Health for life

In yesterday’s posting on care management nurse-staffing ratios and their associated costs, Peter McMenamin pointed out that a per member per month cost (PMPM) that ranged from $8 to $17 was a reasonable estimation.  Whats more, it compared favorably to the monthly management fee in the Comprehensive Primary Care Initiative. 

This is also important for Accountable Care Organizations that are grappling with the amounts that they’ll need to invest in care coordination to achieve the shared savings.  Assuming an ACO becomes accountable for 5,000 beneficiaries, that calculates out to between $480,000 and $1,020,000 per year.

But, asked the Disease Management Care Blog, should there be any differences in care management ratios and costs for Medicare, Medicaid and commercial insurance?  If it’s a commercial ACO, should it estimate $500K, while a Medicare ACO should plan lower ratios and invest $1M?

Peter McMenamin’s thoughts:

A parity between Medicare, commercial, and Medicaid is possible but not exactly plausible.  Thanks to many co-morbidities, Medicare patients have more different docs, more visits, and more drugs.  Unless they are particularly compliant with respect to medications, you’d expect Medicare patients to be more demanding.  Unless they return to a physician so frequently that care coordination is incidental or are hospitalized so much that their care is taken care of, they need considerable care management. If Medicare patients take more time for follow-up, etc. that might explain the difference between $20 PMPM and the somewhat lower PMPM estimates from my calculations.

Good point, of course.  Yet the DMCB is not so sure that there is a correlation between savings and the intensity of care management beyond a certain threshold for any patient of any age.  In addition, while persons with Medicare have greater illness burden, that doesn’t mean the day-to-day management, care plans and shared decision making for conditions like diabetes or heart failure making varies depending on a patient’s age.

Dr. McMenamin and the DMCB will keep their eye out for answers.  More to follow.

Parents know its important for children to eat a wide variety of fruits and vegetables, low-fat dairy products, and whole grains. But its less clear whether spending the extra money on organic foods will bring a significant benefit to their childrens health.

To offer guidance to parents – and the pediatricians caring for their childrens health – the American Academy of Pediatrics (AAP) has conducted an extensive analysis of scientific evidence surrounding organic produce, dairy products and meat. The conclusion is mixed: While organic foods have the same vitamins, minerals, antioxidants, proteins, lipids and other nutrients as conventional foods, they also have lower pesticide levels, which may be significant for children. Organically raised animals are also less likely to be contaminated with drug-resistant bacteria because organic farming rules prohibit the non-therapeutic use of antibiotics.

However, in the long term, there is currently no direct evidence that consuming an organic diet leads to improved health or lower risk of disease. No large studies in humans have been performed that specifically address this issue.

"Whats most important is that children eat a healthy diet rich in fruits, vegetables, whole grains, and low-fat or fat-free dairy products, whether those are conventional or organic foods. This type of diet has proven health benefits," said Janet Silverstein, MD, FAAP, a member of the AAP Committee on Nutrition and one of the lead authors of the report. "Many families have a limited food budget, and we do not want families to choose to consume smaller amounts of more expensive organic foods and thus reduce their overall intake of healthy foods like produce."

The AAP report, "Organic Foods: Health and Environmental Advantages and Disadvantages," will be released at a news conference at 1 p.m. CT Monday, Oct. 22 at the AAP National Conference & Exhibition in New Orleans. It will be published in the November 2012 issue of Pediatrics (published online Oct. 22). The report outlines the research that has been conducted on organic foods, including convincing evidence of lower exposure to pesticides and less contamination of livestock with drug-resistant bacteria.

"At this point, we simply do not have the scientific evidence to know whether the difference in pesticide levels will impact a persons health over a lifetime, though we do know that children – especially young children whose brains are developing – are uniquely vulnerable to chemical exposures," said Joel Forman, MD, FAAP, a member of the AAP Council on Environmental Health and one of the lead authors of the AAP clinical report.

If cost is a factor, families can be selective in choosing organic foods, Dr. Forman said. Some conventionally grown fruits and vegetables tend to have lower pesticide residues. The AAP cites organic shoppers guides like those provided by Consumer Reports and the Environmental Working Group as erences for consumers. The AAP found no individual health benefit from purchasing organic milk, but emphasizes that all milk should be pasteurized to reduce the risk of bacterial infections. Raw milk increases the risk of serious infection with bacteria including Salmonella, E. coli, Listeria, Campylobacter and Brucella.

Purchasing meat from organic farms that do not use antibiotics for nontherapeutic uses has the potential to reduce antibiotic resistance in bacteria that infect people. The AAP calls for large, well-designed, prospective cohort studies that directly measure environmental exposures such as estrogen at low levels to understand the impact of hormonal exposure of children through milk and meat.

The AAP report also notes that the motivation to choose organic produce, meat and dairy products may be reasonably based on larger environmental issues, as well as human health impacts like pollution and global climate change.

"Pediatricians want families to have the information they need to make wise food choices," said Dr. Forman. "We hope that additional research will improve our understanding of these issues, including large studies that measure environmental exposures and neurodevelopment."

