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AN RANCISCO EDICINE S F M VOL.83 NO.11 November 2010


Food For Thought Practical Nutrition for Physicians

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In This Issue


Volume 83, Number 11 Food For Thought: Practical Nutrition for Physicians MONTHLY COLUMNS


4 Membership Matters

10 Doctor’s Orders: What Should Doctors Tell Patients About Nutrition? Marion Nestle, PhD, MPH

5 Classified Ad

11 Finding a Nutritionist: A Guide to Finding a Qualified Nutritionist in the SF Bay Area Erica Goode, MD, MPH

7 President’s Message Michael Rokeach, MD

12 An Unhealthy Food System: Suggestions for Physician Advocacy David Wallinga, MD, MPA

9 Editorial Erica Goode, MD, MPH 46 Hospital News

15 Taking Action: A Health Sector Guide to Food System and Agricultural Policy Brian Raymond, MPH


17 How the Food Industry Drives Us to Eat An Interview with Kelly Brownell, PhD 21 Nutrigenetics: An Introduction Erica Goode, MD, MPH

22 Personalized Health Care: Nutrigenomics Takes Care in a New Direction Carol Ceresa, MHSL, RD 23 Essential Skills for Weight Management Caroline Goodard

25 Eating Sensibly: Using Common Sense and Moderation Narsai David 27 Nutrition and Cancer: What to Eat and What to Avoid Donald Abrams, MD 29 Multivitamin Maze: How to Navigate the Labels Bonnie Liebman and David Schardt

43 Health Policy Perspective: Sugar Politics Versus Health Shannon Udovic-Constant, MD, and Steve Heilig, MPH

44 Inspiring Physicians to Make a Difference: CMA Foundation Partners with Physicians and Communities to Fight Childhood Obesity Carol A. Lee, Esq. 45 Which Nutrition Services Are Covered? Medicare, Medicaid, and SCHIP The American Dietetic Association

32 Food Facts: Practical Nutrition Information to Assist Physicians 32 Calcium for Osteoporoses 33 Fiber in Food 34 Omega-3 Foods 34 Good Sources of Zinc in Food 34 Sleep More, Eat Less 35 Potassium in Food 35 The Healthy Eating Pyramid 36 The Dirty Dozen 37 Dangers of GMO Foods 37 Antioxidants 37 About Flatulence and Bloating 38 Phytochemicals 39 Iron Content of Common Foods 39 Comparing Cheeses 39 Brown Rice Rules 40 Benefits of Mushrooms 40 Resources: Nutrition Newsletters 41 Weekly Calorie-Burning Worksheet 41 Vitamin K 42 Local Farmer’s Market Guide

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: Web: Advertising information is available by request.

November 2010 San Francisco Medicine 3

Membership Matters November 2010 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 83, Number 11 Guest Editor Erica Goode Managing Editor Amanda Denz Copy Editor Mary VanClay

Resident & Fellows Job Fair/Mixer SFHEX Receives $50,000 Grant at the Millberry Union, UCSF from the Metta Fund to Improve Patient Care in San Francisco Campus

Editorial Board

If you aren’t already planning to attend, don’t miss our upcoming job fair and mixer this month! The event will take place on November 18, 2010, 5:00 p.m. to 7:30 p.m. and is free to attend. Contact Jonathan Kyle, (415) 561-0850 extension 240, or email for more information.

Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes Clever

Ricki Pollycove

Gordon Fung

Stephen Walsh

Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman SFMS Executive Staff Executive Director Mary Lou Licwinko Assistant Executive Director Steve Heilig Director of Administration Posi Lyon Director of Communications Amanda Denz Marketing Specialist and Membership Development Associate Jonathan Kyle Board of Directors Term: Jan 2010-Dec 2012

Roger Eng

Gary L. Chan

Thomas H. Lee

Donald C. Kitt

Richard A. Podolin

Cynthia A. Point

Rodman S. Rogers

Adam Rosenblatt Lily M. Tan

Term: Jan 2008-Dec 2010

Shannon Udovic-

Jennifer H. Do


Shieva Khayam-Bashi

Joseph Woo

William A. Miller Jeffrey Newman

Term: Jan 2009-Dec 2011

Thomas J. Peitz

Jeffrey Beane

Daniel M. Raybin

Andrew F. Calman

Michael H. Siu

Lawrence Cheung CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

Save the Date! SFMS Annual Dinner January 27th

This year’s annual dinner will take place on January 27, 2011, at the Concordia Argonaut Club in San Francisco. George Fouras, MD, a child psychiatrist who specializes in adolescents in the foster care system, will be installed as 2011 SFMS President. We have an engaging line up of speakers this year, along with the usual delicious dinner and camaraderie with colleagues. SFMS members: Watch your mailbox for an invitation in December. For more information, or to RSVP, contact Posi Lyon, (415) 561-0850 extension 260, or

Dinner Lecture on Strategies in the Surgical Treatment of Advanced Heart Failure

New Date! February 10, 2011. Please join us for a complimentary dinner and a medical education discussion with G. James Avery, MD, surgical director of the Heart Failure and Transplant Program at California Pacific Medical Center. A 1.0 category CME 1 credit hour is available for attending this event. The dinner and lecture will take place at Town Hall Restaurant, 342 Howard Street, San Francisco, from 6:30 p.m. to 8:30 p.m. on February 10. RSVP required to Posi Lyon, plyon@ or (415) 561-0850 extension 260.

SFMS Symphony Night

Look for an SFMS symphony event in early 2011. Details to follow soon!

4 San Francisco Medicine November 2010

The San Francisco Health Information Exchange (SFHEX), a project of the SFMS Community Service Foundation, received a grant from the Metta Fund that will assist them in attaining the goal of creating a health information exchange allowing patient records across the city to be aggregated and shared between health care organizations and clinicians in a secure manner. “This grant award is incredibly important for SFHEX as we pursue the goal of improved patient care through the secure electronic exchange of health care data in San Francisco,” said Dr. Arieh Rosenbaum, cochair of the San Francisco Health Information Exchange. “SFHEX will use the funding to complete the final phases of the planning process for the exchange, with the goal of beginning infrastructure construction in mid-2011. SFHEX would like to thank Metta Fund for its generous support of this very important city initiative.” The SFHEX was born of a shared vision: the secure electronic exchange of clinical data among health care providers with the goal of improving patient care. Today, exchange of clinical information in San Francisco is highly variable in terms of its timeliness, reliability, and effectiveness. The idea of a unified patient record that aggregates all available clinical data when it is needed has before now been just a dream, one that the SFHEX hopes to finally allow the city to realize. Multiple related benefits from this improved communication will follow, including reduced duplicative testing, a decline in citywide resources devoted to clinical data gathering, and a contribution to provider eligibility for federal stimulus funds under “meaningful use.” Ultimately, the true value of the SFHEX will be realized in the delivery of higher-quality care to the citizens of San Francisco.

SFMS Opposes Campos Ordinance Last month the SFMS Board of Directors voted to oppose an ordinance introduced by supervisor David Campos that would require health care facilities to demonstrate that any new facilities or expansion projects fill a need that is not being met in that particular area of the city—a need as defined by a city-wide health care master plan the ordinance requires the city develop. It is unclear whether the measure would affect facilities already in planning stages. SFMS President, Dr. Michael Rokeach, and SFMS Treasurer, Dr. Keith Loring, testified against the measure at the San Francisco Planning Commission meeting, and SFMS President-Elect, Dr. George Fouras, testified in opposition at the San Francisco Health Commission Meeting. “The San Francisco Medical Society is keenly aware of the disparities of health care access to the different neighborhoods of San Francisco,” said Dr. Fouras. “We understand the desire of the City and County in creating a plan to identify goals and gaps in the care of our residents. However, as a society, we disagree on the method proposed by the Campos ordinance. We support developing a dynamic, continually improving set of health care goals to address these disparities. The language of this proposed ordinance is very broad, and we expect, will have many unintended negative consequences. If the city is truly interested in achieving greater health care services to underserved areas, a better approach would be the carrot, not the stick. We urge you to consider alternatives that would motivate physicians to locate their practices in these areas.” To read the full testimony, visit our blog: http://sfmedicalsociety.wordpress. com.

San Francisco Expands Tobacco Ban, Nullifies Walgreens Lawsuit

The City of San Francisco recently voted to expand its ban on tobacco sales in retail establishments that contain pharmacies, eliminating an exemption in the

original 2008 law that allowed tobacco sales in supermarkets and big-box stores that contain pharmacies. The expansion follows a decision by a San Francisco appeals court that it is unreasonable to apply the ban to drugstores, but not to supermarkets and big-box stores that contain pharmacies. By amending the law, the city hopes to head off further litigation over enforcement of the ordinance, which was the first of its kind in the nation. The original ordinance was challenged by Walgreen Co. as unconstitutional. The drugstore chain argued that the ordinance violated equal protection laws because it exempted supermarkets and retail stores such as Costco. SFMS has supported the restrictions from the outset, including filing legal briefs in support of San Francisco policies. As noted in JAMA recently, overall smoking rates among Americans have stalled, while exposure to secondhand smoke has declined since new policies such as those in question were instituted—more evidence that progress on this front is possible.

PECOS Enrollment Deadline Approaching

Beginning January 3, 2011, any claims for items or services that you have performed will be denied if you are not in the CMS PECOS system.
As of this same date, any claims for items or services referred to you by another physician who is not in the PECOS system, will be denied.

 How do you know if you am enrolled in the PECOS system?

 Option 1 - Download the Ordering and Referring Report:
You can download the report from the CMS Website. If you receive SFMS member emails, we recently sent you the link. Option 2 - Check Online:
You can verify your status through the PECOS system. You will need your Type 1 (Individual) NPI login and password for this. If you receive SFMS member emails, we recently sent you instructions on how to do this. Option 3 - Call CMS at 800-6334227
You will experience very long wait times on this number. It is recommended to

try the first two options before contacting CMS by phone. You will need your PTAN number to reference your information, which is on your original Medicare approval letter. What if you are not enrolled in the PECOS system?
A new enrollment application must be completed online before January 3, 2011. Keep in mind, this is a new enrollment to PECOS, not to Medicare as a whole, so you will still fill out the “New Enrollment” application, even if you have already been practicing for a long time. We recommend beginning this as soon as possible, as it may take some time for them to open and log the application in their system.

Do We Have Your Email Address?

Over the coming year the SFMS will begin communicating much more information electronically to members. From newsletters to webinars to electronic voting, you’ll get the most out of your membership if we have your email address. We do not share your address with anyone else, and aim to keep the messages relevant. If you haven’t recieved an email from us lately, please call or email Jonathan Kyle, (415) 561-0850 extension 240 or

Classified Ad

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November 2010 San Francisco Medicine 5

We Celebrate Excellence – Calvin Lee, MD CAP Member, Internationally Renowned Violinist, and Dedicated Philanthropist


For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like general surgeon Calvin Lee, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

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CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

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President’s Message Michael Rokeach, MD

Nutrition and Heath


s we rapidly approach the end of another hectic and productive year, the holidays begin to come into view just over the horizon. That marks the wonderful time of year when families and friends gather to enjoy each other’s company—and of course, to eat. This current issue of San Francisco Medicine, covering the topic of nutrition, could not be more timely. These pages are packed with articles from a bevy of experts as well as incredibly useful tables of facts related to nutrition and health. With health care reform barreling down on us, the issue of preventive medicine and health maintenance becomes ominously important. Once the government—and other payors—begins giving provider organizations fixed amounts of money to care for specific populations, the ability to keep those patients healthy and out of the hospital will be more important than ever before. No longer will physicians be compensated for providing services; more likely, they’ll be rewarded for preventing the need for such services. Our guest editor this month, Dr. Erica Goode, is a well-known San Francisco expert on nutrition and metabolism. She has put together a robust list of important articles on what we eat, why we eat it, what it does to and for us, and how we can better manage it in order to prevent disease and improve health. The current national interest on the causes and health risks of obesity is well represented in this issue. In particular, the article by SFMS Board Member Shannon Udovic-Constant, MD, on “sugar politics,” is indicative of the advocacy role your medical society has played in shedding light on this monumental problem. When more than half of teens drink at least one soda per day, and soda accounts for almost half of the increased calories we take in daily compared to thirty years ago, it’s no wonder Californians spend more than $40 billion annually treating obesity. Readers will be particularly interested in the Food Facts special section, with succinct information on topics such as fiber, antioxidants, zinc, vitamins, the benefits of mushrooms, and guides to local farmer’s markets and to nutrition newsletters. This information should help all of us educate and inspire our patients to be more discerning about what they put into their own bodies. The future appears bright for better health through

better eating, given the large body of research surrounding nutrition, health, and disease. A family member of mine recently participated in a cancer-survivor study of diet change and cancer recurrence. Even though the initial results couldn’t promise that recurrence could be averted by healthier eating, the study had the positive effect of changing this person’s eating habits for the better. Far fewer Americans recognize the role of diet and nutrition compared to, say, tobacco and sunlight, when it comes to avoiding preventable cancers. In his article on nutrition and cancer, Dr. Donald Abrams gives us the “Cliffs Notes” version of what to include and what to avoid in our own diets in order to prevent cancer. There is a similar cheat sheet on assessing the “multivitamin maze,” which I know our patients will appreciate. As this article goes to print, we await the outcome of midterm elections. Could a change in legislative party balance alter the course and/or speed of health care reform? Will preventive medicine move to the forefront of health care organizations? Will the obesity epidemic, as championed by Michelle Obama, be seriously challenged or just receive governmental lip service? It’s my personal hope that a sea change regarding American’s eating habits will begin with elementary school education. Why not give all school kids the opportunity to grow their own food, and even sell what they don’t or can’t eat? Education as opposed to dictated policy is the key to moving the needle in the right direction. Each one of us can start to move that needle by carefully scrutinizing what and how much we put into our own bodies. I truly believe if we teach the next generation, and the generation after that, society will reap the benefits down the road. Please enjoy this terrific issue of San Francisco Medicine, and share the wealth of information it provides with your patients. I know both you and they will be better for it.

November 2010 San Francisco Medicine 7

Independent But Not Alone.

James Yoss, M.D. Hill Physicians provider since 1994. Uses Hill inSite and RelayHealth services for ePrescribing, eReferrals and secure online communications with patients.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Get more information about Hill Physicians at or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Sacramento area: Doug Robertson, regional director, (916) 286-7048, San Joaquin area: Paula Friend, regional director, (209) 762-5002, Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

Editorial Erica Goode, MD, MPH

Building Solid Infrastructure


n assembling this collection of nutrition materials, I hope to provide a guide to what I think is the most direct way to approach the nutrition crisis we have created in the U.S., as an industrialized but very complex country. All of us, physicians and patients, must view this from a public health (macro) and day-to-day (micro) standpoint. We can develop, for ourselves and our patients, a shift toward making healthy choices about how to feed ourselves and those we love, in ways beneficial to the environment (no more Styrofoam; cooperative community recycling of food wastes and packaging; buying grapes from Napa, not Chile) and with a view toward the minutiae of each day’s choices, meal by meal, with adaptations for each family member, whether healthy or ill. This issue attempts to show that if we are to remain our healthiest in mind, body, spirit, and cohesiveness as a nation, we must make a paradigm shift. This is made more difficult because, if we all simply vote with our feet, sometimes it works and sometimes it doesn’t. It’s clear that trans fats are generally being removed from the food supply after years of media discussion hounding the public to check labels. However, problems abound with the myriad pollutants found our food supply, and much of this was covered in the April 2010 issue of San Francisco Medicine, themed “Medicine and the Environment.” We open this issue with an article by Marion Nestle on nutrition for medical students—a topic she knows too well. As coordinator for nutrition courses at UCSF (1976 to 1982), she makes a plea for more physicians, who received only limited nutrition training during medical school, to learning the basics and at least mention this in our review of systems with patients as we discuss the various risk factors dependent on individual behaviors. To paraphrase Mark Twain, “If one’s main tool is a hammer, all you will see are nails.” If we are to afford health care reform (which includes $12 billion for preventive health aspects of the program), we need to think about diet and exercise—beginning in infancy— so we don’t have to rely on statins and metformin in adulthood. Beginning with Chinese physicians, Tibetan healers, and Hippocrates (whom we know from their writings), nutrition was a core discussion topic between physician and patient. But now, between the meager reimbursement for primary care physicians, time constraints that make that doctor-patient relationship ever more attenuated, and the information/misinformation that the patient brings to that visit (often knowing much more than his

or her physician has had time to even consider), physicians often sidestep the topic. The premise of health care reform is that the primary care physician will serve as a medical “home.” This sounds cozy, except that few U.S. physicians operate on a Mayo Clinic model, with accessible sharing of knowledge and resources among physicians and with the collective incentive of keeping patients healthy. Most primary care people struggle along, provided with a pittance of reimbursement for the time spent, and needing much more staff to handle billing and back-office requests for referrals. We have a long way to go and a huge shift in the ethics of distributing health care dollars, plus electronic medical records for everyone, before efficiency of information will make for a financially sustainable system. Included herein are several parts of the solution. We provide information about referring your patient, before significant disease has developed, to local nutritionists or weight control groups, and information about what is reimbursed. We compiled the Food Facts section that you can photocopy or download from our website to distribute to patients. We provide resources so you can arm yourself to discuss nutrition-related topics with your patients, your family, and your community. Consider speaking at your children’s schools or community groups, or become politically active in this arena. Consider writing an op-ed piece about the politics of nutrition or submitting your commentaries on public radio. And in the spirit of “Physician, heal thyself”: Do you, as a physician, practice good self-care? If you do, you will be much more likely to impart sensible awareness about food, exercise, sleep, and relaxation for stress reduction on to your patients. I consider public health, in all its guises, less exciting than a flail in the Emergency Department, and some of you will always prefer that exhilaration of a “save from the brink.” But the steady work of building a bridge to the future, viewing nutrition as infrastructure, is something we can support to help make the world more livable. The recent San Bruno gas line tragedy, and the Gulf Coast pipeline blowout, occurred due to dismissive attitudes about infrastructure. Individual disasters in the lives of our patients can be delayed or prevented, if you will teach them to think in terms of nutrition as a critical part of that basic infrastructure. To read more, please see Marion Nestle’s Food Politics; Michael Pollen’s Omnivore’s Dilemma; and Thomas Friedman’s latest book, Hot, Flat, and Crowded.

