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IN MEN CANCER BREAST NESS OF AWARE R RAISES R NFL STA FORME

Why do we continue unhealthy behaviors knowing that they are detrimental to our well-being? Former first lady Nancy Reagan’s slogan “Just say no” was a simple, but ineffective solution. Economics, environment and culture are powerful stimuli. And so are habits.

Researchers funded by the National Institutes of Health (NIH) are taking a closer look at what happens in the brain as habits form. “Understanding the biology of how we develop routines that may be harmful to us, and how to break those routines and embrace new ones, could help us change our lifestyles

and adopt healthier behaviors,” Dr. Nora Volkow, director of the National Institute on Drug Abuse, recently wrote in the NIH News in Health. Generally, we are creatures of habit. We perform daily routines, such as bathing and combing our hair without giving them a thought. We’re on auto-pilot as we drive to work. In one sense, these habits are good, according to Volkow, as it frees up the brain to concentrate on other matters. Habits form not only from repetition but also from the stimulation of the brain’s reward centers. Often these habits are not particularly good. When we indulge in behaviors that bring us pleasure, such as smoking, using drugs or eating too much food, the brain releases dopamine, a chemical responsible not only for motivation, compulsion and perseverance, but also for pleasure. In other words, our brains become hardwired to crave and continue bad habits. That does not mean that it’s impossible to change. It means that change is just not easy. There is not one set of rules for change. One size does not fit all, but there are some rules that apply across the board. One must first recognize and accept the habit and acknowledge that change is necessary. In addition, goals for change should be specific. Instead of vowing to exercise, be more exact. How often will you exercise? What type of exercise? There are several models of behavior change, but one of the most applied and tested in the health care field is the transtheoretical model (TTM) developed by psychologists James Prochaska and Carlo DiClemente in 1983. TTM has been successfully applied to health related behaviors such as smoking, diet, exercise and safe sex practices. Practitioners have also used it to change mental health

related behaviors, including alcohol, drug abuse and stress. The theory behind TTM is that at any given time, a person is in one of five different stages: precontemplation, contemplation, preparation, action and maintenance. People move from one stage to the next without skipping since each stage offers preparation for the one following. The time frame to remain in each level depends on the individual. In precontemplation, a person has no conscious intention of making a change, while in the contemplation stage the person is considering a change, but has not made a commitment to a particular action. In preparation, people acknowledge the need to change and are developing an action plan, such as membership in a health club. Action occurs when the person has actually modified behavior, such as to stop smoking. Maintenance occurs once the person has practiced the new behavior for six months. Counselors readily admit that it can take several rounds of these stages for a permanent change to occur. Smokers quit, then quit again. Many new health center memberships go unused. That’s to be expected. Relapse is common, perhaps even inevitable. Experts often look at these relapses as partial successes. People know why they failed and can hopefully avoid that response the next time around. Some make the mistake of relying solely on willpower to change unhealthy habits. Mental health professionals warn that willpower is like a muscle and fatigues when used too much. A recent issue of Mayo Clinic Health Letter cites examples of how self-control may be more effective in changing certain behaviors. For example, a person using sheer willpower to curtail drinking will decide to keep Habits, continued to page 4

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MORE NEED ED ON AMER ICAN PLATES

© July

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by the U.S. mends that Department of Agricu teens consum lture, recomfruits and veggies every e at least five cups of day. It’s not and vegetab just teens that are lacking in le Factor Surveil intake. The 2009 fruit lance System Behavioral Risk out that for adults nationwide pointed interviewed only 23 percent of servings a reported that they those day, ate ranged from as recommended. at least five The percent a low of a high of 32 percent 15 percent in Oklaho age in Washin ma to In Massac gton gender, race, husetts, consum D.C. ption varied males, whites,educational status by college graduat and income. Femake at least $50,000 es and those consume the minimu a year were more who m recomm apt Studies ended amount to bles contain have shown that s. fruits and vegetaerals that a wide variety of vitamins can reduce Muller and minillnesses, the risk of Mirvill including Town Comm e (left) hands heart disease several chronic diabetes and health on farme , some cancers stroke. rs’ marke y treats to The link , his cousin t run by Say this s, Yveke the Food Back in 1932, to food and good rly (middl Project. health is not mind getting about Muller Mirvill it was found e) (Photo vitamin C his hands e. He doesn’t by Greig and Francesca was the culprit that a diet defi new. dirty. Cranna, Farmin Louis. of sailors. own vegetab behind scurvy, cient in Mirville courtesy Scurvy an 18-year g is not a very typical les. works “I grow the of the Food was charact the bane weakness, as he reeled -old at ones erized by anemia and Project.) the Dudley and Dorche city kid that grew past time for extrem C is plentifu string beans, off his long list — I like,” he said, bleeding ster. But up Centers for l in citrus gums. Vitamine your typical then again, in Mattapan beets, broccol peppers and fruits. Disease Contro Mirville kid. In even i, And more 22 percent unlike a signifi eggplan is not recent l and Preven He plants, of student he actually cant number t. weeds, nurture tion, only Nurses’ Health Study times, the Harvar s intervie likes and of his peers, had eaten fruit d-based wed average consumes s and harvest bles. Accord daily intake found that the higher three or more or drunk 100 percentsaid that they fruits and ing to the s his Surveil the fruit juices the lower the chance of fruits and lance system 2011 Youth Risk vegeta- the survey. times per day the week Behavior cular disease s of develop vegetables, , a survey A mere 15 precedi they ate vegetab conducted percent of ing cardiov the student ng those who . Of the 110,000 by the asles people studied averaged s said ChooseMyPlatthree or more times day were eight or 30 percent more serving , e.gov, a program a day. less likely sponsored attack or stroke. to have a s a heart Mirville, continued to page Like most 4 nutritionists, reasons that Vivien Morris that those people should eat healthi can list all of the reason That partly s are falling on deaf er. She also knows explain ears. on getting s why people taste so good,” to eat more Morris takes a differe fruits and she said. vegetables. nt tact There’ “They you only s a reason she empha say they’re sizes the ing,” she good explained. good for you, they’re lesstaste. “If tractive. “Things We are progra that taste appealand fruit good are mmed is natural ly sweet. to appreciate sweetmore atIt’s not a ” things, hard there is at least one sell. Morris has found that eats. She invariably then tries fruit or vegetable more. She to a person likes even offers build on that to entice people and healthier For instanc substit to eat e, people grow to who like utes. like sweet potato chock full plain roasted sweet potatoe pie may of vitami healthy trimmi ns A and s Sonia Booker (left) and her son, Carl, formed a buddy system to support each C — withou— which are ngs. As a registe t all the other in their efforts to stop smoking. (Ernesto Arroyo photo) unred dieticia the body n, Morris require Eating knows all der to functio s at least 30 plant foods, to well that vitamin n proper like fruits not make ly. The problem s and minera And change should be measured in For instance, if you smoke 10 cigaand vegeta Morris recogn those ls in bles, have izes that small victories. “Many people try to do rettes a day, cut it down to nine. If youthose are essential raw materials on its is that the body or- may be off-put been found nutrien canown. ting to some. the cost of fruits to lower too much at one time,” said Christian. trying to exercise, a vow to exercise fipally ve fruits, veggie ts from the foods But it can derive her recommendatio and veggie “Eat season the risk s and that we eat, n. apples in s of severa low-income “Take small steps.” Booker, continued to page 4The only vitamin whole grains. princithe fall. Go “Corn is less expensally and locally,” l chron nership with seniors for the body ic illness with the ive in Augus is Farmer makes is the sun. locally es. Frozen season.” t and vitamin D food stampss’ markets, which less expens foods are a good grown food. in partare plentif substitute most Boston (doubling their ul ier. “Produ ive. In some ways, for fresh value with in the city, accept ce ers’ Marke markets) and both sales up she explain is flash frozen frozen may be a and are t Nutrition to $10 in WIC and bit healthright at the ed. “The Program, the nutrients peak of ripenes While which provid Senior Farmare well s,” maintained.” some of fresh produce is es coupon the nutrien healthy s to ts may dimini , Morris admitte d that sh over time, which can Morris, continu

