Start the New Year Informed

Like many or most of you, I am preparing for the new year. What might be different is that to be healthy I simply (or not so simply) need to keep doing what I have been doing. Whereas, many others start every year pledging - resolving - to do things differently. With that in mind, I want so share some truths with you.

The most important things that any of us can do are these (listed, not necessarily, but maybe, in order of impact):

1. Do not smoke tobacco (don't start or do quit).
2. Exercise - everyday (30 to 60 minutes of activity that increases your heart rate).
3. Maintain a healthy weight (this is relative, but for most people it means losing weight).
4. Eat within a calorie appropriate (controlled) recommended dietary pattern, e.g., the Mediterranean Diet, which is plant based.
5. Get some sun, but not more than 10 minutes without protection (also relative to time of year, your skin pigmentation and where you live).
6. Avoid alcohol in excess (for some this means any alcohol, for others excess means more than 1 or 2 a day or 7 to 14 a week (never more than 3 or 4 in one day).
7. Get vaccinated according to the CDC recommendations for your sex and age (and take your children in for their shots).
8. Practice safer sex - i.e., use condoms and discretion.
9. For those suffering from any substance use disorder, SAMHSA can direct you to supportive services
10. Do not fall for diet and supplement scams - nutrition comes from food and weight control comes from balancing intake with expenditure. If whatever supplement or plan you are hearing about was as much of a break through as the ad says, we would NOT have an obesity epidemic. Please believe me.. there is NO pill for you. Reread numbers 1 - 9 above, this is the key to health.
11. Remember these final words of truth:
1. Non-GMO only means something does not contain genetically modified ingredients, not that its low calorie or necessarily good for you.
2. Organic means something has been raised according to specific standards, and so the plant or animal was not treated with chemicals or antibiotics. Organic foods are not scientifically better for you than conventional foods (though there IS concern about antibiotics in the food chain). Organic foods are not necessarily or ever lower in calories than similar non-organic foods.
3. All natural is finally being defined by the FDA - but stay tuned for the final rule and then years before companies have to comply.  Even if something is truly natural - not at all processed - that does not mean it is good for you, wont' hurt you, or is low in calories.
4. There are legal definitions for low calorie, low fat, low sodium, etc.. and 'lower' means something different than low.
5. Read the nutrition facts panels, think about serving sizes.. pay attention to calories (usually a lower calorie item will also be low in sugar). Hopefully, the added sugar declaration will be added to labels this year and that will lead manufacturers to reformulate their products.
6. Some fat is good for you! Especially consider adding omega 3 fatty acids from food, like salmon.
7. ONLY 1% of white people in the United States have CELIAC DISEASE, and even fewer people of other races/ethnicities do. That means, YOU probably don't need a gluten free diet.
8. Gluten free does NOT mean low in calories or good for you.
9. The health promoting property of olive oil is destroyed when you cook in it. To get the nutrition you are seeking, drizzle a teaspoon over your cooked veggies instead.
10. Get your fiber from plant based foods and whole grains, not mixes and pills.

On a sad note, the national vending and menu labeling law which is NOW set for compliance in May of 2017 is part of the Affordable Care Act - and may or may not survive the next presidency. That means that local and state laws could once again begin to populate which could be better for us and a nightmare for industry. Stay tuned

Lastly and sincerely,  I wish you the healthiest of New Years....remember, though I focus on food, physical activity is the sine qua non of health... make sure you get plenty this year... all year.

~ Deirdre

Why we focus on food deserts and not food swamps

Most people have heard the term food desert. A food desert is a place where people live and do not have reasonable access to whole foods, or fresh produce. Often this is measured by some distance to a grocery store. For example, in some places people live close to convenience stores and fast food restaurants, but would have to travel several miles, sometimes 10 or 20, to get to a grocery store. In these same areas, there may be high rates of obesity - however, there are high rates of overweight and obesity across the USA. Some speculate that not living close to a grocery store where one can access produce is a 'cause' of obesity (i.e., they associate food deserts with obesity). And it is not just availability, it's affordability, too. If the fresh produce costs more than processed foods, they are less accessible. If children have to try foods several times to like them, and a parent is on budget, it makes it hard to buy more expensive items that might not be eaten.

Access and affordability are things that public health advocates work to change AND that the electorate/society supports. Right? Of course we should make sure everyone has access to nutritious foods that are often low in calories. YAY! Let's do it.

Research has not always supported the intuitive, however, and sometimes people who have access to fruits and vegetables still don't purchase or consume them. Why not? Well, my educated/informed opinion is because a good many people live in food swamps. I am not sure where I first heard or read the phrase, but I describe a food swamp as an area where high calorie foods - often low in nutrients - are in abundance, are cheap, easy to locate, highly advertised, branded (e.g., KFC, Doritos, Pepsi) and popular among children, adolescents and adults. Actually, these foods and their promotions (e.g., all you can eat buffets, $1 hamburgers, 3 for 1 honeybuns, 32 ounce sodas) are hard to avoid.  

As noted above, the popular strategy for dealing with a food desert is to bring more fresh foods in - build a grocery store or a farmers market, add produce to the convenience store checkout, send in a mobile produce truck - and hope people will purchase, prepare wisely and eat more nutritious foods. Oh and here is the most important part... eat them instead of the high calorie non-nutritious foods they have been eating. Every one agrees, yes - those are all good strategies... yay, lets fund them! [They don't work so well, but they seem smart and non-paternalistic, therefore, it must be right.]

The strategy for food swamps (which is as unpopular as the food desert strategy is popular) is policy and regulation. I believe that food swamps are the bigger problem and that regulation and policy are our best bet at trying to reduce over consumption of calories (often occurring passively, i.e., not intentionally eating extra calories). Examples include, limiting the number of fast food/quick casual restaurants that can surround neighborhoods, schools, and worksites (zoning laws), putting a sales tax on high calorie, low nutrient items, like sugar sweetened beverages (specifically I say a sales tax because consumers are more likely to notice a sales tax than an excise tax and sales taxes cannot be 'eaten' by the manufacturer unless they literally lower the prices of their products), putting calorie counts out in front on everything, everywhere (menu boards, front of packages, sodas) and educating people on what is considered a 'high' amount of calories (e.g, a dinner entree over 500 calories is high, if it is part of a days worth of meals), portion caps - like suggested in NYC might work, and limiting ads for high calorie foods or ad space (e.g., TV, public transit, magazines, websites, social media). I think our grocery stores should have makeovers as well. The cheap, high calorie foods should not get prominence and promotion. This is one of the main reasons I believe that strategies to add fruits and vegetables to neighborhood stores or whole grocery stores to neighborhoods, fail. It is hard to get through the mire of junk - physically, emotionally, socially, parentally - to the better for you items. 

