
I do have a concern - and I addressed it with RWJF through email. I will share that with you here (i tried to cut and paste but it did not work this time) - my concern is that the industry will take its current approach and apply on a grand scale. That is take out sugar, add water, reduce the serving size and increase the price.
I have been in contact with Kathryn Thomas, a senior communications officer with RWJF and shared my concerns. She did respond with the evaluation goal, but it does not specifically address accessibility. I have asked that she forward my concern to program planners. I just feel that someone needs to say it because this could be a phenomenal intervention that in the ends fails to meet its goals because of that one detail.
Remember socially possible interventions are what we need now.
Tuesday, May 18, 2010
Monday, May 17, 2010
I continue to read in the hopes of understanding this better myself so that I can share my new found knowledge. At times , while reading, I feared that I would instead only succeed in making it more confusing for all of us.
The upshot and upside is that there are initiatives in place to educate not only patients, but physicians, technicians and other health care professionals on the dangers of over exposure to medical radiation. As indicated in previous posts on this issue, machines need to be calibrated, and doses lowered. Additionally, this report states that newer imaging machines have built in sensors that can reduce the amount of radiation used based on organ and person size.
Of special concern has been reducing radiation to children. This is an issue for several reasons. One is that time of exposure is related to incidence of cancer, independent from frequency or amount. In other words, radiation causes damage and if that cellular damage is not corrected on a molecular level, then mutant cells continue to multiply over time and the more time they have - i.e 60 years of life vs 10 - the greater the chance that a cancer could develop. Secondly, children have smaller bodies to absorb the radiation, have more rapid cell changes at certain ages due to developmental issues, and if things don't get reined in, will have a life time of exposures that will accumulate.
Another concern is the increased risk of breast cancer. The PCP report notes that breast cancer from radiation is an "important and controllable risk factor." The problem is that any imaging of organs or bones beneath the breast can expose the breast to this known carcinogen. Bear in mind that a mammogram exposes the patient to approximately .4 mSv of radiation while a coronary angiography can expose the breast and heart to 16 mSvs.
The FDA is also working on a plan to have electronic or paper cards (smart cards) that we can use to keep up with all our imaging and dosing. This could reduce multiple scans of the same body part i.e lost records, patient recall, etc. There is also a program in the works that is intended to help patients talk to their doctors - much as I have suggested - why do I need this exam? Perhaps an alternative test can be used, such as ultra sound, MRI or a blood test. This is meant to address both sides of the unnecessary scan issue. The scans doctors order because they are afraid not to, and the ones they order because the patient insists that they do. One scientist from Columbia University suggested that a third of CT scans could be replaced by other tests.
Even though this chapter explains the different units of measurement with regard to ionizing radiation - it doesn't provide a layperson with the tools necessary to fully grasp what is measuring what. I can tell you with certainty that whether it is an mGy, mSv , rads or rems - MORE of any of them is what you are trying to avoid. It does seem like most measures come back to the Sievert and then the millisievert or mSv.
Several examples in the text use the mSv and that helps me make some good points. Remember there is no known safe dose of radiation - we just try to find what is sometimes referred to as the amount that will provide a result - the "as low as reasonably achievable" dose. Example one: the exposure to radiation from the atomic bomb(s) dropped on Hiroshima can be measured in mSv. It is expected that people were exposed to between 5 and 100 mSv. Regular xrays and mammograms expose people to less than 1mSv. CT scans will have a very wide range based on where the scan occurs, but also on the other factors which have been noted, so a coronary angiography CT can expose a person to 16 mSv and a PET scan even more. In nuclear medicine, where the radiation comes from within - i.e you take the radioactive isotopes into your body orally or through IV, the dose can be double that - esp. if the isotope is thallium 201. But I believe that my Aha moment really came when I read about the limits that are proposed for radiology technicians. Example two: there are two groups that cover this issue and the US one, OSHA allows workers to receive more annual and cumulative mSvs than the International Commission on Radiological Protection does. Well I think we should limit our exposure to the ICRP worker standard, at the very least (or most, depending how you look at that sentence!). So that is 20 a year and no more than 100 within 5 years. A chest CT may deliver 7 mSv with a range of 4-18. The virtual colonoscopy that I used to think was a neat idea, delivers 10 mSv with a range of 4-13. To learn more values, see chapter four of the current President's Cancer Panel annual report.