It was a little over three years ago when I first heard of the concept of the Paleo Diet. I was introduced to it through a podcast on Underground Wellness interviewing Mark Sisson, the author of the Primal Blueprint. I had never thought about diet in the way that Mark did, and I was immediately fascinated by his approach. You mean we were healthier before we adopted agriculture? And we didnt eat grains, legumes, and dairy?? Interesting. I had just finished reading Gary Taubes "Good Calories, Bad Calories", so the low-carb approach was firmly in my radar. Things seemed like they were beginning to come together.

In the next few months, I would dive head first into this Paleo/Primal diet concept... I found Robb Wolfs podcast, I read Dr. Cordains original Paleo Diet book, I discovered several paleo-related blogs... I began to immerse myself in the paleo world. I even wrote a research paper for a class I was taking in Italy in my study abroad experience, called "The Health Benefits of Eating a Paleolithic Diet". No question, I became a paleo machine. I even started this here blog soon after; it all began as a place where I could express my contrarian opinions thoughtfully and back it up with scientific research. I felt like I needed to prove I was right, because everyone in my world thought I was wrong. (I never took on the "paleo" name though... its as if I knew my position might change some day)

It was around this time when I went full paleo... I made a conscious effort to avoid grains, legumes, and to some extent dairy for nearly two years. With promises of "perfect health"... some sort of vast utopia, free of ill health and disease, including even the pesky day-to-day maladies like seasonal allergies and headaches... I set out to feed my body only the foods that we had "evolved" to thrive on. I shunned anything else; no rice, no beans, no oatmeal, no bread, no soybean oil, not too much fruit, limited starch and carbs, no pasteurized dairy. I avoided gluten like the plague, because obviously, its downright evil. I even went through a phase where I thought nightshades might be killing me.

Every day I would go to school and sit in my conventional nutrition classes thinking... "Man, I just dont understand how these professors could dedicate their lives to teaching and researching nutrition and still have their facts so wrong!" As if I, at 25 years old, knew far better than someone whos been at this for twice as long. I couldnt wrap my head around it. How could they not see it... carbs and grains are killing us! Ugh.

The truth is, when you stop and think about how people eat around the world today, none of this paleo stuff makes a whole lot of sense. If gluten were really as bad as the paleo folks say it is, how would we have cultures like the Italians and the French who eat it on a daily basis and experience far greater health than we do in America? If legumes are indeed the scourge of the diet world, then how on earth are all of these Latin American countries not extinct? How do they stay so thin? If carbs really make us fat, then how is it possible that nearly every human being on this earth eats a high carb diet, yet most maintain a healthy body weight?

But perhaps most importantly of all... how can most of the world go on eating what they like, without a shred of doubt and guilt, and without knowing anything about nutrition, yet maintain a thin, healthy body?

These are all questions I have struggled to rationalize through the paleo lens.

Smile. You can eat neolithic foods and not die.

And then I would think about my own experience. For the first 24 years of my life, I ate a high-carbohydrate, gluten-full, typical American diet. Did I experience digestive distress? Rarely, if ever. Did I have chronic mental fog? Nope. Did my athletic performance suffer? Not at all. Did I struggle with my weight? Not once. Did I have trouble sleeping at night? Definitely never.

What did I expect to happen when going paleo? I dont quite know. But whatever it was, it didnt happen. Ive never needed to lose any weight. Maybe I expected to feel better, and to think more clearly, and to sleep better, and to feel happier. These are all things that are supposed to happen. I was told, "You dont even know what its like to have so much energy and feel so great all the time! Your mind cant comprehend it... youre just so used to feeling tired that it feels normal!" Really? I cant believe I ever fell for that. This may be true for someone a little older and a little more metabolically broken, but it wasnt true for me.

I already felt great. I was already thinking clearly. I had already been sleeping eight hours a night. I was perfectly healthy. I felt no different before or after. In fact, I feel even better now because I have a healthy relationship with food. I love food. I dont fear anything.

It was scary the first time I let myself have a slice of pizza at a family party. The first few times, I was convinced I was making myself sick, having imaginary "reactions" to gluten. It wasnt until I let my mind get out of the way that I realized... eating pizza at a party with people I love is a good thing. No, pizza isnt the most nourishing food, but thats not the point. The point is that it tastes good, and that it brings friends and family together. I dont stress anymore over eating a bite of cake, or enjoying a slice of my grandmothers delicious apple pie. Life is too short not to enjoy all that it has to offer.

Paleo is a great place to start. I still believe that the cornerstone of any healthy diet should be fruits, vegetables, and animal foods. Perhaps paleo would be best as a short-term, temporary diet to kickstart a lifestyle change. But in the long-term for most of us, we have nothing to gain by eliminating entire food groups, especially if weve been eating them for most of our lives with no ill effects. Most people will be perfectly healthy including rice and beans in their diet... and the same can be said for oatmeal, corn, potatoes, cheese, yogurt, and even bread. These foods taste good. And lets not forget about the indirect health benefits of eating food you like! Never forget what your personal experience has taught you, and trust yourself first. No one knows whats best for you like you do.

