Page 1


Food: Too Much, Too Little, Too Bad Nutrition Policy, Progress, and Pitfalls Antibiotics in Agriculture We’ve Reached a Crisis State

Genetically-Modified Food: Hazardous or Healthy? Obesity, Soda Tax, and Energy Drinks

VOL. 86 NO. 6 July/August 2013

“ MIEC has never lost sight of its role as a physician advocate. MIEC provides comprehensive resources that range from handling difficult patients to helping me manage pain patients. I feel confident that MIEC is dedicated to the protection of its policyholders.”

Dr. Mei-Ling Fong Member, San Francisco Medical Society Internal Medicine - Insured by MIEC

Join the Insurance Company that always puts policyholders first. MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For over 35 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Policyholder Dividend Ratio* Prevention services. Added value: n No profit motive and low overhead For more information or to apply: n www.miec.com n n

Call 800.227.4527

Email questions to underwriting@miec.com



40% 29%

30% 20% 10% 0%



36% 30%

14% 2.2% 2007

6.4% 2008


5.2% 2009





Med Mal Industry (PIAA Composite)






* (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com


MIEC Owned by the policyholders we protect.



July/August 2013 Volume 86, Number 6

Nutrition Policy, Progress, and Pitfalls FEATURE ARTICLES


10 Food Politics: Plenty of Positive Change Marion Nestle, PhD, MPH


Membership Matters


Classified Ad


President’s Message Shannon Udovic-Constant, MD

11 Confronting Obesity: From Fast Food to Real Food Sean Bourke, MD

13 Agricultural Antibiotics: Abuse in the Industry Leading to Crisis Stage in Human Medicine Robert Gould, MD, and Steve Heilig, MPH 14

Not for Bottling: Food Packaging Is a Major Source of Contaminants and Chemicals Jane Muncke, PhD, Miquel Porta, MD, MPH, PhD, and John Peterson Myers, PhD

16 Genetically Modified Food: Fantastic or “Frankenfood”? The Labeling Debate Steve Heilig, MPH, and Ted Schettler, MD

17 Good Hospital Food: Moving from Oxymoron to Healthy and Sustainable Sapna E. Thottathil, PhD, and Lucia Sayre, MA

19 Produce to the People: Farmers Markets Come to Medical Centers Preston Maring, MD 20 Childhood Obesity: Where Does the United States Stand and What Can We Do? Sally S. Wong, PhD, RD, CDN 21 The Richmond Soda Tax Effort: Lessons Learned Jeff Ritterman, MD 23 Energy Drinks: The Effects on Your Patients Laura Davies, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

7 9

Welcome New Members Editorial Gordon Fung, MD, PhD

24 Medical Community News

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Coalition to Preserve MICRA Medical Injury Compensation Reform Act (MICRA) provisions work to ensure quality medical care for consumers, stabilize out-of-control medical liability costs to keep providers in practice, and preserve patients’ access to fair compensation when they have justifiable claims. Any changes to MICRA to weaken its protections will result in higher health care costs overall, no improvement in quality, and reduced access to services. This is why SFMS and CMA are long-time supporters of the Californians Allied for Patient Protection (CAPP) and are committed to ensuring MICRA remains intact and viable in California. MICRA is being threatened by the Consumer Attorneys’ and their front group Consumer Watchdog. They have threatened to file an initiative if the legislature does not act to change MICRA this year. A 2008 study by the former director of the Legislatures chief policy analyst predicted that simply doubling the cap would result in $7.9 billion in increased health care costs in California. Please visit http://bit.ly/10LfnsF for more information about current anti-MICRA activities and what you can do to defend against the most serious threat we have seen in years.

Five Important Meaningful Use Stage 2 Changes

Meaningful Use Stage 2 is quickly approaching. While Stage 1 was focused on getting EHRs installed and assisting providers to adjust to the new work flows, Stage 2 will add many more requirements that are intended to get providers to actively use their EHRs for patient health management, as well as getting patients more involved in their own care, such as the use of patient portals. Five of the most important things to keep in mind as you transition to Stage 2 are 1) changes to menu and core structure, 2) threshold increases, 3) health information exchange, 4) patient engagement, 5) electronic clinical quality measures. Please visit http://bit.ly/14Ok0WZ for details on the new changes.

Medi-Cal Primary Care Provider Rate Bump Delayed

A two-year-long federally funded rate hike for Medi-Cal primary care providers was launched in January, but that money has not yet been distributed by state officials and likely will not be paid out until the fall. The California Department of Health Care Services (DHCS) anticipates implementation of the pay hike in September, with the increase retroactive to January 1. The next step in the process comes on July 22, when primary care providers will need to fill out an online provider attestation form to ensure they are eligible for Medi-Cal. 4 5

San Francisco Medicine July/August 2013

SFMS Past President Toni Brayer, MD, to Head Sutter Pacific Medical Foundation SFMS member and past president Toni Brayer, MD, is named as the CEO of the 260-doctor Sutter Pacific Medical Foundation. The move takes effect August 1. Dr. Brayer had been vice president and chief medical officer of Sutter Health’s West Bay region since 2010. She succeeds Michael Cohill as chief executive of the multispecialty medical group, which includes physicians in San Francisco, Marin, Sonoma, Lake, and Del Norte counties. Please join SFMS as we congratulate one of our own in her new position. We look forward to a closer collaboration with the Sutter Pacific Medical Foundation to improve and enhance health care delivery in San Francisco.

AMA Calls Obesity a Disease

The AMA adopted policy at 2013 House of Delegates that recognizes obesity as a disease requiring a range of medical interventions to advance obesity treatment and prevention. “Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” said AMA board member Patrice Harris, MD, “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.” The resolution was backed by delegates from the American Academy of Pediatrics, the American Academy of Family Physicians, the American Association of Clinical Endocrinologists, and the American Society of Bariatric Physicians.

SFMS General Meeting—All Members Welcome!

RSVP today for SFMS’ General Meeting, September 9, from 6:00 p.m. to 7:30 p.m., at the Hoffman Room at Saint Francis Memorial Hospital. This is a good opportunity both to meet with SFMS leadership and to learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California. Dinner will be provided. Please RSVP before September 2 to Posi Lyon at (415) 561-0850 extension 260 or at plyon@sfms.org. www.sfms.org

SFMS Seminar—“MBA” for Physicians and Office Managers October 25, 2013, 9:00 a.m. to 5:00 p.m. Join nationally acclaimed practice management consultant Debra Phairas for SFMS’ popular oneday seminar designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This workshop teaches the core business elements of managing a practice that physicians don’t receive in medical school training. $225/ each for SFMS/CMA members and their staff; $325/each for nonmembers. Lunch is included. Questions or to register, please contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260.

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events. August 7: Medicare Transition: MAC Jurisdiction E Implementation Overview • 12:15 pm to 1:30 pm August 21: HIPAA Compliance • 12:15 pm to 1:15 pm August 28: Medicare: Proposed Changes for 2014 • 12:15 pm to 1:15 pm September 11: California’s Health Benefit Exchange: The Positives and Perils of Contracting • 12:15 pm to 1:45 pm September 12: ICD-10 Documentation for Physicians, Part 1 • 12:15 pm to 1:15 pm

Classified Ad Gastroenterology Medical Practice Available for Purchase This lucrative practice has been developed over the past 30 years. Excellent patient base and referral network. Personal medical condition necessitates this sale. Earn out arrangement possible. Inquiries are kept confidential. Call Chris Mok (Broker) at (408) 246-3045 or email for information request at winwin4fun@gmail.com.

Political Famine: Marion Nestle, PhD, MPH on the just-failed federal “Farm Bill” Nobody can be expert on the farm bill. It’s too big and complicated for one person to understand. Lobbyists, advocates and some congressional staff may know parts of it thoroughly, but the whole thing? Hopeless. I taught a course on the farm bill a couple of years ago – a depressing introduction to the worst of American politics. Anyone can figure out what agricultural policy ought to do: promote production of adequate food at an affordable price, provide a decent living for farmers and farmworkers, protect the environment and promote health, for starters, but this is a large order for any piece of legislation and impossible for our current Congress. The House failed to pass it, mainly because Republicans thought cuts to SNAP, food stamps, weren’t deep enough and Democrats were appalled by the size of the cuts and by new requirements for drug testing and work. I have no crystal ball for seeing how this will play out, but I’m not optimistic that this Congress will do anything much for new farmers, small farmers or fruit and vegetable producers. Reprinted from Marion Nestle,’s ‘Food Politics” blog: http://www.foodpolitics.com/ www.sfms.org

July/August 2013 Volume 86, Number 6 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD

SFMS OFFICERS President Shannon Udovic-Constant, MD President-Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Immediate Past President Peter J. Curran, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Associate Executive Director for Public Health and Education Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Ryan Smith BOARD OF DIRECTORS Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Keith E. Loring, MD Ryan Padrez, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD John Maa, MD Edward T. Melkun, MD Justin V. Morgan, MD Kimberly L. Newell, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

CMA Trustee: Shannon Udovic-Constant, MD AMA Delegate: H. Hugh Vincent, MD AMA Alternate: Robert J. Margolin, MD

July/August 2013 San Francisco Medicine


NORCAL Mutual is owned and directed by its physicianpolicyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Contact your broker or call 877-453-4486 today. Visit norcalmutual.com/start for a premium estimate.

A N o r c A l G r o u p c o m pA N y

N o r c A l m u t u A l .c o m

PRESIDENT’S MESSAGE Shannon Udovic-Constant, MD

Family Dinner: Corporate Change Versus Personal Change Recently I read an article in the San Francisco Chronicle health section about how physicians should start prescribing healthy food and even recipes to our patients. A cardiologist who sees the end stages of poor nutrition wrote this. This got me thinking about my role in what the families in my practice are eating. There are many ways I can impact healthy eating, including through health policy, one-on-one counseling, and within my own family. Health care professionals have great credibility on food health policy among policy makers, especially as we are treating more food- and nutrition-related disease among our patients, including rising rates of obesity and its related complications. One in five children is overweight. One of the main reasons that I’m involved in organized medicine is to influence health policy. In the last legislative cycle we had to pass legislation to require potable drinking water in all California schools. This is crucial if I am telling my patients to drink water instead of soda and juice. Another move toward healthier food systems is through the United States farm bill. CMA has policy in place to support healthy agricultural practices, including subsidies for healthy foods (versus our current subsidies for corn that becomes highfructose corn syrup in processed foods), improved food safety, sustainable production methods, reduction of pesticide use, regulation of confined animal feeding operations (CAFOs), and support for local/regional food systems. I don’t have my hopes up for meaningful change in the farm bill, due to corporate special interests. Change can come from more individuals not relying on corporations to make and process our food. Michael Pollan and others talk about eating “real food.” This requires that people know what to do with real food. The fact is that many people don’t know how to cook. My own nine-year-old son recently asked me to teach him how to make some things—we started with scrambled eggs and learning how to cut vegetables. Eating more “real foods” requires that communities have access to fruits, vegetables, and whole grains. Yet we know that there are “food deserts” in many of our patient’s communities. Our hospital has a farmer’s market every Wednesday that brings fresh fruit and vegetables to the neighborhood. I signed my own family up for a farm box full of fresh fruit and vegetables within the past year. I was nervous that a lot of the food would go to waste, because I had been relying on more prepared foods in my busy life than I would like to admit. The wonderful discovery is that since the food is coming straight from the farm, it is fresher and lasts longer. The other benefit is that it has forced me to learn some new, healthier meal options in order to use the wonderful produce. I am also finding inspiration from healthy recipes prowww.sfms.org

vided in our waiting room by our exceptional health educator. Lastly, one of the crucial issues for families is to eat together. Whether or not a family eats together is predictive of many things: the diversity of a child’s palate, higher self-esteem, lower rates of depression. It is also protective against many risk-taking behaviors in teenagers. It is difficult to know if the actual sitting down to the meal is the causal factor or whether other family factors are in place to make having a family meal together a priority, but a recent study did show that the number of times per week that families ate together mattered. Some theories about why eating together is helpful include the development of communication skills and empathy, family cohesion, teaching family values, or having children feels like they matter to the adults in their lives. As a pediatrician, I have been aware of this research. Family meals are a priority in our household. I have always had the no-TV rule during mealtimes, which also extends to no phones or other screens. I was recently saddened when we went out to dinner and a three-year-old at the next table was sitting with headphones on watching a movie on a portable DVD player during the meal. TheFamilyDinnerProject.org has some great resources to encourage quality family meals, including a blog to serve as conversation starters and some ideas for familyfriendly meals. As organized medicine continues its work toward healthier food systems, I encourage you to do something to improve the food choices of those around you. For your patients, consider writing a prescription to eat more fruits and vegetables and attaching a favorite recipe or placing healthy recipes in your waiting rooms. At home I encourage you to enjoy family meals because, as Ronald Reagan said, “All great change in America begins at the dinner table.”