TAKE THE FIRST STEP … AGAIN AND AGAIN Sonia Booker, 79, is good at keeping secrets. She was able to keep her cigarette smoking hidden from the parishioners at Holy Tabernacle Church where she was a choir member and usher. She even tried to keep it from her doctor. “I was ashamed,” she admitted. But she couldn’t keep the secret from herself. The constant hacking cough and the escalating cost of cigarettes finally got the better of her. She did answer truthfully when the doctor asked her about her smoking habits. She thought the answer “now and then” would do, but the doctor’s quick response was “Stop.” Like most people, it was hard for Booker to change this behavior. She started smoking around the age of 25 because her friends did. At one time she was up to two packs a day. Even the health warnings that began to surface 50 years ago did not have an impact. “We can hear and not pay attention,” she explained. Eventually, circumstances changed. Though Booker had not made the decision to stop smoking, certain events began to get her attention. The doctors found a spot on the lung of her sister, who was also a smoker. The health

warnings began to scare her. Booker quit — again, and again and again. Therapists warn that relapses are common. Booker started again after the death of one of her sons. She noticed, however, that she began to taper off without even trying. “I could be out most of the day and not even think about smoking,” she said. “When I came home and saw the pack sitting there, I automatically grabbed one.” The first step toward healthier habits is to recognize and accept the unhealthy behavior — without recriminations. “Don’t judge yourself,” explained Dr. Nicole Christian, a resident in psychiatry at Massachusetts General Hospital (MGH). “We are indeed creatures of habit.” Motivation to change is key — and individual. Outside encouragement is helpful, but the need to modify a habit comes only from within and is particular to each person. Generally, the biggest impetus to change is that people get tired of their behavior and its ramifications. “When they get to the point that ‘enough is enough’ that’s when the change begins,” she said.

It’s all ab colors an out the d taste

ed to page

4

Be Healthy is designed to help you take charge of your health. It’s up to you to know what screening tests you should have based on your age, gender, race and family history. And what it takes for a healthy lifestyle — exercise, a healthy eating plan and weight control.

Your health depends on You. For more information about Be Healthy, contact Karen Miller, Health Editor, at 617-261-4600 or kmiller@bannerpub.com

The Bay State Banner is committed to bringing reliable and understandable health information to our community to help end racial health disparities in Massachusetts.


HPV Publisher Melvin Miller Health Editor Karen Miller Executive Editor Howard Manly Art Director Marissa Giambrone

human papillomavirus HPV Vaccinations key to reducing HPV’s deadly strands..............4 A triple dose........................................................................... 5 Consequences of HPV............................................................. 6 Risk factors for cervical cancer................................................ 6 Cervical cancer screening guidelines....................................8 A parent’s dilemma: Talking about sex.................................9

Proofreaders G. Valentino Ball Lauren Carter Rachel Reardon

HPV viruses linked to growth in oral cancers........................10 Risk factors of oropharyngeal cancer........................................ 11 Signs and symptoms............................................................... 11

For advertising opportunities Please contact Karen Miller at (617) 261-4600 or kmiller@bannerpub.com.

Q&A……………………………………………………………..12

Be Healthy is published by Banner Publications, Inc. Volume 1• Number 1 Spring 2013 Photos from front page: iStockphoto/Thinkstock Be Healthy is printed by Cummings Printing 4 Peters Brook Drive P.O. Box 16495 Hooksett, NH 03106 603-625-6901

Healthy steps Drinking: Just one or two.....................................................15 Smoking: It’s better to never start than stop.........................16 High stepping: A simple exercise with surprising results.......18 Healthy eating One step at a time................................................................... 20 Turmeric................................................................................. 21 Go green................................................................................ 22

National Minority Health Awareness Month National Minority Cancer Awareness Week (April 15−21)

National STD Awareness Month

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Vaccinations key to reducing HPV’s deadly strands

Ursula A. Matulonis, M.D. Medical Director Gynecologic Oncology Dana-Farber Cancer Institute

M

uch progress has been made on the war on cancer. The Journal of the National Cancer Institute recently reported that death rates from all cancers combined are on the decline and improvements were evident in both men and women in all races and ethnicities. Yet, not all the news in the Annual Report to the Nation on the Status of Cancer, 1975-2009 was good. The 2012 report confirmed that the incidences of some HPV-related cancers are on the rise. HPV, or human papillomavirus, is the most common sexually transmitted infection in the country. The Centers for Disease Control and Prevention (CDC) estimates that at any given time, roughly 20 million people are infected with HPV and another 6 million join the ranks each year.  Be Healthy | HPV