Ionizing radiation comes from other sources as well, but about 48% of it comes from medical exposure. In the 1980s the medical amount was closer to 15% and that is the concern - the growing concern, regarding cancer incidence from medical imaging and nuclear medicine.
Sunday, May 16, 2010
Parental Oversight - I noticed another positive thing which involved a protective factor but this time, the protective factor was absent and it has to be the Mother's FAULT. I observed a woman pushing a stroller, canope over the infant, and two young boys (six to eight years old) ahead of them on their bicycles. They had been walking/riding on the sidewalk, but the boys were now at a crosswalk, waiting for the light to change and the stick figure to 'walk.' I was in a car at the stop light. I worried because I have almost been hit a time or two crossing that same side street (running). The boys were NOT wearing helmets.
A Smoker Speaks - Today I was back at my tobacco free beach for an hour or two (wearing sun screen and a hat!) and a lady a few fit in front of me, talking on her cell phone lit up a cigarette. I had to wave at her when she looked over and I said, "Ma'am - this is a tobacco free beach." I said it nicely. She said oh, and told the person on the phone and put out her smoke. (she stubbed it in the sand, but did NOT leave it there) After she got off the phone she asked me about the ordinance etc. I let her know that the rule was actually over a year old but we were only recently able to purchase the signs and set up the ashtrays in the parking lot etc. She said, "Well, okay - it is sort of good, then I won't be smoking while I am at the beach." So again I say to YOU and policy experts - anything we can do to make smoking harder will make quitting easier.
Average Weights - This is something I wanted to get to yesterday when I was speaking of average weights in the USA. The CDC has a FastStats page on body measurements and on that page they offer the average male height, weight and waist circumference and the same for females. I used those numbers to calculate the BMIs of each. To learn more about these and other health related biometrics or measures, click here. Accordingly, a male should have a waist measurement under 40 inches to have less risk of adverse health outcomes and a woman should have one under 35 inches. According to the CDC the average male, who is about five foot nine inches tall has a measurement of 39.7 inches. Way too close to unhealthy to be our AVERAGE. Women fare worse! The average woman, these days, is about five foot four inches tall with a circumference of 37 inches - two inches over. The BMIs come out to OVER 28 for both sexes. Recall that over 25 is overweight and obese is 30 and higher. This is a sad state and must explain why the economics of obesity will be discussed in a prime time CNBC special in a week or two.
Funny You Should Call - What are the chances that a person would dial MY office number by mistake to follow up on her order for the weight loss product Zantrx-3? When she said that she was calling because she ordered a diet pill - before I could stop myself, well, I chose NOT to stop myself, I said, "That is unfortunate." This product markets itself as the next best thing to the outlawed ephedrine products. Here is the disclaimer from the diet product's website, "*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. Use in conjunction with any sensible diet and exercise program. Individual results will vary." Indeed.
Oil Spill - Just a note to say that I have grave concern about the environmental effects not only of the oil but of the chemicals being used to break it up. The chemical process appears to consume oxygen and thus creates pockets of ocean without oxygen - oxygen, for many species, including marine life - equals life.
Diet Coke v Diet Mt. Dew - Special for you, friend Jim - there is less than 10 mg difference in caffeine between the two, but Mt Dew is indeed the higher one.
Saturday, May 15, 2010
It has long been true that sizes can be retailer and country specific - or patterns can be adjusted for specific stores and populations. But what has happened over the last 20 years is that the same stores in the same countries have begun making their smaller sizes bigger - MUCH bigger. This includes low and high end stores.
Think about it. How can so many more people be wearing a size six or eight when such a small percentage of adults are normal weight? This is especially irritating to me, as one of the less than 2% of the population that is considered underweight according to BMI - I am running out of places to shop! What was a size two when I was twenty (and wearing a size eight by the way) is now a large in children's! I am NOT kidding.
You might even have clothing in your closet that is a size "whatever" that fits perfectly - say a skirt -and at the VERY SAME STORE with the same size on the label it now falls off your hips.
I wanted to be sure about how crazy this seems - I mean how can so many more people wear what I always considered skinny clothes - i.e anything size five and under (I graduated high school in the 80s) if two thirds of the adults in America anyways, are overweight or obese.