And before anyone points out that the food swamp policies I mentioned are regressive (i.e., they will have a bigger impact on persons of lower income) I say YES, and obesity and its related disease conditions is also regressive and has a greater impact on persons of lower income. 

My point is, that though it might sound good (especially politically) to make fruits and vegetables and other nutritious foods available and accessible, what we really need is to make low nutrient (junk) foods and drinks LESS available and accessible (less cheap, less popular, less in our face).  And as that annoying prince on the TV show Outlander says, "mark me" I am right about this.

Exercise for Weight Loss?

No.
Exercise for exercise. Exercise for a long, healthy, active live.
Exercise for functional capacity, mood stability, improved attention and learning.
Exercise to prevent disease. Exercise to improve your quality of life.
Exercise because not exercising increases your risk of all causes of death and all disease states.

If you exercise only because you think it will help you lose weight, and exercise is your only weight loss strategy, chances are you won't lose weight. And then you will think exercise failed you. You will be wrong. Exercise is the sine qua non of health; it will never fail you. if you do it for the right reasons.  There are many reasons, see the first paragraph and the research studies below.

If you want to lose weight, change your eating patterns. Many people need to lose weight.
If you want to be healthy, exercise - daily.. Everyone, regardless of their weight status, needs to do this.

(NB. this was posted a few weeks later http://www.vox.com/2016/4/28/11518804/weight-loss-exercise-myth-burn-calories)

Janssen, I., & LeBlanc, A. G. (2010). Review Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. International Journal of Behavioral nutrition and physical activity, 7(40), 1-16.

Nocon, M., Hiemann, T., Müller-Riemenschneider, F., Thalau, F., Roll, S., & Willich, S. N. (2008). Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. European Journal of Cardiovascular Prevention & Rehabilitation, 15(3), 239-246.

Penedo, F. J., & Dahn, J. R. (2005a). Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Current opinion in psychiatry, 18(2), 189-193.

 Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health benefits of physical activity: the evidence. Canadian medical association journal, 174(6), 801-809.

Health Halos, Calorie Labeling, and Vending Machines

     Vending Times, a trade magazine for, you guessed it, the Vending Industry (machines, coffee service and micromarkets), recently announced that Mrs. Freshley’s has a new product, 7 Grain Cookies. You can read a little about them here, but the important information (i.e., nutrition content) is not yet posted. Other cookies by this company have, on average, 200 to 300 calories per package – the serving size.

     Without my explaining, can you guess the problem with a 7 grain cookie? Here is a hint and a term nutrition and obesity prevention researchers often use – “health halo.” You probably figured it out. By saying that this high sugar, high calorie item has 7 grains, people are distracted from the fact that it is still an item that should be consumed in extreme moderation. Cookies, pastries and such are in the discretionary category and I believe the latest version of US Dietary Guidelines suggest that discretionary calories take up no more than 10% of a day’s worth of calories (actually the new guidelines refer to added sugar not being more than 10% of calories). Therefore, if you were a small, active women consuming 1800 calories a day, this pack of cookies would be all you were allotted in discretionary calories for the day. The fact that the cookies might supply you with some whole grains, a positive thing, doesn’t change the fact that they are cookies. (BTW, other health halos you might see on discretionary food and beverage items, REAL sugar, raw sugar, honey, molasses– it’s all sugar, and in this context, not different than corn syrup or table sugar).

     Label declarations such as these (e.g., 7 grains) can give us a false sense of the healthiness of an item. Of course, healthiness is a moving target, but let’s stick with sugar and calories – we do want to limit them across the board, throughout each day. In a similar fashion to label 'nutrient disclosures', researchers have found that some Front of Pack labels (of which I am a huge fan) can also create a health halo! Hamlin, McNeill and Moore(2014) conducted an experiment on choices people make after seeing different types of Front of Pack labels and found that across all types (2), having a label led people to buy that product more often than if it did not have a label, regardless of what the label said. This is only one study, and others show that the labels can be helpful in leading to a reduction in calories, salt or sugar purchased, but it is definitely something that should give us pause, especially because one of the label formats tested was my favorite, the multiple traffic light. 

      When I think of this in the context of our soon to be implemented calorie disclosure law for vending machines, it occurs to me that maybe, simpler IS better. In other words, if every single product has a label and the only thing on the label is calorie content – then choosing the smallest number would be the (usually) right thing to do. I have that parenthetical usually, because a 100 kcal pack of cookies might not be a better choice than the 200 kcal package of granola bars, BUT – it would still be the least caloric.

      Lastly, the 2016 calorie label law (passed in 2010) is very specific about the placement, color, font and size of the calorie disclosure. If you take a look at the pictures below, you can see why that is important.

I took these photos at vending machines where I work and offer some comments in the captions.

This is industry criteria, notice the calorie, sugar and sodium limits to be called a Choice Plus snack

Notice the sodium  - its too high to be a Choice Plus but the snack is in a Choice Plus Slot. Also this snack has a Front of Pack label which could be a health halo.

Great example of how different a Choice Plus snack can be and if you look closely you see some calorie disclosures on the package. You have 250, 190 and 100 here.  Importantly, they are ALL the same price ~ busting that myth.

In my opinion, this is not as helpful as the machines with the calories on the front inside the picture of the sodas. I was within inches of this display when I took the picture and you can barely read the calories on these sugar sweetened ice teas (120 per 20 oz)

A blog post on weight loss worth a share

I read a post today and shared it on Facebook and twitter, but I really like it so I am going to share it here also.  
 I am familiar with the science and the scientists that this blogger refers to, and I trust her interpretation.

I want to add 3 things.

• Exercise, as I say every chance I get, is essential for good health. One cannot live well without it - and just like medicine, it only works when you 'take it' and you should 'take it' every day.
• Pay attention to tip number 5.  They are talking about Volumetrics and my personal style of eating (but they don't call it that or refer to me!!}.   Note that there is evidence that what you eat matters to your overall health, if not your waistline.
• Remember, science is not about facts.  We observe, test, interpret and trust the evidence that we have today.  Someone can observe something different tomorrow.  Science is supposed to be a work in progress, and it is.