Welcome New Members

The SFMS would like to welcome the following members: Neeti Bathia, MD | Physical Medicine and Rehabilitation Jeanna Goo, MD | Internal Medicine Brian Grady, MD | Urology Samantha Kwon, MD | Cardiothoracic Surgery

July/August 2013 San Francisco Medicine


physician’s office, a malfunctioning thermostat ruined $51,000 in refrigerated vaccine. Make sure you’re covered. In a Del Mar

For decades, The Doctors Company has provided the highest-quality medical malpractice insurance. Now, the professionals of The Doctors Company Insurance Services offer the expertise to protect your practice from risks beyond malpractice. From slips and falls to emerging threats in cyber security—and everything in between. We seek out all the best coverage at the most competitive prices. So talk to us today and see how helpful our experts can be in preparing your practice for the risks it faces right now—and those that may be right around the corner.

Call (800) 852-8872 today for a quote or a complimentary insurance assessment. n n n

Medical Malpractice Workers’ Compensation Health and Disability

n n n

Property and General Liability Employment Practices Liability Directors and Officers/Management Liability

n n

Errors and Omissions Liability Billing Errors and Omissions Liability


CA License #0677182

4363_CA_SanFranciscoMedicine_JulAug2013.indd 1

5/24/13 10:41 AM

savings of $ over 95,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s trial lawyers have launched an attack to undermine MICRA and its protections, and we need your help. Membership has never been so valuable!


Internal Medicine




San Francisco





Miami & Dade Counties, FL





Nassau & Suffolk Counties, NY





Wayne County, MI





FL-NY-MI Average





MICRA Savings





* Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.


San Francisco Medicine July/August 2013

San Francisco Medical Society 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415)561-0850 Fax: (415)561-0833 www.sfms.org

EDITORIAL Gordon Fung, MD, PhD

You Are What You Eat When it comes to food policy there are many health-related issues to think about. The health of the consumer is affected by the food creation through farming techniques and manufacturing methods; the additives; the packaging, transportation, and storage; the labeling, pricing, and marketing; and the retail environment where food is sold. It is truly mind-boggling to think about improving this complex system. Considering how pertinent our food system is in national discussion it is interesting that agriculture makes up only 1.5% of the gross domestic product and that, even with all of the food we do produce, the U.S. is actually a net exporter to the rest of the world. Yet the US is plagued with food issues on both end of the spectrum—too much and too little. Hunger still exists despite our abundance and the American Medical Association recently took the bold step of declaring obesity as a disease. From a physician’s perspective, it is important to be aware of food issues so we can counsel and educate patients. Their health is impacted by their food decisions as well as the food policy that is enacted into legislation for our communities and the nation. While we may think going back to the “good old days” of how our parents and grandparents ate is the answer, there is, practically speaking, no way we can return to an agrarian society where people all grow their own food. Since the creation of modern urban lifestyles large portions of the population have become dependent on an entire industry of farmers, distributors, and retailers to bring food into our homes and onto and tables. When our generation was growing up we would only think of food as it is defined in the dictionary, “material consisting essentially of protein, carbohydrate, and fat used in the body of an organism to sustain growth, repair, and vital processes and to furnish energy; nutriment in solid form; something that nourishes, sustains, or supplies” (merriam-webster. com). I certainly didn’t think about how it was produced or how it got to me. I didn’t even think about whether it was nutritious or healthy. I left that decision to my parents, particularly my mother who made the majority of food in our family. I assumed that all the food we ate had some nutritional value and was “good for me”. It wasn’t until I was older that I began to hear about the different types of unhealthy food, such as junk food, fast food, salty food, empty calories, fatty foods, and so on. Then, as a health professional, learning about different diets, including DASH, vegetarianism (and all of its variations), Ornish, Mediterranean, TLC, Asian Diet, Engine 2 Diet, and the many more. Some of these were scientifically studied to demonstrate health advantages but there is little policy around diets and food marketing. Since there is an entire industry creating the food we eat it is important that standards and regulations are scientifically based in order to minimize the risks and hazards of producwww.sfms.org

tion methods and health claims of food made for consumption. This is the genesis of this month’s theme. What are current hot topics in food policy that physicians should know about? Beginning with Marion Nestle who published her groundbreaking book in 2002, Food Politics. Now, eleven years later, she looks back and ponders the progress. We’ve included several pieces on the obesity epidemic including a general look at food policy by Dr. Sean Bourke and recent attempts to limit soda consumption in New York by Dr. Sally Wong, a former member of the New York Advisory Health Commission. We also highlight two important issues in public health: the use of antibiotics in the food source and genetically modifying foods by Drs. Gould and Schettler and Steve Heilig. Another newer issue that we’ll likely start seeing a lot more about is the issue of food packaging and toxicity by Drs. Muncke, Purta, and Myers. In an article by Dr. Thottathil and Lucia Sayre they examine how hospitals can be models for healthy food choices and offerings. One way they can do so is by offering farmers markets so busy staff can eat well at home, an issue covered by Dr. Preston Maring. Finally, we cover recent attempts to decrease the intake of “unhealthy” foods by means of taxes or bans in an article on the soda tax efforts by Dr. Ritterman and another on energy drinks by Dr. Davies. As the old saying goes, “you are what you eat” and we want our patients to be healthy! Since policy dramatically shapes the food that is available to patients, food policy is in important part of the health of our patients and of the nation. We hope that this issue provides a primer on the hot topics in food policy.

July/August 2013 San Francisco Medicine


Nutrition Policy, Progress, and Pitfalls

Food Politics Plenty of Positive Change Marion Nestle, PhD, MPH Q: I see your best-selling book Food Politics is out in a tenth-anniversary edition, with an introduction by Michael Pollan, no less. Has anything changed in the past decade?  A: I can hardly believe it’s been ten years (eleven, actually, but who’s counting) since the University of California Press published Food Politics. This has been a great excuse to look back and realize how much has changed. Optimist that I am, I see much change for the better. My goal in writing Food Politics was to point out that food choices are political as well as personal. In 2002, reactions to this idea ranged from “you have to be kidding” to outrage: How dare anyone suggest that food choices could be anything other than matters of personal responsibility? How times have changed. Today, the idea that food and beverage companies influence dietary choices is well recognized. So is the reason: the industry’s economic need to increase sales in a hugely competitive food marketplace. Business pressures created today’s “eat more” food environment—one in which food is ubiquitous, convenient, inexpensive, and in which it has become socially acceptable to consume foods and drinks frequently, anywhere, and in very large amounts. Given this kind of marketing environment, personal responsibility doesn’t stand a chance. If the “eat more” food environment is the problem, then the solution is to do something to make healthier food choices the easy choices. And plenty of people are doing just that. In the last ten years, we’ve seen the emergence of national movements to promote healthier eating, especially among children. These movements—plural, because they differ in goals and tactics— aim to create healthier systems of food production as well as consumption. On the production side, their goals are to promote local, seasonal, sustainable, organic, and more environmentally sensitive food production. On the consumption side, some of the goals are to improve school food, restrict food marketing to children, and reduce soda consumption through taxes and limits on portion sizes. These movements do plenty of good. I see positive signs of change everywhere. Healthier foods are more widely available than they were when Food Politics first appeared. Vast numbers of people, old and young, are interested in food issues and want to get involved in them. The First Lady is working to improve access to healthier foods for low-income adults and children. Wherever I go, I see schools serving healthier meals, more farmers’ markets, organic foods more widely available, young people joining Food Corps, more young people going into farming, more concern about humane farm animal production, more backyard chickens and urban gardens, and more promotion of 10 San 11 SanFrancisco FranciscoMedicine Medicine July/August July/August2013 2013

local, seasonal, and sustainable food to everyone. When my university department launched undergraduate and graduate programs in food studies in 1996, we were virtually alone. Universities viewed food as too common a subject to be taken seriously. Now, practically every college and university uses food to teach students how to think critically about—and engage in—the country’s most pressing economic, political, social, and health problems. Many link campus gardens to this teaching. Food issues are high on the agendas of local, state, national, and international governments. I can’t keep up with the number of books, movies, and websites covering issues I wrote about in Food Politics. These achievements can also be measured by the intensity of push-back by the food industry. Trade associations work overtime to deny responsibility for obesity, undermine the credibility of the science that links their products to health problems, attack critics, fight soda taxes, and lobby behind the scenes, and they spend fortunes to make sure that no city, state, or federal agency does anything that might impede sales. Food and beverage companies faced with flat sales in the United States have moved marketing efforts to emerging economies in Asia, Africa, and Latin America, with predictable effects on the body weights and health of their populations. Despite this formidable opposition, now is a thrilling time to be advocating for better food and nutrition for the health of children, and advocating for greater corporate accountability. As more people recognize how food companies influence government policies about agricultural support, food safety, dietary advice, school foods, marketing to children, and food labeling, they are inspired to become involved in food-movement action. I’m teaching a course on food advocacy at New York University this semester. I want students to take advantage of their democratic rights as citizens to work for healthier and more sustainable food systems. Whether they act alone or join with others, they will make a difference. So can you. The development of the food movement is the biggest and most positive change in food politics in the last decade. May it flourish.

Marion Nestle, PhD, MPH, is a professor in the Department of Nutrition, Food Studies, and Public Health and a professor of sociology at NYU. From 1976 to 1986 she was Associate Dean of the UCSF School of Medicine, where she taught nutrition to medical students, residents, and practicing physicians. She has written several books on food and writes a monthly “Food Matters” column for the San Francisco Chronicle, she blogs (almost) daily at www.foodpolitics. com and for The Atlantic. She also tweets @marionnestle. This article originally appeared in the San Francisco Chronicle. www.sfms.org

Nutrition Policy, Progress, and Pitfalls

Confronting Obesity From Fast Food to Real Food Sean Bourke, MD “The doctor of the future will give no medicine, but will interest his patients in the care of the human body, in diet, and in the cause and prevention of disease.” —Thomas Edison