November 2010 San Francisco Medicine 9

Food for Thought

Doctor’s Orders What Should Doctors Tell Patients About Nutrition?

Marion Nestle, PhD, MPH


hat should doctors tell patients about nutrition? It intrigues me how often I’ve been asked this question since the late 1970s, when I first was involved in developing a nutrition education program for students and practitioners in the medical and other health professions at the UCSF School of Medicine. Then, as now, it was evident that nearly every patient who landed at San Francisco General Hospital, or even the university’s teaching hospital, would benefit from some kind of nutrition intervention. At a minimum, it would have helped to make sure they were fed on a regular basis. It was equally obvious that almost everyone who visited the outpatient clinics either asked for or needed advice about their dietary habits. Then, as now, few medical students were taught much about basic principles of nutrition, let alone the details of what they needed to know to help patients manage their illness or address less acute dietary concerns. But I am a realist. In today’s health care environment, even doctors with advanced nutrition training don’t have time to use it. I blame this on how our health care system systematically rewards health professionals for treating disease but does little to promote health and prevent disease. How doctors need to advise patients about nutrition depends on whom they are talking to. If they’re dealing with patients who are sick or in hospitals, doctors need to discuss how dietary changes and improvements will help patients recover from their illness and prevent further

disease. But the task here really refers to what to say to healthy patients who want to stay that way. In the outpatient setting, what doctors do and say is profoundly important. Doctors are authority figures, and there is no question that patients take their advice seriously even if they don’t always follow it. In my experience as a patient, primary care doctors routinely ask us about drugs, cigarettes, and alcohol, but hardly ever about what foods we eat. Even if there is only a minute during which to address these issues, diet should be added to the list. Asking about diet can produce great benefits. If nothing else, the mere asking of the question conveys the idea that the doctor cares what the patient eats and wants the patient to understand that diet matters to health. But, again, I am a realist. I am well aware of the fact of time constraints, and my list of suggestions for what doctors should tell patients about diet and health is necessarily short. Fortunately, it doesn’t take long to tell patients that what they eat matters to their health. It takes only a minute to explain that healthy eating simply means attending to food variety, minimal processing, and moderation. Variety means selecting many different kinds of foods from the various food groups: meat, dairy, fruits, vegetables, grains. Variety is a fundamental principle of nutrition because foods vary in nutrient content. Choosing different kinds of foods within and among food groups compensates for differences in nutrient content without anyone having to think about them. People who consume adequate amounts of varied diets rarely exhibit

10 San Francisco Medicine November 2010

nutrient deficiencies (vitamin D, actually a hormone, may be the one exception). Diets that restrict one or another food group are the kinds most likely to be deficient in one or another nutrient. Minimal processing means that the foods should be as close as possible to how they came from the animal or plant. The more thoroughly a food is processed, the less it resembles its plant or animal origins. Processing removes nutrients from foods (even if some vitamins and minerals are added back) and typically adds salt, sugar, and calories to disguise these effects. Minimal processing excludes foods high in salt and sugars and low in fiber. It also excludes sugary sodas and juice drinks. These are popularly known as “junk foods” or “foods of minimal nutritional value.” They are best consumed rarely and in small amounts. My additional rules about minimal processing are only slightly facetious: Don’t eat anything with more than five ingredients. Don’t eat anything with an ingredient you can’t pronounce. Moderation is about balancing calorie intake with expenditure and maintaining a healthy weight through food choices and physical activity. Today, overweight and obesity are leading risk factors for chronic disease and disability. Patients need to hear from doctors about the importance of maintaining a healthy weight through balancing food intake with physical activity. These are general principles. Beyond them, nutrition advice must be personalized to the particular individual or family. To do that quickly: Continued on page 14 . . .

Food for Thought

Finding a Nutritionist A Guide to Finding a Qualified Nutritionist in the San Francisco Bay Area

Erica Goode, MD, MPH

N and the California Dietetic Association’s

What to Look for in a Nutritionist or Dietitian

Nancy Bennett, RD (415) 346-1475. Specifically for inflammatory bowel disease; other issues such as irritable bowel, food allergies

utritionists and dietitians are valuable adjuncts to the health of patients. They can provide nutrition information, track food habits, provide support, and hold a patient accountable for making changes over time. An important first step in helping a patient find this support is knowing who and where these professionals are. A registered dietitian has at least a four-year bachelor’s degree (or a graduate degree) in nutrition and dietetics, has completed an internship, and has passed a national registration exam from the American Dietetic Association. A person with a master’s degree in nutrition can be called a nutritionist. However, the title is used by a variety of persons, even those without formal training. Look for nutritionists with an MS, PhD, MPH or other universitybased degree in nutrition who belongs to the American Dietetic Association, the American Society for Nutrition, the Society for Nutrition Education, the American Public Health Association, or the American Society for Parenteral and Enteral Nutrition. In addition, a number of advanced certification programs are required prior to nutrition care of those with renal disease, congestive heart failure, diabetes, or serious hyperlipidemias.

Where to Find a Nutritionist or Dietitian

Two websites to help you locate nutritionists and dietitians are the American Dietetic Association’s www.

A Short List of San Francisco Nutritionists and Dietitians

Norae Ferrara, RD (415) 666-3220. Cardiac care nutrition issues, allergies and food, diabetes

Judith Levine, MS, RD (415) 273-5606. Specifically for long-term management of nutrition issues for children, adults; some emphasis on weight loss Tami Lyon, RD, certified in eating disorders (888) 945-6887. Nutrition counseling for all types of eating-disordered patients and referrals to other eating disorder services, sports nutrition, obesity Elyse Robin, RD (415) 648-2424. General nutrition, vegetarian or other diets

Manuel Villacorta, MS, RD (415) 692-1480 Weight management

The Association of Professionals Treating Eating Disorders (APTED) (415) 771-3068. Developed and run by Deborah Brenner-Liss, PhD, provides a nidus of information about nutritionists, PhDs, psychologists, psychiatrists,

and other professionals working with eating disorders throughout the Bay Area. A directory of these resource people is available free of charge to professionals (physicians and others) who might refer to those listed. Dr. Brenner-Liss occasionally provides workshops on eating disorders for other professionals.

California Pacific Medical Center (415) 600-6000. The Community Health Resource Center, CHRC, provides a wealth of day and early-evening groups for weight management and some eating disorders, as well as some classes on food preparation. In January 2011 the group will add groups for children and parents, for weight management and other nutrition issues. Laura Shipley, one of the RDs on staff, works particularly with early kidney disease patients. Classes held on the Pacific Campus of CPMC. The Women’s Health Program provides many classes on aspects of nutrition, as well as some individual counseling. Classes held on the East Campus of CPMC. Classes for new parents are held at St. Luke’s, regarding nutrition and feeding for infants following lactation. Lonnie Wong, RD, CNSC (415) 600-0770. Specifically for complex pediatric feeding issues, including eating disorders Jane Tien, RD (415) 600-6000. Renal nutritionist

St. Mary’s and St. Francis (Catholic Healthcare West) Continued on page 14 . . .

November 2010 San Francisco Medicine 11

Food for Thought

An Unhealthy Food System Suggestions for Physician Advocacy

David Wallinga, MD, MPA


ood-related crises are reverberating through our health care system. It’s time for physicians to not simply treat the fallout but to help get to the root of the problem and prevent it. Obesity is an expensive plague, costing at least $147 billion per year just in direct treatment costs.1 Costs of managing the related diseases would push the total higher. But the problems only begin with the obesity epidemic. We face near-continuous outbreaks of food-borne disease: salmonella in eggs this year; a different salmonella strain (S. typhimurium DT104) in Colorado ground beef and in peanut butter last year, and so on. Food safety threats have always been present. What is new are mammoth food plants that amass huge quantities of meat or another product from so many locations, mix it, and then send it all across the country—factors making national disease outbreaks more likely and more difficult to track back to the source. The hamburger felling one particular young dancer with E. coli O157:H7, according to the New York Times, had ingredients from probably tens of different cows and from slaughterhouses in Nebraska, Texas, and Uruguay. Another 10 percent of that burger came from trimmed beef fat from whoknows-how-many cows collected by Beef Products, Inc., a South Dakota company, which after collection douses the trimmings with ammonia to kill the E. coli.2 Then there are problems with arsenic and antibiotics. Both are put routinely into feed for healthy animals. Both are unnecessary practices, as neither European meat producers nor American organic producers use them. This overuse of human antibiotics (tetracycline, penicillin, erythromycins, streptogramins, etc.) helps

create bacterial resistance transmitted to humans. Leadership of the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) acknowledge the routine use of medically important antibiotics in animal feed as a significant public health problem, and one that has to change. 3,4 Arsenic and antibiotics given to animals inevitably end up manure, and thereby in the broader environment, where they help create environmental reservoirs of resistant bacteria. They are just two of a greater number of pollutants arising from industrialized agriculture that wend their way into water supplies. Many others, like atrazine and other common pesticides, are endocrine disrupters—chemicals that disrupt hormone synthesis or function. Other food-chain pollutants of note include food dyes that now appear to worsen hyperactivity, mixtures of pesticides common on produce, and hormone-disrupting bisphenol A (BPA) in baby bottles and the plastic liners of infant formula cans. Last year, we coauthored two papers pulling the curtain off the problem of mercury in high fructose corn syrup. Caustic soda from one particular kind of chemical factory is mercury-contaminated and intentionally used in making this sweetener that’s put into so many foods for children and others.5,6 The list goes on.

The Problem of Industrialization

It’s important to not simply consider the litany of food system problems as isolated incidents. Rather, these crises are interrelated. And the systemic or interrelated nature of these problems cries out for health professionals to stand up and be a voice for change to a healthier food system.

13 San Francisco Medicine November 2010 12 San Francisco Medicine November 2010

Food system crises are related precisely because it is a system. (By the food system, I mean the totality of food production, but also its harvest, processing, marketing, and distribution.) The hallmark of any system—like the human body—is that it is dynamic and functions as a complex whole, making it impossible to easily divorce one part of the system from any other. Thus, the health of the food we put in our mouths cannot be divorced from the health of the natural world, the “agro-ecosystem” that gives rise to it—the atmosphere, soils, fresh water, and genetic resources.7 Uniting these crises as well is their origin in the decades-long process of industrialization. Industrialization rolls along according to its own peculiar logic, but it’s marked by a singular focus on specialization and production to the exclusion of most of other qualities, such as health or sustainability, for example.8 This transformation has radically altered how we produce and distribute food, affecting the fundamental health of both humans and the planet we live on. Under industrialization, the American farm was transformed from a fairly self-sufficient entity that produced a variety of different foods into a specialized factory that produces one or maybe two widgets (corn or soybeans, chickens or hogs), reliant on the intensive use of off-farm resources (feed, oil and other energy, fertilizer, and antibiotics). Aiding this process, as I wrote recently in Health Affairs, has been a U.S. farm policy that for the past thirty-five years has chiefly promoted the overproduction of “cheap food.”9 Not edible fruits and vegetables, mind you, but the overproduction of inexpensive feed-grade corn, soybeans, and a few other “commodity” crops, and the calories derived from them. Through

various incentives, farmers are encouraged to produce as much as possible of these less-than-healthy foods. But this cheap food policy may no longer be affordable. As Nicholas Kristof of the New York Times, himself a farm boy, recently observed, “Industrial operations—essentially factories of meat and eggs—excel at manufacturing cheap food for the supermarket. But there is evidence that this model is economically viable only because it passes on health costs to the public—in the form of occasional salmonella, antibiotic-resistant diseases, polluted waters, food poisoning, and possibly certain cancers.”10 If the long-term costs of the obesity epidemic are thrown into the mix, the “cheap food” system looks even more expensive. And health costs aside, a food system that relies so heavily on cheap, abundant fossil fuels in the form of diesel fuel, pesticides, and fertilizers may soon become unsustainable as energy costs rise. Let’s use a food system perspective, where everything is related, to look at how this cheap food policy since 1974 ties to some of the health crises we’ve seen, starting on the farm. Predictably, we’ve seen a decades-long glut of corn and soybeans, and market prices for the vast majority of that time have dropped below what it actually costs farmers to produce these crops. Since the late 1990s, “emergency” payments to farmers have kept them in business despite low prices. These subsidies have now become permanent. (It’s important to note that federal “cheap food” policies preceded these subsidy programs by almost twenty years. Getting rid of subsidies alone will not solve the glut of corn or soybeans.) So what’s become of the excess calories stemming from this overproduction of corn and soybeans? Food processors and manufacturers have been quite creative, turning raw corn and soy into low-cost ingredients, like the added fats and sugars that factor so prominently in the snacks, sweets, beverages, and fast foods that comprise a large part of the American diet. Since 1970, the average American’s consumption of corn calories—including corn flour, corn meal, hominy, and corn starch—is up 191 percent. Calories from corn sweeteners rose 359 percent over

1970 levels, to 246 calories per day. The now-ubiquitous high fructose corn syrup did not really exist in the U.S. food supply prior to 1970.9 Calories consumed in the form of added fats and oils has increased 69 percent since 1970, with a 260-percent calorie increase in salad and cooking oils. Soy oil accounts for 70 percent of fats and oils eaten by Americans, and another 8 percent are corn oil. You get the picture.9 Retail prices for these food products have declined along with the production glut. From 1985 to 2000, the price of carbonated soft drinks, made with high fructose corn syrup, dropped 23 percent. Fats and oils, mostly from soybeans, dropped 14 percent in that time period; sugars dropped 7 percent. Meanwhile, the real costs of fruits and vegetables rose nearly 40 percent over the same period.8 Still, most of the nation’s corn and soybeans get fed to cattle, pigs, and poultry, either here or abroad. The federal policies that make these feed grains cheaper than a working market would allow serve as a de facto subsidy to the world’s largest meat producers—one they’ve enjoyed for decades now.11 Raising animals on cheap feed grains rather than on forage or grass requires that they be centralized and, at least in the case of chickens and hogs, raised indoors. And so was born the modern-day factory farm. Tens of thousands of animals (and their manure) are crammed into one barn and then fed routine antibiotics to make them grow faster, or to keep them just healthy enough to reach slaughter despite being crammed into an indoor barn. In fact, an estimated 70 percent of all antimicrobials used in the U.S. are fed to chickens, hogs, and beef cattle for just such purposes.12 All these examples illustrate the point that in an industrialized food system, production and little else matters. Not health, not antibiotic resistance, and not pollution. Given the rationale of the cheap food policy, the quantity of calories produced, and not their quality, has been of primary importance.

What You Can Do

President Obama’s cancer advisory panel recently urged the president to “use

the power of your office to remove the carcinogens and other toxins from our food, water, and air that needlessly increase health care costs, cripple our nation’s productivity, and devastate American lives.” The Bush-appointed panel found that “the true burden of environmentally induced cancers has been grossly underestimated.” Among its recommendations: Filter your water, eat certified organic food, and avoid storing food or drink in plastics containing bisphenol A.13 But putting the entire burden of responding to an unhealthy environment on individuals is wrongheaded and in the long run will prove ineffective at preventing disease. Physicians recognized this fact in becoming strong advocates for tobacco-free environments. It had become clear that without environmental change, individuals socialized to smoke and manipulated by marketing and the addictive properties of nicotine would continue to smoke. The health community also provided a critical and necessary counterweight to the financial and political might of the tobacco industry. We are at a similar point with respect to the food system. There is rising acceptance that an unhealthy food environment helps drive obesity and other chronic disease. Because that food environment is a system, change will not be simple or easy. Experts instead are calling for public health interventions at multiple levels—local, state, national, and even international. Many local entities are working to improve access to healthy foods at the community level, or in schools or health institutions, in part due to government stimulus funds. Because of the health implications and the respect they are afforded, physicians are critical voices for generating lasting support for these changes in their communities. Some examples of organizations you can work with for change are listed at the end of this piece. But the food system is national, even global in nature. To counter the decades of inertia and vested interests in an unhealthy food system, even more work will be needed. Sustained change across the country will require national leadership. Major medical associations such as the AMA and the Continued on the following page . . .