It’s no wonder. There are more than 40 types of HPV that infect the genital areas of both males and females. Yet, most people remain unaware of these potentially lethal germs. Typically, HPV doesn’t have any symptoms, and its low-risk as well as high-risk strands are usually eradicated by antibodies found in healthy human immune systems. But some high-risk HPVs, such as HPV 16 and HPV 18, can linger within a body and cause a myriad of cancers. Those two HPV strands account for 70 percent of cervical cancers but can be found in 40 percent of other genital cancers and almost all anal cancers. HPV 16 alone accounts for more than 50 percent of oral cancers. The cause of the rise in HPV-linked cancers is not completely clear, but changes in sexual behavior have clearly played a part. According to the most recent Youth Risk Behavior Surveillance System, a survey conducted by the CDC, almost half of all U.S. high school students surveyed in 2011 said that they had had sexual intercourse, and more than 15 percent of these teens admitted to having sex with four or more people in their short lifetime. The earlier in life sexual intercourse is started and the greater the number of sex partners, the greater the probability of infection and the greater the probability of a cancer-causing HPV strain. Not surprisingly, smoking also plays a role and the combination of the two — smoking and HPV — packs a more dangerous wallop. Smokers who are afflicted with HPV 16 and HPV 18 are at increased risk for genital and oral cancers. So significant is the impact of HPV in cervical cancer that in 2012, the American Congress of Obstetricians and Gynecologists coupled HPV testing with Pap smears for women 30 to 65 years old as part of screening for cervical cancer. The objective is to identify high-risk HPV before it can do permanent damage. Cervical cancer is more common in Latinas and blacks, but black women die of it at a greater rate than any other race. Although its incidence and death rates have plummeted since the inception of Pap smears, the American Cancer Society estimates that in 2013, more than 12,000 women will be afflicted with the disease and roughly 4,000 women will die. It can take up to 20 years for the cancer to form, but it leaves tell-tale signs before it strikes. Fortunately, these differences are detectable under a microscope, which allows treatment for precancerous lesions in the cervix. “The cells look different,” explained


Dr. Ursula A. Matulonis, the medical director of Gynecologic Oncology at Dana-Farber Cancer Institute. “They lose their features of what a normal cell should look like.” If these changes persist, it is recommended for the individual to be followed by a gynecologist experienced in treating these conditions, advised Matulonis. It is possible to prevent HPV infections. Abstinence from any type of sexual behavior is one way, but that is too high a price for most to pay. Monogamy, or sex with only one partner, can reduce the risk of infection, but is fool-proof only when both persons have not had sex with anyone else. One sexual encounter can result in HPV infection. Correct and consistent condom use can reduce transmission but may not be 100 percent effective since HPV is transferred from skin to skin. The exposed areas — even when using condoms — are fair game. Vaccinations are ultimately the best answer. In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended HPV vaccination for females aged 11-12 and as young

as nine. If not administered by the age of 12, catch-up vaccination is recommended for females aged 13-26. The vaccine is administered as a 3-dose series over a 6-month period. In 2011, the ACIP extended this vaccination schedule to males. Two vaccines are available. Gardasil, manufactured by Merck and Co., Inc., protects against HPV 16 and 18 as well as the viruses that cause 90 percent of the cases of genital warts in both males and females. Another vaccine, Cervarix, manufactured by GlaxoSmithKline, protects against two of those subtypes, and is not recommended for males. Although a vaccine has been in existence for six years, immunization rates in this country still remain low. The National Immunization Survey-Teen of 2011 found that nationwide, only a third of adolescent girls aged 13-17 years had received the three recommended doses. Sadly, the lowest vaccination rates are found in minorities, who have a higher incidence and death rate from HPV-caused cancers.

In order for the vaccine “to have a chance to protect

against HPV infection, it must be given to an individual before their first sexual intercourse encounter

— Ursula A. Matulonis, M.D.

Continued to page 

A triple dose

Vaccination against HPV protects females against genital cancers (cervical, vulvar and vaginal) and both females and males against anal cancers and genital warts. Two vaccinations — Gardasil and Cervarix — are available, but only Gardasil is recommended for boys and men. The vaccination is administered in three injections over a 6-month period.

HPV vaccination is recommended for:

Girls 11 to 12 years old can start at age 9

Girls and women 13 to 26 not previously vaccinated

Boys 11 to 12 years old can start at age 9

Boys and men 13 to 21

Men up to the age of 26

not previously vaccinated, although men up to 26 may be vaccinated

who have sex with men and have not been previously immunized

Note: HPV immunization does not absolve females from a regular schedule of Pap smears since the vaccine does not protect against all causes of cervical cancer. Nor does it change the recommendation to limit the number of sexual partners and to use condoms during sex.

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A closer

look

Human papillomavirus, or HPV, is the most common sexually transmitted disease. In most cases, the virus is obliterated within a couple of years and does no harm. A small percentage of high-risk HPV perseveres, however, and can result in cancer. HPV-related cancers of the throat and anus are on the rise. There is no cure or treatment for HPV, but it can be prevented by vaccination.

Consequences of HPV • Genital warts • Cancer of the: • Cervix • Vulva • Vagina

• Penis • Anus • Oropharynx (throat, back of tongue and tonsils)

Risk factors for cervical cancer

HPV infections Lack of regular Pap smears Weakened immune system Age cervical cancer is more common in women older than 40 Smoking Sexual history sex at a young age sex with multiple partners sex with a man who has multiple partners Chlamydia infection and other sexually transmitted diseases Exposure to diethylstilbestrol (DES) before birth

 Be Healthy | HPV

VACCINATIONS continued from page  The reasons for non-compliance are varied. Because of the relative newness of the vaccination and doubts about its safety, parents are not flocking to their pediatricians to obtain the three shots for their children. Some parents also believe that protection brings with it the license for sex. One study published recently in Pediatrics disputed that theory. The researchers followed 11- to 12-year-old girls for three years after HPV vaccination and looked for clinical markers of sexual activity, such as sexually transmitted diseases, pregnancy and contraceptive counseling. They found that sexual behavior in the vaccinated group did not differ significantly from those girls who were not vaccinated. A recent study at Boston University School of Medicine found that although a high percentage of parents interviewed were knowledgeable about HPV and its consequences, they still were slow to have their children vaccinated. Some parents preferred to leave the decision to their children when they reached adulthood. A lack of state mandates is also to blame. Even Massachusetts has fallen short in this area despite leading the nation in other immunization rates. Only half the females had completed the three-dose recommendation for HPV, while the rates for tetanus and hepatitis exceeded 90 percent. To date, only Virginia and Washington, D.C. mandate HPV vaccination for school attendance. This apparent nonchalance toward the HPV vaccination will limit its impact in this country, Matulonis argues. “A high percentage of the population has to be vaccinated in order to achieve a herd effect,” she said. Herd immunity occurs when a significant portion of the population provides some protection for unvaccinated persons. It is this herd immunity that eventually wiped out smallpox. The HPV vaccine is relatively new and only recently was extended to males, but Matulonis is keeping a positive attitude. “We have to follow the group of immunized people over time,” she said. State-mandated or not, vaccines remain an option. But Matulonis adds a word of caution. “In order for the vaccine to have a chance to protect against HPV infection, it must be given to an individual before their first sexual intercourse encounter,” she advised. “The vaccine cannot help people who are already infected with high-risk HPV.”