Are there people who really would benefit from eliminating grains, legumes, and dairy long-term? Probably. But these people are few and far between.


Anyone who tells you paleo is the only way is either A) straight up lying to you, or B) completely ignorant. The nutrition/health world is much more expansive than what can be encapsulated into one catch-all phrase. As a dietitian, the principles of the paleo diet function best as a tool in my tool box. Nothing more, nothing less.

Plus, now I can eat fried butter balls at the fair :)

Ancel Keys, a University of Minnesota physiologist, deserves much of the credit for convincing the public that dietary fat and cholesterol are killers.  He initially became famous through his development of the "K-ration" for feeding combat troops in World War II; the "K" stood for Keys.  He then performed a series of human starvation studies and wrote the book "The Biology of Human Starvation", which made him a well-known, reputable nutrition researcher.  Originally, Keys did not believe dietary fat and cholesterol had anything to do with the rising heart disease rates, but his opinion changed when he attended a conference in Rome in 1951, where he spoke with a physiologist from Naples, Italy who boasted about the lack of heart disease in his city.  The diet in southern Italy was low in animal products, and the people there, especially the poor, tended to have lower cholesterol than those in the United States.  The rich in Naples, however, ate more meat, and had higher cholesterol levels and heart disease rates.  This convinced Keys for the first time that dietary fat from meat was driving the heart disease epidemic in the United States.

There were two key observational studies performed by Ancel Keys that ended up having an impact on the publics view of dietary fat.  The first, which many researchers did not taken seriously, was the 1953 study he performed involving six countries, comparing their fat intake to their heart disease rates.  The six countries he reported on (United States, Canada, Australia, UK, Italy, and Japan), showed a very strong association between fat intake and heart disease.  Now, of course, this is only an observational study and no cause and effect can be determined.  But the biggest problem with his study is that he left out the data from the 16 other countries for which data was available.  When all 22 countries are considered, his perfect correlation turns into a much weaker one.


Initially, in 1957, the American Heart Association (AHA) opposed Ancel Keys on the diet-heart hypothesis.  They wrote a 15-page report that year denouncing Keys and similar researchers for jumping to conclusions about the diet-heart hypothesis when there was no good evidence that it was true.  Less than four years later, in December of 1960, the AHA flipped their stance and adopted the diet-heart hypothesis as their new philosophy on heart health, proclaiming that "the best scientific evidence of the time" strongly suggested a low-fat diet, or at least replacing saturated fats with polyunsaturated fats, is preventative of heart disease.  What had changed in that four-year period?  Not the evidence.  There was no new evidence to either confirm or reject the diet-heart hypothesis.  What had changed is that Ancel Keys and Jeremiah Stamler, another supporter of Keys, had now made up two of the six members on the AHA committee.  Soon after, Ancel Keys was enshrined as the face of dietary wisdom in America in an article in Time magazine.  The article discussed Keys idea of a heart-healthy diet as one in which nearly 70% of calories came from carbohydrates and just 15% from fat.  Despite the fact that there was ZERO evidence from clinical trials to back up this claim, the article only contained one short paragraph explaining that Keys hypothesis was "still questioned by some researchers with conflicting ideas of what causes coronary heart disease."



The second important study done by Ancel Keys was considered to be his masterpiece, The Seven Countries Study.  This study is still, today, considered to be a landmark study because of the pivotal role it played in the acceptance of the diet-heart hypothesis.  Launched in 1956, Keys followed 16,000 middle-aged men for over a decade and tracked their diets and their heart-disease risk.  The populations he chose came from seven countries:  Italy, Yugoslavia, Greece, Finland, the Netherlands, Japan, and the United States.  The results showed, again, a remarkably clear association, but this time the association was between saturated fat and heart disease.  Keys drew three conclusions from this study:  1. Cholesterol levels predicted heart disease.  2. The amount of saturated fat predicted cholesterol levels and heart disease.  3. Monounsaturated fats protected against heart disease.

Seems pretty clear huh?  Not quite... there are a number of problems with the study.  First and foremost, this is an observational study, and like Ive said a million times, you cannot determine any causality from it.  Secondly, Keys chose countries that he knew would fit his hypothesis.  Had he chosen at random, he may have included countries like France or Switzerland that consume high amounts of saturated fat and have very little heart disease.  Third, we know now that middle-aged men are the only population for which total cholesterol numbers can predict heart disease, and the Seven Countries Study only looked at middle-aged men.  Lastly, and perhaps most importantly, Keys didnt look at total mortality, even though what we really want to know is whether or not well live longer.  Coronary heart disease accounted for less than a third of deaths.  He said himself in a 1984 follow-up paper, "little attention was given to longevity or total mortality."  Interestingly, if all-cause death had been taken into account, Keys would have found that the American population he studied lived longer than any other population with the exception of the Crete islanders, despite their high cholesterol. 

Even with all of the problems with Ancel Keys research, his findings on saturated fat and cholesterol would have a profound impact on the public due to a sort-of perfect storm of events that would eventually lead up to the first government dietary recommendations, Senator George McGoverns 1977 Dietary Guidelines for America.  More on that in part 4!