Reader beware: I’m not a policy expert. I’m the CEO of

JumpstartMD, the largest medical weight-management practice in Northern California. At JumpstartMD, thousands of patients transform their lives and diminish their health risks weekly through a sensible and effective Pollanesque distillation: “Eat real food.” What’s clear from those transforming experiences is that the elephant in the room in the health care debate is obesity and the health risks that lie in its wake. Affordable Care Act? Do you really believe affordable overall health care expenditures are within reach when one out of three children (one out of two for minorities) born in this century are predicted to develop type II diabetes? And that flourishing plague of weight-related diseases laid bare on published prevalence maps (see http://www.cdc.gov/ obesity/data/adult.html ) flows directly from Farm Bill policies that subsidize and incentivize the consumption of what can only be viewed as “nonfoods,” those nutritionally vacuous and arguably pathologic majority of processed food items filling the center of our grocery stores and composed largely of cheap, taxpayersubsidized corn, soy, and wheat. Why criticize policies that catalyzed a sea change in eating habits away from whole-food, fully transparent home cooking into a food culture ripe with engineered, processed, carbohydratebased foods that are as simple to prepare as the touch of a button on the microwave? The answer is twofold: science and the public health. Consider this: Atherogenic dyslipidemia is increasingly associated not with fat but with carbohydrates, in particular refined flours and sugars. Over the last forty years, rates of type II diabetes have more than tripled, while large-scale survey and consumption data show that the predominant change in our dietary intake has been a markedly increased consumption of higher-glycemic-index carbohydrates. These processed carbohydrates drive the formation of the most atherogenic small, low-density lipoprotein (LDL) particles. Small LDL-particle distribution underlies an individual proclivity to metabolic syndrome and insulin resistance even prior to rises in insulin and fasting glucose. Said another way, the metabolic sickness preceding diabetes is already in motion prior to rises in insulin. The likely pathogenic mechanism driving that scourge is the ubiquitous sea of taxpayer-subsidized refined carbohydrates central to our modern diabetes-inducing diet. Is it possible that obesity is the external manifestation of that underlying metabolic sickness, not the primary cause? Consider further: Multiple studies have shown that two of www.sfms.org

the best predictors of who will develop type II diabetes over ten to twenty years are serum biomarkers of inflammation and lipogenesis (the conversion of carbohydrate into saturated fat in the liver). Increasing dietary simple sugars and high-glycemic carbohydrates drive both markers up. Both are tightly linked to the pathogenesis of diabetes. So what does this all mean from a policy point of view? To drive policy change, illuminate the truth. Unfortunately, bad data flourishes and obscures our needs. But here in the Bay Area, luminaries like Ronald Krauss, Robert Lustig, Steve Phinney, and Gary Taubes are changing people’s perspectives. They helped me, for one, better understand a physician friend’s macabre offhand joke that he was going to hand out cigarettes to the kids on Halloween rather than candy, “because they’re driving a similar risk.” And that might be an interesting way to think about where we should take our public policies today. Our government has made remarkable strides in reducing smoking as a public health risk through the illumination of scientific truth, education, regulation, and our courts. Obesity and, perhaps more important, the refined carbohydrate nonfoods driving that risk are the new tobacco. A number of initiatives both personal and governmental could promote the public health and well-being of “we the people.” They are as follows:

Define food. I heard this from New York Times food writer Mark

Bittman (although I think it came from Michael Pollan): “Agree upon a definition of food” (versus nonfood) as foods that “maximize the amount of nutrients supplied (nonsupplemented) for the number of calories consumed.” Only those items that met the minimum defined nutrient-to-calorie ratio would be included as “foods.” As an example, a can of Coke or a box of Skittles would get a zero, because sugar is devoid of any nutritional value and yet ripe with calories. Read Dr. Robert Lustig’s book Fat Chance or the British scientist John Yudkin’s 1972 premonition of our modern diabesity epidemic, Pure, White and Deadly, and you may begin to see sugar as toxic, a “poison” in light of our 156-pound per annum, per capita average consumption. From that definition, proactively regulate and tax nutritionally vacuous, disease-promoting pseudo-food imposters. Picture a Surgeon General warning, food stamp ineligibility, and public school restrictions on Snickers, Coke, and York Peppermint Patties. Obesity is the number-one cause of preventable death in our country today. Why should those substances driving that risk be treated (and taxed) any differently than cigarettes? To the self-serving food industry retorts, echoing big tobacco, that “there is no question that sedentary lifestyles have caused

Continued on the following page . . .

July/August 2013 San Francisco Medicine


Confronting Obesity Continued from the previous page . . . the obesity epidemic to get out of control” (Indra Nooyi, PepsiCo CEO), don’t listen to the poppycock! It’s the food (and drink). So let’s tax the nonfood foods instead of subsidizing them and use the proceeds to move us toward the next stage of progress: incentivize real food.

Incentivize real food. It’s hard to dominate the dinner table

when nonfoods have a competitive advantage through Food Bill policies that subsidize and promote monoculture farming of lowcost corn, soy, and grains. Farmers today are shackled from growing “specialty crops” (read fruits and vegetables), for they’re not currently allowed to receive subsidies for specialty crops if they’re receiving subsidies for the dominant monoculture crops. At JumpstartMD, during the weight-loss phase, we eliminate those products and the associated sugars and urge people to ask Dr. Lustig’s simple question, “Does it have to be sweet?” And to move from there to foods that come whole from the earth—foods that are composed solely of fruits and nonstarchy vegetables, legumes, meats (ideally pasture raised), sustainable seafood, nuts and seeds, and dairy products. On weight loss, all grains are eliminated until the maintenance stage, when limited quantities of whole grains are reintroduced to those without overt insulin resistance. Having emerged in a society where “give us this day our daily bread” (and now, I might add, sugar) is part of our culture, that’s not initially an easy change to make. But in time, the benefits are protean and abundant and patients thrive. The next move forward is to shop locally and sustainably in the diverse group of seasonal, nutritious, and nonprocessed whole, delicious foods found in farmers’ markets. Yes, they’ll cost more, and that’s a problem that could be improved by modifying incentives. And my goodness, to taste a tomato that wasn’t picked green for transport, infused with ethylene gas to artificially turn it red, and molded through that process to taste like plastic. Some things are worth it.

Fund research that will illuminate the truth. It’s diffi-

cult to illuminate truth in nutrition science because of the noise obfuscating clarity. Confusion thrives amid an abundance of flawed studies promoting causal links that don’t exist, yet are perpetuated through mainstream media attention, politics, entrenched interests, false assumptions, and misguidance. Yet obesity is the health care crisis of the twenty-first century. Definitively determining how foods and nutrients affect metabolism, fat formation, hormone levels, disease formation, inflammation, addiction, and weight gain is critical. So, collect a broad range of thought leaders to address, through large-scale, well-controlled trials, the shortcomings of previous research efforts to ascertain what really influences healthy weights and a healthy diet. Weave those truths into policy to promote the public good.

Put food regulation in the hands of the Surgeon General. Doctors were marginalized from conversations about the

original structure of the United States Department of Agriculture (USDA) food pyramid. Let the Surgeon General lead food education and regulation so as to wrest dominant influence away from

12 13

San Francisco Medicine July/August 2013

the meat, dairy, and agricultural interests in favor of public health.

Start locally, beginning with each of us. That said, I’m less optimistic that the federal government will exert positive change, given political gridlock and the collective power of agricultural and food industry giants. But we can each make a collective difference at the grass roots and that will trickle up to our elected officials and the food industry as we educate ourselves (and our patients) about what healthy eating means, for us as individuals and for our environment. From that awareness and the consumption of whole and real foods that are (ideally) sustainably, humanely, and locally grown, we will shape our food supply through our forks and wallets. Michael Pollan, Gary Taubes, Robert Lustig, Steve Phinney, and Jeff Volek have all written illuminating books on this subject. Food, Inc. is a documentary not to be missed. Informative websites include: • http://www.jamieoliver.com/foundation • http://eatingacademy.com • http://sustainableagriculture.net • http://civileats.com.

But be careful: After checking out these sites you might find yourself with a local Community Supported Agriculture (CSA) box, farm-fresh eggs, and pastured meats delivered to your doorstep. Pick the right CSA, and I guarantee you won’t regret it.

Model best practices in schools (and the workplace)

Given the long-term challenges we have addressing food quality in our homes, it would be marvelous to model best practices through our school lunch programs so as to give children a better sense of what healthy, real food is. Great initiatives in this direction include programs such as the Rethinking School Lunch Guide (http://www.ecoliteracy.org/downloads/rethinking-schoollunch-guide) and Alice Water’s Edible Schoolyard Project (http:// edibleschoolyard.org). The next step from influencing healthy choices in schools: Create similar best-practice models for workplaces. Employers spend $73 billion a year on health care costs and productivity losses associated with obesity, while their break rooms and cafeterias more often than not model the opposite of what people should eat to maintain healthy weights today. These problems are arguably complex, but the beauty of the food system challenges we face is that solutions are within reach through education and illumination. We see that every day at JumpstartMD in the thousands of patients who pass through our doors and who, through the simple act of returning to a diet composed of whole, real, and fresh foods, make a dramatic difference in their weight, health risks, and quality of life. Sean Bourke, MD, is CEO of JumpstartMD (www.jumpstartmd. com), Northern California’s largest nonsurgical medical weightmanagement practice. A member of the SFMS and the American Society of Bariatric Physicians, Dr. Bourke is a graduate of Yale College and the University of Southern California School of Medicine. He received his postgraduate training in emergency medicine at Stanford University. JumpstartMD has two offices in San Francisco and seven others encircling the Greater Bay Area.


Nutrition Policy, Progress, and Pitfalls

Agricultural Antibiotics Abuse in the Industry Leading to Crisis Stage in Human Medicine Robert Gould, MD, and Steve Heilig, MPH “Centers for Disease Control sounds alarm on deadly, untreatable superbugs”—USA Today, March 2013 “Study shows bacteria moves from animals to humans”—New York Times, March 2013

As soon as antibiotics were discovered and developed for medical use, bacteria began the Darwinian “arms race” that has been fought ever since.

Pathogens constantly develop resistance to antibiotics, necessitating continual development of new types of medications. Increasingly difficult infect agents arise with increasing regularity. Some of the most informed experts have been warning that humans are now starting to lose more of these battles every year, and, as was just reported in the New York Times, federal officials are now so concerned that they have made a special grant to develop “drugs for superbugs.” The specter of untreatable and virulent outbreaks, local or pandemic, increases with each decade; as a review in the journal Pediatrics put it, “Antimicrobial resistance has reached crisis stage in human medicine.” Physicians have been educated and urged to be judicious regarding antibiotic use for many years now, with increasing success. But as it turns out, 70 to 80 percent of all antibiotics produced are in fact used in farm animals to get them to market quicker and bigger. As it also turns out, this continual, low-level use is a perfect way to breed resistant strains, which can then find their way into humans. Reports on this potential threat appeared as long ago as 1976 in the New England Journal of Medicine—and government panels set up to make recommendations on the threat were tainted by industry-linked scandal from the start. A decade ago, a coalition of concerned medical and public health organizations convened a meeting at the SFMS, cochaired by UCSF Chancellor Emeritus Phil Lee, MD, and the late Lester Breslow, MD, dean of the UCLA School of Public Health and past president of the American Public Health Association. Spurred by an SFMS-initiated policy adopted in 2001 by the AMA that urged less use of antibiotics in agriculture, the assembled group developed a strategy to move such policy forward. Even the editor of California Farmer, the state’s leading agriculture journal, attended the meeting and then editorialized, “We call on producers and vets to stop overuse of all antibiotics. . . . Antibiotic resistance is a wake-up call that ag must answer.” An editorial in the Western Journal of Medicine by Lee, Breslow, and Heilig concluded, “Leading experts unequivocally state that our current practices of feeding antibiotics to www.sfms.org

animals goes against a strong scientific consensus that it is a bad idea and that the long stalemate on this issue constitutes a struggle between strong science and bad politics. The intentional obfuscation of the issue by those with profit in mind is an uncomfortable reminder of the long and ongoing battle to regulate the tobacco industry, with similar dismaying exercises in political and public relations lobbying and even scandal. As with tobacco control, science and health concerns should take precedence over profit in regulating the overuse of antibiotics in the production of meat and other agricultural products. Antibiotics do have a place on farms, but the benefits of their use can likely be preserved while minimizing harm. We need to learn more about the extent of risk, but the delay tactic of allowing current practices to continue while ‘more research’ is conducted is unacceptable. Enough is already known to justify a more cautious, preventive approach.”

Based on the evidence, the European Union banned the use of nontherapeutic antibiotics in livestock production in 2006.

Alas, that more science-based approach has remained elusive here in the United States—and not for scientific reasons. More research supports the 2001 AMA policy, and subsequent AMA policy drafted by the Santa Clara County Medical Association, with each year. Some of the necessary pressure for change has begun to surface from large institutional “consumers” such as hospital systems. Locally, the University of California, San Francisco Medical Center; the Academic Senate Coordinating Committee; the School of Pharmacy Faculty Council; and the School of Medicine Faculty Council unanimously approved a resolution in April to phase out the procurement of meat and poultry raised with nontherapeutic antibiotics at UCSF. The resolution also encourages all University of California campuses to do the same. Beyond consumer pressure, much better regulation is warranted. Representative Louise Slaughter (D-NY), the only microbiologist in Congress, has four times introduced the Preservation of Antibiotics for Medical Treatment Act (PAMTA), and she did so again just after the March 2013 CDC warning quoted at the top of this article. PAMTA would ban nontherapeutic uses of medically important antibiotics in food animal production. In April, a group of medical and public health leaders, including Drs. Lee and SFMS President Shannon Udovic-Constant, wrote to political leaders to “require stronger reporting requirements for livestock antibiotic sales and distribution that can help illustrate current use patterns,

Continued on page 15 . . .