Cervical cancer screening

Ryan McKey/ Digital Version/ Thinkstock

As recently as the 1940s, cervical cancer was a major cause of death among women in this country. That changed when Dr. George Papanicolaou developed the Pap smear, or Pap test, that enables doctors to detect suspicious cells in the cervix before they became cancerous. It can also diagnose cancer in an early stage when treatment is more successful. The cervix is the lower end of the uterus. The development of the Pap smear had a significant impact. According to a report by the National Institutes of Health, between 1955 and 1991, the incidence and death rates attributed to cervical cancer declined by more than 60 percent, making it now the 14th most common cancer in women. The American Cancer Society (ACS) estimates that 12,340 women will be diagnosed with cervical cancer in 2013 and 4,030 will succumb to the disease. During the test the provider takes samples of the cells of the cervix using a soft brush or a flat scraping device. The samples are viewed under a microscope for suspicious changes. A positive result, which means that abnormal or unusual cells were discovered, does not necessarily indicate cancer. Several infections can cause temporary changes. However, if the abnormalities persist over a period of time, additional testing is required.

A test for HPV, which is responsible for virtually all cases of cervical cancer, is now recommended in conjunction with the Pap smear for women of a certain age. The protocol listed below is a general guideline. Your doctor may recommend a different schedule for you. The American Congress of Obstetricians and Gynecologists and the ACS recommend: Age 21

Begin Pap smears regardless of prior sexual history

Ages 21 to 29

Repeat Pap smears every 3 years

Ages 30 to 65

Repeat Pap smears combined with HPV testing every 5 years or continue Pap smears alone every 3 years

Age 66 and older

Discontinue screening in women who have had adequate screenings and normal results

After hysterectomy

Recommend against screening in women of any age who have had a hysterectomy with removal of the cervix

Women who have been immunized against HPV should continue screening. Vaccination protects against HPV 16 and 18, which are the leading cause of cervical cancer. However, other types of HPV infections cause cervical cancer as well.  Be Healthy | HPV


a parent’s dilemma: talking about sex (Yawu Miller photo)

Nabeehah, 14 (r) is shown with her mother, LaVonda Epps-Murphy, (l) and her father, Maurice Murphy. Nabeehah followed her parents’ advice and was vaccinated against HPV at the recommended age of 11.

I

t was back in 2009 when LaVonda Epps-Murphy was riding on a train and noticed a poster about a vaccine that claimed to offer protection against HPV. The poster also said the vaccine was for pre-teen girls ages 11 and 12 and that it would help reduce the risk of cervical cancer. The message struck a chord in the 35-year-old mother. Her daughter, Nabeehah was 10 at the time going on 11. Epps-Murphy admitted that the relative newness of the vaccine was a bit of a concern, but the health of her daughter, already plagued with asthma and food allergies, was of greater concern. Epps-Murphy made sure she was up to date on all her vaccines including a yearly flu shot. It didn’t take her long to make a decision. A talk with her pediatrician and a bit of independent reading convinced EppsMurphy that she was doing the right thing. She had another reason as well. In the back of her mind, she recalls, was the experience of a close friend who had undergone major surgery on her cervix as a consequence of an HPV infection. Epps-Murphy wanted better for her daughter. But Nabeehah was not that keen on the idea. “She was scared at first,” explained Epps-Murphy. “She’s afraid of needles.” But Epps-Murphy knew that a temporary bout of anxiety was not a good enough excuse to forgo protection against a preventable disease that could hit her daughter in her prime.

She developed a two-part plan. First Nabeehah had a private one-on-one with her pediatrician. Then Epps-Murphy sat her daughter down at the computer. “I talk to my daughter about everything,” she said, including sex and its often deadly consequences. She showed her pictures of HPV-infected body parts. That was enough to convince her daughter, but her husband took a bit more doing. “He was apprehensive at first,” she explained. Like many parents, he was concerned that providing the vaccination was an implicit permission to engage in sex. But that seemed to be the furthest thing from Nabeehah’s mind. “I don’t even have a boyfriend,” she explained. Her maturity sealed the deal. He too became convinced that getting vaccinated at that age was the best choice. Nabeehah began her three-dose regimen and, according to her mother, completed it in the recommended six-month period without any side effects. She was a perfect candidate for HPV vaccination. She was inoculated at a young age and before her first sexual encounter, which is the ideal time to get the maximum benefit from the vaccine, according to the Centers for Disease Control and Prevention. Also, response to the vaccine is better at a younger age. Nabeehah made a wise choice. Of course that’s to be expected. Nabeehah is a Muslim name that means eminent, brilliant and intelligent. behealthy.baystatebanner.com 


HPV viruses linked to growth in oral cancers

W

hile the annual report on the status of cancer in this country indicated a decline in the incidence and death rates of all cancers combined, some particular cancers did not fare that well. HPV-related cancer of the throat is one of them. You don’t have to explain that to Dr. Robert I. Haddad, the disease center leader of the Head and Neck Oncology Program at Dana-Farber Cancer Institute. “I see two patients a week for HPVrelated head and neck cancer,” he explained. “It’s very common and now the number one cause of oropharyngeal cancer.” Oropharyngeal cancer affects the throat, back of the tongue and tonsils. For HPV-associated cancers, it trails only cervical cancers in number and medical experts predict that if the current trend continues, these oral cancers will move to first place. More than 50 percent of the cases are caused by HPV 16. According to the Centers for Disease Control and Prevention (CDC) almost 12,000 new cases are confirmed each year, and men bear the brunt of the illness at 80 percent of the diagnoses. The rate of occurrence in white and black males is similar, according to the latest CDC data. Although the statistics are clear, the reasons for the uptick are less so. Haddad agrees. “It is difficult to pinpoint the reason for increased incidence of oral cancer,” he said. Some clinicians blame oral sex. A 2012 CDC report on the prevalence of oral sex found that roughly two-thirds of males and females aged 15-24 had engaged in oral sex,

10 Be Healthy | HPV

Robert I. Haddad, M.D. Disease Center Leader Head and Neck Oncology Program Dana-Farber Cancer Institute

and cited birth control as a reason. Indeed, non-coital sex prevents pregnancy, but not sexually transmitted diseases. Even more puzzling is the description of patients diagnosed with throat cancer. The typical patient is now a non-smoker and non-drinker male in his mid- 40s or early 50s. At one time, oral cancers were more commonly attributed to heavy smoking, especially when combined with heavy drinking. Victims were generally in their 60s.