While the Disease Management Care Blog tries to be an equal opportunity cynic and generally sides with policy underdogs and lost causes, it supposes that its conservative leanings sometimes comes through in its writing. 

That was enough to prompt a series of well-written email exchanges with Greg Brown, a retired educator from the Kansas City area. He did a great job of compactly summarizing the views of supporters of the current version of health orm. 

It seems to boil down to five main arguments:

1. Medicare and Social Security: While passage of these landmark safety net programs was likewise met with deep concerns about the erosion of liberty, their ultimate success cannot be denied.  Most of the persons who are against the Affordable Care Act are ironically happy to have the feds appropriate a portion of their income in exchange for economic security in their old age. They cant have it both ways.

2. This is not buying shoes:  One role of the federal government is to step in when markets fail, and that has been amply demonstrated when it comes to health insurance. While its difficult enough to remember to even buy a product that you may not need, shopping for the best value in commercial insurance is practically impossible.  Proposals to expand this unworkable solution are a pipedream.

3. The public good: Keeping people from going bankrupt in the course of an unexpected illness is everyones interest.  Its ultimately a better bargain for society to proactively manage this with near-universal insurance than to deal with poverty after the fact.

4. Purchasing power: To date, Washington DC has chosen to not flex its purchasing power with providers.  Think of how much cheaper drugs would be if Medicare leveraged this for Part D.  Just wait until the happens in the rest of health care system and how much all of us will all benefit. 

4. Status quo: Even if you dont accept the track record of Medicare, the realities of buying insurance, the merits of a public good and the advantages of purchasing power, the status quo has led the U.S., compared to the rest of the developed world, to be a unsustainable per-capita cost outlier.  Something has to change. and theACA is doing just that.

I am not an expert by any stretch. I am just an interested layman. I really wish Obama had pushed for a single payer or at least a strong government alternative delivery system. But here we are and as imperfect as it is, it is the best thing I see on the horizon right now. It does at least attempt some cost controls, it broadens access, and it may lead to better quality with a focus on health outcomes rather than billable procedures. At least it attempts to address all three.

Image from Wikipedia

Penned by the effervescent Leigh, Veggie Might is a weekly Thursday column about the wide world of Vegetarianism.

Twice in the last two months Ive said to someone, "This is just like the fair!"

Sheep shearing, midway rides, and pig races: for a kid in central Ohio, the county fair was the hottest ticket of the fall social calendar; and the Ohio State Fair was the most thrilling event of the year.

Walking through the competition barns, I would beg to join 4-H and have my own sheep. Every year, my father would remind me that we lived within the town limits and our yard was not zoned for farm animals.

I also lived for the midway. My friends and I would gorge ourselves on fried and sweet delicacies and then hit the fastest, whippingest, most vomit-inducing rides.

My favorite fair fare came in a greasy paper cone: salty, skin-on french fries drenched with mouth-puckering malt vinegar. Rarely do I find fries as good as those, but Im always on the lookout.

In August, I came close when I accompanied my college pal KC and her daughter to Prince Edward Island, which is not only home to Anne of Green Gables, but the best potatoes Ive ever eaten. As it turns out, the soil and climate of PEI are perfect spud-growing conditions.

Particularly outstanding were the french fries at a little seaside sandwich shack in the beach town of Victoria. And there, on the ledge next to the ketchup and other condiments, was a bottle of malt vinegar. KC and I smiled. A fellow Buckeye, she eats her fries with malt vinegar too.

We doused our taters and found a picnic table across the lane, just below the signal house overlooking the harbor. It was a postcard-perfect scene. "KC," I said, "this is just like the Ohio State Fair." She laughed, "Only Im not throwing up from the Scrambler."

Just a couple months later, my friend MS and I attended the New York State Sheep and Wool Festival in Rhinebeck, New York. We wandered the stalls, fondling the softest fibers and cooing over the fuzzy animals. I thought of the 6- through 11-year-old me who wanted a sheep in the city as MS and I discussed smuggling an alpaca back to the Big Apple. We were pretty sure getting the 6.5 foot animal on Metro-North would be the most difficult part of the proposition.

It may be impossible to recreate the spirit of fair and festival and idyllic seasides, but the malt vinegar oven fries I whipped up this week are pretty dang close. Salty and tangy, crispy and chewy, they have less fat and fewer calories than traditional fries but all the flavor. CB, who isnt crazy about fries said, "I would eat these again." High praise.

Its been an excellent fall for making new fair memories. A sheep even licked my hand.

~~~

If this post tipped your canoe, swim over to:

• People Need Potato Salad
• Roasted Asparagus and Chick Peas
• Dijon Roasted Potatoes

~~~

Malt Vinegar Oven Fries
Serves 2


2 medium russet potatoes (about 7 ounces each)
2 tbsp malt vinegar
1/2 tbsp olive oil
3 generous pinches sea salt

1) Scrub and dry potatoes. Slice widthwise into 1/2" disks, then slice disks into 1/2" strips. Place cut potatoes into bowl or zipper-seal bag.