July/August 2013 San Francisco Medicine


Nutrition Policy, Progress, and Pitfalls

Not for Bottling Food Packaging Is a Major Source of Contamination and Chemicals Jane Muncke, PhD, Miquel Porta, MD, MPH, PhD, and John Peterson Myers, PhD Food contact materials are used to make food packaging, bulk storage, and food processing equipment—they come in contact with foods or beverages. Their chemical components can diffuse into

food, thereby becoming indirect food additives (“indirect” because they are not intentionally added). Perhaps surprisingly, many food contact material substances are biologically active. For most, very little information is available about their potential toxicity for humans. As a consequence, some chemicals with poorly understood properties and clinical effects enter the food supply through both purposeful and incidental inclusion in food packaging. Some are in fact known to be toxic but are nonetheless permitted if levels are considered insignificant. A team of government regulatory enforcement scientists deemed food contact materials “the largest and least controlled source” of chemical exposure (Grob et al 2006). By a process known as migration, substances present in food packaging can diffuse from the packaging into the packaged foodstuffs. This happens readily with liquid contents of cans (such as soups), bottled beverages, or canned sauces. Perhaps unexpectedly, it also can occur with dry foods including cereals, bread, or cakes, which absorb volatile chemicals from the materials in which they are packaged. Consumers are exposed to low levels of contaminants delivered via food packaging every day. More than 4,000 chemical substances are thought to be regularly used in food contact materials, most with no or inadequate toxicity information (Neltner et al 2011). Of even greater concern: The supply chain for these materials is so opaque that regulatory agencies, and indeed the companies that use them, do not always know what substances are included in specific products. The use of recycled materials (for example cardboard, whose chemical contamination varies from batch to batch depending upon the intended and unintended mixture of materials) compounds the problem further still. The result is that many foodstuffs on the market today are packaged and sold in containers that leach a multiplicity of chemicals of concern, sometimes at levels well within a range that may lead to adverse effects. Recent examples involve the migration into food of mineral oils, “photoinitiators” (which promote polymerization reactions), and plasticizers (compounds added to plastics, adhesives, and printing inks to vary the material characteristics) (Biedermann et al 2013). In a European study, concentrations of mineral oil in food due to migration rose to the tens of parts per million (ppm or milligrams per kilogram), in a few cases increasing above levels currently considered safe in Germany. The mineral oils found to migrate contain aromatic hydrocarbons (MOAH). These 14 15

San Francisco Medicine July/August 2013

substances are linked to cancer, although few data are available. In the German market study, more than half of the tested food products contained at least 1 ppm (=1 mg/kg food) MOAH, with a maximum of 16 ppm detected. The safe exposure level set by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) (ADI=0.01 mg/kg bw/d) corresponds to a MOAH migration limit of 0.6 mg/kg food (0.6 ppm), a limit that was exceeded in many foodstuffs. Carton cereal boxes are often made from recycled material and are printed on the outside. Both the recycled carton itself, as well as the printing ink, are sources of chemical contamination in the cereal if no appropriate inner liner bag is used. Paper and cartons have large pore sizes that do not keep chemical diffusion in check. Therefore, even printing inks used on the cartons’ outside can diffuse through the carton into the cereal. And the chemical composition of printing inks is a trade secret no producer is required, or usually willing, to openly share. In fact, even food producers that purchase inks and packaging materials from their suppliers rarely, if ever, know the details about their composition. One example is the 2010 recall of 28 million cereal boxes in the U.S. due to migration from the inner liner bag. The “uncharacteristic off-flavor and smell” was caused by a substance used in the liner bag’s wax coating (http://www.webmd.com/food-recipes/news/20100625/ kelloggs-cereal-recall-due-to-odd-smell). It caused nausea and vomiting, which, by FDA’s definition, is not an “adverse effect.”

Therefore, a most relevant question is, what effect does chronic exposure to many different food packaging contaminants have on consumers’ health? Unfortunately, this is largely unanswerable today. Regulatory authorities do have certain guidelines and principles for evaluating the safety of food contact substances—chemicals used in food packaging, food processing equipment, kitchen utensils, and tableware. But these suffer from a series of weaknesses that undermine the practices by which safe exposure levels are currently estimated. First, as indicated above, the opaque nature of the supply chain means that there are chemicals in food packaging unknown to the food producer or the regulatory agency. Some may be there as part of a material design decision, others because of the manufacturing process or the choice of materials. For example, polymerization is the chemical reaction process whereby monomer molecules are covalently linked www.sfms.org

to each other, thus forming the large polymer molecule. It is an inherently complex process that virtually always incorporates varying contaminants from the air. As a result, polymers contain different and varying reaction by-products, depending on starting material impurities, process conditions, and environmental factors such as air pollutants. Identifying these by-products is challenging despite powerful chemical analytical tools that are available today (Bradley and Coulier 2007). Second, the FDA allows manufacturers to determine that a food contact substances’ use is “generally recognized as safe (GRAS)” without notifying FDA. For a substance to become GRAS, experts qualified by training and experience, and typically selected by the substance’s manufacturer, determine GRAS status and assume their peers would agree with their safety determination (http://www.fda.gov/Food/IngredientsPackagingLabeling/GRAS/). Notably, FDA has no conflict of interest policies for experts performing GRAS determinations. Third, the scientific methods used by regulatory agencies to assess safety of food contact materials are woefully out of date. Compounds are tested one by one, instead of in real-world mixtures (Kortenkamp and Faust 2010). Regulatory agencies do not require experimental designs capable of thoroughly assessing the potential for adverse effects in adulthood following early life exposures (Barouki et al 2012, Balbus et al 2013). And they assume that high-dose testing is sufficient to detect adverse consequences of low-dose exposures (Vandenberg et al 2012, http://www.fda.gov/Food/GuidanceRegulation/ GuidanceDocumentsRegulatoryInformation/ IngredientsAdditivesGRASPackaging/ucm081825.htm). Fourth, while FDA’s requirements apply to all food contact materials, including kitchen utensils and tableware, current industry practice treats these products as exempted. The FDA has stated that it is not enforcing legal requirements unless there is evidence of a potential health hazard (http://www. fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/IngredientsAdditivesGRASPackaging/ucm081833.htm#_ftn2 and http://www.packaginglaw. com/1648_.shtml). Kitchenware producers are responsible for ensuring their products’ safety under the intended conditions of use. Most citizens have detectable levels of bisphenol A (BPA), a ubiquitous synthetic molecule known to mimic estrogens (Soto et al, in press), and many are exposed to BPA via food packaging, among several other sources. France is the first country worldwide to have enacted a total ban of BPA in food contact materials, starting from January 2015. The case of BPA illustrates the gap between contemporary scientific knowledge and current chemical risk assessment practice: Substances like BPA are deemed safe using today’s methods, where chemicals are tested individually at very high, not exposure-relevant concentrations, then extrapolated to low concentrations. These experimental procedures do not take mixture effects into account, nor do they acknowledge that hormone-active substances can have different effects at low levels compared to high concentrations. A recent analysis of the FDA’s safety assessment for food additives in the U.S. highlights this issue (Maffini et al 2013). In conclusion, contaminants to which people are exwww.sfms.org

posed because of their presence in food packaging are an important yet underrecognized source of chemical food contamination. Even low-level exposures to food packaging migrants cannot be neglected, based on recent scientific understanding regarding mixture toxicity, low-dose effects, and the developmental origins of health and disease (DOHAD). Concerned consumers may choose to avoid packaged and processed foods to effectively reduce their chemical body burdens (Rudel et al 2011). Individual efforts, however, are inefficient and incomplete. Effective protection depends upon improved regulatory oversight. Jane Muncke is with the Food Packaging Forum Foundation in Zurich. Miquel Porta is with the Hospital del Mar Research Institute (IMIM) in Spain; the School of Medicine, Universitat Autònoma de Barcelona, Spain; and the School of Public Health, University of North Carolina at Chapel Hill, North Carolina. John Peterson Myers is with Environmental Health Sciences in Charlottesville, Virginia, and Carnegie Mellon University in Pittsburgh. References available online at www.sfms.org.

Agricultural Antibiotics Continued from page 13 . . . explain resistance trends, and monitor progress in assuring responsible livestock antibiotic use. Such reporting would provide critical information to help track progress in reducing the inappropriate use of antibiotics and help target attention where it is needed.” The battle to reduce agricultural use of antibiotics continues. Almost 800 leading clinicians—including Udovic-Constant, past presidents Drs. Stephen Follansbee and George Susens, and public health icon Philip Lee—are urging action on stalled policies on this threat. The stakes are high—and may be even higher than previously known, as evidence builds that even low-level antibiotics in our food and water can alter our gut flora—our “microbiome”—in unhealthy ways. The big money—pharmaceutical and agricultural—will fight a prolonged battle, as the profits in the status quo are huge. But if science loses in this case, humanity’s fate may indeed be to end, as T.S. Eliot warned, “not with a bang but a whimper.” Dr. Robert Gould is associate adjunct professor and director of health professional outreach and education for the Program on Reproductive Health and the Environment, Department of Obstetrics, Gynecology, and Reproductive Sciences, UCSF School of Medicine. He is also president-elect, Physicians for Social Responsibility. Steve Heilig is on the staff of the San Francisco Medical Society and of Commonweal, a health and environment research institute. References for this article appear online at www.sfms.org.

For more information on this issue, see www.keepantibioticsworking.com. July/August 2013 San Francisco Medicine


Nutrition Policy, Progress, and Pitfalls

Genetically Modified Food Fantastic or “Frankenfood”? The Labeling Debate Steve Heilig, MPH, and Ted Schettler, MD At least nine billion humans are expected to be alive by the end of this century—two billion more than now. Hunger and malnutrition have been endemic to our species

throughout history, and that’s true today: Two billion people don’t get enough to eat now, a result of regional shortages, maldistribution of food, and rising prices. Climate change and water shortages threaten to worsen the problem, perhaps worldwide. What to do? Biotechnology companies promote genetic modification of some crops, and even fish and livestock, as essential for addressing worldwide food needs now and in the future. So far, genetic modification has mainly found a market in crops that tolerate herbicides and resist pests.  They have done little to increase yields and, as predicted, herbicide-resistant weeds are becoming a major problem. Foods that add nutrients, like vitamin A-enhanced rice, and varieties meant to withstand droughts are just emerging.  These technological approaches to supplying food for a growing planetary population have met a mixed reception. A recent package of articles in the esteemed journal Nature was summarized in Time magazine thus: “While GM crops haven’t yet realized their initial promise and have been dominated by agribusiness, there is reason to continue to use and develop them to help meet the enormous challenge of sustainably feeding a growing planet.” A recent unanimous United States Supreme Court decision upheld strict patent rights on GM seeds owned by Monsanto Corporation, forbidding farmers from collecting or using seeds from GM plants without purchasing them from the company. In addition to concerns about corporate control of agriculture, many members of the general public are also concerned with possible personal health risks. An attempt to require labeling of GM products in California failed last year (at least in part due to dubious claims that labeling would substantially increase prices), but consumer campaigns to require such disclosure are having more success elsewhere, including recently in Connecticut, and will likely return here. Grocery chains such as Whole Foods and others are requiring labeling or are outright refusing to sell GM products. Online, the claims about GM foods range from their being a panacea for solving the problems of world hunger, agricultural productivity, and the general economy to fears that such crops threaten our health, food security, and environmental quality with dire consequences for the human species. What’s a doctor to do—or, rather, say—to concerned patients? In briefest form, here are a few thoughts on these vastly complex issues.