Review the post on weight loss tips that are supported by science written by Alice G. Walton HERE.

PS< I am still here!  My dissertation writing is the most insane hardest thing I may have ever done (to be fair, I collected and analyzed my own data  - twice (2 studies) (but can you believe I lack skill in making written arguments!)... anyways, I will be back, sporadically at first and more consistently in the future.

Does Information Make It Easy?

   This past Monday, the Huffington Post ran an article on menu labeling that was written by two former USDA secretaries.  They were writing in support of the mandate found in the Affordable Care Act that requires restaurant chains and similar establishments to post the calorie contents of their items on menus and menu board.  
   The secretaries, Dan Glickman and Ann Veneman were specifically speaking to the debate over similar establishments, and as I have suggested here, they urged the FDA to include movie theaters in the mandate.  They also called for supermarket inclusion and alluded to sports arenas, but did not mention bowling alleys.  They appeared to be in support of having all of the venues included because they spoke of consumers being able to compare items no matter where they were choosing them.  They said that the regulations should be "inclusive."  They also said, and here is where I disagree, that having information available at all locations will make the healthy choice the easy choice.
    Though it is necessary to have information to make an informed choice and information is necessary to make one that meets your values, having it does not make the healthy choice easy.  Why not? Because information is only one factor that goes into food decisions and if survey research is correct, it is not the number one or even number two factor in this choice.  Along side those lower calorie items (on that menu) are the cheaper ones and the more palatable ones(high sat fat and sugar).  In order for the healthy choice to truly be easy, we have to do something about the unhealthy choice.  We have to find a way to make it LESS desirable.  (raise the price or limit the advertising for instance)

When the average is a bad thing.

A friend shared a smart phone app with me yesterday.  It is called Fooducate.  You can visit the webpage by clicking here.  If you have a smart phone (iphone or android) you can download the free application.  The link was shared with me because I am studying the use of nutrition information in college students and my colleague thought that menu labeling wasn't going to cut it with this age group. (I plan to find out)
I went ahead and downloaded the app to test it out. You can hold your phone's camera lens near the barcode of the food item and it will read it.  Then you are taken to a webpage that gives you information about that product - including calories, saturated fat and even if it has GMOs.
To set up the application on your phone, you enter 6 pieces of information.  One of them is your weight.  When I got to that screen, there was this message "the average woman weighs 160 pounds and the average man weighs 190 pounds."  I am pretty sure it said the average American....  Let me make something very clear - the average weight is overweight or obese - greater than 60% of the US Population falls into this category.  In fact, the NHIS released data reports today that show the obesity rate is at about 30% currently.  Many women who weigh 160 pounds are not at a healthy weight.  Do NOT be comforted or fooled into thinking that  a 'normal' or 'average' weight is good. (I am not speaking to anyone individually here - a healthy weight is determined by your blood work (glucose, cholesterol etc) and blood pressure, physical stamina, physical and mental comfort, etc)
I read the statement re: 160 pounds yesterday and today the NHIS brief was in my mailbox.  I thought that was a neat coincidence. Here is the latest data - in graph form.  This comes from the CDC. 

NOTE: this is one of our Health Indicators... The goal is that white line... we want to be UNDER it.

 
Remember that excess weight is associated with metabolic dysfuntion.  This puts a person at risk for diabetes and heart disease.  The state of obesity in this country affects children and adults.  It is not okay for our normal to be unhealthy.  Adults are living longer sicker and our youth are expected to have shorter life expectancies than their parents.  Its a serious problem.

Safe Doses Depend on Exposure Frequency

   Today I am going to share a document that was created by the Center for Health, Environment and Justice.  I have been holding on to it for a few days and do not remember how I came to find it.  It may have been a link in a news story.
   The handout was prepared for parents.  The issue it addresses is chemicals in products that children use for school.  The message and the handout are important for all people - of any age.
   Understanding that we have more hazardous, toxic, and carcinogenic chemicals in our environment (land, water, air, products) than we can count and classify, protecting ourselves from them is a concern.  Those that we have identified as having a harmful effect at any level, such as lead, are regulated and products that contain it (lead paint, leaded gasoline) are banned.   We also have substances that are harmful but a certain amount can be found in the human body before any health risk occurs.  Think of methylmercury found in fish.  It is measured in parts per million and we can eat a certain fish many times because it is low level (tilapia = .013PPM) or just a few times, if ever, because it is high (tuna, swordfish = .99PPM).  The mercury released from coal fired power plants is the main source of fish contamination.  The EPA could impose regulations (as mandated in the Clean Air and Clean Skies Acts) on those power plants but is stymied by the tremendous push back and power from the energy industry.
    Sometimes the amount of exposure to a chemical doesn't matter as much because the likelihood of that exposure is so rare.  This was once the idea with radiation from medical imaging.  The radiation amounts were moderately high in CT scans, but hardly anyone got them and if they did, maybe it would be one in a lifetime.  That has changed and efforts are being made to lower the dose and limit the frequency.  Remember the many posts on this issue and ask your doctor why you need the scans.  
  Within a similar context, consider the chemicals that are leaching out of our plastics. BPA, phthalates, polyvinyl chloride.... It is not that these chemicals are high in any one place but that they are in EVERYTHING -  EVERYWHERE.  This means we are under constant exposure.  If a substance is toxic, any level is too high if you are being exposed to it repeatedly every day.  So read this handout and consider the environment and your health a little more seriously.  In fact, it makes the banning of certain chemicals for use in plastics make a lot more sense.
 Here is the handout.
   And since so many of us want more info on fats in food, we can think of artificial trans fats as another of those toxic substances.   If you have something with 4 grams of trans fat on one holiday a year - than a dose of 4 grams is a safe dose.  If you have something with 4 grams of trans fat every day - you are substantially increasing your odds of a heart incident (stroke, infarction, death)  In that way, the dose is too high.  A dose of less than .5 grams a day is still a risk.  Less than 1 gram a month is a better level.

Did we become overweight on purpose?