Remember for adults a BMI of 18.5 to 25 is considered normal weight and a BMI 30 plus is considered obese. (Children's overweight status is based on their BMI according to age based percentiles, so it is a little different)
According to US surveys with data from 2003 - 1.8 % of the adult population is underweight, about 35% are overweight and another 33% or more are obese...That doesn't leave a lot of normal weight people does it?
I found a great CDC/NHANES document that lists the average BMI for women and men for age groups from 20 up to 80. NONE of the age groups had a BMI under 26 - NONE - the average weight for all age groups was over weight.
So I ask you, if the average weight in this country has only increased over the last few decades- how can people wear smaller sizes than they wore 20 years ago??
Friday, May 14, 2010
They were against the FDA regulation that forbids a company from marketing a drug for an indication other than what it was approved to treat. This has been discussed in my blog pages many times. I am against off label marketing and in support of the FDAs scrutiny of it. It found it ironic that I wrote about the new Bad Ad initiative with regard to drug marketing just a few days before the Forbes article was written. The new FDA program isn't specifically addressing off label marketing, but misleading marketing.
Still I read the article on Forbes with the hopes of keeping an open mind. The gentlemen argued that the restriction from the FDA was so tight that patients might suffer. Well, you know how easy it is to rile up the public. "The Government is deciding your medical care." The argument from their perspective is that the drug companies are hamstrung because any communication about an off label use could get them fined. This keeps physicians in the dark about new uses for a medicine and could conceivably prevent a patient from receiving an adequate or better treatment.
I see it differently, however, and they did not sway me. The drug companies must test their chemicals or biologics and apply for approvals. The clinical trials should be, and I hope that they are, rigorous. The trials test things like dose, efficacy and side effects. I just don't think that this step should be skipped (but I am in favor of an abbreviated application for new uses of an approved drug). If a drug company wants to market for another use then, in my opinion, they should do the work.
I still wanted to keep an open mind- especially because the Forbes piece said that the American Medical Association was against the restriction - and I tend to trust them. So I looked up the policy of the European Union and Commission. They have an agency similar to the FDA which is called the EMA (EMEA) - or European Medicines Agency. Here is a good synopsis of the similar EMA policy which I am directly quoting from a book chapter comment from a June Raine - " In Europe, subject to certain exemptions explained later, no medicine can be marketed for human use without a Marketing Authorisation granted either by a Member State competent authority or by the European Commission. The regulatory system exists to protect patients by ensuring that marketed medicines meet acceptable standards of safety, quality and efficacy in their indications. Nonetheless, for a range of reasons use of medicines outside their authorised indications, commonly known as offlabel use, and use of unlicensed medicines (i.e. medicines without a marketing authorisation) are common." source here
I wonder what they mean by unlicensed medicines and what the policy is on that? Suffice it to say - if the EU and EC have a similar policy in place, I continue to believe that we are doing the right thing. Bear in mind, the EU is a group of many European countries. You can see the list of countries here and you can review the EMA website here.
Thursday, May 13, 2010
The report has two distinguished authors, Drs. Lipke and Leffall. Dr. Lipke was a guest on the radio show On Point this past week. I was able to hear that show, which included other expert guests as well. From that show and the actual report I have gleaned a few points that I wanted to share with you.
The report focuses on the need to reconsider and address the environmental carcinogens that contributed to the 1.5 million cases of cancer in the USA last year.
In the study year (2009), over 500,000 persons died from cancer. It is now expected that 41% of people will be diagnosed with a cancer and 21% of the population will die from a cancer. Though environmental toxins have always been part of the picture, it is suggested that the impact is grossly underestimated. Certainly there are more chemicals in our environment and there are more exposures to ones that already existed.
I love that the report takes the cancer risk from radiation exposure seriously and breaks down the amount of radiation by medical device. It includes a chart that identifies the effective dose of radiation in tests and the range of radiation we actually get. Looking at that chart one can see the difference in exposure by exam. There is REAL concern about the exposure to radiation in these tests. There is also significant discussion of exposure to what now amounts to over 80,000 chemicals. We do not know the extent of harm, if any, that each of these chemicals independently or in combination will exact. (only a few hundred of the 80,000 have been thoroughly tested)
There is some debate as to the percent of cancer cause from environmental toxins - the categories including:
The scientists also break down the amount of cancer risk per agent - because so much of the risk - 50% to 60% -is attributed to individual behavior, some experts are wary of drawing attention away from those because the impact is so great. However, Dr. Kripke makes a good point by saying that PEOPLE put chemicals in the environment and PEOPLE can take them out.