November 2010 San Francisco Medicine 13

An Unhealthy Food System Continued from previous page . . . American Academy of Pediatrics are becoming increasingly involved in food policy issues. The AMA, along with the American Dietetic Association and the American Public Health Association, has developed positions on healthy, sustainable food systems. The American Academy of Pediatrics is working with the First Lady’s Let’s Move campaign to involve physicians in writing prescriptions for parents “laying out the simple things they can do to increase healthy eating and active play.” Finally, these and other health organizations are interested in a healthier Farm Bill, the huge piece of legislation that lays the foundation not only for the food stamp program but for what farmers grow, how they grow it, and what methods they will use in the future. The Farm Bill is due to be rewritten in 2012. Individuals can join Healthy Food Action ( to stay apprised of this and other efforts. This national initiative provides busy health professionals with easy ways to stay informed about the links between health, food, and farm policy, and it identifies a few important policies they can weigh in on to try and make a change. Given clear science and signals that our industrialized food system is helping cause many of the health crises physicians face in their practice, the medical community can no longer afford to stand on the sidelines. Now is the time for physicians to lead in the building of a healthier food system. A Healthy Food Bill, rather than a Farm Bill, is a good place to start. David Wallinga, MD, MPA, is Director of the Food and Health program at the Minneapolis-based Institute for Agriculture and Trade Policy. He is also a William T. Grant Foundation Distinguished Fellow in Food Systems and Public Health at University of Minnesota, School of Public Health. References are online at Advocating for Healthier Food Systems In schools:, www.; in hospitals: www.; in communities: www.HealthyFoodAction,

Doctor’s Orders Continued from page 10 . . . • Ask patients what they and their children eat. You can start with a waiting room questionnaire that probes typical intake of foods and supplements. This alone will make it clear that you think diet is worth discussing. • Screen the responses for variety, minimal processing, moderation, and excessive or unusual supplement use. Note whether body weights are within healthy ranges. Ask someone on your staff to do the screening and mark items that could use attention. • Reassure patients whose diets are varied, minimally balanced, and moderate that they are doing wonderful things for their health and should keep doing what they are doing. • Refer observations that need further discussion to a nutritionist. This last point means that doctors don’t have to do it all. Making it clear to patients that diet matters is often enough to encourage them to make better dietary choices. Patients who seem unlikely to respond or who need further discussion and intervention can be referred to a well-trained nutritionist who is skilled at dealing with such issues. These days, the effects of food on health are matters of great public interest and concern. Patients expect their doctors to care about what they eat, to ask about their dietary practices, and to answer questions about food issues they have heard or read about. A referral can help with the questions, but any doctor ought to be able to care and ask—and do much public good as a result. Marion Nestle, PhD, MPH, is a professor in the Department of Nutrition, Food Studies, and Public Health at New York University. Her degrees include a PhD in molecular biology and an MPH in public health nutrition, both from the University of California, Berkeley. From 1976-86 she was Associate Dean of UCSF School of Medicine, where she taught nutrition to medical students, residents, and practicing physicians. Her book about food issues for the general public is What to Eat (North Point Press/Farrar, Straus & Giroux, 2007).

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Finding a Nutritionist Continued from page 11 . . . (415) 438-5500. These hospitals have their own referral services; available by calling the general number and asking for the Food and Nutrition Services Dept. Veteran’s Administration Hospital Carol Ceresa, RD Director of Clinical Nutrition Services for the hospital For Outpatient Nutrition Services, providing a wide range of clinics, classes, and individual counseling for veterans, call (415) 221-4810 extension 2895.

UCSF General directory (415) 476-9000. Outpatient adult services are obtained through the WATCH program, (415) 353-2291. Andrea Garber, RD, PhD (415) 514-2180 Outpatient pediatric nutrition Robert Lustig, MD (415) 502-8672. Nutrition for children, health policy issues. Laurel Mellin, RD, Dept. of Family and Community Medicine (415) 476-3751. Founder of the Shapedown Program for weight management in pre-adolescent children, Mellin now focuses on mindfulness eating, which is critical for people developing self-control and self-esteem around issues regarding food.

Wider Bay Area Programs and experts in nutrition are available in Marin, the East Bay, and the South Bay, particularly at Alta Bates Hospital, Berkeley, and at Stanford. For children, call (650) 497-8000 at Lucile Packard Children’s Hospital.

Food for Thought

Taking Action A Health Sector Guide to Food System and Agricultural Policy

Brian Raymond, MPH


hen considering agricultural policy and the foods we eat, consider the following: • The health sector has the opportunity and responsibility to address the nation’s chronic disease burden and health care cost crisis by promoting a healthy and sustainable food system. • A wide variety of legislative initiatives to promote sustainable agricultural practices and a healthier food system would benefit from greater health sector involvement. • The U.S. Farm Bill is a critical piece of legislation that health care leaders can influence to ensure that future policies support healthy diets, are ecologically sound, and foster a sustainable agricultural economy.

What Health Care Leaders Need to Know

Health care leaders are becoming more involved in reform of the nation’s food systems and agricultural policies as a means to address the growing chronic disease burden and health care cost crisis. Poor nutrition, which links directly to America’s food and agricultural policies, is a risk factor for four of the six leading causes of death in the United States: heart disease, stroke, diabetes, and cancer. Furthermore, the current industrial model of food distribution and production has significant health impacts by promoting antibiotic-resistant bacteria, air and water pollution, food-borne pathogens, climate change emissions, and the declining wellbeing of rural communities. Agricultural and food policies play such an influential role on health that many experts are arguing that future policy

should be reframed through a health lens. Health care leaders can act upon the following policy opportunities to shift the food system in service of health.

Key Opportunity for Policy Influence A critical piece of federal legislation, the Farm Bill, will be reauthorized in 2012. The bill includes hundreds of programs that influence the food production and distribution systems. It is the primary agricultural and food policy tool of the federal government and addresses issues such as nutrition, food stamps, conservation programs, agriculture trade, and more. As a result of the close interrelationship between food, agriculture, and health, it should be considered a Food, Farm, and Health Bill. However, the 2008 reauthorization of the Farm Bill was notable for the absence of health sector involvement.

Promote Sustainable Agricultural Production What farmers grow, how they grow it, and how it gets to our tables has a profound impact on our health and our environment. Sound agricultural policy is the starting point for a sustainable food system.

Support for New and Existing Small and Mid-Sized Farms

Preserving a network of small and mid-sized farms is at the core of forging a strong agricultural base. Support is critical to motivating and sustaining a new generation of farmers. Policies can also help owners of small and mid-sized farms compete and succeed by opening new markets.

Support for Local/Regional Food Systems With food traveling an average of 2,500 to 4,000 miles from farm to plate,1 purchasing food from regional suppliers and establishing local distribution and light processing infrastructure can help create a seamless, convenient process for everyone in the supply chain, while also reducing air pollution and reducing asthma and other respiratory illnesses.

Support for Improved Food Safety

The many food-borne disease outbreaks—from spinach to hamburgers to peanut butter to pet food—have drawn attention to the weak state of the Food and Drug Administration, both in terms of its authority and its resources to protect the food supply.

Promote Subsidies for Healthy Foods

Current agricultural policies underwrite a food system that is out of balance with federal nutrition policy. For instance, the 2008 Farm Bill provided $41.6 billion to Commodity Title Programs2—including subsidy payments for corn, wheat, and soybeans, used for animal feed and as ingredients in our high-calorie, highly processed food supply. The recent debate over reauthorization of the Farm Bill began to question whether these subsidies should be shifted to support production of healthier foods, such as fruits and vegetables.

Promote Sustainable Production Methods

Given appropriate incentives, growContinued on the following page . . .

November 2010 San Francisco Medicine 15

Continued from previous page . . . ers can be encouraged to engage in more sustainable agricultural production practices that protect human health and the environment. This includes policies that encourage or require growers to produce food with little or no synthetic pesticides, hormones, or antibiotics, and to address the waste management practices of agriculture production, such as Concentrated Animal Feeding Operations (CAFOs).

Reduce Pesticide Use

Reducing pesticide use is a key health priority, not only for humans but for all species. Organic agricultural production has successfully produced quality crops without use of harmful pesticides.

Regulate Confined Animal Feeding Operations (CAFOs)

CAFOs—huge, enclosed animal feedlot operations—require appropriate regulation to preserve the environment and protect human health from antibiotic resistance and other dangers. Several states and localities have successfully addressed this issue.3

Eliminate Nontherapeutic Antibiotics from the Food Supply

Rising rates of antibiotic resistance in humans is making otherwise treatable illnesses more difficult to treat. With more than 70 percent of all antibiotics consumed in this country being used as feed additives for poultry, swine, and beef cattle for nontherapeutic purposes,4 public policy must begin to address this critical issue.

Ensure Climate Change Policy Includes Sustainable Food Systems as a Mitigation and Adaptation Strategy

About 30 percent of global emissions leading to climate change are attributable to agricultural activities, including land use changes such as deforestation.5 Industrialized agriculture methods are fossil-fuel intensive; the U.S. food system accounts for an estimated 10.5 percent of the nation’s energy use and 19 percent of its fossil fuel consumption.

Improve Access to Healthy Food in Underserved Neighborhoods Many community organizing efforts have been launched to improve and return grocery stores to underserved neighborhoods. This takes significant time, money, and government support. These efforts have relied on public-private partnerships to reduce entry costs for new stores and to streamline their development process. Health care leaders can encourage local political leadership to recruit healthy food retailers and provide financial and regulatory incentives, siterelated assistance, expedited permitting, and tax breaks to stimulate grocery store development and improvements in underserved neighborhoods.

Bolster SNAP (Food Stamp Program)

The Supplemental Nutrition Assistance Program (SNAP), the new name for the Food Stamp Program designated by the 2008 Farm Bill, is the pivotal program for mitigating hunger. It provides monthly benefits through an Electronic Benefit Transfer (EBT) card, which can be used to buy foods and beverages at authorized outlets. With greater purchasing power, low-income customer bases may be able to sustain grocery stores and other food merchants in their neighborhoods. Revenue from SNAP (and from the WIC and the Senior Farmer’s Market Nutrition Programs) has helped some farmer’s markets survive in poor neighborhoods.6

Support Restrictions on Food and Beverage Marketing to Children

The Institute of Medicine issued a seminal report in 2005, “Food Marketing to Children and Youth: Threat or Opportunity?” This report reached the conclusion that “food and beverage marketing practices geared to children and youth are out of balance with healthful diets and contribute to an environment that puts their health at risk.”7 Strategies to address television advertising include working with food and beverage companies to strengthen and develop pledges restricting children’s advertising and engaging media companies, including television

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networks and movie studios, to develop and/or reinforce their own standards for children’s advertising.

Support Food Labeling and Health Claims

American consumers and health care purchasing professionals have shared their interest in receiving more transparency in the supply chain so that they can make informed decisions about the foods they buy. This includes what is in their food; how it is produced; how livestock is treated; and what chemicals, additives, and/or hormones are used to grow and produce the food.


New approaches to agricultural and food policy are vital if we are to reverse the trend of spiraling health care costs, widening health inequalities, and rising rates of disease related to food and food production. Future policy must promote agricultural practices that sustain ecological function and promote human and environmental health. Health care leaders have a broad range of opportunities allowing them to play a decisive role in advancing food system policies that are healthy for patients, communities, and the planet. Brian Raymond, MPH, is a Senior Policy Consultant for Kaiser Permanente Institute for Health Policy. Reprinted with permission from In Focus, a publication by Kaiser Permanente Institute for Health Policy. In Focus is a series of briefs designed to bring key research findings on important health policy issues to the attention of health policymakers. This issue brief is based on Harvie J, Mikkelsen L, Shak L. “A New Healthcare Prevention Agenda: Sustainable Food Procurement and Agricultural Policy.” Commissioned background paper for the Food Systems and Public Health Conference, Airlie Center, Warrenton, VA, April, 2009. For more information on this and related issues, please visit the Institute for Health Policy website at A full list of references is available online at

Food for Thought

How the Food Industry Drives Us to Eat An Interview with Kelly Brownell, PhD


elly Brownell is a professor in the Department of Psychology at Yale University. He is also a professor of epidemiology and public health. Brownell cofounded and directs Yale’s Rudd Center for Food Policy and Obesity, which works to improve the world’s diet, prevent obesity, and reduce weight stigma. Brownell, who is a member of Nutrition Action’s scientific advisory board, has published more than 300 scientific articles and chapters and fourteen books, including Food Fight: The Inside Story of the Food Industry, America’s Obesity Crisis, and What We Can Do About It (McGraw-Hill). He spoke to Nutrition Action’s Bonnie Liebman from New Haven. Excess pounds raise the risk of diabetes, heart disease, stroke, cancer (of the breast, colon, esophagus, kidney, and uterus), gallbladder disease, arthritis, and more. And once people gain weight, the odds of losing it and keeping it off are slim. “Estimates are that this generation of children may be the first to live fewer years than their parents,” says Kelly Brownell. “Health care costs for obesity are now $147 billion annually.” What are we doing about it? Not enough. “The conditions that are driving the obesity epidemic need to change,” says Brownell. Here’s why and how. Q: Why do you call our food environment toxic? A: Because people who are exposed to it get sick. They develop chronic diseases like diabetes and obesity in record numbers. Q: How does the environment influence what we eat? A: When I was a boy, there weren’t aisles of food in the drugstore, and gas stations weren’t places where you could

eat lunch. Vending machines in workplaces were few and far between, and schools didn’t have junk food. Fast-food restaurants didn’t serve breakfast or stay open twenty-four hours. Today, access to unhealthy choices is nearly ubiquitous. Burgers, fries, pizza, soda, candy, and chips are everywhere. Apples and bananas aren’t. And we have large portion sizes— bigger bagels, burgers, steaks, muffins, cookies, popcorn, and sodas. We have the relentless marketing of unhealthy food, and too little access to healthy foods. Q: Does the price structure of food push us to buy more? A: Yes. People buy a Value Meal partly because that large burger, fries, and soft drink cost less than a salad and bottle of water. A large popcorn doesn’t cost much more than a small one. A Cinnabon doesn’t cost much more than a Minibon. Q: And most stores are pushing junk food, not fresh fruit? A: Yes. There’s a Dunkin’ Donuts at our Stop ’n Shop supermarket and at the Wal- Mart near us. And if you look at retail stores, they’re set up in ways that maximize the likelihood of impulse purchases. For example, the candy is on display

at the checkout line at the supermarket. And when you go to a modern drugstore, the things you usually go to a drugstore to buy—like bandages, cough medicine, pain reliever, your prescriptions—are all at the back. People typically have to walk by the soda, chips, and other junk food to navigate their way there and back.

Old Genes, New World

Q: You’ve said that our biology is mismatched with the modern world. How? A: Thousands of years ago, our ancestors faced unpredictable food supplies and looming starvation. Those who adapted ate voraciously when food was available and stored body fat so they could survive times of scarcity. Our bodies were programmed to seek calorie-dense foods. They were exquisitely efficient calorie-conservation machines, which matched nicely with a scarce food supply. But now we have abundance. And there’s no need for the extreme physical exertion that our ancestors needed to hunt and gather food. It’s a mismatch. Continued on the following page . . .

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Continued from previous page . . . Q: How do ads encourage overeating? A: Overeating is written into the language that companies use—names like Big Gulp, Super Gulp, Extreme Gulp. At one point, Frito-Lay sold dollar bags of snack foods called the Big Grab. The burger companies describe their biggest burgers with words like the Monster Burger, the Whopper, the Big Mac. The industry capitalizes on our belief that bigger is better and promotes large amounts of their least healthy foods. Q: Why do we want a good deal on a bad food? A: Everybody likes value. Getting more of something for your money isn’t a bad idea. You like to do that when you buy an automobile or clothing or laundry detergent or anything. But when the incentives are set up in a way that offers value for unhealthy food, it’s a problem. If you buy the big bag of Cheetos, you get a better deal than if you buy the little bag. A big Coke is a better deal than a little Coke. But if you buy six apples, you don’t always get a better deal than if you buy three.

Q: Is indulgence a code word for overeating? A: Right. You deserve a reward and we’re here to offer it to you. And ads describe foods as sinful. Or we make light of eating too much, like the ad that said, “I can’t believe I ate the whole thing.”

Are We Irresponsible?

Q: How does the food industry blame people for the obesity epidemic? A: The two words it uses most frequently are personal responsibility. It plays well in America because of this idea that people should take charge of their own lives and because some people have the biological fortune to be able to resist our risky environment. But it also serves to shift blame from the industry and government to the individuals with a weight problem. It’s right out of the tobacco-industry playbook.

Q: What else is in the food industry’s playbook? A: Industry spokespeople raise fears that government action usurps personal freedom. Or they vilify critics with totalitarian language, characterizing them as the food police, leaders of a nanny state, and even food fascists, and accuse them of trying to strip people of their civil liberties. They also criticize studies that hurt the food industry as “junk science.” And they argue that there are no good or bad foods—only good or bad diets. That way, soft drinks, fast foods, and other foods can’t be targeted for change. Q: So people think it’s their fault? A: Many people who struggle with weight problems believe it’s their own fault anyway. So exacerbating that is not helpful. But removing the mandate for business and government to take action has been very harmful. For example, if you look at funding to reduce obesity, it has lagged far behind the extent of the problem. It’s because of this idea that people are responsible for the way they are, so why should government do anything about it?