2) Pour malt vinegar in a small bowl. Drizzling in olive oil, emulsify oil and vinegar with a whisk or immersion blender.

3) Pour oil and vinegar over cut potatoes, sprinkle with salt, and toss well. Allow to marinate for at least 30 minutes.

4) Preheat oven to 350°. Arrange marinated potatoes on a baking sheet, evenly spaced without much, if any overlap. Bake for 30 to 40 minutes, stirring after 15 minutes, until crispy.

5) Sprinkle with more vinegar and salt, if desired. Serve with your favorite sandwich or in a paper cone for true state fair authenticity. Pucker up…a kiss is in your future.

Approximate Calories, Fat, Fiber, and Protein per Serving
201 calories, 3.5g fat, 3g fiber, 5g protein, $0.47

Calculations
2 medium russet potatoes: 336 calories, 0g fat, 6g fiber, 10g protein, $0.86
2 tbsp malt vinegar: 6 calories, 0g fat, 0g fiber, 0g protein, $0.02
1/2 tbsp olive oil: 60 calories, 7g fat, 0g fiber, 0g protein, $0.04
3 generous pinches sea salt: negligible calories, fat, fiber, protein, $.02
TOTALS: 402 calories, 7g fat, 6g fiber, 10g protein, $.94
PER SERVING (totals/2): 201calories, 3.5g fat, 3g fiber, 5g protein, $.47

While aspirin has been shown to be effective in preventing heart attacks in men, it also increases the risk of gastrointestinal bleeding and possibly stroke, even at low doses. As such, national guidelines suggest that aspirin be used for prevention only in men at higher risk for cardiovascular events, so that the benefits of aspirin are greater than its adverse effects.

Recent data suggest that aspirin may also be effective for reducing cancer deaths. Would the possible combined health benefits of reducing heart attacks and cancer outweigh the risks of gastrointestinal bleeding and stroke for middle-aged men?

A research team, including UNC scientists, reports that including the positive effect of aspirin on cancer mortality influences the threshold for prescribing aspirin for primary prevention in men. The benefit of aspirin for cancer mortality prevention would help offset the risks and thus lower the age and increase the number of men for whom aspirin is recommended.

Their results were published in the June issue of the Journal of General Internal Medicine.

Michael Pignone, MD, MPH, and study lead author, says, “We found that including a risk reduction for cancer deaths had a substantial impact on the overall benefits of aspirin, especially for early middle-aged men from 45 to 55 years of age. Based on this effect, several million men who were not previously good candidates for aspirin prevention would now become eligible.

The U.S. Preventive Services Task Force, of which Dr. Pignone is a recently appointed member, recommends aspirin for primary prevention in men “when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage.” This recommendation was issued in 2009, before the potential benefits for cancer reduction were recognized.

"Well, my husband is a board certified endocrinologist, and he told me that whenever a Type 2 patient is good, and gets their numbers normalized, that he removes the Type 2 Diabetes diagnosis, and changes it to a Metabolic Syndrome diagnosis, instead, to help them out." -- Misinformed Mrs. Know-It-All.

The woman was very angry at me. How dare I suggest Type 2 Diabetes has no cure. And furthermore, I could go get a gastric bypass surgery, if I wanted. That, for certain, was also a cure. This, of course, was followed by a few "You people will never be like us; you need to stop comparing yourselves to us... You keep trying to act like we are the same, or have it worse than us, or that your disease is just as bad as ours" type of comments. I cant say that I blame her entirely for her misinformed, self righteous attitude. (Okay, I know she was being kind of a bitch. Im just trying to be nice, here.)

This is the every day bread of Type 2 Diabetes awareness. Raising Type 2 Diabetes awareness is not easy. In fact, its one of the most painful things Ive ever had to do in my life. My husband certainly doesnt understand it, sees a redundant theme in it, and wonders why I dont just get out of it... since its obvious I cant change the world. Ive gone to bed crying, on more than a few nights.

The comment above, is of course, ridiculous. If there is a board certified endocrinologist out there, doing this, he needs to have his license revoked. Simple as that. He is doing NO ONE any favors. He is hurting his patients a lot more than he knows. I understand that insurance companies love judging us -- hey why not, the media has done a great job of misinforming the world, and insurance companies get their news just like the rest of us, and want to use that to safeguard their old, mighty dollar -- but the value of a small defense against an insurance company does NOT outweigh the psychological harm and denial you feed into a person by acting like their diagnosis doesnt exist. Would these people dream of telling someone who had AIDS "If youre good, and your labs come back good, Ill change your diagnosis to HIV positive, instead?" Yeah, I dont think so! (Its not entirely a perfect analogy, but you get the idea...)

But people dont GET the permanence of Type 2 Diabetes. Whats worse is that, while we preach day and night that this is an epidemic of epic proportions, our medical establishment does not act like it! (Oh, lots of people are acting like it, dont get me wrong... but its, mostly, the people who want to scam us, and take advantage of us...) If this is such a serious threat, why isnt the American Medical Association, and the American Association of Clinical Endocrinologists, making it a priority to get doctors educated, and prepared, for diagnosing, and empowering patients? Why are they not working hard to give patients the weapons to fight back, and effectively not feel themselves the hopeless victims of this disease? (I know someone out there will claim that they are... but the proof, or lack of proof, is in the pudding, folks.)