   In the September 2012 issue of the American Journal of Public Health, Mary T Bassett, MD MPH, discusses the role of government in "leveling the playing field" so that consumers have a real choice when choosing a food item.  A level playing field could increase consumption of higher quality foods.
   This statement, her article and my own studies lead to the same conclusion.  Most of us make food choices based on taste, cost, marketing shaped preferences, availability and convenience.  Healthiness comes in last - after these attributes have been considered - by us or for us.
   Dr. Bassett made mention of the food industry's support for initiatives that encourage physical activity as a strategy to reduce obesity.  This is clear by the placement of actual exercise icons on some food packages.  
   Here is a sad truth.  Exercise is not a popular way to spend leisure time.  Two hundred years ago that didn't really matter, we moved for sustenance and survival.  In the more recent past, our physical activity levels during work and non work hours has decreased.  We have become sedentary and for that reason alone need to exercise.      
   Both of these energy expenditure issues play a role in our obesity (over fatness) epidemic, but a much smaller one than you'd expect.  Trends of weight status in the US and similar countries show a steady and sharp rise beginning in 1970 and continuing to this date.  It has occurred in every age group - infants included.
   Certainly, the entire country did not have a sudden cellular shift  that made us ALL genetically predisposed to gain weight.  And with regard to burning less calories from work and travel, the best estimates from scientific studies suggest at most a decrease in 100 calories expended.
   Could it be then, that the entire country made a conscious and deliberate decision to gain weight?  Even before we learned of the connection between fat and disease, we knew that being too large for our bones was uncomfortable and stigmatizing.  Few of us would invite those things. So I say NO, we did not seek out calorically dense, nutrient poor, portion inappropriate foods. They came to us.
   Sure, our changing culture had us looking for convenience and increased the number of meals we purchase away from home.  We did not however, know that our 200 calorie meal had doubled into a 400 calorie one- before adding the super sized sized milk, juice or soda.
    Today, we find ourselves in need of a few less calories (compared to 1970) but consuming a WHOLE lot more - often passively.  Calorically dense foods are what the food industry offers  - at a price we can't refuse.
   Our environment changed around us, we got fat, our heart disease, diabetes, cancer and stroke risk went up.  Indeed the playing field from which we make our choices became leveled against us.

The article referenced in the opening paragraph : Mary T. Bassett.  Of Personal Choice and Level Playing Fields: Why We Need Government Policies on Food Content. American Journal of Public Health: September 2012, Vol. 102, No. 9, pp. 1624-1624.

Your Numbers - Your Risks

   Before we move on to another topic, I want to assure myself that the information I shared with you yesterday made some kind of impact.

from the American Heart Association website

   Did you view any food labels today?  Were the trans fat grams high or low?  If they were not 0 to 0.5  then they were high.
   Do you have any existing health condition that makes avoiding trans fat especially important?  (heart disease, high blood pressure, diabetes)
   Is there any reason to avoid trans fats if you do not have those conditions?  YES.  Do normal weight people need to avoid trans fats? YES.  Do people who exercise every day? YES.
   Not sure what I am talking about?  Maybe you missed yesterday's post. You can review it here.



 

Odds and Ends (3 of 3)

Diet Pill Warning – why would ya??  I hope you wouldn’t.  A certain batch of diet pills from Japan are said to contain a cancer causing agent called phenolphthalein.

Measuring Fatness – The BMI is an inaccurate measure of fatness, especially for individuals. It is the best we have right now for tracking the weight status of populations.  Some researchers are calling for the use of a DEXA scan or a blood test instead.  The BMI is a math calculation based on height and weight - i.e. it is basically free. We can get height and weight by self report (it may be inaccurate, but most people can tell you their numbers). Otherwise, why not use WHR  - which tends to be more accurate than BMI. Here we would have to measure a persons waist and hip circumference because most people won't be able to articulate this in a phone interview.    I can’t believe researchers would suggest the routine use of  DEXA which costs 100s of dollars and offers some radiation exposure. Blood tests are also expensive and invasive.

What's the fuss – So Mary J Blige and BK got a lot of flack over her singing a song about chicken snack wraps, and the ads have been pulled, temporarily they say.  Are these the same snack wraps I already reviewed for calorie and fat content?  Not sure, so might as well do it again…Oh I think that was McDonalds.  Anyways, BKs wraps have about 400 calories and 6 grams of sat fat.  They are high in sodium also.  I have a feeling that the 400 calories is for one wrap.

Death in Old Age – One of my favorite sayings , by Richard Doll, is  "Death in old age is inevitable, but death before old age is not.”   I think of that when I hear absurd statements like , “he died of natural causes” when someone is in their 50s, like Thomas Kinkade.  It is much more likely that Mike Wallace died of natural causes at 93.

Odds and Ends

Birds of Prey? I was eating lunch at the beach Saturday and though I have seen this before, I was still stunned when the sea birds began swooping in for my food. Seriously, one of them actually hit my head with its wings! Now I don’t eat much and I only take out enough for one serving so by gosh.. that bird was NOT getting my lunch. I had to hold my sunscreen can and swing at them.. I was agog. How did these fowl learn that people on the beach had food that they 1) wanted and 2) could steal? Well from us I am sure. For goodness sakes... how does a sandwich attract a beast meant to eat fish?

Parents and Choices: Years ago, I was going to be a daycare teacher. I began college studying child development before switching to social work and later worked in child abuse and neglect for about seven years. I took courses on parenting skills and also taught them. One thing I remember very clearly which helped others and myself, is that one should never give a child or an incompetent adult a choice that doesn’t exist. Still a choice should always be given so the person is empowered. I.e., not “what do you want for lunch?”, but “which of these two things do you want?” Or, “what shoes would you like to wear to the store?”, not “do you want to go to the store?” And lastly, “which Assisted Living Facility do you think would be better for you?”, NOT “do you want to go and live in the ALF?” I thought of this over the weekend as an adult and elementary school aged child arrived at the beach. The adult said, “Do you want to put on your sun block?” and the child said…. “NO,” and bounded off for the surf. The better question? “Would you like to put on the sun block yourself or shall I?” Remember that the biggest risk factor for skin cancer is having significant sun burns as a child. [after this, I saw my nieces who had spent over seven hours at another beach the day before.. and there was not one spot of pink on them. They applied and re applied.. good girls!]