Q: Are people irresponsible? A: There’s been increasing obesity for years in the United States. It’s hard to believe that people in 2010 are less responsible than they were ten or twenty years ago. You have increasing obesity in literally every country in the world. Are people in every country becoming less responsible? We looked into the literature to find data on other health behaviors like mammograms, seat belt use, heavy drinking, and smoking. All those other behaviors have remained constant or have improved in the U.S. population. If irresponsibility is the cause of obesity, one might expect evidence that people are becoming less responsible overall. But studies suggest the opposite. So if people are having trouble acting responsibly in the food arena, the question is why? There must be enormous pressure bearing down on them to override their otherwise responsible behavior.

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Q: It’s not as though society rewards obesity. A: No. Obesity is stigmatized. Overweight people, especially children, are teased and victimized by discrimination. Obese children have lower self-esteem and a higher risk of depression. They’re less likely to be admitted to college. And obese adults are less likely to be hired, have lower salaries, and are often viewed as lazy and less competent. So the pressure to overeat must be overwhelming. Q: Are the pressures worse for children? A: Yes. Kids don’t have the natural cognitive defenses against marketing. And they’re developing brand loyalty and food preferences that can last a lifetime. To allow the food industry to have free rein with our children has come at a tremendous cost. A third of kids are now overweight or obese. And when you project ahead to the adult diseases that will cause, it’s incredible. Someday, our children may wonder why we didn’t protect them from the food companies. Q: Do we do anything to protect kids? A: We do some nutrition education in schools, but it’s a drop against the tidal wave of what the food industry is doing to educate those children. The Robert Wood Johnson Foundation is by far the biggest funder of work on childhood obesity, and it’s now spending $100 million a year on the problem. The food industry spends that much every year by January fourth to market unhealthy food to children. There’s no way the government can compete with that just through education. If parents ate every meal with their children, that would amount to 1,000 teaching opportunities per year. Yet the average child sees 10,000 food ads each year. And parents don’t have Beyoncé, LeBron, and Kobe on their side. Q: So if irresponsibility isn’t to blame, what is? A: When you give lab animals access to the diets that are marketed so

sively in the United States, they become obese. We have abundant science that the environment is the causative agent here. So the environment needs to be changed. That’s what public policy is all about. We require that children get vaccinated and ride in child-safety seats. We have high taxes on cigarettes. Your car has an air bag. The government could educate us to be safe drivers and hope for the best. Or it could just put an air bag in every car. Those are examples of government taking action to create better defaults.

Keeping It Off

Q: Why is it so important to prevent obesity? A: Because it’s so difficult to fix. The results of studies on treating obesity are very discouraging, especially if one looks at long-term results. The exception is surgery, but that’s expensive and can’t be used on a broad scale. So this is a problem that screams out to be prevented.

Q: Why is it so hard to keep weight

off? A: There’s good research, much of it done by Rudolph Leibel and colleagues at Columbia University, that shows that when people are overweight and lose weight, their biology changes in a way that makes it hard to keep the weight off. Take two women who weigh 150 pounds. One has always weighed 150 and the other was at 170 and reduced down to 150. Metabolically, they look very different. To maintain her 150-pound weight, the woman who has dropped from 170 is going to have to exist on about 15 percent fewer calories than the woman who was always at 150. Q: Why? A: It’s as if the body senses that it’s in starvation mode, so it becomes more metabolically efficient. People who have lost weight burn fewer calories than those who haven’t, so they have to keep taking in fewer calories to keep the weight off. That’s tough to do day after day, especially when the environment is pushing us to eat more, not less. And Leibel and others have shown

that there are changes in hormones, including leptin, that explain why people who lose weight are hungry much of the time.

Q: Are you saying that our bodies think we’re starving when we lose just 10 percent of our body weight? A: Right. It’s not hopeless, but the data can be discouraging. The results of weightloss studies are clear. Not many people lose a significant amount of weight and keep it off. All these environmental cues force people to eat, and then this biology makes it hard to lose weight and keep it off. Q: Does genetics play a role in obesity? A: Yes. Genetics can help explain why some people are prone to gain weight and some are not. But genetics can’t explain why there are so many overweight people. The reason we have more obesity than Somalia, let’s say, is not because we’re genetically different. The fact that so many people are overweight is all environment.

Addictive Foods

Q: Are some foods addictive? A: My prediction is that the issue of food and addiction will explode onto the scene relatively soon, because the science is building almost by the day and it’s very compelling. I think it’s important to put the focus on the food, rather than the person. There are people who consider themselves food addicts, and they might be, but the more important question is whether there are enough addictive properties in some foods to keep people coming back for more and more. That’s where the public health problem resides. Q: What are those properties? A: What’s been studied most so far is sugar. There are brain-imaging studies in humans and a variety of animal studies showing that sugar acts on the brain very much like morphine, alcohol, and nicotine. It doesn’t have as strong an effect, but it has a similar effect on reward pathways in the brain. So when kids get out of school and they feel like having a sugared beverage, how much of that is their brain calling

out for this addictive substance? Are we consuming so many foods of poor nutrient quality partly because of the addictive properties of the food itself?

Q: What do you mean by “reward pathways”? A: There are pathways in the brain that get activated when we experience pleasure, and drugs of abuse like heroin hijack that system. The drugs take over the system to make those substances extremely reinforcing and to make us want those things when we don’t have them. The drugs do that by setting up withdrawal symptoms when we don’t have them. The drugs set up the addiction by creating tolerance, so you need more over time to produce the same effect. The drugs set us up to have cravings. The same reward system is activated by foods, especially foods high in sugar. Q: Do we need more research in people? A: Yes, but we already have animal and human studies, some done by highly distinguished researchers. I think this is a top priority because if we get to the point where we say that food can be addictive, the whole landscape can change. Think of the morality or legality of marketing these foods to children. Could the industry ever be held accountable for the intentional manipulation of ingredients that activate the brain in that way? The stakes are very high. Q: How much does exercise matter to losing weight? A: Exercise has so many health benefits that it’s hard to count them. It lowers the risk for cancer, heart disease, and cognitive impairment as people age. There’s a very long list of reasons to be physically active, but weight control may not be one of them. Recent studies have suggested that the food part of the equation is much more important than the activity part. Q: Because you can undo an hour of exercise with one muffin? A: Yes. The food industry has been Continued on the following page . . .

November 2010 San Francisco Medicine 19

Continued from previous page . . . front and center in promoting exercise as the way to address the nation’s obesity problem. The industry talks about the importance of physical activity continuously, and they’ve been quite involved in funding programs that emphasize physical activity. The skeptics claim that that’s the way to divert attention away from food.


Q: So what’s the answer to the obesity epidemic? A: The broad answer is to change the environmental conditions that are driving obesity. Some of the most powerful drivers are food marketing and the economics of food, so I would start there. I don’t think we have much chance of succeeding with the obesity problem unless the marketing of unhealthy foods is curtailed. Q: Not just to kids? A: No, but children would be a great place to start. Second would be to change the economics so that healthy food costs less and unhealthy food costs more. So a small tax on sugar-sweetened bever-

ages—say, one penny per ounce—would be part of that effort. Ideally, the tax revenues would be used to subsidize the cost of fruits and vegetables. That creates a better set of economic defaults. Now, especially if you’re poor, all the incentives are pushing you toward unhealthy foods.

Q: Like zip codes where there are no grocery stores? A: That’s a great example of a bad default. Another, which applies not just to the poor, would be what children have available in schools. You can sell a lot of junk in schools and then try to educate your way out of it. Or you can just get rid of the junk food and kids will have healthier defaults. They’ll eat healthier food if that’s what’s available. You can inspire that just by changing the default. Imagine the optimal environment to combat obesity. We would have affordable and healthful food, especially fresh fruits and vegetables, easily accessible to people in low-income neighborhoods. TV commercials for children would encourage them to eat fresh fruits and vegetables

rather than pushing processed snacks that are associated with TV and movie characters. And every community would have safe sidewalks and walking trails to encourage physical activity.

Q: So people wouldn’t have to struggle to avoid eating junk? A: Right. We have a terrible set of defaults with food: big portions, bad marketing, bad food in schools. These conditions produce incentives for the wrong behaviors. So the question is: Can we create an environment that supports healthy eating, rather than undermines it? If you count the number of places where you can buy sugared beverages and salty snack foods and candy, it’s enormous. If you count the number of places where you can buy baby carrots and oranges, it’s a fraction of that. So if you were creating an environment from scratch, you would do the opposite of what we have. The population deserves a better set of defaults. Reprinted with permission from the Center for Science in the Public Interest’s Nutrition Action Health Letter, May 2010.

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Food for Thought

Nutrigenetics An Introduction

Erica Goode, MD, MPH


utrigenetics involves exploring the genome of one individual, or more often a subset of some group (an Amish community in Pennsylvania, for example, with known genetic variation from other groups), to determine, based on that person or pattern seen in a group, what has gone awry that then makes for higher susceptibility to problems with one’s responses to foods. Since DNA produces mRNA, encoding for proteins, which then leads to normal or aberrant metabolism, this process is extremely complex. (Recall that DNA involves three billion base pairs; mRNA involves 25,000 genes.) Although any two humans are 99 percent identical genetically, there can still be variations in 1/1000 base pairs. When a single base pair is altered or lost, this shift is a “SNP,” or Single Nucleotide Polymorphism. Understanding these genetic variations among humans will help us better tailor medical treatments, diet, and so forth. The U.S. News and World Report article “The Diet of the Future: Geared to Your Genes?” (December 2009) does an interesting job of exploring the state of our ability to translate genetic information into behavioral recommendations. And on a practical level, the authors focus on what sorts of diets might work best for which people—in the realm of weight loss. This is a good place to start; after all, 25 percent of all U.S. adults are currently either diabetic or have full metabolic syndrome—this at a staggering expense to society, not to mention to the individuals involved (Mokdad 2003, Ford 2004). However, thousands of studies have shown that obesity is much easier to prevent than to treat. Many programs,

from Michelle Obama’s Partnership for Healthy America that focuses on reducing childhood obesity to targeted funding for research on the origins of obesity in infants and children (Robert Wood Johnson Foundation and others), are showing the issues to be complex, sometimes beginning during the development before birth, and based on factors affecting the pregnant mother. This mother must then provide her infant and small children with a nurturing home, neighborhood, and societal environment for optimal development and reasonable weight and response to his or her food environment. Researchers at the Jean Mayer USDA Genomics Laboratory and Human Nutrition Research Center on Aging at Tufts University are exploring just how genes and diet—nutritional genomics—translate into individual responses to diet. Beginning early, how can people grow into normal-weight adults, with reasonable levels of cholesterol, blood sugar, and fat storage? What factors in our food environment have made this so difficult? Most adults in 2010 know that we “should” eat sensibly to make our bodies feel good, such as following some semblance of the Harvard Pyramid or a DASH diet. But because we are genetically unequal, I may prefer a high-protein breakfast, and you might do better with small, frequent snacks with more complex carbohydrates. But food experiences, frequency, allure, and the deviation of most food from being nutrient dense have changed so alarmingly in the past fifty years that it’s rare to find individuals who simply eat when hungry, guided by a lodestar that seems geared toward need—in other

words, those who follow Michael Pollen’s advice: “Eat food. Not too much. Mostly plants.” Variations can be made, one change at a time, away from aberrant eating—just as we have made shifts toward seat belt and bike helmet use and away from smoking. But it will take a complex of factors, from how we farm to how food is manufactured, packaged, and presented to how we respond to it as individual eaters, to bring us back into balance as a society. If we are adults who have escaped the slow and relentless increase in weight over time, good for us; but to be healthy, we, too, must be thoughtful about food choices and exercise to avoid costing ourselves and society the financial burdens we could have avoided. Hopefully, the work being done to further identify genetic patterns in many subsets of people in our country, beginning with infants and groups most intensely affected by our currently “out of whack” food environment, should lead to a world of specifics and of refined diet recommendations in the future. These messages must be reflected in changes in all aspects of our food supply, for us to survive as a nation. Erica Goode, MD, MPH, recently retired from practicing general medicine with an emphasis on nutrition at the CPMC Institute for Health and Healing. She is an associate clinical professor at UCSF. Before getting her medical degree, she worked as a publichealth nutritionist for years and wrote a weekly nutrition column for the Washington Post. Among other activities, she is a member of the Ethics Committee at CPMC and frequently lectures on eating disorders, cancer and nutrition, health care reform, and other topics. She guest editor of this month’s issue of San Francisco Medicine.

November 2010 San Francisco Medicine 21

Food for Thought

Personalized Health Care Nutrigenomics Takes Care in a New Direction

Carol Ceresa, MHSL, RD


ealth care consumers need and expect that their physicians will be able to recognize and reduce their health disparities and chronic disease risk factors—in other words, that they will provide personalized health care that includes what patients need to know about interactions between diet, genes, and disease. You, as the physician, can explore and discuss specific genetic predispositions and risks (in many cases you may need to refer your patient to a registered dietitian for MNT, or medical nutrition therapy) to enable your patients to identify and make the necessary diet/ lifestyle changes to reduce their health risks.


Nutritional genomics: Nutrigenetics and nutrigenomics are often used interchangeably, but there are some distinctions. “Nutrigenomics” refers to the prospective analysis of differences among nutrients with regard to the regulation of gene expression. “Nutrigenetics” refers to the retrospective analysis of genetic variations among individuals with regard to their clinical response to various nutrients. These terms are used in the context of human biology, in reference to the integration of functional genomics, nutrition, and health. Medical nutrition therapy (MNT): This is the development and provision of a nutritional treatment or therapy based on a detailed assessment of a person’s medical history, psychosocial history, physical examination, and dietary history. It is used to treat an illness or condition or as a means to prevent or delay disease or complications from diseases such as diabetes.

Consideration and inclusion of a person’s genetic makeup can be used to support strategies for targeting certain amenable factors that could result in improved health outcomes. No longer will “It’s my genetic history and I can’t do anything about it” be the “do nothing or do little” excuse. As a collaborative health care team effort, we will, at some point in the near future, be able to individualize your health care advice and provide nutrition guidance appropriate to the specific genetic makeup of your client/patient. This is already done with drug therapy; for example, several chemotherapy treatments are based on the underlying pathogenetics of the disease. Nutrition counseling that is both expected and driven by the consumer will be specific and targeted to most effectively reduce health risks linked to genetic risk factors. A few examples of current research and programs include improving identification and management (drug and therapeutic lifestyle intervention) of hypertension to reduce organ damage and early death; identifying obesity genes and genetic variations in hormones that regulate appetite, contributing to obesity; identifying individuals most likely to achieve

22 San Francisco Medicine November 2010

cardiovascular risk benefit from specific dietary interventions; regulation of gene transcription by diet – ligands (lipids for PPARs, phytosterols for estrogen receptor beta, and so on), with diet-contributing cofactors and substrates for global (and probably specific) gene regulation. For more information, join the listserv at U.C. Davis at http://nutrigenomics. Or sign up to receive the U.C. Davis nutrigenomics newsletter by going to newsletter.htm. Carol Ceresa, MHSL, RD, is currently the Clinical Nutrition Section Chief at the San Francisco V.A. Medical Center. She is a strong proponent of wellness and the role of healthful eating and good nutrition status in health promotion and chronic disease risk reduction. Author of The Bad Back Diet (Chronicle Books) and nutrition consultant for Jacques Pepin’s book Jacques Pepin’s Table, KQED, as well as for The Bohemian Club, the Oakland A’s, The San Francisco Police Academy, the Shriner’s Hospital San Francisco, The Jewish Home for the Aging, and The City of Hope. Carol served as president of the California Dietetic Association and Bay Area Dietetic Association.