• Patients are out there, going undiagnosed, not because they dont regularly see a doctor (though some, undeniably dont...), but because doctors dont know how to recognize the signs of diabetes, or are UNWILLING to mark down a "diabetes diagnosis" in a patient record, thanks to insurance company scheming. More and more Type 2 Diabetes patients are being diagnosed by other medical professionals, such as gynecologists, urologists, dentists, and eye doctors. Often, a patient even gets misdiagnosed based on ridiculously old knowledge, like assuming that an adult could not be a Type 1 Diabetic, instead, leaving the patient vulnerable to Diabetic Ketoacidosis, and Diabetic Coma.  
• Most doctors, especially Primary Care Physicians (or Family Doctors), get a MINIMAL amount of diabetes education in medical school, and NO extended diabetes education throughout their careers. Diabetes information, care, and knowledge is growing about as fast as technological advances are... why should doctors remain in the dark, if we, as patients, cant afford to do so? Some doctors are going by on 20, and 30 years of OLD diabetes education! As a consequence, when a diabetic patient gets diagnosed, thanks to this lack of knowledge and insurance company scheming, patients get denied access to specialists, denied access to certified diabetes educators, denied access to dietitians, denied access to insulin, etc. Doctors, ROUTINELY, give NO information or direction to a newly diagnosed Type 2 Diabetes patient, leaving them vulnerable to whatever might be out there, on the internet. There is something vastly wrong with an insurance company that denies access to a dietitian, or certified diabetes educator, but is happy to approve gastric bypass surgery. In other scenarios, doctors give patients extreme misinformation, such as "STOP eating ALL fruit because they are high in carbs." Ummm, hello, not all fruit is made the same... We need to learn to MANAGE food, not put the fear of God in people.   
• The medical establishment is allowing itself to be ruled by the treatment guidelines of the American Diabetes Association -- an Association with clear conflicts of interest, per a recent study done by the Mount Sinai School of Medicine, and which has been SLOW AS MOLASSES in embracing the future of diabetes tight control, and management. Whats worse, they have GREATLY contributed to diagnoses getting delayed and delayed. This is WRONG and unacceptable. Doctors and Endocrinologists need to be educating the ADA, and not the other way around! 
• Instead, more and more "doctors" and "medical professionals" are taking advantage of the serious need for diabetes patient education, as a door to write books, push supplements, spread their own pseudoscience, and MAKE MONEY. 

 

This week’s question comes from a student. Man, havent we all been here?

Q: One thing I have always struggled with is having a good breakfast, especially on the go. Im a college senior (class of 2010!) and my time is very limited in the mornings (probably because I get up at the latest I can). I have come to hate buying breakfast from the food carts or spending money (college/intern=broke) and would like to know any suggestions for any nutritious (and quick) meals in the morning. I have long commutes to Manhattan and usually have to eat on the go. Normally I try to eat fruit and a yogurt, or some sort of "cereal bar."

Anyway hope you can help with some suggestions!

A: Good question, sweet reader. You’re definitely moving in the right direction with fruit; portable, cheap, and healthy, it beats the everloving crud out of Go-gurt and its rainbow-colored kin. If you can pack a big ol’ fruit salad, it would provide a little variety, too. Sprinkle nuts on it for kicks.

Since you’re eating on the subway, I assume oatmeal and/or cereal are poor options. Do you mind baking? If you can set aside an hour or two every other week, you can do granola bars, muffins, or banana bread. It’d set you up for the whole month, and each piece will probably run you between $0.15 and $0.35. These Cranberry Zinger Muffins from Cooking with Amy are wonderful, and I remember digging Everybody Likes Sandwiches version of Chai-spiced Apple Oatmeal Bread very much.

Readers, beyond that, I throw the question to you. What are your favorite portable breakfasts? How do you eat on the go?

Want to ask the interweb a question? Post one in the comment section, or write to Cheaphealthygood@gmail.com. Then, tune in next Tuesday for an answer/several answers from the good people of the World Wide Net.

A University of Colorado Cancer Center study published online ahead of print in the journal Nutrition and Cancer describes the laboratory synthesis of the most active component of grape seed extract, B2G2, and shows this synthesized compound induces the cell death known as apoptosis in prostate cancer cells while leaving healthy cells unharmed.

“We’ve shown similar anti-cancer activity in the past with grape seed extract (GSE), but now we know B2G2 is its most biologically active ingredient which can be synthesized in quantities that will allow us to study the detailed death mechanism in cancer cells,” says Alpna Tyagi, PhD, of the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. Tyagi works in the lab of CU Cancer Center investigator and Skaggs School of Pharmacy faculty member, Chapla Agarwal, PhD.