Oropharyngeal cancer There are no FDA-approved tests to detect HPV infections in men. Nor are there screening methods similar to Pap smears to find cell changes caused by HPV infections of the throat, but that does not mean one should not be vigilant. There are tell-tale signs. A sore throat and difficulty swallowing are two of them. A lump in the neck or enlarged tonsils is another. “The lump should bring you into the doctor’s office right away,” cautioned Haddad. Doctors often rely on dental hygienists and dentists to spot the problem. “They are in a unique position to examine the mouth,” Haddad explained. “We rely on them to be the first line of detection.”

“We talk about not smoking and drinking to prevent oral and other types of cancer. We have to emphasize vaccination as well.” — Robert I. Haddad, M.D. Prevention is key. “We talk about not smoking and drinking to prevent oral and other types of cancer,” he said. “We have to emphasize vaccination as well.” Although there has been no research on the impact of HPV vaccination on throat cancer, Haddad argues there is little reason to believe it will not affect HPV-related oral cancer as well. Yet the vaccination rate, especially among males, is very low. “Many parents think this is taboo and are uncomfortable having it done,” explained Haddad. HPV-related throat cancer is treated by surgery, chemotherapy and radiation and depends on the stage of diagnosis. The good news is that the treatment works well. According to the American Cancer Society, oropharyngeal cancers that contain HPV DNA tend to have a better outlook than those without HPV. Still, treatment comes with long-term side effects. “The treatment is difficult and can affect speech,” Haddad explained. People have difficulty with dry mouth. Anxiety and depression are common. “Many people will be cured, but it won’t be easy,” he warned.

Risk Factors • Human papillomavirus • Smoking and chewing tobacco • Heavy alcohol use • A diet low in fruits and vegetables • Weakened immune system • Gender - more common in males • Sexual behavior - multiple sex partners and exposure to oral sex

Signs and symptoms Although the following symptoms do not necessarily indicate oral cancer, if they persist and cannot be attributed to another cause, it is recommended to seek medical advice. A sore throat that does not go away Trouble swallowing A lump in the neck or back of the mouth or throat A change in voice, such as hoarseness Ear pain A cough Weight loss for no known reason

behealthy.baystatebanner.com 11


Q&A with Dr. Susana Campos Is it possible to prevent cervical cancer without a vaccine?

Cervical cancer screening done according to American Cancer Society guidelines in conjunction with proper follow up will prevent most, but not all cases of cervical cancer. Pap smears (with or without the Susana M. Campos, M.D., M.P.H. HPV test) can find cell changes Gynecologic Oncologist Dana-Farber Cancer Institute in the cervix early before they become cancerous. In addition, when cancer screening guidelines are followed, most, but not all cervical cancers are found at an early, curable stage.

What are the risk factors for genital HPV?

The main risk factors for genital HPV are age and sexual history. Those younger than 25 and those who had their first sexual intercourse at age 16 or younger or have had multiple sex partners are at increased risk. Even women who have only had one sex partner can become infected with HPV. This is more likely for women who have a partner who has had many different sex partners.

If a woman is told her Pap smear is “suspicious,” does that mean she has or will have cancer?

No. An abnormal result does not mean a woman has HPV or cervical cancer. Other reasons for an abnormal Pap smear include infections, such as yeast infections, irritation and hormonal changes. If a Pap smear is abnormal, the doctor may do the test again or perform an HPV test. If the suspicious changes persist, other tests such as a colposcopy or a biopsy may be warranted. A colposcopy is a procedure to closely examine the cervix, vagina and vulva for signs of disease.

If HPV goes away, can you get it again?

Yes. There are many types of HPV, so you can get infected again.

Why do other sexually transmitted infections, such as HIV infection, increase the risk of HPV?

Infection with HIV dampens the immune system and reduces the body’s ability to fight infections that may lead to cancer. Many people infected with HIV have other viruses that cause certain cancers like HPV, which can causes cervical cancer and some types of anal, penile, vaginal, vulvar and head and neck cancer.

Can genital warts cause cancer?

No. HPV types that tend to cause genital warts are not those that cause cancer. However, an individual can be infected with multiple types of HPV. The presence of warts does not rule out the possibility of high-risk types of the virus also being present.

If HPV has no symptoms, how does a person know he or she is infected?

One way is the presence of genital warts, which are typically small, flesh-colored or gray swellings in the genital area or throat. Most women who have HPV infections, however, never know it unless an HPV test is performed with a Pap smear. This is a DNA test that detects most of the high-risk types of HPV.

If a woman has a normal Pap smear, does that mean she does not have HPV?

Not necessarily. There are often no symptoms associated with HPV. Patients with a normal Pap smear can have HPV but it does not necessarily develop into cervical cancer. It means only that no cell changes were seen on the Pap smear.

Does infection with HPV 16 or 18 always result in cancer?

No. The body’s immune system can often eradicate HPV 16 and 18 within one to two years. Some HPV infections, however, can persist for many years and can lead to more serious cellular abnormalities or lesions that, if untreated, may progress to cancer.