Food for Thought

Essential Skills for Weight Management Don’t Ask Me How Much I Lost, Ask Me How Much I Learned

Caroline Goodard


here are two patients highlighted here, both long-term obese women. One is a previous patient who recently underwent bypass surgery and is now back in our program for post-weight loss support. The information presented here has not been scientifically proven but comes from my thirty years of clinical experience in the field. At our Sacramento clinic, the Lighten Up! Weight Management Center, our objective is to have patients get off as many medications as possible, obtain a healthy weight, and be active and well nourished. We employ a very low calorie diet (VLCD) using 150 percent of gender- and height-dependent maintenance protein (usually 60 to 110 gms per day during weight loss), monitored weekly by providers including the medical director; an internist who is also practicing sports and preventive medicine; our on-site physician, a UCD internist and geriatrician; and a nurse practitioner or the physician’s assistant. Prior to beginning weight loss, all patients have fasting labs (including TSH, or thyroid-stimulating hormone, and magnesium), an EKG, a medication review, and a physical. Weekly visits include recording weight, checking blood pressure and medications, completing compliance review and a one-hour behavioral class focusing on the unique physical long-term needs of the formerly obese, and developing skills to avoid weight regain regardless of the vicissitudes of life. The follow-up program lasts for eighteen months, with a focus on getting the emotion out of problem-solving, developing and experiencing strategies for varying situations likely to crop up as time goes on, and, above all, being accountable and recognizing that “reasons” are usually

“excuses” for eating-related behaviors. We have a strong focus on nutrition, wanting our patients to eat a variety of foods in as close to a natural state as possible, while avoiding processed foods. The guidelines for weight maintenance are as follows: a maximum 300 calories per day from fat; minimum 60 to 90 gms of protein, depending on gender and height; 200 to 400 calories per day from whole grains; at least 500 calories from fruits and vegetables, with a focus on fiber; 3 quarts plain water; avoidance of processed foods; 160 to 200 minutes per week of purposeful activity in four or five episodes of 40 to 50 minutes each; stretching and flexibility exercises, as physically possible, three to four times per week. The first four to six months following weight loss, calories are important. After that, data indicates that calories can range much higher if the food choices have a high nutritional content. We emphasize that the following are the usual reasons for weight regain: resistance and resentment ( “I don’t want to” and “It isn’t fair”); discipline and deprivation (versus knowledge, willingness to learn, and acceptance of the fact that all foods eaten are the result of choices made); choices based on emotional responses versus analysis of personal data regarding individual, satisfying food choices. A common phrase around here is “This is your life” on the one hand and “This is your program” on the other. Problem situations do not need to lead to weight gain any more than the same experiences would return any addict to his or her drug of choice. It is critical that participants make the individual and clear decision that it is no longer acceptable to live a “fat life” and that they are willing to do whatever it takes

to keep it off. The clinic’s job is to guide and monitor them on their journeys as they personally discover just what it takes. Meg (not her real name) began weight loss in 2008. At 61 inches in height, she weighed 287 pounds and had been obese for the past 23 years with a history of multiple successful weight-loss experiences followed by complete regain cycles. She entered the post-weight loss program (“Skills”) at 140.5 pounds at week 50 of weight loss. She continued to lose to 134.5 pounds in the first 10 weeks after stopping the VLCD, which we see commonly at the clinic. Her work involved 13 hour days, 6 days per week. She continued to maintain within a 3-pound range for 16 weeks, keeping full food and exercise records of her average weekly weight, or AWW (the only weight we follow in Skills to follow individual weight trends)—until her personal routine was severely disrupted. Both she and her husband were laid off from long-term, professional positions within 6 weeks of each other, followed by multiple trips to Southern California for job opportunities, preplanned foreign travel for 3 weeks, and preparing to put their house on the market. Then no records for 7 weeks, returning at an AWW of 149.4, maintained for the next 16 weeks with spotty clinic attendance and no records for 5 of those weeks. She returned to weight loss at week 66 in the Skills program at 188.2, maintaining 65.6% of her original weight loss. She has lost 45 pounds in the past 15 weeks and plans to lose 10 more before returning to Skills. She recently told me that she has finally begun to look at food choices as helpful or harmful to her weight. Her willingness to change her thinking Continued on the following page . . .

November 2010 San Francisco Medicine 23

Continued from previous page . . . that foods are “good or bad,” “should have or shouldn’t have,” and “can or can’t have” to the helpful or harmful model is a significant reframing that will lower her anxiety about weight gain. She had already learned to record her own food history for use at a later date to see what has been helpful or harmful to stabilizing her weight. We have noticed a definite trend regarding regain. Almost all patients in Skills experience creeping, albeit sporadic, AWW weight gain of between 0.2 and 0.6 pounds per week beginning at about week 15 of Skills. If the AWW weight gain reaches 12 pounds, regardless of calories, the rate of weight gain increases dramatically to 0.9 to 1.3 pounds per week. Consistently, food choices show an increase in starches, in particular wheat products, from 200 to 400 or more calories per day. At this point most people reenter VLCD weight loss and are successful. We consider this the critical point in weight management in that learning occurs with mistakes, not with perfect performance. Patients return to Skills with an arsenal of information and experiences behind them for maintenance, which was not their original situation. Alice (also not her real name) has been with the program several times over the last 20 years. Originally she achieved a weight loss of 92 pounds. Subsequent attempts were much less successful, all with complete regain. She returned at 283.5 to lose the requisite 20 pounds prior to bypass surgery, losing 24.5 pounds in 19 weeks. The pre-op protocol at UCD Hospital and Medical Center was strictly followed and included psychological testing and counseling, food records, baseline and pre-op lab work, and keeping all appointments. Alice stated that she wanted to return to Lighten Up! for the education it provides, to be accountable weekly for full records, and to employ the problemsolving skills it teaches. She was successful, and her compliance with the program was complete, unlike any previous enrollment. Alice stated that while the weight loss was for her own ease of movement and overall health, she realized that her husband would most likely predecease her due to

his lack of self-care and serious diabetes, and she wanted to be able to care for him and be healthy to continue to enjoy her grandchildren. Additionally, she had visited several post-op groups and found the information wanting in that it was “unrealistic, dogmatic, and too sterile for real-life situations” (her words). She has learned that she could eat her way around the bypass, which was disappointing. However, she also stated that “coloring within the lines” was a much more desirable decision. Her most recent epiphany occurred while she was staying in a hotel that included breakfast (“After all, I paid for it”) and she realized she also paid for the gym and the pool. From that point on, she had fun in the pool every morning. She is now back to full records, continuing to view food choices as helpful or harmful. Both Meg and Alice now realize that when the coping mechanism of eating is not used to numb anxieties or fears, a most unnerving event occurs. The formerly numbed feelings will well up, often powerfully driving the desire to eat. However, the initial impact will lessen as the willingness to feel continues, allowing

24 San Francisco Medicine November 2010

the anxieties to be anchored and explored. We define failure as using ineffective means to manage weight. Learning to be effective, not emotionally reactive, leads to successful weight management. Twelve weeks post-op, Alice has lost 37 pounds. Still in Skills, she has discovered that many of her new behaviors include setting limits and boundaries, and defining herself to herself! The decision to keep the weight off and the willingness of both women to learn about themselves and their bodies portends well for their long-term success in remaining at a healthy weight. Since 1979, Caroline Goddard, has worked with obese patients in the field of medically supervised weight loss and weight management, developing the behavioral re-education component accompanying the weekly monitoring visits. The 18 month aftercare portion of the program at her current Sacramento clinic, Lighten Up! Weight Management Center, emphasizes and reinforces the unique interaction of the physiological, nutritional and emotional needs of the obese patient, promoting rational responses vs. emotional reactions to various life situations.

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Food for Thought

Eating Sensibly Using Common Sense and Moderation

Narsai David


he once-simple acts of shopping for groceries and cooking a meal at home have become so confusing and so intimidating in our informationsaturated age that many otherwise intelligent and competent people find themselves paralyzed in the supermarket aisles and crippled in their own home kitchens. Government reports, university studies, articles in academic journals, news reports about salmonella or E. coli outbreaks and food recalls, experts in books and newspapers and magazines and online, the Food Network 24/7 on cable television: Food is suddenly Big News, you can’t escape the maelstrom of data, discussion, and debate. Politics and moral choices now enter into it, too, as the modern consumer is asked to weigh the value of fair-trade practices, for example, and the ethical considerations of how animals are treated on their way to our plates. So much to know nowadays, so much to think about. It didn’t used to be that way. It doesn’t have to be that way now. Information and education are critical, of course; the more, the better. But a little common sense tossed in will go a long way toward helping to parse that information, keep it all in a reasonable perspective, and free you to make your best decisions. One of the first hurdles to get around is the thicket of contemporary food jargon. Organic, sustainable, free-range, locavore, and so on. Often these buzzwords don’t compute; sometimes these buzzwords are deliberately misused and abused. Organic, for example, is widely assumed to mean by definition that the product was grown free of chemical

ticides and free of chemical fertilizers. Not necessarily true. The packaging won’t tell you that, and your neighborhood produce vendor or butcher might not tell you that either. For the sake of allegiance to a word, you might be buying and feeding your children exactly what you have pledged to avoid. So what are you to do with a suspect vocabulary? Use your common sense and your five senses. Do your research and ask your questions—but, when all is said and done, you’ve got to really look that potato in the eye and thump that melon and stick your nose in those herbs and taste everything! Explore, taste, determine which market or markets in your area consistently offer quality fruits and vegetables and meats that you enjoy and trust. Color, smell, texture, and sound can tell you much. We are encouraged to eat locally and to support local farmers. Common sense instantly tells you that this is correct, that it is wrong economically and environmentally to be dependent on foods airlifted from tens of thousands of miles away. Local farmers markets, it stands to reason, are the best and maybe the only sensible place to shop. Unfortunately, simple practicality might point you in another direction. Although I helped establish the Pacific Coast Farmer’s Market Association in 1988 and remain its president emeritus, and although I strongly believe in the underlying philosophy of farmers market’s, it all too often is simply impractical and/ or economically nonviable for families to patronize farmer’s markets. Despite how fresh and delicious and varied the foods offered might be, prices at farmer’s mar-

kets do tend to be more expensive, and their hours of operation (typically only one day each week, if that) aren’t always convenient for working moms and dads. So again, common sense and simple practicality will be your best guides. One of the most beneficial commonsense rules to bring to your cooking and eating practices is simple moderation. When I was a boy in Chicago, a big treat for me and my two brothers was to share a single bottle of Vernor’s Ginger Ale. Today kids routinely knock back 64-ounce Big Gulps on their way home from elementary school. Too much is too much, and we all know it when we see it. The keys are restraint in using the “white stuff” (salt, sugar, flour) in your cooking and moderation in the portions you eat and serve to your family. If we all followed our common sense and not our taste buds, this country wouldn’t be suffering an epidemic of obesity. Ironically, with the rise of celebrity chefs and television’s blitz of food and cooking shows, many folks are finding themselves too overwhelmed and intimidated to put into practice what the Food Network is preaching. “I could never make something like that,” they say— and don’t bother to try. Add to this that the fact that both parents are handling 40-plus-hour workweeks and everyone has increasingly hectic schedules, and you’ve got an express lane to fast food joints and the exploding phenomenon of in-store prepared food departments (deli, bakery, etc.) at your local Safeway and every other supermarket chain. Everyone wants to eat, but no one is up to doing the cooking anymore. Continued on the following page . . .

November 2010 San Francisco Medicine 25

Continued from previous page . . . It really isn’t difficult to cook good food at home. For example, my wife and I have fallen in love with bean stir-fries. We sauté onions or leeks in a tablespoon of olive oil and then add a half-cup of broth (or water), a lump of frozen cooked beans, and some fresh vegetables from the refrigerator. Put a cover over it and cook for about twenty minutes, and you’ve got your meal on the table. My favorite pasta dish, Amatriciana, can be ready in fifteen minutes. Chop a slice of bacon and cook it in a pan, then drain the fat and replace with a spoonful of olive oil. Stir-fry some chopped onions for a few minutes, add a can of chopped tomatoes, and after five minutes of simmering you’ve got a delicious sauce. Simple, quick, satisfying. Feeding yourself and your family, the buying of groceries and the cooking, isn’t always easy. But it isn’t always impossibly difficult either. Don’t create obstacles for yourself; don’t think it through so much that you can’t even boil water for the pasta. A dash of simple common sense can work wonders and may even reignite your joy of cooking. Narsai David is the food and wine editor at KCBS in San Francisco. For sixteen years, he owned Narsai’s, the internationally renowned restaurant in Kensington, California. A past columnist for the San Francisco Chronicle and the San Francisco Examiner, David was also host of the nationally syndicated PBS television series Over Easy and cohost of Cook-Off America. In 2000 He added “winemaker” to his resumé with the release of his Narsai Cabernet Sauvignon from the Narsai and Venus David Vineyards in St. Helena.

Healthy Recipe: Ratatouille Here’s a specialty of the Provencal area of France, best made in the late summer when all the vegetables are at their glorious peak. Fixed this way, each vegetable should keep its own identity yet combine for a dish that would tempt any appetite. Serve ratatouille hot, or cold as an appetizer as we do at the restaurant. While we garnish with Mediterranean olives, there is a much more unconventional method. My friend Joe Hyde, who trained under the legendary Fernand Point at the Restaurant de la Pyramid in France, says Point served it with a cold soft-poached egg on top and garnished it with—catsup!

1 lb eggplant 1 lb zucchini Salt 1 lb onions 3/4 lb green or red peppers 2 lb tomatoes 2 Tbs good-quality olive oil, or 2 Tbs canola oil 1 Tbs minced garlic Freshly ground pepper

Peel eggplant and cut into 1/2-inch cubes. Toss both with salt and let drain for 30 minutes. Meanwhile, slice the onions, clean the peppers, and cut into 1/2-inch cubes. Peel, seed, and quarter the tomatoes. Dry the eggplant and zucchini. Heat 4 tablespoons of the oil in a large sauté pan, add one batch of eggplant, and brown on all sides. Remove to a strainer set over a pan that will collect the oil draining off the eggplant. Sauté the remaining eggplant, and the zucchini and peppers, using the drained oil and additional Pam® lecithin if needed to prevent sticking. Sauté the onions until wilted and lightly colored. Stir in the garlic and tomatoes, and cover the pan. Cook for 3 to 4 minutes, uncover pan, and raise the heat. Cook briskly until the juices have evaporated. Season to taste with salt and pepper, and combine with the sautéed vegetables, or layer in a saucepan or casserole. Cover, and simmer for 10 to 15 minutes, basting occasionally. Uncover, and cook until the juices are reduced. Or layer in a casserole and bake in a preheated 325° oven for 25 minutes, remove, and reduce the juice. Serve either hot or cold. (Serves 6–8)

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Food for Thought

Nutrition and Cancer What to Eat and What to Avoid

Donald Abrams, MD


ccording to a survey conducted by the American Institute for Cancer Research, 94 percent of Americans recognize tobacco as a cause of avoidable cancers, 87 percent recognize ionizing and UV light, but only 51 percent appreciate the contribution of diet and nutrition. In fact, it is estimated that 30 percent of avoidable cancers may be attributed to what we eat and what we don’t eat, a proportion equivalent to those caused by tobacco use. Data also continues to mount that cancer patients consuming the Standard American Diet (abbreviated SAD for a reason!) have worse outcomes than those who select a more “prudent” menu. The American Institute for Cancer Research/World Cancer Research Fund’s Food, Nutrition, Physical Activity, and Cancer Prevention: A Global Perspective guidelines updated in 2007 lists nine recommendations for cancer risk reduction with the tenth being: “After treatment, cancer survivors should follow the recommendations for cancer prevention.”

Foods to Increase or Incorporate into the Diet

Fruits and vegetables are important components of the cancer-fighting diet. It is ideal to consume five to nine servings of fruits and vegetables per day, yet recent data from the Centers for Disease Control suggests that only 14 percent of adults in the U.S. are consuming even the minimum 5 servings a day. Fruits and vegetables are rich in fiber and vitamins and are our most potent source of antioxidants. In addition, they contain a number of phytonutrients that are being found to promote anticancer activity.

Cruciferous vegetables—broccoli, cauliflower, Brussel’s sprouts, cabbage, kale, collard greens, and radishes to name a few—are particularly potent cancer fighters. Not only are they high in vitamin C and soluble fiber, but they also contain phytonutrients such as sulforaphane, indole-3-carbinol, and diindolylmethane, which have impressive anticancer properties. Broccoli in particular has been shown in numerous scientific studies to reduce the risk of many malignant cancers. Some studies suggest that raw broccoli may be more potent than cooked, but blanching, steaming, or stir-frying cruciferous vegetables does not decrease their potency significantly. In addition to cruciferous vegetables, I advise patients that adding orange-yellow vegetables to the shopping list offers a good source of beta-carotene as well as color and variety to the diet. For leafy greens, I favor those that are also cruciferous so we get a two-for-one, both the glucosinolates as well as the folate in the leafy green foliage. Heavily pigmented fruit—the berries, red grapes, and pomegranates—are important and powerful antioxidants. Patients who are receiving active radiation treatment may be advised to avoid antioxidant supplements as they could interfere with radiation. Whole food sources of antioxidants, like berries, however, are likely not concentrated enough to affect radiation or chemotherapy drugs that work via oxidative damage to tumor DNA. Therefore, I recommend that my patients eat an antioxidant-rich diet, even during active treatment, but I often advise that they delay antioxidant supplementation, especially if our goal is cure. Regarding produce, and all food for

that matter, I encourage my patients to eat organic as much as possible. This is only partly to avoid the pesticides, herbicides, and fertilizers that have no right to be in our bodies, but because an organically grown plant needs to fight to protect itself from other plants, birds, insects, and the sun. And the only way a plant can protect itself is by making chemicals called phytoalexins, which, fortunately for us, are often the phytonutrients that benefit us. So a plant grown outdoors organically is a much richer medicine than conventionally grown produce. I do appreciate that it may not be realistic or affordable for some to consume organic produce. We live in a country where for the price of the organic apple that I end my lunch with daily, someone can purchase a double cheese burger, fries, and a sugary soft drink. If one can’t buy organic all the way, www. is a good resource for avoiding the most toxic conventional products. When it comes to adding both flavor and nutrients to a dish, garlic and onion are great way to enhance a meal. Garlic is a powerhouse in the cancer-fighting kitchen. It is also antifungal, anti-inflammatory and helps to lower blood pressure and cholesterol. Ginger and turmeric are great options too. Ginger not only helps to relieve nausea but research has shown that it has anticancer effects. Turmeric, a spice that is widely used in India, providing the yellow pigment of curry, also has been demonstrated in vitro to inhibit cancer at many stages of the cell cycle. Adding black pepper to turmeric increases absorption of the active ingredients a thousandfold. Shiitake mushrooms are enjoyed in Asia for their immune-enhancing, antituContinued on the following page . . .