Human health: A growing body of research raises concerns about adverse impacts associated with consumption of GM foods. Novel toxicants, allergens, or changed nutritive value have been 16 17

San Francisco Medicine July/August 2013

reported in various studies, some of which have attracted widespread attention. Some studies report organ damage and increased risk of cancer in long-term feeding studies in laboratory animals. Unfortunately, the quality of this research varies considerably and debates remain unresolved. Moreover, the FDA has decided that GM crops are “essentially equivalent” to conventionally produced crops and do not require long-term feeding studies. Rather, FDA relies on the industry producing the food to attest to its safety. A former research scientist for Agriculture Canada and GM supporter with much experience in GM work, Thierry Vrain, PhD, concludes: “I have, in the last ten years, changed my position. I started paying attention to the flow of published studies coming from Europe—some from prestigious labs and published in prestigious scientific journals—that questioned the impact and safety of engineered food . . . I refute the claims of biotechnology companies that their engineered crops yield more, that they require less pesticide applications, that they have no impact on the environment, and, of course, that they are safe to eat.” However, it should also be said that some former opponents of GM foods have reversed their position as well. Takeaway: The evidence as of today is that GM foods pose little direct risk to human health. But concern is growing among some scientists that there are potentially harmful effects from long-term consumption and that these are not adequately evaluated before regulatory approval. The AMA has joined other organizations in calling on premarket safety assessment of GM foods, and the editors of Nature advise that this be done by nonindustry sources to lessen, at a minimum, the “PR problem” the GM industry now faces. Many consumers wish to take a precautionary approach and avoid GM food whenever possible until these concerns are resolved.

Socioecological impacts: The USDA has just postponed approval of a new herbicide-resistant GM corn due to widely voiced concerns that such products might actually contribute to increased weed resistance, damage other crops, and contaminate those sold as organic. And, in fact, herbicide use has increased with more widespread use of herbicide-resistant crops. Critics also point out that genetically engineered crops are generally dependent on patented seeds and synthetic pesticides and fertilizers that help to perpetuate the highly industrialized agricultural model that many farmers around the world cannot afford and do not want. GM crops have also spread on their own, raising both ecological and business/patent conflicts. A UN report, Agriculture at a Crossroads, concluded that addressing global hunger must be relatively inexpensive, require low inputs, and use lo-

Continued on page 18 . . . www.sfms.org

Nutrition Policy, Progress, and Pitfalls

GOOD HOSPITAL FOOD Moving from Oxymoron to Healthy and Sustainable Sapna E. Thottathil, PhD, and Lucia Sayre, MA “Hospital food” does not usually conjure up visions of delicious, healthy meals. A simple Web search

of the phrase will pull up multiple Tumblr sites and Pinterest boards dedicated to photos of unappetizing, unidentifiable meals that patients have been served during their stays in hospitals. Many of these pictures are of meals that are highly processed; loaded with fats, salt, and sugars; and light on fresh fruits and vegetables. From diabetes to heart disease, the leading causes of deaths and chronic diseases in the U.S. today are diet-related and thereby preventable. Given these facts, it is ironic that hospitals have not historically provided better food within their facilities to their patients and visitors, especially in light of their mission to be places of healing and wellness. Hospital staff have been impacted as well—even more so, since they often spend long hours within hospital settings, unable to leave large medical campuses to grab meals elsewhere. Some staff members eat multiple times per week in their facility cafeterias or rely primarily on vending machines on the evening and night shifts. Numerous studies have detailed that health care professionals, like nurses, tend to have high rates of unhealthy eating practices and poor exercise habits. One study from the University of Maryland charts obesity rates among nurses at 55 percent. What adds irony to this situation is the fact that several hospitals nationwide are also home to fast-food outlets that sell deep-fried and processed foods. It is not just what people eat that affects their health but the production, processing, and transportation of food as well. The food system has been evolving since the early twentieth century into one that is increasingly industrialized and unsustainable. Much of the food in the U.S. is now mass produced, highly processed, light on nutritional content, and transported over long distances. The production of food has become dependent on large amounts of chemical fertilizers, fossil-fuel inputs, pesticides, antibiotics, hormones, and other artificial inputs. These industrial inputs and pollutants have contaminated the air, waterways, and land. The contemporary food system now contributes indirectly and directly to an increase in exposures to environmental toxicants, threatening public health. Many of these chemicals from agricultural production also leave their residues on food, which make their way from fields to dinner plates and then into human bodies. Pesticide exposure has become so ubiquitous that blood from the umbilical cords of infants is testing positive for pesticides and other agroindustrial compounds. The health care sector bears the burden of treating diseases that result from these environmental exposures to toxins, as well as from unhealthy diets. Hospitals and health care professionals are progressively www.sfms.org

taking a more preventive approach to addressing the health effects of the food system by purchasing, serving, and promoting food choices that are healthier, local, and sustainable. With its sizable food budgets and the task of protecting public health, the health care sector is emerging as a leader in the sustainable food movement. Hospitals are heavyweights in the food system, spending billions of dollars annually on food and beverages. Numerous healthy and sustainable food initiatives, including the Healthy Food in Health Care program, are now leveraging this purchasing power. Healthy Food in Health Care is a national campaign coordinated by Health Care Without Harm (HCWH), an international nonprofit that has 520 member organizations in fifty-three countries. Its mission is to transform the health care sector so that it is no longer a source of harm to public health and the environment. HCWH works on a wide array of issues, from the responsible use and disposal of pharmaceuticals to mitigating climate change. In 2005, HCWH ventured into healthy and sustainable food and created the nationwide Healthy Food in Health Care program by organizing the first FoodMed conference in Oakland, California. This conference brought together the health care sector, sustainable agriculture partners, and the public health community to redefine the meaning of “hospital food.” Conference participants discussed strategies regarding how to incorporate the food served in hospitals into the broader mission of the health care sector, build a healthier food system, forge farmto-hospital relationships, and create alliances between hospital food service, clinicians, and other stakeholders. Since then, more than 440 hospitals have signed the Healthy Food in Health Care Pledge, which states that healthy food must come from a food system that is ecologically sustainable, economically viable, and socially just. The Healthy Food in Health Care program work has also been incorporated into a larger, more comprehensive sustainability agenda for the health care sector called the Healthier Hospitals Initiative (HHI). HHI guides and supports hospitals to reduce energy and waste, choose safer and less toxic products, and purchase and serve healthier and sustainable foods. More than 200 hospitals have joined HHI’s Healthier Food Challenge since April 2012, illustrating that the interest in more sustainable food service operations within health care continues to grow. Several of these hospitals, from Fletcher Allen Health Care in Burlington, Vermont, to St. Joseph Mercy in Ann Arbor, Michigan, to Union Hospital in Cecil County, Maryland, have developed food policies that prioritize the purchase of organic, fresh, and local food that is accessible to patients, staff, and visitors. For example, Fletcher Allen formulated a long-term antibiot-

Continued on the following page . . .

July/August 2013 San Francisco Medicine


Good Hospital Food Continued from the previous page . . .

Genetically Modified Food Continued from page 16 . .

ics reduction plan in 2005, and currently close to 100 percent of its beef has been raised without nontherapeutic antibiotics. St. Joseph Mercy in Ann Arbor just finished the construction of an accessible greenhouse that produces fresh produce year-round. Union Hospital creates nearly all of its meals from scratch, with several organic and local ingredients, providing the kitchen staff greater flexibility in creating meals for patients with specialized diets. Clinicians are also becoming involved in redefining hospital food, taking a more active role in promoting better food within their health care facilities, and advocating for a healthier food system in their clinical practice, local communities, and at the regional and national policy levels. More than 2,000 clinicians around the country have participated in advocacy and education training programs about the environmental and health impacts of the food system. Doctors, nurses, and other health professionals have also weighed in on myriad policy issues and legislation, from genetically engineered food to antibiotics in animal agriculture. HCWH has rallied hundreds of clinicians to write letters to President Obama, the Food and Drug Administration, and U.S. Senators to express their concern about public and environmental health. In California, close to 100 hospitals have signed Health Care Without Harm’s Healthy Food in Health Care pledge. Fifteen of these hospitals are a part of the San Francisco Bay Area “Leadership Team” and are collaborating on ways to increase their institutional-level procurement of healthy food from local and sustainable farmers. Together, they have pooled their purchasing power to source and provide healthy and sustainably grown foods in their facilities. Members of this leadership team have already successfully pressured large food corporations to provide rBGH-free yogurt and have convinced a major food service distributor to carry cage-free eggs. In the summer of 2012, the team procured more than 6,000 pounds of locally grown and, in some cases, organic produce. These hospitals, including the University of California at San Francisco Medical Center, are now actively looking to source meat that has been raised without nontherapeutic and medically important antibiotics. The leadership team model has been so successful that Health Care Without Harm is replicating this work in San Diego and Los Angeles. As a result of these efforts, hospital food is undergoing major transformations in places like the San Francisco Bay Area. Hospitals here are now serving antibiotic-free chicken, organic strawberries, and fresh salad from local farms. These facilities are actively a part of building a more sustainable and healthy food system in the state and nationwide.

cal and regional resources as much as possible, with a goal of food sovereignty rather than dependence on outside sources. Takeaway: Evidence of socioecologic problems related to use of some GM crops is growing, and fundamental questions about the direction of agriculture are among basic concerns. The calculation of costs versus benefits in this regard is still evolving and may never be resolved.   The food system and the consumer: A 123-page UK “evidence-based” review in 2009 titled GMO Myths and Truths concluded, “Based on the evidence presented in this report, there is no need to take risks with GM crops when effective, readily available, and sustainable solutions to the problems that GM technology is claimed to address already exist.” Inevitably, this report was both lauded and attacked. A book-length 2010 review of GM food issues by the National Academy of Sciences painted a much rosier picture in economic and ecological terms (it did not address human health) but also warned that “excessive reliance on a single technology combined with a lack of diverse farming practices could undermine the economic and environmental gains from these GE crops.” That warning hints at the broader perspective that many, including us, feel is warranted—essential, in fact. It is increasingly evident that today’s dominant food system is unsustainable, not only in the U.S. but also as a global model. As currently designed and operated, this system not only produces a surfeit of food and beverages that contribute to disease and disability but also is responsible for local, regional, and global environmental impacts that directly and indirectly add to the disease burden and degrade ecosystem services on which life depends. Moreover, increasing water scarcity, climate instability, and continued dependence on high inputs of energy, fertilizer, and pesticides challenge the viability of this industrial agricultural model in many regions, even in the near term. Many GM foods fit into this unsustainable model— supporting practices in terms of resource use and environmental impacts that are unsustainable and unhealthy in the long run.   Takeaway: Consumers who attempt to make purchasing and eating decisions based on a more comprehensive systems analysis might want to reduce their purchase of GM food products for any one of a number of reasons. Or they might not. But in order to make that choice, they need to know. Thus, we join the American Public Health Association and many of the world’s top food authorities in supporting required labeling of GM foods. This will allow informed choice, not unlike the basic ethical precept of informed consent, firmly established in law and the practice of medicine. For now, we agree with New York Times food columnist Mark Bittman that “despite the hype, there’s scant evidence that the involvement of genetic engineering in agriculture has done much to boost yields, reduce the use of chemicals or improve the food supply.”

Sapna E. Thottathil, PhD, is a senior program associate in the Healthy Food in Health Care program at Health Care Without Harm and the SF Bay Area Chapter of Physicians for Social Responsibility. Lucia Sayre, MA, is the coexecutive director of the SF Bay Area Chapter of Physicians for Social Responsibility and the co-coordinator of Health Care Without Harm’s Healthy Food in Health Care program.

To learn more about this work in California, visit www.cahealthyfoodinhealthcare.org/. 18 19

San Francisco Medicine July/August 2013

Ted Schettler, MD, MPH, is science director at the Collaborative on Health and the Envionrment and Science and Environmental Health Network. Steve Heilig is on the staffs of both the San Francisco Medical Society and the Collaborative on Health and the Environment. References for this article appear online at www.sfms.org. www.sfms.org

Nutrition Policy, Progress, and Pitfalls

Produce to the People Farmers Markets Come to Medical Centers Preston Maring, MD On a spring day in 2002, I asked myself a question: “What if we had a farmer’s market outside our medical center?” I shopped at farmers’ markets.