Still the breakdown is estimated to be thus:
Tobacco 30+ %
Overweight/Nutrition/Physical Activity 20%
Genetic 1-5% (and that involves many interactions)
for example, hepitis C can lead to liver cancer, HPV can lead to cervical cancer
(percentages were not offered for all causes)
Environmental causes of cancer are estimated at no less than 6% which would be equal to about 30,000 deaths per year of the over 500,000
(bladder cancer caused by contaminated drinking water is an example of an environmental cancer)
I was also fascinated by a discussion in the report regarding DNA damage and genetics. Some new concepts which I am only beginning to grasp include -
single gene inherited cancer syndrome
endogenous processes that lead to cancer (free radicals and DNA damage)
exogenous factors (from the outside of the body)
genetic component PLUS an environmental exposure = risks for cancer
hormone production and function related to exposures
gene suppression and expression
epigenetic changes and epigenetic inheritance
- some exposures can change the messages that cells send and receive which can change the very delicate processes in the body and put a person at risk for a cancer and the increased risk from epigenetics can be passed on to ones children
A caller into the show made a great point. He said that though the risk for cancer from environmental toxins is much lower then it is for tobacco or diet, if a person does not smoke, get sun burned, eat too much or fail to exercise then his individually based risk of cancer from the environment is VERY high compared to his lifestyle risks.
BTW, everyone who is diagnosed with cancer is entered into a cancer control registry and scientists can access this registry (no names included) and assess the findings. Scientists can learn what people with certain cancers have in common and that is how we determine things like - tobacco causes lung cancer!
These links were mentioned in today's blog:
Cancer Panel report
Wednesday, May 12, 2010
As part of the initiative, abbreviated as the Bad Ad Program- the FDA will target health care professionals who prescribe medications. The professionals will be trained to spot the inappropriate ads and shown how to report them to the FDA. Anonymity is allowed but not encouraged.
Some issues of note are that the ads must be balanced - whether this is a drug industry "face to face", brochure or TV spot. Both the efficacy and the risks MUST be disclosed. Drugs are only to be advertised for the purpose they were approved. If an ad or spokesperson presents outcomes that applied to only a small sample of the subjects or as we say, an outlier, instead of the average results - they can be fined for false and misleading claims.
I do not know at this time if health care professionals who do not prescribe medicines or consumers can report bad ads, but I have called the DDMAC to find out. (of course I have)
You can read more about this program for which I am in 100% support by clicking on this link. The bad ad program does not include OTC drugs, supplements or medical devices. A second study will involve the effects of music and graphics with regard to watering down the seriousness of adverse side effect warnings.
Tuesday, May 11, 2010
Here are the points that I wish to make:
Cause of Death VS Cause of Cost
- The leading causes of death are not always the top in medical expenditures. The top five causes of death are heart disease, cancer, stroke or cerebrovascular disease, chronic lower respiratory disease (which I learned DOES include asthma), and unintentional injury or accidents. Heart disease or heart conditions and cancer have remained the top two causes of death and expenditures over the decade. Together they account for about 49% of annual deaths and over 180 billion dollars. The five diseases that cost the most to treat include those two, and trauma related disorders which I am going to say are accidents, mental disorders and asthma. WOW. This is true for the past ten years and the costs to treat went up across the board.
Most Shocking Info
The information on mental illness, even knowing what I know about over-medication and misdiagnosis was still confounding to me. The largest increase in expenditure over the ten years (1996-2006) was for treatment of accidents and mental illness. I bet this has a lot to do with more treatment options for the accident victims and more diagnosis and medications for the mentally ill. According to the MEPS Statistical Brief #248, the number of people included in the category for mental health expenditures went from over 19 m to over 36 m in ten years.