November 2010 San Francisco Medicine 27

Continued from previous page . . . mor and antiviral, and general antibiotic properties. They are rich in amino acids and fiber and are a good source of vitamins, particularly B12 and ergosterol, which is converted by sunlight into vitamin D. Shiitakes also contain an antitumor polysaccharide known as lentinan, which triggers lymphokines, interferon, and interleukin. This cascade augments natural killer-cell function. Shiitake, maitake, and enoki mushrooms and their constituents are often used concurrently with chemotherapy and radiation in Japan as adjuvant therapies. All edible mushrooms must be cooked. White button mushrooms (Agaricus species), commonly sliced raw and tossed into salads, actually contain a carcinogen, agaritine, that is mostly inactivated with cooking. There is some suggestion that the Agaricus species (white buttons, cremini, and portobello mushrooms) may contain an aromatase inhibitor-like activity.

Things to Avoid or Limit

It is as important to know what to include in a well-balanced diet as it is to know what to avoid or limit. The first of the AICR guidelines to address food says simply to avoid sugary drinks. I went to the microphone at the 2007 meeting to ask if all sugary drinks are the same. One could drink a cola beverage, a fruit punch (which is likely glucose and high fructose corn syrup) or one could squeeze three oranges every morning. The response from the podium was a surprising, “energetically, they are all the same.” That is to say, when we eat an orange, the fiber slows the absorption of the sugar into the bloodstream. But when we juice the orange, and separate the sugar from the fiber, we get the same spike as we do with any other sugary beverage. So I now only juice twice a week! I also recommend limiting the consumption of energy-dense foods, specifically processed foods that contain large amounts of added sugar or its act-alikes, ones that are high in fat but without a lot of fiber. I feel that sugar listed in the “Nutrition Facts” box is OK since that’s the sugar that fuels our brain, but I advise avoiding foods that include

sugar, fructose, syrups, crystals, dextrin, maltodextrin, ad infinitum, in the ingredients list. It is also important to limit consuming red meats and to avoid processed meats entirely. Research has shown that there is a direct correlation between consuming increasing amounts of red meat and colon cancer. Beef has also been associated with pancreatic cancer. In their natural environment cows eat grass. Most cows today are primarily corn-fed. The result is that a cow that predominantly eats corn will in turn produce fat that is high in omega-6 fatty acids, those that promote inflammation and platelet aggregation. In place of beef, I encourage patients to eat deep cold-water fish like salmon, albacore tuna, black cod, herring, mackerel, and sardines, which are rich in omega-3 fatty acids,anti-inflammatory, and may also be a bit antidepressant. If poultry and eggs are part of the diet, they should also be organic to minimize the imbalance of omega-6 to omega-3 in conventional products. Alcohol consumption, if not completely eliminated, should be limited to one drink a day for women and two for men. Women at high risk for breast cancer should limit themselves to one alcoholic beverage a week. An ideal drink of choice would be a glass of red wine, as it contains resveratrol, which is considered to be an antiaging and life-extending phytonutrient that is less available in white wine or other alcoholic beverages.

Green Tea, a Superfood

The drink I recommended the most to my patients is green tea. It contains polyphenols, particularly ECGC, which is a potent antioxidant and has cancer risk-reducing properties similar to what is found is cruciferous vegetables. Green tea is revered as a powerful medicine, particularly in Asia, more than any other beverage. It has been shown to prevent heart disease and strokes, reduce cancer risk, regulate blood sugar, lower blood pressure, boost immunity, increase bone density, help prevent arthritis, facilitate weight loss, prevent ulcers, slow aging, increase fertility, and fight colds and flu.

28 San Francisco Medicine November 2010

I typically recommend that my patients drink four large teacups (about 1 liter) of green tea daily. Achieving a well-rounded, balanced diet is palatable and beneficial to our health and well-being. Would that we had learned more about nutrition during our training! In these days of health care reform and focus on wellness, please share this information with all of your patients so that we are not only creating awareness about beneficial ways to reduce cancer risk through diet and nutrition but we are also promoting a healthier lifestyle and a healthier society. Donald Abrams, MD, is an integrative oncologist at the UCSF Osher Center for Integrative Medicine. He is also chief of hematology and oncology at San Francisco General Hospital.

Suggested Resources Abrams DI and Weil A. (eds) Integrative Oncology. Oxford University Press, New York, 2009. American Institute for Cancer Research/World Cancer Research Fund. Food, Nutrition, Physical Activity and Cancer Prevention: A Global Perspective. 2007. Beliveau R, Gringas D. Foods to Fight Cancer. DK, 2007. Gonzalez CA, Riboli E. Diet and cancer prevention: Contributions from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Eur J Cancer. 2010; 46:2555-62. Katz R. The Cancer-Fighting Kitchen. Celestial Arts, 2009. Kushi LH, Byers T, Doyle C et al. American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2006; 56:254-81. Servan-Schreiber D. Anticancer: A New Way of Life. Viking, 2009.

Food for Thought

Multivitamin Maze How to Navigate the Labels

Bonnie Liebman and David Schardt


hopping for a multivitamin is like trying to hit a moving target. Each supplement has at least twenty— and sometimes forty or fifty—ingredients. Combine that with the evolving science (“beware of excess vitamin E,” “bones need more vitamin K,” “don’t overdo vitamin A”) and the claims on the packages (“More energy boosting ingredients!” “More cell-protecting antioxidants!” “Helps promote a healthy heart!”), and you’ve got the makings of a migraine. That’s just the beginning. How are people supposed to know if they need lycopene, lutein, ginseng, ginkgo, or digestive enzymes? No wonder stress vitamins sell so well. Here’s our guide through the multivitamin maze. It’s worth taking a multivitamin, just for insurance. But how do you cut through the hype, toss out the overpriced shams, and home in on a multi that has enough of what you need and not too much of what can harm you? Here’s what you need to know.

Watch Out for Too Little

A good multi should supply roughly 100 percent (or more) of the recommended Daily Value (DV) for most vitamins and minerals. Exceptions: Calcium and magnesium are bulky, so the only multis that have a day’s worth require you to take two or more capsules a day. Don’t bother. Look for 100 milligrams (mg) of magnesium (25 percent of the DV), which can easily fit into a single pill. Get your calcium from foods or a separate supplement. Chromium, selenium, and zinc should be there, but they may be missing. Among the popular brands that fall short of the

recommended levels for selenium: Geritol Complete, GNC Preventron and Solotron, One a Day (Active, Essential, and Maximum), Whole Foods Daily, and Centrum (regular, Silver, and Chewables) and its copycats. The DV for vitamin K is 120 micrograms (mcg), but research suggests that people need more to reduce the risk of a hip fracture. Many multivitamins have little or no vitamin K, probably because it can interfere with blood thinners like Coumadin (warfarin). If you take a blood thinner, check with your doctor before taking a multi that contains vitamin K. You can also get vitamin K from leafy greens, such as romaine lettuce and spinach.

Watch Out for Too Much

In their competition for customers, some multivitamins go overboard. Look for brands that limit their beta-carotene, iron, magnesium, phosphorus, and vitamin B-6 to safe levels. Best Bites also limits vitamin A acetate or palmitate, vitamin E, and zinc. Here’s why: Too much vitamin A acetate or palmitate (retinol) can raise the risk of hip fractures. The Tolerable Upper Intake Level—the most you can take without worrying about any adverse effects—is 10,000 IU (International Units) a day. But if you get that much in a multi, whatever you get from foods would put you over the top. Among the multis with at least 10,000 IU: KAL (Mega Vita-Min and MultiFour+), NOW Vit-Min 75+, Solaray (MultiVita Mega-Mineral, Provide, Spectro, and Three Daily Super-Energy), and TwinLab Vita Quick. Vitamin E is another one to check. The Vitamin Shoppe Multi-Vitamins pack

has 1,000 IU of vitamin E. That’s too much, considering that an analysis of nineteen trials found that the risk of dying rose steadily as the vitamin E dose increased from 100 IU to 2,000 IU a day. The highest safe level of iron is 45 mg, from supplements and food combined. Given how much iron people get from red meat and other foods, the 25 mg in some multis could bring you close to that max. Too much iron from pills can cause constipation or (if you’re genetically susceptible) iron overload. The jury is still out on whether excess iron can increase the risk of heart disease and cancer. As for zinc, you need only 8 mg (women) or 11 mg (men) per day. Too much zinc can make it hard to absorb or retain copper. (At doses close to 300 mg a day, zinc can also impair the immune system.) The highest safe level is 40 mg, but that includes zinc from food. So it’s wise to avoid the 30 to 35 mg in some formulas and the 50 mg in Solgar Male Multiples and the Vitamin Shoppe Mature Male pack.

What Do You Need?

For some nutrients, how much you need depends on who you are. Continued on the following page . . .

November 2010 San Francisco Medicine 29

Continued from previous page . . . Iron, for instance. Many brands have 18 mg because that’s the Daily Value, but only premenopausal women (who lose iron during menstrual periods) need that much. Men and postmenopausal women need 8 mg a day, but the 9 or 10 mg in many multis is close enough. Think twice before you switch to an iron-free multi, though. If you rarely eat red meat, you may run short on iron, especially if you donate blood regularly. Vitamin B-12’s DV is only 6 mcg, but some experts recommend 25 mcg a day if you’re over 50. In theory, people who take acid blockers such as Pepcid, Prilosec, Prevacid, Tagamet, or Zantac may be less able to absorb B-12, but few studies have looked. To play it safe, take 250 to 500 mcg a day of B-12 if you take acid blockers daily (you’ll probably need a separate supplement). High levels of B-12 have no known side effects. Vitamin K can be an issue if you’re on certain medications. If you take blood thinners, ask your doctor how much daily vitamin K you can take. Check chewables and liquid vitamins. Don’t assume that a chewable or liquid multi has the same nutrients as a pill with the same name. For example, Centrum Chewables have no selenium, and Centrum Silver Chewables have no vitamin K. Many liquids are low in nutrients. For example, Centrum Liquid is missing calcium, copper, folic acid, magnesium, selenium, and vitamin K.

How to Read the Label

Vitamin A (retinol): The Daily Value (5,000 IU) is outdated. You need only 3,000 IU a day of vitamin A. Too much retinol (listed on labels as vitamin A palmitate or acetate) may increase the risk of hip fractures, liver abnormalities, and birth defects. Beta-carotene, which the body converts to vitamin A, doesn’t cause those problems, but very high doses (33,000 to 50,000 IU a day) may increase the risk of lung cancer in smokers. Our advice: Don’t get more than 4,000 IU of retinol or 15,000 IU of beta-carotene from your multi (less retinol would be even better). Instead, load up on beta-

carotene-rich fruits and vegetables like carrots, cantaloupe, sweet potatoes, and broccoli, which may help prevent cancer. Vitamin D: It helps you absorb calcium. Yet many people over 50 get too little D from sunshine (especially in the winter) or from their food. The Institute of Medicine (IOM) recommends 200 IU a day for adults 50 and under, 400 IU for people aged 51 to 70, and 600 IU (some experts say it should be 1,000 IU) for anyone over 70. Those amounts include what you get from the sun, from salmon and other fatty fish, and from fortified foods like milk, breakfast cereals, and some brands of yogurt, margarine, and orange juice. They also include the vitamin D that’s added to many calcium supplements. Look for a multi with 400 IU of vitamin D (100 percent of the DV), even if you’re under 50. Thiamin (B-1), riboflavin (B-2), niacin (B-3), and B-6: While there’s no reason to get more than the DV for these B vitamins, the high doses found in some multis are harmless. But that doesn’t mean the sky’s the limit. More than 100 milligrams (mg) a day of B-6 can cause (reversible) neurological damage. Super-high doses of niacin (3,000 mg a day or more) may cause liver damage, though you’re unlikely to find that much in a multi. Vitamin B-12: Most multivitamins have at least 6 mcg (the DV), which is fine for people under 50 and for vegans (who may not get B-12 from their food because they eat no meat or dairy). People older than 50 may lack the stomach acid needed to extract B-12 from food, so they should get at least 25 mcg (micrograms) a day from a multi, a separate supplement, or fortified foods. People who take acid blockers may need 250 to 500 mcg a day. A B-12 deficiency can cause irreversible nerve damage and may masquerade as Alzheimer’s disease. Iron: Many people are deficient, but too much can cause constipation or iron overload, if you’re susceptible. To play it safe, men and postmenopausal women should look for a multi with no more than 10 mg of iron. The DV (18 mg) is fine for premenopausal women.

30 San Francisco Medicine November 2010 31 San Francisco Medicine

Magnesium: Americans get too little from their foods (among the best sources: whole grains and beans). A deficiency may increase the risk of diabetes and colon cancer. Look for a multi with at least 100 mg, just for insurance. The IOM recommends 320 mg a day for women and 420 mg for men. More than 350 mg a day from a supplement may cause diarrhea. Selenium: Many leading multis (such as most Centrum formulas) have considerably less than the DV (70 mcg) or the IOM’s latest recommended level (55 mcg). A large study is under way to see if a high dose (200 mcg a day) can lower the risk of prostate cancer. Taking more than 800 mcg a day can make your nails or hair brittle (or fall out), so the IOM set the highest safe level at 400 mcg. Iodine, manganese, molybdenum, chloride, and boron: Ignore. There’s no evidence that people need more than what they get from their food. Daily Value (DV): It means the same as “USRDA” (U.S. Recommended Daily Allowance). Labels use them interchangeably. The Daily Value for each vitamin or mineral is the Food and Drug Administration’s advice on how much to shoot for each day—from food and supplements combined. In some cases it doesn’t reflect the most current research. Vitamin C: The DV (60 mg) is lower than the new IOM recommendations: 75 mg a day for women and 90 mg for men. Roughly 250 to 500 mg saturates the body’s tissues, so more than that is probably excreted. Taking more than 1,000 mg of vitamin C at one time in a supplement may cause diarrhea. Vitamin E: The DV is 30 IU. In large studies, high doses didn’t protect against heart disease, stroke, or dementia, and they may have raised the risk of dying. Studies are under way to see if 300 IU to 400 IU a day prevents prostate cancer. To play it safe, stick to 100 IU or less. Vitamin K: The IOM now recommends 120 mcg a day, and recent studies suggest that 150 to 250 mcg a day may be best to reduce the risk of hip fractures. Yet most multivitamins have much less than the DV, which is 80 mcg. You can get K from leafy greens, some calcium

supplements (such s Viactiv), and vitamin K supplements. Vitamin K can interfere with blood-thinning drugs such as Coumadin, so people who take them should check with a doctor before taking a multi with vitamin K. Folic acid: Look for the DV (400 mcg) to reduce the risk of birth defects (for women who could become pregnant) and to keep a lid on homocysteine, an amino acid that may damage arteries. It’s unclear if folic acid reduces the risk of heart disease, stroke, or colon cancer. Biotin and pantothenic acid: Ignore. You’d have to eat a bizarre diet to run short. Calcium: To reduce the risk of osteoporosis (and possibly colon cancer), shoot for 1,000 mg a day (if you’re 50 or younger) or 1,200 mg (if you’re over 50). But men shouldn’t go overboard, since 2,000 mg a day or more may increase the risk of prostate cancer. A day’s worth of calcium won’t fit in a one-pill multivitamin. So if you don’t eat three or four servings of low-fat milk, yogurt, cheese, or calcium-fortified orange juice every day, take a 300 mg calcium supplement for each serving you miss. Phosphorus: Unnecessary. The less you get in your multi, the better. Too much may impair calcium absorption, and we already get more than we need from our food. Zinc and copper: Look for 8 mg (women) or 11 mg (men) of zinc and 0.9 mg of copper. There’s no harm in taking a multi with the DV for each (15 mg for zinc and 2 mg for copper), but don’t take extra zinc. Getting more than 40 mg a day (from pills and foods like meat, poultry, beans, nuts, dairy foods, and fortified cereals) may make your body lose copper. Higher doses of zinc (close to 300 mg a day) may depress your immune system. Chromium: The IOM recommends only 20 to 25 mcg a day (for women) or 30 to 35 mcg (for men). Many brands have closer to 120 mcg (the DV), which is safe. Potassium: Ignore. It may help prevent high blood pressure, kidney stones, and osteoporosis, but amounts in multivitamins are low. Instead, eat plenty of fruits and vegetables.

Nickel, silicon, tin, and vanadium: Ignore. It’s not clear that they’re needed.