Medicaid: My mother told me about a radio show she had recently heard. From her description, it appeared to be related to long term care planning. Some of the information appears to have been sound but when she started talking about Medicaid in regards to long term care, I became upset.
Basically one should figure it this way. IF you have been unable to support yourself most of your life and the government has assisted you with health insurance and housing, it is likely to continue to do so when you are older. If you are independent and have had the good fortune to work, save and prosper... paying for a home perhaps or for housing and cars and the like, it is NOT expected that the government will suddenly pick up the tab for your housing in an assisted living or nursing home. Nor should they... unless the whole system changes.
I think that lawyers who can make your home and money “invisible” are cheating our system and are one of the causes for the health care crisis… similarly I am upset when lawyers make non disabled persons suddenly disabled enough for social security disability income. Really, I think it is bullshit. Needs based programs are just that – needs based.

Physical Therapy: Interesting statement made by a physical therapist this past week. We don’t usually see people who are active; we more often are treating problems due to inactivity.

700 calorie burn: I enjoyed an awesome spin class over the weekend. The teacher was great, energetic, skilled, etc... music good.…participants lively and helpful. There was just this one thing... At the end of our 45 to 60 minute class, the teacher said that we had just burned 700 calories…..doh!... As a former instructor, I take issue with any of us claiming a particular calorie burn for a class. One can not offer legitimate general data like that. Now to say that this burned more than walking or the elliptical or as much as running for 20 minutes, something like that, OK.. but numbers are based on well... numbers... YOURS .. I may have burned 200 in that class, and my neighbor maybe 400. I doubt that anyone burned the 700 but could be. I just worry that people hear that and then base their calorie INTAKE on it.

A Twist of Phrase: I recall three separate things that I heard this week that led me to think myself clever-
1) Some one was talking about French fries and said “But you can’t eat just one.” And I thought, “Oh, but I can eat just none and be the better for it.”
2) My auntie said, “You can’t live forever,” in a conversation where I was lamenting over her becoming a seeming recluse and I responded, “No, but you can live while you’re living!”
3) And lastly, I saw a magazine with the caption, “Eat better for less.” And thought, “Eat less for better.”

Oh that last one reminds me of my grocery shopping. Alert! Pay attention to your foods. There can be a drastic difference in price and calorie content for the same foods by different companies. Look at UPC labels on the shelf and calorie by gram on your foods.

Let the Comparison Begin

I am actually torn about tonight's post. Yesterday I received an article in the mail from a dear friend in Maine. I did not read it closely until just now.
Last night the first news stories were published about the cost of treating obesity (147 billion a year) and out of curiosity I looked up the cost per year that Tobacco Free Kids estimates is spent on tobacco related illnesses (96 billion a year). Obesity has indeed passed tobacco, I expected it would.
And this morning, I read an article about reducing hospital re admissions and got rather frustrated at a lack of personal responsibility in the patients. So all that is on my mind!

The article, ironically, compares Big Tobacco with Big Food and was written by Ellen Goodman. She notes a new film and a new book regarding the food industry's tactics to get us to eat more cheap, fast and harmful food and wonders if the mood of America isn't about to change and say, "Enough." She does note a concern that always frustrates me and that is the controversy over accepting ones weight or size and rallying against obesity. Well, the fact that it is considered a controversy is the problem. I actually had the thought today that maybe our Armageddon is going to be related to our total lack of responsibility in taking care of the body that the creator(s) gave us. Many times it seems a total disregard for health and wellness. An abuse of our very essence... we wouldn't treat our cars or motorcycles this way and expect them to keep running, would we?

I am not without empathy and I do feel that addictions exist and are not something that can be willed away.. however, one has the personal responsibility to adopt a treatment or follow a plan to change what is wrong. In the article I read this morning, a woman with chronic heart failure was dismissed from the hospital after an exacerbation of her illness. She was advised not to eat hot dogs, as the July 4th Holiday was approaching. The patient is quoted as saying that she went to the picnic and said, I am not supposed to have a hot dog, but give me one anyway. She further commented that if she was dead in the morning she would never know. Well, ha ha, isn't that funny. Instead, she was back in the ER and admitted to the hospital because she did NOT do what the doctor's said. Perhaps people need to understand that not taking care of themselves has a ripple effect. Her family would have been worried and strained by this readmission, doctors and nurses would have to care for her and somebody did not get a bed at that hospital because she was in it. Oh, and she is a Medicare patient so premiums for everyone can be effected.

I suppose everyone has a right to go to hell in a hand basket at their whim.. as my friend Tom Brown used to say.. but only if they can do so without wasting the rest of our valuable resources to get there.

So yes, I feel incensed by some of the recent news...

A New Flu Vaccine

There has been news recently regarding the 2009 swine flu (oops, that is Influenza A H1N1) and how we can best prepare for the second wave of this now declared pandemic. Pandemic meaning that the infection is active world wide and affects a great number of persons.
There is some concern that the flu is going to hit us harder this fall and that makes sense knowing that colder temperatures (inside and out) are more appealing to the virus.
What is concerning to me is that several governments, including that of the USA, are seeking vaccines for this strain of the flu by telling drug makers to rush and I have seen at least a suggestion that the makers will not be held accountable for adverse outcomes. My concern over the push for vaccines is on several levels.
1) the vaccine may not work
2) the cost of making and distributing the drug
3) the availability of the vaccine
4) adverse events associated with it
and 5) haven't we done this before?

We had a scare of flu in 1976 referred to as the Asian or Hong Kong flu. The then president rushed the vaccine and gave the drug makers immunity. The pandemic did not come and some cases of Guillain-Barre Syndrome, ( an auto immune disorder) were blamed on the drug.
I understand that vaccines are important and have eradicated many life threatening diseases. I am grateful that my parents had me vaccinated against many diseases when I was young because as an adult I am scared of the drugs. I do get my tetanus and that is about it. I do not get sick very often. I do my best to keep my body healthy so that it can resist viruses.. however, I am also protected to some degree because other people DO get vaccinated. That is referred to as herd immunity.
I don't know what to say about the new flu and the campaign to fight it.. I only know that we should consider the past.