DANA-FARBER/HARVARD CANCER CENTER Initiative to Eliminate Cancer Disparities 2013 — National Minority Cancer Awareness April 8-April 30 Boston Public Library Cancer Awareness Display

April 11, 11:00am-2:00pm Alternative and Complementary Health and Wellness Fair

“The Choice is Yours” Dudley Branch Library, Roxbury Fields Corner Branch Library, Dorchester South Boston Branch Library, South Boston

University of Massachusetts Boston Campus Center, 1st floor terrace 100 Morrissey Boulevard Dorchester

April 13, 12:00-2:00pm Healthy Behaviors Karen Burns White Sponsor — AARP Twelfth Baptist Church 150-160 Warren Street Roxbury

May 20, 11:00am-1:00pm What does cancer research have to do with you? Dr. Karen Emmons Sponsor — Seniors on the Move Roxbury YMCA 285 Martin Luther King Boulevard Roxbury

All programs are open to the public. For any additional information, please contact Karen Burns White at 617-632-3244.

12 Be Healthy | HPV


behealthy.baystatebanner.com 13


Healthy steps When it comes to fighting cancer, lifestyles matter. Just ask the Washington, D.C.-based American Institute for Cancer Research (AICR). The Institute contends that eating a plant-based diet of fruits, vegetables, whole grains and legumes, can help ward off many cancers. Add exercise and weight control to the mix and one third of all cancers each year in this country could be avoided, according to the AICR. Healthy living is not a guarantee against cancer and other serious diseases, but it may reduce their risk.

Quit smoking tobacco use is the single most preventable cause of disease, disability and death in the United States.

Maintain a healthy weight overweight and obesity are linked to increased risk of heart disease, type 2 diabetes and certain cancers.

EXERCISE physical activity can reduce the risk of chronic disease, improve balance and help lose weight.

Follow a healthy eating plan include a variety of foods from fruits, vegetables, whole grains, low-fat dairy products, lean protein and healthy fats.

Avoid excessive alcohol use alcoholism is the third leading lifestyle-related cause of death and a risk factor for many cancers. 14 Be Healthy | HPV


Just one or two While HPV is a growing risk factor in the incidence of oral cancer, tobacco and heavy alcohol use are top contributors as well. What’s more, using both tobacco and alcohol puts a person at greater risk than either of these habits alone. In addition, some studies suggest that tobacco and alcohol use increase the risk of both HPV-associated and HPV-independent head and neck cancers. The American Cancer Society defines low to moderate use of alcohol as one to two drinks a day for a man or one drink a day for a woman. One drink equals one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine or 1.5 ounces of 80-proof distilled spirits, such as whiskey or rum. For some, however, it is hard to hold the line at just one or two. In addition, many people are not aware that their drinking has grown out of control. For them, alcohol is often a part of socializing, celebration and even relaxation. Yet, it is important to acknowledge and understand the effects of excessive alcohol use on a person’s body and personal life. According to the Centers for Disease Control and Prevention, excessive alcohol use can lead to an increased risk of several health problems and is the third leading lifestyle-related cause of death for people in the United States each year. The National Institute on Alcohol Abuse and Alcoholism has developed screening tools to aid in identifying people with alcohol problems.

CAGE: A self-test Answering the following four questions using the letters CAGE can help you find out if you or a loved one has a drinking problem: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover, as an “Eye-opener”? Two positive responses are considered a positive test and indicate further assessment is warranted.

Quitting drinking Here are some steps to consider: • Start by asking questions: How much and how often do you drink? Has your drinking been harmful in any way? For instance, has it jeopardized your health or your job? Talk to your doctor or check online for quizzes to help you assess your drinking habits and get information on cutting back or stopping. • Consider joining a self-help group. Best known is Alcoholics Anonymous (AA), which outlines a 12-step program for its members to follow and offers plenty of support. An alternative is SMART Recovery (Self-Management and Recovery Training), a nonprofit, non-spiritual group focusing on a range of addictive behaviors. Family members may find Al-Anon or Alateen helpful. • Seek counseling from a substance abuse professional if you cannot stop drinking or need additional support. • Ask your doctor if medicines might help. Medication can often help ease withdrawal symptoms, block the high from alcohol, defuse cravings or relieve depression or anxiety. • Heavy drinkers require a specialized, intensive program, including detoxing to get alcohol out of the body. Be sure to consult your doctor.

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Smoking It’s better to never start than stop Trying to pick the best time to quit tobacco? Whether this is your first or fifth attempt, today is the perfect day to launch a new plan. Start by thinking hard about the facts. All tobacco products — cigarettes, cigars and smokeless options like chewing tobacco or snuff — cause cancer. And not just lung cancer, either. According to the American Cancer Society, using tobacco raises risks for cancers of the mouth, lips, nose, sinuses, voice box, throat, stomach, pancreas, kidney, bladder, uterus, cervix and other sites in the body.

Smokers who are afflicted with high-risk human papillomavirus are at increased risk for genital and throat cancers.

16 Be Healthy | HPV

Reaping the Benefits

Want more reasons to quit? According to the American Cancer Society, you’ll reap major health benefits Time after quitting

Health benefits

20 minutes

Blood pressure and heart rate drop

12 hours

Carbon monoxide in your blood returns to normal levels

2 weeks to 3 months

Circulation and lung function improve

1 to 9 months

Coughing and shortness of breath decrease

1 year

Heart disease risk drops by half

2 to 5 years

Stroke risk decreases to that of a non-smoker

5 years

Risks for certain cancers (mouth, throat, esophagus and bladder) are halved, and cervical cancer risk drops to that of a non-smoker.

10 years

Risk of lung cancer death is cut in half

15 years

Risk of heart disease is that of a non-smoker

O

ne in five deaths can be traced to tobacco. Twenty more people wind up with serious health problems for each person who dies. Smoking leads to heart disease, strokes and lung diseases like emphysema and bronchitis. It prompts further complications in people with diabetes. Second-hand smoke kills thousands of people annually and harms many more. Children of smokers are more likely to have ear infections and lung infections like pneumonia and bronchitis. Youngsters who have asthma suffer attacks more often and more severely. “When you quit, you begin to stop the damage,” said Dr. Thomas Hawkins, medical director for health informatics at Blue Cross Blue Shield of Massachusetts. “Your risk for heart disease goes down 50 percent in twelve months. Cancer risks also decline, although more slowly.” Your health improves vastly in many ways. And your wallet benefits, too.


Who smokes?

Among adults, 21 percent of African Americans, 13 percent of Hispanics and 9 percent of Asian Americans reported smoking in 2011. Every day, nearly 3,500 children ages 12-17 have their first cigarette.

Are you ever too old to quit?