Knowing the adverse environmental impacts of conventionally grown produce, I bought organically grown fruits and vegetables whenever I could from local growers at farmers markets. I, like other shoppers, made a special trip to find the best produce on market day. At my medical center, I knew there were thousands of employees already there on any given day, and many more patients visiting for services. What if we brought the produce directly to them? In more than forty years with the Permanente Medical Group at the Kaiser Permanente Medical Center in Oakland, it has been clear to me, as it is to health practitioners everywhere, that what people eat is a prime determinant of their health. A farmer’s market, I reasoned, could encourage people to improve their diets. Only about 15 percent of the general population consumes even five servings of fruits and vegetables per day. Forty percent of the food dollar is spent on food away from home regardless of income bracket, and another 15 percent is spent on packaged and processed foods in the home. Not all these dollars are spent on healthy food. We are nowhere close to following Michael Pollan’s advice: “Eat food. Not too much. Mostly plants.” I would add “Sustainably produced.” Back in 2002, while strolling around Oakland’s Jack London Square Farmers’ Market, I met John Silveira, the director of the Pacific Coast Farmers’ Market Association. I asked him if he would start a farmer’s market at my hospital. He said, “Your organization’s mission and our mission are the same. We are both trying to improve the health of the community. Let’s talk.” In May 2003, the first all-organic hospital-based farmer’s market opened at our hospital in Oakland. Kaiser Permanente now hosts fifty-two markets at its facilities in eight states and the District of Columbia. Most of our markets have a mix of organic and conventionally grown food. We also work with other community groups to sponsor markets. In South Central LA, for example, Kaiser Permanente has joined several other organizations in sponsoring a robust Saturday market in Watt’s Ted Watkins Memorial Park for almost six years. In a recent survey taken at seventeen of our markets, 76 percent of the 2,500 respondents stated they were eating more fruits and vegetables, and 71 percent said they were eating new and different kinds. About 50 percent of the shoppers are medical center staff and the other 50 percent a mix of patients, visitors, and the surrounding neighbors. Some pawww.sfms.org

tients make their medical appointments or get their routine lab tests on market days. The markets make the right thing easy to do. Other hospitals have followed our lead. There are now about fifty markets at other health care facilities around the country. Doctors are sometimes writing prescriptions for an arugula salad with Meyer lemon vinaigrette. It is hard to pass up fresh asparagus in spring or a fresh peach in the middle of summer. The farmers’ markets led us to look at the broader food system at our hospitals. In 2006, we realized we were buying two tons of red seedless grapes from Chile each year when Marlene Gonzalez of Reedley, California’s Lone Oak Ranch was selling them outside my hospital. Working with the Community Alliance with Family Farmers (CAFF), we began partnering with the distributors and local producers to source some of the fresh fruits and vegetables making their way to inpatient meal trays. With support from Kaiser Permanente’s Community Benefit, CAFF and the Bay Area Physicians for Social Responsibility are working together with many Bay Area hospitals to source more sustainably produced fruits and vegetables as well as antibiotic-free meats, rBGH-free dairy, and other healthful foods. It is our hope that the collective purchasing power of these institutional purchasers can help drive the marketplace. A defined market helps encourage growers to take the steps to be certified for good agricultural practices so they can potentially participate in this supply chain. People spend, on average, only one day out of the year in a hospital or doctor’s office. Real health is created out in the community where people work, learn, and play. The real challenge for health care is to figure out how to help community members to get back to basics. We all do medication reconciliation. We need to do nutrition reconciliation and encourage those on the usual Western diet to try a diet based more on whole grains, legumes, fruits, and vegetables while limiting dairy and meat. A good resource is an article recently published by Tuso et al in the Permanente Journal, “Nutritional Update for Physicians: Plant-Based Diets” (http://bit. ly/16Caxqj). Ultimately, a sharp chef’s knife, a cutting board, and a salad spinner may be some of the best public health tools there are. With these simple tools, we can all move toward eating food that is good for us, for our kids, and also good for the environment and the people who grow it for us. Preston Maring, MD, has worked at the Kaiser Permanente Medical Center in Oakland since 1971. He is a member of the SFMS. July/August 2013 San Francisco Medicine


Nutrition Policy, Progress, and Pitfalls

Childhood obesity Where Does the United States Stand and What Can We Do? Sally S. Wong, PhD, RD, CDN In the United States, approximately one-third of all children are overweight or obese, which is becoming the number-one perceived health concern for parents, ranking higher than smoking and drug abuse.1 Obese and overweight young children are at a much

greater risk for serious health conditions such as high blood pressure, type II diabetes, high cholesterol, psychological problems, and self-esteem issues. In addition, overweight children have a 70 to 80 percent chance of staying overweight their entire lives.2 This has serious repercussions for our already strained health care system, as obesity is now responsible for 9.1 percent of total adult medical expenditures.2 Each year, the American Heart Association, in conjunction with Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, collates the most recent data on cardiovascular diseases and their risk factors in the Heart Disease and Stroke Statistics update. The 2013 report indicates that poor eating patterns and a lack of physical activity are the key areas that must be addressed to significantly impact heart health. Among children aged two to nineteen, 16.9 percent are obese and 31.8 percent are overweight or obese. Over the past three decades, the prevalence of obesity in children aged six to eleven has increased from approximately 4 percent to more than 20 percent. The increases in weight aren’t surprising based on the latest information on caloric intake. Data from the National Health and Nutrition Examination Survey indicate that average total energy consumption increased by approximately 20 percent from 1971 to 2004. The extra calories are coming primarily from starches, refined grains, and sugar. Portion sizes are larger, and people consumed more sugar-sweetened beverages, snacks, fast foods, and other energy-dense foods than ever before. “Empty calories,” calories that have limited or no nutritional value but add to the calories of a food or beverage, contribute a large portion of the average daily caloric increase. Sugary beverages are a large source of empty calories and include carbonated soft drinks, non-100-percent juice drinks, and sports drinks. According to the American Heart Association, between the years 1970 and 2000, the average per-person daily consumption of caloric soft drinks rose 70 percent, from an average of 7.8 ounces per day to 13.2 ounces per day. The fourteen-to-eighteenyear-old age group has the highest mean sugary intake at 22.2 ounces, followed by children age three to eight, with an average sugary intake of 21.0 ounces.5 These are much higher amounts per day than the American Heart Association’s recommendation of 3 teaspoons per day for children under the age of eight and 5 to 8 teaspoons for older children.2 Added sugars should comprise of no more than 25 percent of total calories consumed.3 20 San 21 SanFrancisco FranciscoMedicine Medicine July/August July/August2013 2013

New York City: A Case Study of Public Health Nutrition Efforts The children of New York City are no exception, and, according to the New York City Department of Health, are even more likely to be obese (21 percent versus 17 percent) or overweight (18 percent versus 14 percent) than the national average.4 At approximately $242 million, New York’s health care expenditure directly linked to obesity and obesity-related disease is staggering.5 The dramatic prevalence of childhood obesity in New York City, as well as in the rest of the country, has occurred from the interplay of lifestyle habits and environmental factors. Children have become more inactive while average portion size has simultaneously increased. Although there is not a single cause of childhood obesity, the American Heart Association attributes the average consumption increase of 250–300 calories per day as a leading cause of this epidemic. Work has already been done, locally and nationally, to limit children’s access to sugary drinks. In 2003, New York City banned the sale of soft drinks in elementary and middle schools. Two years later, the Alliance for a Healthier Generation was founded and began advocating for schools around the country to limit portion sizes and reduce the number of calories available to children during the school day. Since its inception, there has been an 88 percent decrease in total beverage calories shipped to schools.6

What Should We Teach Our Children?

So how exactly should health care professionals tackle childhood obesity? To achieve ideal cardiovascular health for both children and adults, the American Heart Association and the Academy of Nutrition and Dietetics recommend a diet in line with the Dietary Approaches to Stop Hypertension (DASH). Under these guidelines, adults and children should achieve at least four of the five following recommendations by consuming more than 4½ cups of fruits and vegetables per day, more than two 3.5-ounce servings of fish per week (preferably oily fish), three 1-ounce daily servings of fiber-rich whole grains (defined as more than 1.1 gram of fiber per 10 grams of carbohydrate), fewer than 1,500 milligrams of sodium per day, and fewer than 36 ounces (450 kilocalories) of sugar-sweetened beverages. Like the DASH dietary pattern, the Mediterranean dietary patterns emphasize fruits, vegetables, fish, and whole grains along with beans, nuts, legumes, olive oil (and red wine for adults). In general, both dietary patterns include lean proteins such as fish, poultry, low-fat dairy, and limited sweets and red meat. While the “calories in” continue to rise, the “calories-out” aren’t keeping pace. Children and adolescents in the U.S. are accustomed to a sedentary lifestyle with little or no physical activ-

Continued on page 22 . . . www.sfms.org

Nutrition Policy, Progress, and Pitfalls

The Richmond Soda Tax Effort Lessons Learned Jeff Ritterman, MD Dr. Wendel Brunner, Contra Costa County’s public health director and a trusted friend and colleague, made it clear to me. Either we come up with a

successful intervention or a third of Richmond’s Latino and African-American school children will have their lives cut short by diabetes, heart disease, and other diseases related to obesity. What would a successful intervention look like? New York City Health Commissioner Thomas Farley, CDC Director Thomas Frieden, and Kelly Brownell from the Rudd Center at Yale University, all acknowledged experts in public health, recommended a one-cent-per-ounce tax on sugary drinks. Following their advice, the Richmond soda tax effort was born. Part of the story was, of course, the David and Goliath struggle with Big Soda. The beverage industry spent $2.5 million on the No campaign, and a movie chain based in Texas added another $1.5 million to the No treasure chest. Big Soda’s strategy in Richmond was similar to its efforts in New York City, where it enlisted the support of the NAACP and the Hispanic Federation in exchange for hard currency. It worked well for Coke, Pepsi, and Dr. Pepper. Big Soda beat us two to one. The sad irony was that the very communities that helped them win suffer the highest rates of childhood obesity and had the most to gain from the soda tax. On the Sunday before the election, a news headline read, “Study: Local Soda Taxes Would Boost Health of Blacks and Latinos.” To no avail: With Richmond awash in Big Soda dollars, science took second place to cold, hard cash.

Big Soda’s success in enlisting community support in exchange for funding is a sign of our times.

Corporate elites have immense power and wealth. They are able to buy the allegiance of groups who have seen most of their other funding sources dry up. The United States is currently more unequal in terms of income and wealth than at any time in our history. The collateral damage this causes is immense. Corporate contributions to electoral campaigns weaken our democracy. We end up with auctions rather than elections. In addition, great disparities in income result in significantly poorer population health and social well-being. Life expectancy, child and infant mortality, rates of incarceration, mental illness, drug abuse, obesity, trust, teen pregnancy, academic achievement, social mobility all get worse as we get more unequal. The inequality epidemic is invisible to most. It is this greatly unfair and unbalanced wealth and power dynamic that has allowed Big Soda to beat back all challenges to its bottom line. To learn www.sfms.org

more about the adverse health and social well-being impacts of rising inequality, go to www.equalitytrust.org.uk. The corrosive impact of corporate largesse was not the only lesson learned from the Richmond soda tax effort. Many of us were confronted with our own ignorance concerning the causes and mechanisms of obesity. I had served as a cardiologist for nearly thirty years without once wondering about fructose metabolism. One of the wonderful lessons for me personally was to learn more about the science of obesity—a lesson we all can benefit from, as a medical community. An understanding of evolutionary biology is helpful in providing clues to the causes of the obesity epidemic. For 150,000 years, the humans who preceded us quenched their thirst with water. Thirst is part of the body’s regulation of salt and water. It has nothing to do with the body’s regulation of energy. The sensation related to the body’s energy system is hunger. When we humans began quenching our thirst with water mixed with huge quantities of fructose (either from sucrose or high-fructose corn syrup), we began to put undue stress on the pancreas, eventually leading to overuse, leading to diabetes. The large dose of absorbed fructose also overwhelms the liver’s ability to metabolize it through the Krebs’ cycle, with much of the excess fructose converted to fat—including fat that will pack the liver, muscles, and other organs, and fat that will begin plugging up the coronary arteries. The lesson: When the demands of our day-to-day life are out of balance with our biological limits, disease is sure to result. If our thirst system is not well equipped to deal with anything other than water, we ought to be respectful of who we really are and act accordingly. Adding fifteen teaspoons of sugar to the water may satisfy our desire for sweetness and nourish our reward center, but it causes havoc elsewhere in our body, bringing on obesity, diabetes, premature heart attacks, stroke, hypertension, and cancer. This concept of disease being the inevitable result of a mismatch between our physiology and our daily reality has broader applicability. As a profession, we treat huge numbers of people with antihypertensives. Wouldn’t it also be wise for us to advocate policies that lower the threat level and increase the support level for our most stressed fellow residents? After all, blood pressure elevation is a normal response to social and physical stress. As physicians, it appears that we need to be both clinicians and public health advocates. We need to treat the individual patient and also advocate for a healthier social and physical environment. As you would imagine, the “nanny state” question surfaced often during the Richmond soda tax campaign. There

Continued on the following page . . .