I feel that the CDC is a credible (and up to date) source for information if you would like to read more: http://www.cdc.gov/h1n1flu/qa.htm

the high cost of eating well

Every blog post does not have to be a research paper and so tonight I will just express opinion and grave concern about the state of disease prevention.
Health care reform is happening and within the congressional debates and presidential meetings are many nods to the importantance of prevention. Specifically, prevention of disease can be tied to three things of which we have control, and a fourth of which we don't, genetics. We do have control over our weight for the most part, for what we eat, again for the most part and for the amount of exercise we do.
With regard to what we eat, when legislating change, I implore the powers that be to confront the issue of how our food has changed and how readily available and cheap the worst types of food have become.
I say this as in the last day or two I have seen the 1 dollar double cheeseburger promotion, the 25 cent hot dog and the 1.50 dollar discrepency between a snack that is full of sugar and one that is sugar free. What IS THAT>?!
We have a crisis and it is because people cannot afford to eat nutritious low calorie food. Furthermore, they don't know exactly which food is healthy and low calorie nor how to prepare that food so it remains so.
I feel frustrated because I could absolutely educate society with a public health grant.. I could take the information that I have on my blog and You Tube to people who do not access the web. I cannot however, change the price of food.
Even today at the beach, I saw a family where the mother and perhaps her sister were substantially overweight.. they came from the snack bar with french fries, which they shared with the children who were not YET overweight. Was there another option at the snack bar? I do not know. Was it as cheap as the french fries? Likely not.
It is so hard for me to know the right thing and witness the wrong thing. Many people, regardless of circumstance, are naive when it comes to how food and exercise affect their health but pointing it out individually is not the right technique. It will backfire. Community education and policy change is less threatening and more cost effective and physically effective than pointing out individual misgivings and mistakes.
There are people who are in my inner circle who do not do the right things even though they are pretty well informed. I get that. I DO get that. It is like smoking. Smokers know that it is killing them, but not smoking is a completely different lifestyle for them. Same with ME and running. Running all the time is not the best thing to do, I often have over use injury, I KNOW that but I love running.
So my job, my quest.. it is two fold. Food has to be affordable and people have to know how to prepare it and eat it. We joke about backing away from the table, but seriously, we HAVE to back away from the table.
An example, I found these awesome 100 calorie snacks today... on my Mom's counter!! They are Newton's Fruit Crisps, pretty expensive so I probably won't buy them.. but there are two "crisps" in the package and the package has 100 calories. When I tried them it was like I finally found my low calorie Pop Tart.... very very yummy. I ate a pack today and thought, I can see that people would eat several packs at once, exactly how NOT to moderate calories. If people would retrain themselves to eat every few hours and to have a general idea of what those foods are going to be, they will STOP eating (when the meal is over) as they remind themselves that they will eat again very soon.
So today I just wanted to express my frustration I suppose. I am frustrated that healthy food is not affordable. I am frustrated that many people do not know which foods are healthy and how to keep them that way when preparing them. And I am frustrated that people do not do what works even when they know what it is. Many of these things are not the fault of the individual, except in the end, you decide whether or not you will do the "treatment".

Acetaminophen

The concern regarding acetaminophen or Tylenol is not new today. The medicine itself has been around for possibly a hundred years, but as Tylenol since 1961 (so says Microsoft's Encarta). The concerns about acetaminophen and the liver are also not new. I recall learning as a young adult that people who drank a lot should not use Tylenol. What I did not know is that even the recommended dose of acetaminophen can cause harm to the liver and it is said in the literature that 200 persons lose their lives each year from acetaminophen overdoses.

As early as 2002, health care professionals were raising concerns and requesting some label changes because too many products, both over the counter and prescription, contain this drug. People were and continue to be inadvertently taking in more than the 4g limit.
Acetaminophen Toxicity
Maren Mayhew, MS, ANP, GNP

Knowing now that it can cause liver damage in non alcoholics really concerns me. Knowing that it can cause harm after taking the recommended dose for four days, concerns me more. It is likely that all of the medicine hasn't been metabolized and excreted before more is ingested. It is building up.

Today an FDA panel suggested a change to the recommended daily dose of the drug. I hope that the FDA itself mandates the label change. Even if they do not change the label dose, YOU know it is too high. In fact,It sounds like extra strength tablets at 500mg a pop are too strong a dose period.

That being said, I am not sure why so many of us think that more is always better. I was the same before the Vioxx recall. I then read about NSAIDs and just changed my whole way of thinking about any pills. I went almost a year without taking anything because I thought I would have a heart attack if I took one pill. Now, when I have a bad headache or muscle problem I take ONE 200 mg ibuprofen and wait. I am amazed by two things. One is that it works, just one pill works and two, I used to take three or four, at once. We all need to rely less on medicine and more on ourselves. Instead of extra strength everything we need minimal strength as we seem to be low on common sense.

We had a saying at WFUBMC when medicating the elderly.. start low and go slow. Sounds like we ALL need to take that advice.

So be mindful as well... acetaminophen is in many products. Also, on some medication bottles it is referred to as APAP. Here is a link that offers a wonderful print out to help you. Also below is a link to an FDA web source on this issue.

http://familydoctor.org/otc/knowmeds.html

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm168830.htm

Most importantly, do NOT take more than the recommended dose and do not take it for more than a few days. If you have been consuming acetaminophen (Tylenol) on a regular basis please let your health care provider know this.

Keeping Rush Limbaugh Honest

Today’s post is in response to a video http://www.msnbc.msn.com/id/21134540/vp/31332672#31332672
that I viewed courtesy of a face book friend. He sent me the clip as he correctly assumed it would get my attention. The clip is of a TV show host responding to something that Rush Limbaugh said on his radio show. To paraphrase, Mr. Limbaugh said that people who exercise so much, exercise nuts I believe he called them, were likely to blame for the rising costs of health care in this country. The reason? He suggested that all of their physical activity, of which he mostly named group sports, resulted in a significant amount of injuries and emergency room visits.

First of all, I have only once gone to the emergency room with an injury fitting that distinction and it was from a ballet class mishap and I only went because my sister insisted. I believe it was a torn tendon and it was not emergent but painful.

We have spoken a lot lately about calorie reduction for weight loss and physical activity for disease prevention. There is a causal link between lack of physical activity and disease and vice versa (meaning exercise and weight control also prevent disease). People who are physically fit and of a normal weight are much less likely to require prescription medications and the frequent physician visits to monitor the progress and side effects so there associated.

Yes, I do have pulled muscles from time to time for which I might see my primary care doctor, massage therapist and or physical therapist; however, I do NOT take medicines. I do not have any chronic disease for which I need disease management.

Though we already know that Mr. Limbaugh is in err, we can back it up with some fact checking of our own. In fact, he should have looked at the CDC’s Advance Data documents himself where he could easily deduct the cause of emergency room visits.