The group has spent more than a decade demonstrating the anti-cancer activity of GSE in controlled, laboratory conditions. For example, previous studies have shown the GSE effectiveness against cancer cells and have also shown its mechanism of action. “But until recently, we didn’t know which constituent of GSE created this effect. This naturally occurring compound, GSE, is a complex mixture of polyphenols and also so far it has been unclear about the biologically active constituents of GSE against cancer cells,” Tyagi says.

Eventually the group pinpointed B2G2 as the most active compound, but, “it’s expensive and it takes a long time to isolate B2G2 from grape seed extract,” Tyagi says.

This expense related to the isolation of B2G2 has limited the group’s further exploration. So instead of purifying B2G2 from GSE, the group decided to synthesize it in the lab. The current study reports the success of this effort, including the ability to synthesize gram-quantity of B2G2 reasonably quickly and inexpensively.

In the paper’s second half, the group shows anti-cancer activity of synthesized B2G2 similar in mechanism and degree to overall GSE effectiveness.

“Our goal all along has been a clinical trial of the biologically active compounds from GSE against human cancer. But it’s difficult to earn FDA approval for a trial in which we don’t know the mechanisms and possible effects of all active components. Theore, isolating and synthesizing B2G2 is an important step because now we have the ability to conduct more experiments with the pure compound. Ongoing work in the lab further increases our understanding of B2G2′s mechanism of action that will help for the preclinical and clinical studies in the future,” Tyagi says.

Many observational epidemiologic studies have found an inverse association between alcohol consumption and hematological cancers (such as lymphoma and leukemia). This study, based on the Million Womens Study in the UK, is large enough to permit an evaluation of associations with various types of such cancers. Further, it takes into account newer coding systems for morphology so that diseases associated with the lymphatic system can be separated from those of the myeloid system.

The key findings are that alcohol consumption appears to lower the risk of several types of lymphoma and plasma cell neoplasms, but has little effect on the risk of myeloid tumours such as acute myeloid leukaemia. Smoking is associated with an increase in risk for most such cancers. Approximately 1.3 million middle-aged women were recruited in the United Kingdom during 1996 and followed for death, emigration and cancer registration until 2009 (mean 10.3 years per woman); potential risk factors were assessed by questionnaire. Adjusted relative risks were estimated by Cox regression.

During follow-up, 9,162 incident cases of haematological malignancy were recorded, including 7,047 lymphoid and 2,072 myeloid cancers. Among predominantly moderate alcohol drinkers, higher intake was associated with lower risk of lymphoid malignancies, in particular diffuse large B-cell lymphoma [relative risk 0.85 per 10 g alcohol per day (95% confidence interval 0.75.96)], follicular lymphoma [0.86 (0.76.98)] and plasma cell neoplasms [0.86 (0.77.96)]. Among never- and current smokers, higher cigarette consumption was associated with increased risk of Hodgkin lymphoma [1.45 per 10 cigarettes per day (1.22.72)], mature T-cell malignancies [1.38 (1.10.73)] and myeloproliferative/myelodysplastic disease [1.42 (1.31.55)].

Forum reviewers considered this to be a very well-done analysis, and the ability of the authors to separate the effects on lymphoid and myeloid cancers is important. Forum members emphasize the strong differences in effect of smoking (an increase) and alcohol consumption (a decrease) on the risk of these cancers. They support future research to discover the mechanisms by which moderate drinking may lower such risk.

Hi,

I went shopping today at Sams Club with a friend. I decided to go there so I could stock up on meat and salad veggies. I brought the large packages of pork chops and hamburger patties home and talked with my friend as I separated everything into individual zipper lock bags and placed them in the freezer. It only took about 30 minutes to get it all in the freezer. Of course, now I need to stock up on the zipper lock bags that I like to buy from Aldis because they are cheaper there.

I will still need to go to Kroger for the cage free eggs and smaller packages of bleach, etc., but the main protein and veggies are bought.

Im thinking about getting a new table top convection oven. I have a Nuwave Oven which Ive been using for a couple of years and Id like to get a new one. The design of the NWO could be improved upon. For one, I would like to be able to choose the temperature I am using to cook my food. It has a "high, med, low" but Id like to be more precise. I also no longer like the plastic dome because it has become cracked (not yet broken) and discolored -- even a part of the edge at the bottom has "bubbled." The bubbles are extremely small but I dont like them and no matter how long I let the plastic dome soak in the dish water it just does not come out clean looking. My sink is very small so I can only let it stand in the water and turn it after a while to soak it, but It still works so I am using it until I decide which new one to get.

I like the ones that are a glass bowl because they appear to be easier to clean. You just fill the bowl with soapy water and turn the cooker on -- at least that is what is advertized online. Although I read one review that said the glass bowl is very heavy and awkward to handle in the sink which is a consideration for me, but if I use the aforementioned method, perhaps I wont run into too much of that.

I can see only one disadvantage to the deep bowl: you have to reach down into a hot bowl to remove the hot food. I suppose tongs will work fine for that, and some of them come with a pair of tongs, but the NO design is easier to retrieve your food. The only thing that is a small problem is that the cooking rack has four standing metal loops that protrude above the grill and I sometimes brush my hands against them when Im slicing meat on the grill while checking for done-ness. They are, of course, very hot at that point in time and they burn. I guess you just have to adjust to the design youve purchased.