No. While smokers 65 or older are just half as likely to try quitting as 18-24 year olds, older smokers are nearly twice as likely to succeed when they do try. That’s good since they have much to gain. A 2011 study of older adults found less cognitive decline over a two-year period in those who quit or never smoked versus those who continued smoking. Other research shows older smokers who quit have two to three years longer life expectancy, lower odds for a second heart attack or amputation and better lung function, which may translate to more mobility and independence. Check with your health plan about quit tobacco programs and incentives. Experts recommend a quit plan tailored to your needs that involves a combination of approaches: • Set a quit date and regular check-in dates to report on how you’re doing. • Identify great reasons to quit. • Identify your smoking triggers and plan to avoid them. • Recall past slip-ups and plan around them. • Learn which nicotine replacement products (patches, gum, lozenges, sprays and inhalers) could help you. • Talk to your doctor about medicines that help quash cravings and withdrawal symptoms.

• Seek support from your doctor, a smoking cessation counselor, loved ones or social networking sites for others who are trying to quit.

What step should you take first? Choose one of the following:

• Call your doctor, who can prescribe helpful medicines and refer you to a smoking cessation program. • Contact your health care plan about smoking cessation programs. Blue Cross Blue Shield of Massachusetts members can call the number on the front of their ID card or find a full-featured quit program at www.mybluehealthma.com complete with tools that let you track your progress, show just how many days quitting adds to your life, and total up the cash you’re saving. There are also community forums and “ask an expert” tools. • Request a step-by-step guide to quitting from Smokefree.gov (www.smokefree.gov or 1-800-QUIT-NOW). Quitline counselors are available by phone — or even via text message — to answer questions and offer encouragement every step of the way. Perseverance really counts! To quit tobacco successfully, people often have to try several times. Understanding why you failed in the past can help you succeed next time. What ruined your resolve? Which situations or people made cravings impossible to resist? How could you handle stress better? Should you talk to your doctor or a smoking cessation counselor about which nicotine replacements or other medicines might work best for you? Would more support or other incentives encourage you to stick with quitting?

Need help to kick the habit? It’s a call or click away Massachusetts Smokers’ Helpline Telephone M-Th 9am–7pm F 9am – 5pm 800-QUIT-NOW 800 – 784-8669

www.trytostop.org Interactive website 24 hours www.trytostop.org

American Cancer Society Quit For Life Program 24 hour Quit Coach 866-784-8454

Boston Tobacco Prevention and Control Program Educational material M-F 9am–5pm 617-534-4718 tobaccocontrol@bphc.org

National Cancer Institute Smoking Quitline Telephone M-F 8am–8pm 877-44U-QUIT (877-448-7848) LiveHelp Online Chat Instant messaging M-F 8am–11pm https://livehelp.cancer.gov/app/ chat/chat_launch Internet Interactive website Smokefree.gov

This article first appeared in the Bay State Banner’s Be Healthy section in November 2011.

behealthy.baystatebanner.com 17


High Stepping a simple exercise with surprising results

I

Carla Webster-Reid, a certified group fitness trainer, demonstrates the technique of walking in place. To spice it up she adds foot kicks, steps forwards and back and hikes her knees higher. Webster-Reid teaches a fitness class at Melnea A. Cass Recreation Complex in Roxbury.

18 Be Healthy | HPV

t’s easy to come up with excuses not to exercise. Lack of time is one excuse. The cost of gym memberships is another. Yet, there is an exercise that blows all those excuses away. It does not take much time; it’s free and you don’t need company to do it. All you need are comfortable walking shoes and a little bit of floor space. It’s what researchers at the University of Tennessee (UT) call “TV commercial stepping.” That’s a catchy phrase for walking in place. The connection between TV and exercise seems a bit of a stretch. Couch potato more readily comes to mind. But given the fact that hour-long shows run an average of 42 minutes of entertainment, and half-hour shows a mere 21 minutes, that leaves 18 and 9 minutes, respectively, to get moving instead of sitting through mind-numbing commercials. In just two hour-long shows, exercise time could meet the recommended 30 minutes of moderate exercise a day, as advocated in the 2008 Physical Activity Guidelines. The Centers for Disease Control and Prevention have determined that not even half of all adults meet these guidelines. Less than one-third of high school students get at least the recommended 60 minutes of physical activity every day. Walking is an excellent exercise. It’s accessible, simple and does not require any training. Yet, the benefits are tremendous. Walking can lower blood pressure, “bad” cholesterol and the risk of type 2 diabetes. It can improve one’s mood and help a person stay fit. These health benefits do not accrue only when you walk from one location to another. It’s the activity, not the distance that counts. Because Americans seem reluctant to give up screen time, the researchers at UT decided to convert sedentary TV time into active TV time. They conducted a small-scale pilot study to determine if walking in place during television commercials could increase physical activity and expenditure of energy. They discovered that walking in place during commercials in a one-hour show burned almost twice as many calories as reclining or sitting during one hour of TV time. The participants were active for an average of 21 minutes and accumulated about 2,100 steps during commercial breaks.


These results have an impact because of their practicality. In the most recent report of American time use, the U.S. Bureau of Labor Statistics found that watching TV was the leisure activity that occupied the most time every day for those aged 15 and over. While sports, exercise and recreation accounted for an average of 18 minutes a day, TV watching came in at a walloping three hours per day of leisure time. Inactivity has been cited as one cause of the burgeoning obesity problem in this country. In addition, when making a lifestyle change it is recommended to make small improvements for success. For those who have a tough time getting going, TV commercial stepping is a good spring board.

(Ernesto Arroyo photos)

Short on time and space? Walking in place can help you achieve your fitness and weight loss goals. Here are some pointers to keep it interesting. • Lift your feet higher • Try going in circles • Move 10 steps forward then 10 steps backward • Add arm exercises, such as biceps curl and shoulder circles • Vary your speed by walking at a fast pace for two minutes, then at a regular pace for four minutes • Add leg movements such as kicks and high knee lifts

behealthy.baystatebanner.com 19


One step

at a time

Whole milk

150 Calories 8 grams of Total fat

5 grams of

Saturated fat

24 milligrams of Cholesterol

When making lifestyle changes, modifications that are incremental and unobtrusive are more easily integrated into everyday life and can result in a permanent change. Take baby steps. For instance, instead of a giant leap from whole to skim milk to improve one’s health, it is easier to make the change in four steps.