Here are some results from the National Hospital Ambulatory Medical Care Survey (NHAMCS). The survey was conducted from December 29, 2003, through December 26, 2004. I appreciate that this data is five years old (though the report is only three years old) but it includes a review of over 110 million emergency department or ED visits and will certainly show if Mr. Limbaugh’s assertion holds any weight. You can review this very detailed report and conduct your own data queries at http://www.cdc.gov/nchs/data/ad/ad372.pdf.

Though the entire report is fascinating, the bottom line is this, Rush Limbaugh is ignorant. I enjoyed writing that sentence. The truth is that the plurality of ED visits is related to abdominal pain, chest pain, and fever. The report does note musculoskeletal complaints but later breaks down injuries and we can make a cleaner assumption from that data.

For example and by category:

Injury and Poisoning make up 26% of the ED visits and 20 % of that 26% is for fractures, sprains and strains, open wounds, superficial injury, contusions with intact skin. To be extra extra safe, we can add 1.4 % for “other” injuries. So 21.4 percent of 26 percent is 5.5%.

When the report breaks it down to the top twenty diagnosis, however, bruising is on the top, I am referring to the contusions with intact skin. In very close range, only .1 % apart follow abdominal pain, open wounds (non head), chest pain and then respiratory infection. That makes the report a little confusing however, if it were broken down by cost of care, I feel fairly certain that evaluating and treating some bruises is a lot less expensive then working up chest and abdominal pain.

The report goes even further however and categorizes injuries by intent and mechanism. In review of that table it appears that I significantly over estimated which injuries were related to exercise because only 4.3% of unintentional injuries were said to be caused by overexertion and strenuous movements with an additional 1.1 % due to non traffic “pedal cycle” accidents. This would take us down to 5 percent of 26 percent of ED visits related to sports and or exercise. APPROXIMATELY! So 1.3% of ED visits are the cause of the health care crisis.. yes.. that makes sense. (!)

In conclusion, with an ever increasing overweight, diabetic, hypertensive population, we would do well to not only encourage physical activity but to legislate the promotion of it.

The report that I referenced today is cited below:

McCaig LF, Nawar EN. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Advance data from vital and health statistics; no 372. Hyattsville, MD: National Center for Health Statistics 2006.

Well, don't just sit there! Move IT

Physical Fitness

I am working on today’s blog from my seat on the plane. I do not think I am supposed to try and go on line, so I will write about some things that I just read in the Wall St Journal and not add any additional research points.

Yesterday’s post mentioned the need to lower energy intake to lose weight and suggested eating low calorie foods to do so.

In the paper today there were side by side articles referencing a physical activity routine and a calorie expenditure gadget. The routine was interesting and note worthy as it was that of New York Police Commissioner Ray Kelly. He notes that since his time as a marine many years ago he has made weight training a significant part of his life. In fact, it has been said that his commitment to his routine borders on addiction. It is something that he has to do to feel right. Amen to that. He does work out for about an hour a day four days a week. He spends about 30 minutes of that time in cardio activity. He walks and runs, on a treadmill. He certainly dedicates a lot of time to his weight lifting and does many more sets than I would ever do, but he does vary the number of repetitions based on the pounds he is lifting. He made a good point, an iteration of one made here, that there is a difference between lifting to build and lifting to maintain. It is his current goal to maintain and to also to do functional exercises. Functional exercises help you do the activities of daily living, or ADLS. Working your legs to maintain your ability to take the stairs, doing core work so that your back and abs are strong and perhaps most importantly, adding balancing exercises to prevent falls.

He also eats a low fat high produce diet.

I have never watched the TV show the Biggest Loser but a certain device was used on the show that is supposed to help people track their calorie expenditure. These devices are somewhat less accurate than ones used in research studies and could cost you up to 200 dollars, but are certainly more on target than ones embedded in say, a treadmill or elliptical machine. Laura Johannes mentioned a few of these accelerometers in the paper today. The one used on the TV show has been involved in several studies. The studies were small and that certainly dilutes their validity but interestingly the gadget underestimated calorie burn, only slightly, which is far better than over estimating it. We do that without the help of an accelerometer! Anyways, it would be consistent in it’s under estimation and could still be a helpful tool for a person.

My Garmin Forerunner GPS tells me time, distance, pace and calories too and I can see when I run further I burn more, but it does not take into account when I sweat or shiver more, so I don’t think it is high in accuracy for calories. I do not wear it for that, so it is okay.

Lastly, there was a small note that got my attention. A large research study is to begin soon which will track users of vitamin D and fish oil capsules over time, to see if the purported health benefits, Drs. Willett and Cooper, will prove true and also to see if these benefits hold with blacks who will make up 25% of the study population. As you know I take Vitamin D and recently began the fish oil, so this is very exciting stuff!

Okay, that is enough I think. I am freezing to death on this plane.. and I am not alone, many people are digging out their jackets. That is just dumb.

Heat Syncope

I remember the word syncope from my days in the hospital (working !). It was not the first thing I thought of today, nor the second really, when my friend went down hard during our kayaking lesson.

A little back story then.

Today I tried a new activity. I have a running friend who lives the hottest time of the year in Maine, but has been in Florida the last several months. She is due to leave June 30th so we planned this last minute "learn to kayak" adverture for this morning, having heard about it from another running pal.

We began relatively early, but not early by Florida standards. We usually start running no later than 7 a.m. this time of year, and our kayak "class" didn't get under way until after 8:30 a.m.

We began as a group, perhaps ten of us. We spread out in the grass and the instructor led us through some movements, standing up, with our paddle. The sun blazed upon us as we stood with our backs to it. All ten of us. All but one of us had on a hat. My friend had a hat, but it was a visor, that may have mattered.

Most of us were dutiful with our sunscreen and sun glasses as well.

I believe the standing in the sun part may have lasted an hour. The sweat dripped off the back of my neck and down my shirt. I felt uncomfortable.

(I had some significant over heating with my runs lately, it was not that bad.)

I worried about my friend because she will often have to take breaks during our runs when it is over 80 degrees. She was in the back and I was in the front.

We, the group, returned to our starting place near the instructors van and back into the shade. We then all had to put on life jackets. It was time to get in the water when my friend told me, very casually, "I feel nauseous." Maybe a bit later, "I am sort of dizzy."