The Multi-Mega-Vita-Sell

Most supplement claims are unregulated, so companies often stretch the truth. Here’s the scoop behind some popular claims. Antioxidants: So far, studies haven’t shown that antioxidants such as vitamins E or C or zinc prevent cancer or heart disease or protect the brain. Energy: “Performance,” “Active,” and “Energy” formulas sound impressive, but there’s no good evidence that any vitamin or herb makes you more energetic or boosts athletic performance. Lutein: Even if lutein does help prevent cataracts, the 250 mcg in a typical lutein-containing multi is less than two percent of the 14,000 mcg (largely from green vegetables) consumed by people who had fewer cataracts in some studies. Lycopene: Despite label claims, there’s hardly any evidence that it “helps promote a healthy heart.” The FDA rejected a claim that lycopene prevents prostate cancer (though lycopene-rich tomatoes may). Ginkgo and ginseng: In the best studies, large doses of ginseng (at least 200 mg) don’t boost energy, and it’s unclear whether large doses of ginkgo (180 to 360 mg) sharpen the mind. There’s no evidence that the small amounts in many supplements do anything. Disclaimer: The FDA requires a disclaimer when the supplement makes a “structure-or-function” claim, which uses words like “maintains,” “promotes,” or “supports” heart health, immunity, prostate health, and so on. These claims require no approval, and many are backed by little or no evidence. USP: The United States Pharmacopeia (USP) tests supplements, if manufacturers pay fees to cover the testing. This mark means that the listed ingredients are in the supplement and will dissolve or disintegrate, not that the supplement is safe or has any benefits. Weight control: Extra calcium burns fat in studies from a researcher with a

patent on the claim. In other studies, it doesn’t. There’s no good evidence that extra chromium melts away the pounds or that green tea extract boosts metabolic rate. High potency: Most people assume that “High Potency” means more than the Daily Values (DVs). Not necessarily. To the FDA it simply means that at least two-thirds of a multi’s nutrients have at least 100 percent of the DV. “Advanced,” “Complete,” and “Maximum” formulas can mean anything. Stress formula: There’s no good evidence that their extra B vitamins and vitamin C reduce stress or repair the damage stress causes. Women’s formula: Premenopausal women need 18 mg a day of iron, from food and supplements combined. Postmenopausal women need half as much. Men’s formula: Men need 8 mg a day of iron. Until ongoing studies are done, we won’t know if high levels of selenium (200 mcg), vitamin E (400 IU), and lycopene (15 mg) reduce the risk of prostate cancer. Seniors: “Mature,” “50+,” or “Senior” formulas often have more vitamin B-12 (good), less iron (good), and less vitamin K (not good). Unless you’re taking blood thinners such as Coumadin, your multi should have vitamin K, which may reduce the risk of hip fractures. Pharmacist recommended: Ignore. Some Nature Made multivitamins carry a “Pharmacist Recommended” seal. While it’s true that 5.9 percent of pharmacists surveyed said that they recommended Nature Made to their customers, the seal doesn’t let shoppers know that 6.4 percent recommended One a Day and 64.4 percent recommended Centrum. Excerpted from the full article “The Multivitamin Maze” in the Center for Science in the Public Interest’s Nutrition Action Health Letter, March 2006, Volume 33, Number 2.

November 2010 San Francisco Medicine 31

Food for Thought

Food Facts

Practical Nutrition Information to Assist Physicians


enetic differences aside, most people need foods that are palatable, colorful, with enough variety to provide ample levels of vitamins, minerals, phytochemicals, and fiber to provide health, energy, and the ability to manage stress. For infants and children, these components of intake must also provide normal growth and development of all systems, beginning during intrauterine life. We are learning that some substances are difficult to get unless the diet is unusually complete. However, in many cases a careful set of changes regarding diet and exercise, sometimes emphasizing certain foods, can preclude the need for supplements or pharmaceuticals. In speaking to those in primary care while assembling this issue, it became clear that physicians—whether obstetricians, pediatricians, family medicine practitioners, or internists—are interested having reproducible handout material for patients. In my former private office, with Drs. Brayer, Dobrow, M. Liberman, and Watanabe, we shared a superb set of nutrition, exercise, and joint rehabilitation patient handout materials. These proved to be of most use to busy parents and other adults, since the materials could be discussed with the patient. Included in this section, entitled “Food Facts,” are tables, charts, and explanations about important foods, vitamins, etc. for you to use when planning your own diet and when advising patients. I have also created a list of newsletters that offer a wealth of information on nutrition and related topics, the most valuable being the CSPI Nutrition Action newsletter, which has an introductory subscription rate of only $10 for the first year. Please read, share, and eat well! —Erica Goode, MD, MPH

Information on Calcium to Prevent Osteoporosi Calcium facts: The adult human body (average ) contains 1250 grams (1.2 kg = 2.6 lbs) of calcium. Ninety-nine percent is in bones and teeth as calcium phosphate. A blood sample measures the small, soluble portions of calcium in the body. Sixty percent is free “ionized.” Forty percent is bound to proteins. (Eighty percent of the body’s phosphorous is in bone.) Calcium is essential for heart, respiratory, and other muscle function. A low level of serum calcium can lead initially to muscle cramps. Calcium is also important for nerve conduction and coagulation. Calcium and phosphorous are seen together in adult bones in a crystalline structure call apatite. Calcium balance is improved by: Exercise in reasonable amounts. Fluoride (1/2mg/ day is probably enough to provide improved calcium balance). Normal calcium in diet (800 to 1500 mg/day, depending on need). Calcium:phosphorous ratio of about 1:1 in diet. Calcium balance in bone deteriorates with: Daily steroid doses. Inactivity or excess exercise sufficient to prevent menstrual cycles. High phosphorous diet. Renal failure.

Some substances increase absorption of calcium from the gut: Vitamin D and UVB sunshine wavelength; High calcium, relative to phosphorous in the diet

Some medicines or other substances may decrease intestinal absorption of calcium: High amounts of antacids. High-oxalate diet (spinach, rhubarb, chard, chocolate, sorrel, beet greens, parsley, bran). High amounts of phosphorous relative to calcium: from drugs such as Neutra-Phos; from foods (a high-meat or -bran and low-calcium diet is high in phosphorous and protein relative to the calcium; both of these further lower calcium absorption). Smoking. Significant alcohol intake.

Good food sources for calcium: Milk, buttermilk Cheese Cottage cheese, ricotta, farmer’s cheese Canned salmon (when bones are eaten) Leafy greens without oxalates (collards, bok choy, kale, and mustard greens) Sunflower and sesame seeds Blackstrap molasses Broccoli Tofu (bean curd) Fortified soy milk Masa harina Tortillas (corn, not flour) Rutabagas

Calcium Supplements Needed to Provide + 1,000 mg Elemental Calcium Salt forms

Calcium gluconate

Calcium lactate

Calcium carbonate: Generic Caltrate 600

Os-Cal 500


Tablet size E l e m e n t a l E l e m e n t a l R e q u i r e d (mg) Calcium (%) Calcium (MG) dose/day*







* Needed to provide 1.0 gm elemental calcium



















Other excellent calcium supplements: calcium citrate, Citracal capsules, Twin Labs capsules, MRM powder

Goode E. Patient handout. Riggs B. Lawrence, MD. Endocrinology Mayo Clinic, Mayo Medical School. Lindsay R, MD Clinical Medicine, Columbia College of P&S NYC. 32 San Francisco Medicine November 2010 33 San Francisco Medicine November

Food for Thought Fiber in Food Fiber is found primarily in fruits, vegetables, whole grain foods, seeds, nuts, and products made from these foods. Many fiber sources serve many functions. People tend to work toward having more fibrous foods for better stool bulk, but, more than that, water-soluble fiber (especially in beans, oat bran, and some vegetables) has a benefit of reducing absorption of cholesterol from foods in the digestive tract. Fibrous foods are critical in delaying absorption of sugar, thus prolong-

ing a feeling of satiety and helping to regulate the highs and lows of blood sugar. Psyllium seeds (sold as Metamucil, but also available in some health food stores) are an excellent bulk former. The fiber requirement is as follows: under age 50, women, 25 gm; men, 38 gm. Over age 50, women, 21 gm.; men, 30 gm. The following list provides information about how to hit those levels each day.



BREAD Whole wheat, stone-ground French pumpernickel Rye Corn, whole-ground White, enriched

2 slices 2 slices 2 slices 2 slices 2 slice

2.8 2.0 8.6 1.8 5.4

1/3 cup 1 cup 3/4 cup 1/3 cup 2/3 cup 2/3 cup 2/3 cup 2/3 cup 3/4 cup

10.0 4.1 5.9 4.2 3.3 4.0 3.6 5.7 2.8

6 nuts 10 nuts 2 nuts 2 nuts

1.1 0.8 0.5 0.4

1 medium 1 medium 1/2 cup 2 fruits 1 small 1/2 cup 1/3 cup 1 fruit 3/4 cup 1/2 melon 1 1/2 tbsp. 1 medium 3 small 1/2 cup 2 fruits

3.7 5.0 4.5 1.6 1.2 4.6 5.8 2.8 2.0 3.2 1.0 2.0 1.8 2.5 1.5

BREAKFAST CEREALS All bran Oat flakes Corn bran Oat bran Shredded wheat, sm. 40% bran flakes Raisin bran Bran squares Oatmeal, cooked NUTS AND SEEDS Almonds, roasted Peanuts, roasted Pecans Walnuts FRUIT Figs, dried Pears Blackberries Dates Oranges Raspberries Prunes Apples (with skin) Strawberries Cantaloupes Raisins Bananas Plums Blueberries Apricots



Getting your daily fill: Be aware that all the studies showing benefits from fiber have been based on diets rich in high-fiber foods, not fiber supplements. Most pills and powders are made from methylcellulose or finely ground seed, and it’s still not known whether highly purified or ground fiber works the same way in your digestive system that natural fiber does. Also, it’s much easier to overdose with pills and powders, and eating too much fiber can hinder your body’s absorbtion of nutrients. SERVING SIZE

RICE, PASTA Spaghetti Rice, brown

SNACKS Crackers, graham Crackers, whole wheat VEGETABLES Green beans Yellow beans Broccoli Brussels sprouts Carrots Cauliflower Corn Eggplant Okra Parsnips Pumpkins, canned Sauerkraut, canned Spinach Acorn squash Sweet potato Zucchini

LEGUMES Kidney beans, cooked Pinto beans, cooked Lima beans, cooked White beans, cooked Chickpeas Green peas, cooked Lentils, cooked

1/2 cup 1/2 cup

DIETARY FIBER* (grams) 0.8 2.4

2 squares 5 crackers

2.8 1.9

3/4 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 3/4 cup 1/2 cup 1/2 cup 1/2 cup 1 large

3.1 2.1 2.3 2.5 3.9 1.3 2.0 3.5 2.0 3.0 3.1 3.3 2.4 2.0 3.6 3.4

1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup

5.8 5.3 4.4 5.0 15.0 4.1 2.0

November 2010 San Francisco Medicine 33

Food for Thought Omega-3 Foods In 2007, the CSPI, in its monthly Nutrition Action Health Letter, reviewed the weight of evidence for including omega-3 (linolenic acid)-containing foods in our diets as a source of importance to our health. Briefly, we know the following: Since the early twentieth century, with the introduction of more saturated fats in our diets, the ratio of omega-3- to omega-6 (linoleic acid)-containing foods has declined. With the advent of developing and using more hydrogenated fats (whereby an oil, with unsaturated fatty acid bonds, is subjected to heat, pressure, and exposed to hydrogen), those bonds become saturated with hydrogen in the wrong position relative to what normally occurs in nature: the trans- (as opposed to cis-) position. Our bodies, and those of other mammals, are not equipped either historically or metabolically to quickly remove this atypical form of fat, and it thus becomes incorporated into cell membranes in the brain, heart, gut, and kidneys—everywhere. Manufactured foods were considered healthier when this hydrogenation shift began; it allowed foods to last longer at room temperature without becoming rancid, which made transportation and storage (shelf-life) less of a problem for everyone, including restaurants, school lunch programs, military personnel receiving foods sent from overseas, etc. But, as Al Gore would say, there were “unintended consequences.” The role of a cell membrane is to keep water-based activity outside and inside the

cell, with a fatty barrier, called a lipid bilayer, separating the two. This cell membrane is studded with receptors for taking in and ridding itself of various molecules important to the cell’s metabolism and longevity. If that membrane is composed of significant amounts of trans fat, the receptor function is disrupted. Glucose (sugar) may have trouble entering (it always requires insulin and potassium to enter, hence the problems with trans fats and diabetes). As a result, blood sugar will also rise to harmful levels in the bloodstream, causing damage to many organ systems. It also makes the removal of toxic wastes (products of mitochondrial metabolism and possibly stored lead, mercury, or other damaging substances that wind up in cells) more difficult for those malfunctioning receptors. To remedy this, people have generally become aware of the hazards of trans fat and are reading labels more often and more carefully. Some manufactured foods, such as peanut butter or crackers, are more likely now to proudly state “no trans fat.” Of course, some foods never did contain trans fats. And while items like butter and cream are quite saturated (more bonds are hydrogenated as cis-fat, not trans-), they carry less harm, if eaten occasionally, than do the trans fats. Read labels carefully. During the Bush administration, food companies were allowed to label products “0% trans fat” even though those foods, if you read the small print, did contain some partially hydrogenated fats,

which means some of those bonds were developed as trans-fat bonds. Keep it simple in the supermarket and follow the rules promoted by Marion Nestle: “Enter the store and buy only those things on the perimeter. That’s the source of meats, fish, dairy foods, refrigerated juices, fruits, fresh salsa, vegetables, and some plain breads.” From inner shelves, shop wisely and lean toward items with simple ingredient lists and whole grains.

Good Sources of Zinc in Food

Zinc is found in a variety of foods. High sources are: Dairy: Cheeses, 2oz. or more, not processed or high-water content (like cottage cheese or ricotta); lower-fat or nonfat yogurt (this has added milk solids, hence the increased zinc) Cereal/grains: Oatmeal (1 cup unless otherwise specified); buckwheat, wild rice, dark rye (3 slices); wheat germ (1/4 C.) Fish, shellfish: Canned shrimp (½ C. unless otherwise noted); clams; crab, crab cakes (one) but not imitation crab; lobster, eel, oysters; salmon, canned Meats: Beef (3 oz. unless otherwise specified); all lean cuts; spareribs (3); lamb chop (blade, not loin or rib), leg of lamb, lamb shoulder; veal; chicken (dark meat); turkey (dark meat); gizzard, liver Seeds: Sesame, 2 Tbs. Beans: White beans (one cup, all listed); refried, low-fat pinto beans; garbanzos, lentils Source: Mahan K, Escott-Stump, S. Krause’s Food, Nutrition, and Diet Therapy. Saunders, 1996 (ninth edition).

Sleep More, Eat Less Wondering why you’re so hungry? Maybe it’s because you’re not getting enough sleep. Researchers allowed twelve healthy young, lean men to sleep for either four or eight hours in a laboratory. After one night of four hours of sleep, the men ate 22 percent more calories the next day than they did after eight hours. They also reported being more hungry before breakfast and dinner. In a separate study, scientists found that a single night with only four hours of sleep led to insulin resistance in nine healthy, lean men and women in their forties. After the night of restricted sleep, the participants were less able to move blood sugar into their cells, which suggests that their bodies were at least temporarily resistant to insulin. Insulin resistance can lead to heart disease, diabetes, and possibly breast cancer. What to do: Get enough sleep. Most adults need seven to eight hours a night. (School-aged children need at least 9 hours.) Other studies that limit adults’ sleep find higher levels of ghrelin (which makes people hungry) and lower levels of leptin (which makes people feel full) in their blood. Changes in ghrelin, leptin, and insulin resistance may explain why studies find a higher risk of obesity, heart disease, diabetes, and high blood pressure in people who get too little sleep. Am J Clin Nutr. 2010; 91:1550 and J Clin Endocrinol Metab. 2010; 95:2963. Reprinted from the Center for Science in the Public Interest’s Nutrition Action Health Letter, July/August 2010. 34 San Francisco Medicine November 2010 35 San Francisco Medicine November

Food for Thought Potassium in Food Sources of Potassium (in milligrams) Butternut squash (one cup baked) 1200 Lima beans (dry, 1 cup cooked) 1200 Spinach (1 cup cooked) 1160 Black beans (1 cup cooked) 970 Soybeans (1 cup cooked) 940 Pinto beans (1 cup cooked) 940 Navy beans (1 cup cooked) 790 Acorn squash (1/2 squash, baked) 750 Green lima beans (1 cup cooked) 720

Papaya (medium) Cantaloupe (1/2 melon) Avocado (1/2 medium) Raisins (1/2 cup) Kidney beans (1 cup cooked) Chard (1 cup cooked) Prune juice (1 cup) Parsnips (1 cup cooked) Split peas (1 cup cooked) Blackstrap molasses (1 Tbs.)

710 680 650 650 630 600 600 590 590 580

Dates (10 medium) Potato (cooked) Orange juice (1 cup) Beet greens (1 cup) Banana (medium) Low-fat milk (1 cup) Kohlrabi (1 cup cooked) Peas (1 cup fresh) Brussels sprouts, 1 cup cooked Nectarine (medium)

The Healthy Eating Pyramid

520 500 500 480 440 430 430 420 420 410

Department of Nutrition, Harvard Public School of Health Infographics of the perfect diet abound in the United States. First there was the U.S. government’s Food Guide Pyramid, followed by its replacement, My Pyramid (which was basically the same thing). The problem with past efforts, while generally well intentioned, is that their recommendations have often been based on out-of-date science and influenced by people with business interests in their messages. A better alternative is the Healthy Eating Pyramid from the Department of Nutrition at the Harvard School of Public Health, a simple guide based on the latest science, and unaffected by businesses and organizations with a stake in its messages. Here are five tips for following the pyramid’s recommendations:

1. Start with exercise. A healthy diet is built on a base of regular exercise, which keeps calories in balance and weight in check. 2. Focus on food, not grams. The Healthy Eating Pyramid doesn’t worry about specific servings or grams of food. It’s a simple, general guide to how you should eat when you eat. 3. Go with plants. Eating a plant-based diet is healthiest. Choose plenty of vegetables, fruits, whole grains, and healthy fats, like olive and canola oil. 4. Cut way back on American staples. Red meat, refined grains, potatoes, sugary drinks, and salty snacks are part of American culture, but they’re also really unhealthy. Go for a plant-based diet rich in nonstarchy vegetables, fruits, and whole grains. And if you eat meat, fish and poultry are the best choices. 5. Take a multivitamin, and maybe have a drink. Taking a multivitamin can be a good nutrition insurance policy. Moderate drinking for many people can have real health benefits, but it’s not for everyone. Those who don’t drink shouldn’t feel that they need to start. Copyright © 2008. For more information about The Healthy Eating Pyramid, please see The Nutrition Source, Department of Nutrition, Harvard School of Public Health, http://www., and Eat, Drink, and Be Healthy, by Walter C. Willett, MD, and Patrick J. Skerrett (2005), Free Press/Simon & Schuster, Inc.