2% milk

122 Calories 4.8 grams of Total fat

3.1 grams of Saturated fat

20 milligrams of Cholesterol

1% milk

102 Calories 2.4 grams of Total fat

1.5 grams of Saturated fat

12 milligrams of Cholesterol

Skim milk

86 Calories .4 grams of Total fat

.3 grams of

Saturated fat

5 milligrams

of Cholesterol Just moving from one 8-ounce glass of whole milk to 2 percent milk has more impact than it appears. It results in about an 18 percent reduction in calories and cholesterol, and roughly a 40 percent decrease in fats. The ultimate transition from whole to skim milk results in a 43 percent drop in calories and a 79 percent drop in cholesterol. Fat content is minimal. That is an impressive benefit and doesn’t cost a penny more.

20 Be Healthy | HPV

Source: Calorie Count


turmeric Sodium, more commonly called salt, has crept into more of the foods we eat. Salty snacks, like potato chips and pretzels are obvious. The Centers for Disease Control and Prevention, however, found that sodium is a chief component of many foods we least suspect, such as bread, cold cuts and canned soups. Salt may enhance the flavor of food, but it does not do much for our health. Sodium contributes to elevated blood pressure, which can result in a stroke and heart and kidney failure. The American Heart Association recommends consuming no more than 1500 milligrams of sodium a day for middle-aged and older adults, African Americans and people with high blood pressure. This amounts to about twothirds of a teaspoon of salt. Some spices, on the other hand, may have health benefits. Turmeric, often referred to as “Indian solid gold” gives foods their yellow-orange color as well as unique flavor. It is the main spice in curry and is frequently used to flavor mustards and other condiments. But it might offer a bit more. Turmeric has long been used, especially in the East, to treat a variety of conditions, including arthritis, liver problems and skin conditions. More recently in this country, turmeric is being investigated as a possible treatment for cancer. Turmeric is an antioxidant, which can counteract the damage caused by harmful molecules called free radicals. This damage can result in cancer. Researchers have found that curcumin, the chief ingredient of turmeric, may prevent cancer, slow the spread of cancer and make treatment for the disease more effective by reducing the dosage and toxicity of chemotherapy. Two recent studies suggest that curcumin is effective in treating head and neck cancers. This research is in its infancy. Regardless, turmeric is considered a healthy alternative to sodium to give flavor to foods.

Tandoori Chicken with Brown Rice

4 servings | About $2.38 per serving 1 pound chicken breasts or tenderloins, skin and visible fat removed ¼ cup lemon juice (fresh or from the jar)

1 teaspoon ground cumin ½ teaspoon paprika ½ teaspoon turmeric ½ teaspoon ground ginger

½ cup plain fat-free yogurt

¼ teaspoon pepper

3 teaspoons garlic minced from the jar or 3 cloves minced

1 cup instant brown rice

1. Preheat oven to 400 degrees. 2. Place chicken in a 9x9 baking dish and pierce chicken pieces with a fork all over. 3. In a small bowl, whisk together lemon juice, yogurt, garlic, cumin, paprika, turmeric, ginger and pepper. 4. Add mixture to chicken, turning to coat, let stand 20 minutes (or refrigerate overnight). Bake for 15 minutes, turn chicken and bake 15 minutes more. 5. While chicken bakes, prepare rice to package instructions. 6. Serve chicken over rice. Source: American Heart Association Simple Cooking with Heart Program

Per serving: Calories

243

Sodium

162 mg

Total Fat

4.0 g

Carbohydrates

22 g

Saturated Fat

0.5 g

Fiber

1g

Trans Fat

0.0 g

Sugars

0g

Polyunsaturated Fat

1.0 g

Protein

28 g

Monounsaturated Fat

1.0 g

Potassium

569 mg

Cholesterol

73 mg

Calcium

78 mg

For more recipes visit heart.org/simplecooking. Photo courtesy of Kozzi.com

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Go Green There’s no guarantee that a diet rich in fruits and vegetables will ward off cancer, but, according to health experts, it sure helps. Research suggests that some of these plant-based foods contain cancer-fighting compounds called antioxidants, which help keep cancers and other diseases at bay. Leafy greens are one such example. A report by the American Institute for Cancer Research (AICR) suggests that consuming non-starchy, darkcolored leafy greens, such as spinach and deep green lettuces, may protect against cancers of the mouth, throat, voice box, esophagus and stomach while providing fiber and antioxidants. Examples of other leafy greens are kale, bok choy, chard, mustard greens and mesclun, a salad mix. Beta-carotene, a particularly powerful antioxidant, is the powerhouse behind these greens. As a rule of thumb, the greater the intensity of the color of a vegetable, the more beta-carotene it contains. In addition, cooking beta-carotene-rich vegetables in a small amount of oil can increase the body’s ability to absorb it in the small intestine, according to the AICR.

Simple Leafy Green Sauté 1-2 cloves of garlic 1/2 medium onion chopped 1/2 lb. leafy greens (kale, chard or collard greens) 1 tbsp. extra virgin olive oil 1 tsp. freshly ground black pepper Salt to taste Chop the garlic and onions, and then set aside. Research shows that allowing garlic to stand for 15-20 minutes before cooking can help retain its health-beneficial enzymes. With a knife, remove and discard very tough or damaged end portions of the greens. Keep the majority of the stems attached. “Core” the center portion of the greens, then chop the leaf cores and stems into bite-sized pieces and set aside. Roll the leaves into a tube shape, about three at a time, and cut lengthwise to create thin 1 inch ribbons. Heat the oil over medium heat in a large skillet. Add the onion, garlic, black pepper and green stems and cores. Heat covered for 3-5 minutes, stirring occasionally until onions are translucent. Add the leaves and cook, covered, another 3-5 minutes until stems are tender and leaves are wilted and brightly colored. Add a tablespoon of water to the pan if it seems like the leaves are getting too dry. Add salt to taste.

You can eat this dish on its own, or use it to spice up other dishes: • Whisk it into eggs for an omelet • Mix it into a broth for a simple soup • Toss with cooked whole grain pasta • Mix with chickpeas for a simple side-dish Makes 4 servings; Each serving equals about 1 cup Per Serving: 65 calories, 4 g total fat (<1 g saturated fat), 7 g carbohydrate, 2 g protein, 1.5 g dietary fiber, 25 mg sodium Source: American Institute for Cancer Research

Photo courtesy of Kozzi.com


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STAnd Up To HPV The human papillomavirus infects millions of Americans each year Take control of your health and get vaccinated Call your Dimock physician to schedule an appointment today *All insurance plans accepted

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Be Healthy — HPV