July/August 2013 San Francisco Medicine


The Richmond Soda Tax Effort Continued from the previous page . . . are many helpful answers to it. It occurred to me that if I, a cardiologist, had been ignorant of the biochemistry of fructose, how could I expect the average family to understand how dangerous excess fructose is for them and their children? This awareness of my own ignorance also made me realize that many who now oppose the soda tax may well change their minds as the medical science implicating sugary drinks makes its way from medical journals to the popular consciousness. An article showing that men who consume one can of soda a day have a 20 percent increase in heart attacks came out in March of last year in the cardiology journal Circulation. It will take some time for that kind of knowledge to enter mainstream consciousness, but it is coming as the science implicating sugary drinks continues to pile up. During our campaign, community members asked how we would propose to spend the soda tax revenue. One popular idea was after-school swimming lessons for our third graders. Water safety is a health disparity issue. Richmond has thirtytwo miles of shoreline and municipal pools, yet many of our African-American and Latino children cannot swim and are not water safe. I am happy to report that even without the soda tax revenue, our city will begin this program next September. We can say, tongue in cheek, that when Richmond got lemons (losing the soda tax effort), we chose to make lemon water (lemonade without the sugar).

Another lesson we learned during the campaign was just how revolutionary tap water is as an alternative to sugary drinks. You can honestly tell someone that by substituting tap water for sugary drinks, they will be thinner and healthier. They will live longer, and they will help save the planet. Imagine for a moment that we shifted half of our beverage choices from something that comes in a bottle (plastic or glass) or a can to tap water. Imagine the decrease in vehicle miles traveled, the decrease in recycling effort, the water saved, the aluminum/glass/plastic saved, the benefit to the oceans from less plastic, the decrease in GHGs . . . the list goes on and on. Once we realized in our city how important it is to encourage tap water use, we developed a plan to put in new taps in public places, in partnership with the Chicago-based company Global Tap and with funding from the California Endowment. Dan Whitman, the founder and CEO of GlobalTap, donated three new “hydration stations” to our city to get this initiative started. This return to tap water is a necessity, as climate change will place significant strain on water supplies. Half of the Sierra snowpack, and therefore half of our drinking water, is predicted to vanish if the temperature increases by 2 degrees celsius, a likely possibility. Almost all of the beverages that come in bottles and cans that we drink require huge amounts of fresh water to produce. Do we really want to waste water on the production of unhealthy beverages? Unless we intervene successfully, the obesity epidemic 22 23

San Francisco Medicine July/August 2013

will shorten the lives of our children. The science continues to accumulate. Dissolving huge amounts of fructose in water may feed our addiction for sugar, but it also rots our teeth, makes us fat, causes diabetes and premature heart attacks, and increases the risk of high blood pressure and many cancers. There is a simple way out for our community: Substitute tap water for sugary beverages. Unfortunately, getting out that message loud and clear is difficult, as the “Mad Men” who sold us cigarettes for decades are now doing their best to convince us that sugary drinks are “the real thing.” Let’s not be fooled. The real thing is water, the elixir of life. As doctors, we can advocate for programs and policies that improve the health of entire communities. We have a chance to do just that right now and to lead the nation in reversing the childhood obesity epidemic. State Senator Bill Monning, a true leader for California, sponsored SB 622, the California Soda Tax Bill, which is now on hold. California’s doctors can make the difference in whether or not this bill passes. We can become the health champions for California’s children and families. We understand the ravages caused by diabetes, premature heart disease, and preventable cancers. We can help our legislators understand the tragic human consequences that result when the beverage industry hooks our children on their unhealthy products. It is this medical knowledge, if acted upon with the best interests of our children front and center, that will propel us to a new age where health and social well-being are seen as the most important goals of social and political policy. Dr. Jeff Ritterman is the retired chief of cardiology, Kaiser Richmond Medical Center. He is a former Richmond city council member who led the 2012 Richmond soda tax ballot initiative campaign.

Childhood Obesity Continued from page 20 . . . ity. To combat this problem, the Institute of Medicine released new recommendation guidelines on May 23, 2013, to instill lifelong physical activity habits in children. In this latest report, the Institute of Medicine recommends at least sixty minutes of moderate- or vigorous-intensity physical activity, of which more than half should be accomplished during regular school hours. The importance of diet and physical activity in preventing the childhood obesity epidemic cannot be overstated. The promotion of healthful behaviors throughout the lifespan will be the best population-based way to improve health factors for all American adults and children. Sally S. Wong, PhD, RD, CDN, is a registered dietitian and New York State-certified dietitian-nutritionist. Dr. Wong is the clinical nutrition manager at Beth Israel Medical Center and is faculty assistant professor at the City University of New York’s School of Public Health at Hunter College, where she teaches the graduate MPH-nutrition track. Her research interest included health disparities in cardiovascular disease and diabetes, specifically how nutrition and lifestyle modifications may impact the outcome of these diseases for at-risk populations. References are available online at www.sfms.org. www.sfms.org

Nutrition Policy, Progress, and Pitfalls

energy drinks The Effects on Your Patients Laura Davies, MD Energy drinks have been around for more than twenty-five years. In that time, many people have suffered

from drinking them. Unlike sodas, which have a maximum caffeine limit (71 milligrams/12 ounces), or medications, which are regulated, energy drinks are not regulated, either by caffeine content or by ingredient. Energy drinks aren’t magic potions—they just have a lot of caffeine and, often, sugar. Many of the other ingredients have not been researched. Some, such as guarana, although they sound exotic, work because of high caffeine content. Many energy drinks underreport their level of caffeine. 5-Hour Energy Extra Strength has about 242 milligrams caffeine. A typical 8-ounce cup of coffee has 100 milligrams. A 16-ounce grande from Starbucks has 330 milligrams. Coke has 35 milligrams, tea has 45-74 milligrams, No Doz has 100 milligrams per tab, and Rockstar has 160 milligrams. Certain groups of people seem made for energy drinks— soldiers, shift workers, and college students. Unfortunately, the more caffeine people drink, the worse their attention and alertness actually becomes. Soldiers who drank more than three energy drinks a day were twice as likely to fall asleep on guard duty and in briefings compared to those who drank less. Our bodies are not designed to run on fumes. Caffeine does increase alertness. In typical doses (85-250 milligrams, or one to three cups of coffee), it may decrease fatigue. We all remember this from residency. However, at higher doses it can cause anxiety, restlessness, and shakiness. Palpitations, agitation, tremor, and GI upset are the most common symptoms. Blood pressure (both systolic and diastolic) is higher with energy drinks than with just caffeine. Even teeth are affected—energy drinks tend to be much more acidic than sports drinks.That leaches calcium from your bones. It dramatically changes sleep—not just changing the time of falling asleep but also the restfulness of sleep. High doses cause hyperadrenergic syndrome, resulting in seizures and cardiovascular instability. Too much caffeine causes rapid or irregular heartbeat, vomiting, anxiety, and seizures. About half of all teens and young adults drink energy drinks. Half of the caffeine overdoses in the U.S. occur in youth under nineteen years of age. In youth, energy drinks cause seizures, worsen diabetes and heart conditions, and lead to worsening of mood disorders. As of 2011, the American Academy of Pediatrics recommended that energy drinks should never be consumed by children or teens. Caffeine overdose can lead to death. Everyone is at risk, but some populations should be especially careful. Children are especially vulnerable to caffeine poisoning. Children younger than five have the most caffeine and energy drink poisonings. There have been several case rewww.sfms.org

ports of patients with bipolar disorder who have had manic episodes sparked by energy drinks. Obviously, people with preexisting cardiac or seizure disorders should avoid energy drinks. Pregnant women should avoid them because caffeine metabolism is slowed in pregnancy, and there have been spontaneous abortions associated with energy drinks. The FDA is investigating deaths related to 5-Hour Energy (at this point, thirteen over the past four years) and Monster (five deaths). There have been MIs, CVAs, hallucinations, arrhythmias, and seizures. (http://www.fda.gov/downloads/ A b o u t F DA / C e n t e r s O f f i c e s / O f f i c e o f Fo o d s / C F S A N / CFSANFOIAElectronicReadingRoom/UCM328270.pdf). Drinking an energy drink mixed with alcohol leads to much higher levels of intoxication, partly because the body’s normal protective mechanism of passing out is shut down, and partly because there is even less than normal awareness of intoxication. The amount of caffeine (whether in an energy drink or a cola) mixed with alcohol directly impacts the level of intoxication. Energy drinks mixed with alcohol are a risk factor for youth to use other drugs. Bad judgment and a sense of invincibility are a risky combination. Like many things, caffeine is best in moderation. Unfortunately, there is no way to consume it in moderation when drinking energy drinks. Asking our patients about energy drink consumption should be a part of all adolescent exams. As physicians, we come in contact with energy drink consumers in many ways: in the ER, working with outpatients, and in our neighborhoods.

Laura Davies, MD, completed her internship and residency at the University of California, San Francisco, and was an assistant clinical professor before beginning her private practice. She is affiliated with St. Luke’s Hospital and is part of the psychiatric consultation-liaison team. Her areas of expertise are with anxiety, depression,  ADHD, pregnancy, and postpartum issues.  She does adult, adolescent, and child psychotherapy; psychopharmacology; couples and family psychotherapy; and home calls and nursing home visits.

July/August 2013 San Francisco Medicine





Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Gropper, MD

As part of a large, integrated health system, we physicians at Kaiser Permanente know that health extends to all aspects of a person’s life, including the food he or she eats. As an organization, we have developed program-wide food policies that extend to all of our medical centers across the country. By choosing locally grown, sustainably farmed foods without synthetic pesticides and chemicals, we are not only ensuring the health of our patients but also of the environment. We advance the principles of biodiverse farming and healthy food choices through several efforts, including increased sourcing of locally grown, ecologically farmed and produced food in Kaiser Permanente hospitals, cafeterias, and vending machines. We also sponsor farmers’ markets at our own facilities as a means to promote access to fresh, local produce and to support investments in local economies. Through our food policies, we increase awareness about toxins in the food chain and their effects on human health. Food procurement is another area where Kaiser Permanente has begun to collaborate with other major health care systems and nongovernmental organizations to accelerate improvements in sustainable food purchasing, such as Partnership for a Healthier America. These collaborations enable the systems to leverage large buying power to affect change across markets and support regional food programs. Kaiser Permanente devotes approximately 16 percent of our overall food spending to sustainable food across the organization, nearly two times as much as most other hospital systems of our size. By the end of year 2015, that number is expected to grow to 20 percent. Locally, at the San Francisco Medical Center, we use Food Service Partners as our patient food vendor, and they currently provide us with seasonal, locally sourced produce from farms within a 100-mile radius of their production facility in South San Francisco. We have just begun offering cage-free eggs for all patient meals with eggs, and all food containers on which patient food is served are biodegradable, as we have a composting system within our hospital.