Some interesting Points
According to the listed documents, cancer patients have the lowest out of pocket expenses, while the mentally ill have the highest. The highest amount for inpatient care was spent on heart disease and the highest emergency room fees were in the trauma category. Again, the one that shocked me the most and shouldn't have was the cost of prescription drugs for the mentally ill - the HIGHEST out of over 50 referenced conditions - 26,143.75 million dollars on drugs. The second highest drug category was for hyperlipidemia - cholesterol and triglycerides at 22,148.17 - it is all about the marketing of prescription drugs! Heart disease patients have a lot more ER visits than cancer patients. I find it interesting that asthma and COPD are more costly to treat than diabetes. Diabetes is sixth.
Most Curious Data
I think I was thinking of the asthma. I am surprised that it costs so much to treat and I checked to see where it fell on the causes of death list. I am still digesting that people die from asthma, but I believe the lungs become damaged from inflammation and scaring over time. Anyways, according to some sources and the CDC Vital Statistics document, asthma is included in the Chronic Lower Respiratory Disease CLRD category which is the 4th leading cause of death. There were over 124,000 deaths attributed to CLRD in 2006 and just under 4000 are related to asthma. The costs for treating asthma are the lowest in regards to the five stated above but the medication expenditures are second highest of the five.
Most Brow Furrowing Statistic
I work in public health and one of the issues we explore and target is disparities among genders and races. In this blog I have made note of higher incidence in many disease conditions in the black population. So I was surprised that in the leading causes of death, more white people die each year than black. This includes heart disease and cancer where as the difference in stroke death is .3 percent - and yet blacks have higher rates of hypertension. However there are some causes of death that are high for blacks, such as homicide and diabetes than are not as high for whites. Over all, many more black people die each year than white, per 100,000 persons the death rate is 982 black and 764 white. That has everything to do with access to prevention and treatment.
Well I have done it again - hours writing a blog when I should be reading a novel - I hope you found this as interesting as I did!
Monday, May 10, 2010
Thus this blog post is really about the high cost of treating chronic disease in the USA. Cancer is considered a chronic disease - which is something right there isn't it! A chronic disease is one that is considered incurable and lasting. These include diabetes, hypertension, cancer, heart disease and asthma. Most chronic disease can be prevented through personal action. I found a nice two page primer on this issue published by the CDC and I am sharing that information with you in this post. Accordingly, just short of half the country has at least one chronic disease. Though these disease conditions use the most health care dollars, I did not see a breakdown of the percentages.
I was about to give up - ha ha - like that ever happens- when I googled my way to the Agency for Healthcare Research and Quality website. There is SO much information there. I could come up with the percentages I sought if it hadn't gotten so late on me. Instead, I am going to link you to one of their tables where they list the disease conditions and break down the expenses by type and amount, i.e. in patient care, drugs, etc. You will see that cancer is first, followed by treatment for traumas, and then the many manifestations of heart disease and the several other chronic disease states.
As a matter of fact, I am going to use my prerogative and make this a TWO PART post because there is a lot to explore on that website.... tune in tomorrow then :)
Sunday, May 9, 2010
Radioactive water: Apparently one of our nuclear power plants has a leak and some radioactive water has escaped. It is in a water supply and the company stated that it was nothing to worry about at this time. So here is my thought, "I understand that many corporations consider the average public to be uneducated - but seriously, do they think we are all STUPID?" When can nuclear waste ever NOT be harmful.
Ads: I have to tell you that all these commercials for weight loss, aging prevention, physical performance and sexual enhancement are just making me tired. If the products worked the way that the ads said that they do and if there were no risks what so ever - don't you think that a legitimate health organization would be the one telling you so.
Obese Children: I had an hour to myself on Anna Maria Island this morning after my run. I took a little stroll and saw a boy walking to the shore - he may have been between 8 and 10 years old. He had breasts bigger than mine and rolls of fat. It wrenched my heart to see this. He is the example when our health experts tell us that our children will be on medications for diabetes and hypertension in their twenties and will die at younger ages than their parents. It is Mother's Day - let us do some mothering - perhaps Michelle Obama should be the role model. [you can see a map of my run by clicking on the garmin link on the left]
Wind Farm: No the Nantucket mill isn't breaking ground - but a European company has already indicated that it is going to purchase x amount of kilowatts of energy for the UK. What? No offense to the UK - I have Scottish genes! but don't we need to use our alternative energy here first!