The class was moving towards the waters edge (lake) but we stayed back. I asked if she wanted to sit, and she said, "Where would I sit?" I said, "I guess right here in the grass, so you are still in the shade." We had our paddles still. Maybe I had put mine down.

No one was near us anymore. My friend seemed to be leaning into her upright paddle with all of her weight. She doesn't remember this part. She was definitely pitching forward. I dropped my paddle, if I had it still, and lunged for her, but her legs went out and under mine as I yelled, "Help." We both fell in a rather tangled mess, and she hit her head.

People came then, but no one was medically inclined. I got her life jacket undone very first thing, sort of the "loosen the collar" of TV first aid. We got water on her, I checked her pulse. In fact it was strong, not thready as they say and not irregular. I knew that was at least not a bad sign.

We cooled her off etc. She went in the lake in a kayak after the class was over and rather got a private lesson. The Economy Tackle people were extremely accomodating to my friend and she does get to take the class again, no charge.

My biggest thought was why did she faint and I didn't and what do you call it when someone faints in the sun, but it isn't heat stroke?

First my investigation of the scene and the person>

My friend and I are about ten pounds different in size, we are both small people. She is about 20 years older then I am, but can at times out run me. She is physically active and eats nutritiously. She ate this morning at 6:30a and I ate at 8a. We both have low normal blood pressure. I do not think she is on medicine, I can't believe I forgot to ask!!

Our hats were different. Remember I felt bad, she actually fainted. She drank less water before and during than I and we think that the lack of hydration and the fact that about three hours had passed since her last meal.. may have pushed her over. She withheld water because... are you ready... there were no bathrooms nearby. A park with no bathrooms.


I was conscious of that too, however, I never "pee" when I run and I hydrate often. As I told my friend, you won't need to use the bathroom because you will be sweating! And we were.

So she is all good, had a nice lunch afterwards and stayed in the cool inside. Though she bumped her head, she has no sore spot.


What I learned since then is that a milder form of heat exhaustion is called heat syncope. At least some sources say it is a milder form of a more serious condition. I will stick with what I learned from the American Academy of Family Physicians. There are several types of heat related illnesses and some are life threatening and require medical stabilization, while others are mild and require hydration, a cool down, a lie down perhaps, and getting out of the heat. The best preventative measure is acclimatization. If you are going to be doing out door activity, get used to the heat gradually. It is clear that one needs to hydrate before, during and after activity in intense heat.

There absolutely is a way to over hydrate and a medical consequence to that as well. We are not discussing that today.

My friend did not hydrate prior to or during the activity.. that is likely the biggest contributing factor to her syncope. We did lie her down and cool her down, so good for us we responded as we should have.

So the heat related illness, in order of severity are:

Heat Edema - swelling in the limbs because one is not used to the hot temperatures (mildest)

Heat Cramps - not used to the heat yet, lack of sodium, perhaps medicine related (hydrate)

Heat Syncope - blood pressure drops and dizziness occurs, often from standing too long or from standing too quickly from sitting, (that is what orthostatic hypotension is) the heat can induce it. Heat syncope also comes from dehydration and lack of acclimatization. I should have gotten my friend on the ground as soon as she said she was dizzy. (recovery is quick)

Heat Exhaustion - may need IV rehydration, usually better in a few hours. No neuro deficits

Heat Stroke - very serious, may lead to death, does involve mental status changes (serious)

All right, try new things but be careful out there!

This was a nutshell synopsis, a syncope synopsis if you will... more technical stuff is yours to be had at :

http://www.aafp.org/afp/980901ap/barrow.html


[after note, June 21st. My friend said that she did NOT feel sick to her stomach and remembers saying instead, "I don't feel right." Now that she mentioned it, I believe she is quite right about that. Otherwise, it pretty much happened as I said. ]


OH my and here is a little extra thing I learned. Funny how we learn things. I wanted to make sure I was spelling nauseous right so I googled it of course, (though Bing is cool too). And I learned that my friend meant to say, I feel nauseated, as saying you feel nauseous means that you make other people sick... Huh....That is weird though isn't it, because if someone bothers us, don't we say "he/she is nauseating?"

Drugs Not Needed

I was pretty dumbfounded this morning when I heard a commercial regarding a medication created to treat the very condition discussed in my last blog. The reason I was taken aback is because as I wrote here, the experts state that the most effective treatment for lowering triglycerides and raising HDL-C is NOT a medication but watching your weight, exercising and eating lean proteins and including unsaturated fats in ones diet.

So why in the world would the FDA approve a medication for this. A medication which does not lower any heart disease death or disability over the statin therapy one takes for lowering their LDL-C. Even the TV ad tells us that the medicine will not do that.

The reason we lower any of the numbers, whether it is cholesterol, blood pressure, CReactive protein, triglycerides, etc is to lower the risk of disease and death. If this new medication lowers triglycerides while putting the patient at great risk for side effects for NO OTHER REASON than to have a lower number.... WHY would a person take it, a doctor prescribe it or an insurance company PAY for it. This is how our country spends so much money on health care without having the best healthy life expectancy.

So, I am blasting about a drug called Trilipix... cute huh. The scientific name is fenofibric acid. The drug company did complete severe phase III trials before gaining FDA approval and I was able to read a little about that. The company used the drug in conjunction with statins (i.e. Zocor and Lipitor) of different strengths compared to a group that just used the new drug. In the combo therapy all numbers changed to the better, lower LDL and TG and higher HDL but again, there are no improved health outcomes so why would you subject yourself to the risk factors and the cost of another medicine?

Better than that, the TV ads and the literature on the drug insist that it is to be used WITH a diet regimen. In fact, the print warnings and prescribing info for clinicians states that diet and other non medicine strategies should be exhausted before prescribing Trilipix. The consumer ads and website just say to talk to your doctor about this new drug. Heck they even give you a print out of talking points so that you, the patient, can educate the doctor and advocate for this treatment on your own behalf. This is certainly playing to our cultural leanings toward pill focused solutions.

But pills come with more than a financial cost. The physical risk can be great as well. For this drug, side effects include

Muscle Pain
Tenderness
Weakness
Tiredness
Fever
Abdominal Pain
Nausea
Vomiting

And more seriously, muscle wasting and possibly kidney and liver problems. The serious side effect risks go up when the drug is used in combo with the statins, but it is with statins that it works. Again, why would one take this drug.

Eat Smart Move More... Live better, longer... Extend your life not your death...