San Francisco VA Medical Center (SFVAMC) is committed to veteran health promotion and disease prevention, integrating a variety of healthy eating and nutrition programs throughout our health care system. Our health promotion programs include nutrition and cooking classes at the SFVAMC and clinics and at residential housing for formerly homeless veterans. These classes focus on food shopping; food preparation; and eating healthy, low-cost meals. A nutrition and garden program started last year enables veterans to explore a plant-based diet using simple gardening techniques to grow their own vegetables and herbs to support healthy eating. Our outpatient nutrition services include individual counseling and group programs for weight management and diabetes. These programs are available at San Francisco and all six of our community-based outpatient clinics, many services for the rural clinics being provided through telemedicine. Within our home-based primary care program, all veterans are screened for nutrition risk, and educational services are provided based on nutritional needs. Our inpatient nutrition services for our long-term care facility include restaurantstyle dining in our Community Living Center Café, snack baskets, and an oasis beverage cart. Patient meals are prepared with sustainable food practices, and our menu includes foods that are heart healthy and high fiber, with an emphasis on fresh, local ingredients. There is a farmer’s market on the Medical Center campus every Wednesday, offering a variety of fresh, organic vegetables, fruit, nuts, local bread, and cheeses for staff, patients, and visitors. We also offer a localfarmer, community-supported agriculture program for staff interested in weekly produce boxes.

24 25

San Francisco Medicine July/August 2013

The rise of obesity is usually blamed on too much eating and not enough exercising, but my colleague Robert Lustig, MD, a pediatric neuroendocrinologist at UCSF Benioff Children’s Hospital, asks us to look beyond the obvious. The fact is, behaviors that some might refer to as gluttony and sloth are merely consequences of the true cause of the epidemic, Lustig says. The problem is the increase in sugar, and specifically fructose, consumption. Fructose, ubiquitous in soft drinks and many other processed foods, both drives fat storage and makes the brain think it is hungry, setting up a “vicious cycle of consumption and disease,” according to Lustig. Here at UCSF, where many are trying to understand obesity and its causes, Lustig stands out for his concern about the negative effects of sugar overconsumption. He’s also a strong advocate of policy changes that would lessen what he believes are sugar’s contributions to the obesity, diabetes, and fatty liver disease epidemics in the U.S. and around the world. Lustig’s arguments are being heard. A YouTube video of one of his UCSF lectures, “Sugar: The Bitter Truth,” has received more than three-and-a-half-million views. His book Fat Chance is a New York Times best seller. His arguments have also found an audience with some major politicians, including New York Mayor Michael Bloomberg, who spearheaded a drive to ban restaurant and concession stand sales of sugary drinks larger than 16 ounces. While a judge struck this down, Lustig nonetheless argues that the science fully supports such public health interventions. Lustig feels that our food supply has been adulterated right under our very noses, with our tacit complicity and approval. But, he says, “at the current rate, if we do nothing, Medicare will be broke by 2024. I think the public is starting to get it, and the tide is turning.” www.sfms.org

St. Mary’s


St. Francis

Peter Curran, MD

Michael Rokeach, MD

Patricia Galamba, MD

In 2007, San Francisco created a new health care access plan, Healthy San Francisco (HSF), for the indigent. With the HSF program expected to shrink as patients go to an expanded MediCal and Covered California Exchange for health insurance, I thought it would be interesting to look at HSF’s track record from the perspective of a private-practice physician. HSF was created to provide comprehensive health care for the 96,107 uninsured San Franciscans who were ineligible for Medi-Cal. Using a medical home model with neighborhood health clinics and an array of hospitals, the city bet that an emphasis on primary care and a common electronic enrollment system would help contain health care costs while meeting the demand of its uninsured residents. The program cost just under $200 million per year to operate, with approximately 50 percent of the funding coming from the city’s general fund for indigent care, 25 percent coming from the federal government in the form of grants to the clinics, 15 percent from employers, and about $11 million from charity care provided by non-county-owned hospitals. A majority of the 54,348 enrollees are below the poverty level and pay nothing, and over the last three years less contribution has come from the employers using the “city option” of providing HSF or reimbursement accounts to their employees without health insurance. Several neighborhood clinics stopped taking new HSF patients. “Healthy San Francisco is a model for health care delivery, but not for payment,” said Stephen Shortell, the dean of the U.C. Berkeley’s School of Public Health. What is less often talked about publicly is the effect that increased access to charity care has on the individual private-practice physician trying to run a business in an era of decreasing Medicare reimbursement. One of my colleagues estimated that he provides $40,000 annually in unreimbursed specialty care at his hospital, while overhead costs in operating a practice continue to rise. Obviously, the delivery and reimbursement of health care is evolving in this country, hopefully for the good of the patient. But this reform should not be at the expense of physicians who cannot sustain a practice in San Francisco, or there really will be an access-to-health-care problem. www.sfms.org

The American Society for Gastrointestinal Endoscopy (ASGE) honored Dr. Kenneth Binmoeller with the Master Endoscopist of the Year award during the ninth annual ASGE Crystal Awards. Dr. Binmoeller is the founder and director of Interventional Endoscopy Services (IES) at CPMC. Hosted by ASGE and the ASGE Foundation, the event was held at SeaWorld in Orlando, Florida, during Digestive Disease Week (DDW). The ASGE Crystal Awards symbolize the finest in leadership, research, and scientific pursuit. These awards recognize physicians who spend the majority of their time in patient care and are recognized regionally or nationally for their expertise and longitudinal contributions to the practice of gastrointestinal endoscopy. Proceeds from the event benefited the ASGE Foundation in support of GI endoscopy-related research, physician education and training, and public outreach initiatives. Launched in 2001, CPMC’s IES program has become the premier referral center in Northern California for patients requiring complex endoscopic therapy. Together with his associates, Drs. Janak N. Shah and Yasser M. Bhat, Dr. Binmoeller performed more than 5,000 interventional endoscopy therapeutic procedures. CPMC has received the American Heart Association’s Mission: Lifeline® Gold Receiving Quality Achievement Award. The award recognizes CPMC’s success in implementing the highest standard of care for heart attack patients. Each year in the United States, nearly 300,000 people have the most severe form of heart attack, a STEMI, known as ST-segment elevation myocardial infarction. A STEMI occurs when a blood clot completely blocks an artery to the heart. As a STEMI-receiving hospital, CPMC meets high standards of performance in quick and appropriate treatment of STEMI patients in the emergency department and the cardiac catheterization labs, as well as during hospitalization. Before they are discharged, patients begin aggressive risk-reduction therapies such as cholesterollowering drugs, aspirin, ACE inhibitors, and beta-blockers.

The quality of hospital food has long served as source material for comics and scriptwriters who need an easy laugh. But the joke is on them, especially if more institutions follow Saint Francis Memorial Hospital’s trendsetting approach to food. Deirdre Heisinger, our director of Nutrition Services, began raising the bar on food quality at the hospital three years ago. With the Bay Area’s access to some of the finest, freshest fruits and vegetables on the planet, she called for more vegetarian meals, healthier snacks, and entrees designed to be nutritious and balanced to meet special dietary requirements. She has applied her concepts not only to the food we serve patients but also to the meals we provide in the hospital cafeteria, which serves hundreds of family members, visitors, and hospital staff members every day. A robust salad bar, vegetable-based soups, and entrées such as stir-fry tofu and stuffed bell peppers are options on a weekly basis. And our commitment to nutritious, delicious food doesn’t stop at our doors. This year, Saint Francis gave $150,000 in grant money to seven San Francisco organizations, including the North of Market/Tenderloin Community Benefit District. The organization is using the grant to work with mom-and-pop stores in the city’s Tenderloin to improve access to affordable, nutritious food in one of San Francisco’s poorest neighborhoods. In addition, Saint Francis further displayed its commitment to our community through the recent donation of more than 300 “MREs,” or Meals Ready to Eat, to the homeless in the City of San Francisco. Serving our community is a core value of Saint Francis Memorial Hospital and Dignity Health. Emphasizing the importance of good nutrition in our hospital and our community is another way we fulfill our mission—and put all those hospital-food jokes to rest while we’re at it.

July/August 2013 San Francisco Medicine



Tracy Zweig Associates INC.

Sutter Pacific Medical Foundation Bill Black, MD, PhD







Nurse Practitioners ~ Physician Assistants

Healthy eating is especially critical for women who have diabetes and are considering having a family. Proper diet and exercise are essential for these women to control blood sugar and to result in the delivery of a healthy baby. At Sutter Pacific Medical Foundation, our maternal-fetal medicine specialists oversee a diabetes and pregnancy program that helps women manage their health and adopt behaviors resulting in a healthier pregnancy and optimal outcomes for both mother and baby. Women see a team that includes maternal-fetal medicine specialists, registereddietitian Certified Diabetic Educators (CDE), and RN CDEs. Patients receive diet evaluations, meal plans, and nutrition assessments. A patient’s prepregnancy body mass index (BMI) is recorded, and weight gain is tracked on one of the four Institute of Medicine weight-gain graphs. Women learn the importance of avoiding sugary foods and eating balanced meals throughout the day. Meal plans are developed with the right proportion of carbohydrates, protein, and fats. Families are encouraged to attend sessions with the patient, as it is important for the whole family to learn how to eat a healthful diet for the rest of their lives. Patients are also encouraged to walk or do appropriate exercises to optimize blood glucose management. Key to working with women who have preexisting diabetes (prediabetes, type II, and type I diabetes) and to reducing birth defects is to identify patients before they become pregnant. Women may be referred from primary care physicians, OB/GYNs, or endocrinologists. Women with gestational diabetes, as well as obese and overweight women, benefit greatly from the program. Patients who have had bariatric surgery have special nutritional needs and may be referred. Patients may use the program to develop a plan to work on the goal of preventing type II diabetes.  

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m

Breathe Again !! CALIFORNIA SINUS CENTERS & Institute We CARE for:

San Fran Med Mag 01-29-09

Bacterial Infections / Sinusitis Culture directed treatment Functional Endoscopic Sinus Surgery Orbital Decompression / Graves’ Disease Image Guided Surgical Navigation Revision - complex cases Frontal Sinusitis Advanced Endoscopic Techniques Sinuplasty Sinus Surgery WITHOUT packing Nasal Obstruction / Septoplasty Allergic Fungal Sinusitis Sinonasal Tumors / Polyps Smell / Taste problems CSF leak repairs Mucoceles / Abscesses In-Office CT Scanner Urgent appointments Joint care: ENT - Allergy Pulmonary

Atherton (Stanford area) Walnut Creek (East Bay) San Francisco (Union Square) Winston Vaughan, MD Karen Fong, MD


San Francisco Medicine July/August 2013

Kathleen Low, NP

Sherry Derakhshandeh, MD


www.CalSinus.com www.sfms.org

A former employee sued me for wrongful termination.

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. SFMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are: A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

For more information on these important benefits, and the special SFMS First-Time Buyers program, please contact Marsh at: 800-842-3761 or email us at CMACounty.Insurance@marsh.com

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim. Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

Sponsored by:

EEO compliance training for managers/supervisors. An internetbased training program, compliant with California law, provides supervisors with sexual harassment training. Optimal Wage and Hour Defense Coverage. Ask about our First-Time Buyers Program.

60980 (7/13) ©Seabury & Smith, Inc. 2013 • 777 S. Figueroa St., Los Angeles, CA 90017 www.CountyCMAMemberInsurance.com • CMACounty.Insurance@marsh.com

d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 • 800-842-3761


Advanced Gastroenterology  Cancer  Heart & Vascular  Microsurgery  Neuroscience  Organ Transplant  Pediatric Specialty Care 

SOMETIMES EVEN SPECIALISTS NEED SPECIALISTS Whether it’s advanced liver cancer, ALS, or dysphagia, our experienced physicians routinely care for the most advanced medical cases. With ongoing clinical research and new therapies, our doctors partner with you to heal your most acute patients. Working together for excellent outcomes; it’s one more way you plus us and we plus you. SPECIALTy REfERRALS AND TRANSfERS 888-637-2762 suttermd.com

California Pacific Medical Center Novato Community Hospital Sutter Lakeside Hospital Sutter Medical Center of Santa Rosa Sutter Pacific Medical Foundation

Profile for San Francisco Marin Medical Society

July/August 2013  

San Francisco Medicine Vol. 86, No. 6 Food Policy

July/August 2013  

San Francisco Medicine Vol. 86, No. 6 Food Policy