I have not decided whether I want to go with the 10.4 quart or the 12 quart in some other model. I usually cook for only one so dont really need the 12-qt for everyday cooking... but what if I want to make a nice meal for someone? I suppose I could use the big oven for that, so perhaps I should just go for the smaller one for everyday practicality. 

I also like the counter-top height of the appliance. No more bending over a huge hot oven to check, baste, or remove hot dishes. Being able to manage the cooking from the same height I do everything else in the kitchen is very convenient and easier on the back. Since I dont eat starchy vegetables like potatoes and such, the only thing I actually cook is meat. Ive been seasoning nearly everything with lots of garlic and curry powder and loving the robust flavors. I really like the curry powder on hamburger patties -- it gives them a flavor punch.

Ive also been using reduced sugar ketchup (which I learned about at Thrive) along with spicy brown mustard which Ive always used. I may not purchase the ketchup again, because it has sucralose in it, even though a reduced calorie amount. I just dont think I need to get used to using ketchup. So, for now, Ill use it, but when it is gone, Ill not replace it.

About the coconut oil experiment: It has been a little difficult to remember to down the two tablespoons of CO thirty minutes before each one of my meals. It is simply a rather odd thing to do. I cant imagine my great grandmother doing such a thing, except for her health. I know that our ancestors used to take cod liver oil by the spoonful, so maybe it is not as odd as I was thinking. They used to take castor oil, too.

My mother had some ancient bottles of both of these under the sink when I was growing up. I remember being very curious about them. I had never seen her open or use them so I asked Mom what they were for. I dont recall her precise wording but I remember her telling me they were supposed to be good for you but they did not taste very good. I had to, of course, try them. I only tried them once. Whew-eeee! I never did that again. Now that I think about it, they were probably rancid. The bottles were very old even when I was a child.

I have tried a simple dry (unsweetened) coconut recipe that is interesting. I take about a tablespoon of desicated coconut and mix it with a pinch of xylitol, a shake of salt and a teaspoon of baking cocoa along with the tablespoon of coconut oil. It becomes a little like fudge and is pretty tasty, but I cannot eat more than that small batch. It is very filling.

The coconut oil also seems to do something to my throat which makes me cough. It somehow seems to coat the top of the throat and then melt, leaking down the wrong pipe. It is somewhat uncomfortable. It seems to be worse when made into the "fudge" than simply taking it straight. (Im not sure why.) I think I also per to mix the CO into something or cook with it rather than to take it "straight.".

I will have to continue the experiment now that I have the proper foods to eat. I was not actually eating "improper" foods, I just had run out of raw veggies and was eating simple meals of protein only. My body gets out of balance when I do that and I have to start taking antacids, but now that I have the right supplies I shall continue the CO experiment and see if I lose weight doing it properly.

Ive got some water seepage in my back bathroom and have asked a local handy man to come and look at it. He will be here at ten in the morning. My idea of the solution to the problem is threefold: 1 Apply a fresh coat of roof seal on the entire roof, 2. Clean the gutters, and 3. fill any gaps in the metal siding with "Great Stuff." I will have to wait and see if he thinks that is the proper route, and if he will do it, and for how much. I will be glad when the job is done and there is no more seepage.  I had to apply many sprayings of Febreze to get rid of the smell of mildew last week and this weekend it rained pretty long and hard so the carpet was wet again. There is still a faint oder of mildew which might be coming from the walls. Dont know what can be done about that, except for more Febreze. (Heres a link to some Febreze coupons if you need them: http://www.febreze.com/SpecialOffers.aspx .)

Thats all for now,

Be back soon,

Marcia

Nature often plays a delicate balance, like these two bugs holding on against the wind, behind these delicate, white blooms.  Its a rainy, cold, and wet  day, in Iowa.  Fall is just around the corner. (September 11, 2008)

One of the biggest challenges, when helping newly diagnosed persons with diabetes, is finding balance in the information provided. Helping create a positive environment, which encourages a person to learn the scope of the disease and its complications, but still keeping their heads above water. No matter the diabetes community -- this is a struggle that I have found almost everywhere. Even in my own diabetes groups.

Whenever I share any information, my hope is for you, the patient, to be able to make your OWN decisions -- and not make MY decisions as yours. I have this crazy idea that, when empowered with basic information, people will tailor their diabetes regimes to their own circumstances, and find balance. That I dont need to tell anyone what to do, and that since this is diabetes were talking about, what has worked for me... will definitely, and not necessarily, work for you.

The problem is that diabetes is a dick. Diabetes doesnt play fair, and it doesnt give two shits about our feelings. It doesnt. It doesnt care that the news of the things it can do, can scare us, nor does it politely pass us over when we decide to close our eyes against it. So... sometimes, this harsh bit of reality might lead people to behave in one of two ways: either by becoming inflexible with their ideas of control, or by becoming completely lax in their control. Neither of these two ideas is good, even if one of them has much, much better numbers.

Inflexible Control

Laxed Control