November 2010 San Francisco Medicine 35

Food for Thought The Dirty Dozen

The Dirty Dozen Peaches almost always carry pesticide residues. Onions seldom do. Apples? Yes. Avocados? No. If you want to avoid pesticides but don’t want to buy everything organic, use this table to find out which organic produce makes the most difference. It was created by the Washington, D.C.-based nonprofit Environmental Working Group (EWG). EWG rated the 43 most commonly consumed fruits and vegetables, using the results of nearly 43,000 analyses for pesticides conducted by the U.S. Department of Agriculture and the Food and Drug Administration from 2002 to 2004. It gave each fruit or vegetable a score based on: the percentage of samples that had detectable pesticides; the percentage of samples that had two or more pesticides; the average number of pesticides found on a sample; the average concentration of all pesticides found; the maximum number of pesticides found on a single sample; the total number of pesticides found. The worst offender? Peaches—97 percent were contaminated with pesticide residues. The average peach contained residues of three different pesticides. “Peaches have a soft skin, and the pesticides tend to go right through into the pulp,” explains the Organic Center’s Charles Benbrook. “That’s why soft-skinned fruits and vegetables have the worst residues compared to produce with thicker skins or peels.” One important shortcoming of the rankings: They don’t take into account the toxicity of each pesticide, which is hard to quantify. So a fruit with a small amount of one toxic pesticide won’t look as bad as another fruit with several, far less toxic pesticide residues. But the table is still useful as a measure of the fruit’s “total pesticide load.” According to the EWG, you can lower your pesticide exposure by almost 90 per cent if you avoid “The Dirty Dozen” (the twelve most contaminated fruits and vegetables) and eat the twelve least contaminated ones instead (see chart). Another option: Buy organic. But whatever you do, you’re better off eating fruits and vegetables with pesticides than not eating fruits and vegetables.

Fruit or Vegetable


% with Pesticides % with 2 or more Pesticides





Sweet bell peppers Celery


Strawberries Cherries Pears

Grapes (imported) Spinach Lettuce

Potatoes Carrots

Green beans Hot peppers Cucumbers

Raspberries Plums





Mushrooms Cantaloupe

Honeydew melon Tomatoes

Sweet potatoes Watermelon

Winter squash Cauliflower


The Consistently Clean Papaya



Bananas Kiwi

Sweet peas (frozen) Asparagus Mango


Sweet corn (frozen) Avocado

100 86



































11 9









































23% 7%































13% 8%

10% 5%











Onions 1 0% 0% © 2010 Environmental Working Group. Reprinted with permission.

36 San Francisco Medicine November 2010 37 San Francisco Medicine November

Food for Thought Dangers of GMO Foods; Higher Herbicide Residues

Antioxidants: Twenty of the Best Health-Boosting Foods

Americans are becoming aware of the dangers of genetically modified organisms (GMO) foods, but most don’t know that scientists have created GMO crops specifically designed to be resistant to weed killer. This allows farmers to produce good crop yields and to use weed killers at higher concentrations. Recent studies have found much higher concentrations of weed killer in these crops. A growing number of carefully conducted studies are showing that weed killers may produce significant damage to human DNA, mitochondria, and immune cells. A study from a French laboratory in 2009 reported in the journal Toxicity found that weed killers do produce changes in genetic structure. They concluded that weed killers should be considered carcinogens. Further, they accumulate in food, animal feed, and the environment. Since these residues remain in and on foods, it is difficult to avoid exposure. In the U.S., from the late 1970s until 1992, there was a 50 percent increase in lymphoma, with the greatest incidence occurring in the farm belt of the Midwest. As far back as 1981, a study from Sweden found that there was a sixfold increase in malignant lymphoma in those exposed to herbicides. Another highly fatal cancer, multiple myeloma, may also be linked to weed killers. In general, everyone should follow a few basic steps to the best of their ability: Greater protection can be gained by eating a good diet. Thoroughly wash all fruits and vegetables. Take a few supplements that are known to increase your antioxidant defenses and hinder the development of cancer. Many pesticides produce toxicity by generating massive amounts of free radicals. The following nutrients help protect from these free radicals: • Probiotics twice daily to stimulate gut production of vitamins K and K2 • Curcumin (turmeric, one teaspoon a day) • Quercetin (found in apples, onions) • Indole-3 carbinol (in cruciferous vegetables) or taken as pressed tablets or capsules • Alpha-lipoic acid, 250–300 mg/daily • Coenzyme Q10, 100 mg once or twice daily • Vitamin D-3, starting with 2000 mg daily (taken with fatty meal)

In 2004 the U.S. Department of Agriculture presented a top 20 list that provides a helpful guide for picking out some of the healthiest foods the next time you go to the supermarket. The results weren’t altogether surprising: Fruits, vegetables, and beans claimed nearly all the spots in the Top 20.

From Bottom to Top 20. Gala apples 19. Plums 18. Black beans (dried) 17. Russet potatoes (cooked) 16. Black plums 15. Sweet cherries 14. Pecans 13. Granny Smith apples 12. Red Delicious apples 11. Strawberries 10. Raspberries 9. Prunes 8. Blackberries 7. Artichokes (cooked) 6. Cranberries 5. Blueberries (cultivated) 4. Pinto beans 3. Red kidney beans 2. Blueberries (wild) 1. Small red beans (dried)

About Flatulence and Bloating Some adults have variable levels of lactose (milk sugar) intolerance. This sugar is in milk, as well as in some processed items (cheese, some breads and bread products, creamed soups, and sauces.) You can counteract much of this with Lactaid drops (to put in with milk about 14 hours before drinking) or tablets (to take with eating these foods). Follow the directions on the package of tablets or drops. Flatulence Scale, Beans (In order of more to less) Soy (less with tofu and soy milk) Pink Black Pinto Small white Great Northern Baby Lima Garbanzo Large Lima Black-eyed Peas

Small red beans, which topped the list, looks like a kidney bean, except smaller. It’s sometimes identified as a Mexican red bean, but is grown in Washington, Idaho, and Alberta, Canada. The USDA list is useful, but it’s important to remember that the best way to get your antioxidants is not by eating bowls of small red beans, but rather by eating a wide variety of antioxidant-rich foods. As you might imagine, most antioxidant foods lose some of their antioxidant capacities in processing. So while blueberry pie may seem like a somewhat healthy treat, it can’t begin to compare with a bowl of blueberries, picked fresh from the meadow. This list is excerpted from a 2004 USDA nutrition study published in the Journal of Agricultural and Food Chemistry. The title: “Lipophilic and hydrophilic antioxidant capacities of common foods in the United States.”

Beans cause gas mainly due to lignin in the skin. If they are treated by bringing them to a boil two to three times and emptying the water each time before the final cooking, much of this problem is eliminated. Some foods are often a problem as well. Foods That May Cause Gas Lettuce Apples Milk and milk prodApricots ucts Bagels Onions Bananas Pastries Beans Pretzels Brussels sprouts Potatoes Cabbage Prune Juice Carrots Raisins Citrus fruits Wheat Germ Eggplant

A product called Bean-O is sold over the counter; it’s expensive but only requires one tablet per potentially gassy meal. It helps! Some people find that the situation is much less of an issue over time if they add a probiotic to their daily routine, taken one or two times daily, just before a meal. These capsules tend to stay fresh longer when stored in the refrigerator.

November 2010 San Francisco Medicine 37

Food for Thought Phytochemicals Phytochemicals are ingredients that occur naturally in fruits, vegetables, and grains. They have not been shown to be essentials nutrients and their functions in the body are under investigation. Some phytochemicals function as antioxidants to squelch free radicals. Currently the emphasis remains on food sources, not supplement or pills.

Phytochemicals and their Food Sources • Allyl sulfides (allium, as S-allyl-cysteine or SAC; diallyl sulfide; allyl methyl trisulfide) Role: Decreases tumor cell growth; inhibits kinase activity; arterial vasodilator Onions, garlic (especially oil), leeks, chives, scallions, and red pepper • Carotenoids (a, b, lutein) and lycopenes Role: Increases activity of killer cells slightly; photoprotective agent Carrots, broccoli, spinach and other leafy green vegetables, winter squash, papaya, mango, cantaloupe, tomatoes, and watermelon • Coumarins Role: Anticoagulant effect; inhibits proteolysis and lipoxygenase; anti-inflammatory Leafy green vegetables (broccoli, cauliflower, cabbage, kale, Brussels sprouts, collard greens, mustard, and turnip greens) • Dithlothoines (containing sulfur) Role: Antimutagenic; chemoprotective for epithelial cells Cruciferous vegetables (broccoli, cauliflower, cabbage, kale, Brussels sprouts, collard green mustard, or turnip greens) •D-limonene, terpenes Role: Decreases bacterial and fungal growth; decreases cancer cell growth Citrus fruit oils (orange, grapefruit, lemon), cherries, and citrus fruit peel • Epigallocatechin gallate (EGCG) Role: Decreases growth of hydroquinone oxidase toxicity Green and black tea • Flavonoids (quercetin, kaempferol, myricetin) Role: Fights free radicals Citrus fruits, apples, whole grains, and potato skins • Folate Role: Decreases cancer cell multiplication; efficient DNA synthesis and repair; regulates cellular S-adenosylmethionine levels and gene expression Leafy greens and orange juice

• Herbs not commonly eaten Astragalus, Role: Increases macrophages Echinacea , Role: Immune cells (interferon, killer cells, interleukin 2) Ginseng, Role: Increases lymphocytes • Herbs, spices, seasonings Roles: Preserves alpha-tocopherol; decreases liver inflammation; protects plasmid DNA from degradation by radiation; decreases ATPase; lower lipid peroxidation; maintains antioxidant effect; contains flavonoids, which decrease ascorbate-dependent free radical oxidation; decreases inflammation, tumorigenesis, and malarial impact Turmeric/cumin, rosemary, thyme, sage, and oregano, chili powder, black pepper, and turmeric, cinnamon, caraway, cumin, coriander, and turmeric, ginger, licorice (glycyrrhiza) • Indole-3 carbinol Role: Modulates and down-regulates effects of estrogen and testosterone on tumor formation and growth; inhibits cell adhesion Cruciferous vegetables (broccoli, cauliflower, cabbage, kale, Brussels sprouts, collard greens, mustard, or turnip greens) • Isoflavones (genistein, daidzein, biochanin A) Role: Phytoestrogens, which attach to estrogen receptors and block real estrogen; they also lower cholesterol levels and decrease cancer activity Soybeans (tofu, soy milk), legumes, raisins, and currants • Isothiocyanates (sulforaphane, etc.) Role: Increases period of cancer latency; effective agents against fungi such as Aspergillus Cruciferous vegetables (broccoli, cauliflower, cabbage, kale, Brussels sprouts, collard green mustard, or turnip greens) • Lignans Role: Phytoestrogens, which attach to estrogen receptors and block real estrogen; they also lower cholesterol levels and decrease cancer activity Flaxseed, whole grains, berries, and vegetables • Monounsaturated fats Role: Decreases tumorigenesis Canola and olive oils • Oligosaccharides Role: Increases short chain fatty acid formation; decreases cholesterol and lower insulin levels Whole grains • Phenolic acids (polyphenols) (or flavonoids) Role: Superoxide, anion radical (SOR)-scaveng-

38 San Francisco Medicine November 2010 39 San Francisco Medicine November

ing activity; interaction of the tumor promoter benzoyl peroxide (BPO) with murine peritoneal macrophages; protects against oxidation of LDL • Ellagic acid, ferulic acid, gallic acid, chlorogenic acid, tannic acid, caffeic acid Role: Inhibits proliferation of cancer cells Tomatoes, citrus fruits, carrots, whole grains, and nuts; grapes and wine, green and black grape juices, cherry juice, green and black tea and coffee • Phytates Role: Can decrease oxidative damage to cells Whole grains • Protease inhibitors Role: Inhibit action of protein-splitting enzymes; may prevent cancer cell formation or may crease tumor size Whole grains • Resveratrol Role: Decreases platelet activity Red grapes, wine, and grape juice • Saponins Role: Decreases heart disease and cancer risks Beans and legumes, soybeans • Selenium and glutathione Role: Increases immune cell functioning; DNA methylation; regulation of cytokine production Brazil nuts, lean meats, and seafood; potatoes (glutathione) • Vitamin B6 Role: Increases lymphocyte numbers Legumes, whole grains, chicken, pork, and bananas • Vitamin C Role: Minimizes damage to neutrophils Citrus fruit, peppers, broccoli, tomatoes, and strawberries • Vitamin E Role: Increases antibody production and B and T cell functioning Wheat germ, mayonnaise, creamy salad dressings, pistachios, almonds, peanuts, and walnuts • Zinc Role: Increases neutrophil function and killer cell numbers; decreases cytokines; increases T and B cell numbers Wheat germ, lean beef, seafood, and blackeyed peas Source: Escott-Stump, S, Nutrition and Diagnosis: Related. Derived from Environmental Nutrition newsletters (January–February 2001: Steinmetz and Potter, 1996; American Institute for Cancer Research, 1994; Dwyer et al 1994.

Food for Thought Iron Content of Common Foods Food

Serving Size

Iron (mg)

Oysters Beef liver Bran flakes, enriched Beef heart Chipped beef Lean beef roast Veal roast Hamburger Prune juice Sardines Dried beans Spinach Lima beans Ham Canned tuna Dandelion greens Green peas Leg of lamb Chicken, meat only Mustard green Strawberries Egg Tomato juice Rice, enriched Brussels sprouts Dried apricots Winter squash Whole-wheat bread Blackberries Pumpkin Canned salmon Cooked cereal Blueberries Spaghetti, enriched Macaroni, enriched Broccoli Potato chips Raspberries Peanut butter White bread Dried fig Muffin Applesauce Cooked tomatoes French-fried potatoes Popcorn, no fat Pear Potato Corn on the cob

3/4 c 3 oz 1/2 c 3 oz 3 oz 3 oz 3 oz 3 oz 1/4 c 3 oz 1/2 c 1/2 c 1/2 c 3 oz 3 oz 1/2 c 1/2 c 3 oz 3 oz 1/2 c 3/4 c 1 1/2 c 1/2 c 1/2 c 4 halves 1/2 c 1 slice 1/2 c 3/4 c 3 oz 1/2 c 1/2 c 1/2 c 1/2 c 1/2 c 15 1/2 c 2 tbsp 1 slice 1 1 1/2 c 1/2 c 8 3c 1 1 small 1 small

10 8 6.2 5 4 3 2.9 2.7 2.6 2.5 2.5 2.4 2.2 2.2 1.6 1.6 1.5 1.4 1.4 1.3 1.1 1.1 1.1 .9 .9 .8 .8 .8 .7 .7 .7 .7 .7 .7 .7 .7 .6 .6 .6 .6 .6 .6 .6 .6 .6 .6 .5 .5 .5

Comparing Cheeses Calories Fat (g) Sat. (g) Fat Calcium (mg) Sodium (mg) Blue cheese 353 29 19 528 1395 Brick 371 30 19 674 560 Brie 334 28 17 184 629 Camembert 300 24 15 388 842 Cheddar 403 33 21 721 621 Colby 394 32 20 685 604 Cottage cheese, 2% 90 2 1 69 406 Cottage cheese, 1% 72 1 <1 61 406 Cottage cheese, creamed 103 5 3 60 405 Cottage cheese, dry curd 85 <1 <1 32 13 Cream 349 35 22 80 296 Edam 357 28 18 731 965 Feta 264 21 15 493 1116 Fontina 389 31 19 550 800 Gouda 356 27 18 700 819 Gruyère 413 32 19 1011 336 Limburger 327 27 17 497 800 Monterey Jack 373 30 19 746 536 Mozzarella, part skim 280 17 11 731 528 Mozzarella, whole milk 318 25 16 575 415 Muenster 368 30 19 717 628 Neufchâtel 260 23 15 75 349 Parmesan 392 26 16 1184 1602 Port salut 352 28 17 650 534 Provolone 352 27 17 756 876 Ricotta, part skim 138 8 5 272 125 Ricotta, whole milk 174 13 8 207 84 Romano 387 27 17 1064 1200 Roquefort 369 31 19 662 1809 Swiss 376 28 18 961 260 Tilsit 340 26 17 700 65 Margen S. Wellness Encyclopedia of Food and Nutrition, Rebus, Random House New York. 1992.

Brown Rice Rules Why choose brown rice over white? Researchers tracked nearly 200,000 men and women for fourteen to twenty-two years. Those who ate at least five servings of white rice per week had a 17 percent higher risk of type II diabetes than those who ate less than one serving a month. In contrast, people who ate at least two servings of brown rice a week had an 11 percent lower risk of type II diabetes than those who ate less than one serving a month. A separate study found that among women who already had diabetes, those who ate the most bran (around 10 grams per day) had about a 35 percent lower risk of dying of heart disease than those who ate the least bran (1 gram per day). It didn’t matter if the bran came from whole grains or was added to meals as bran itself. What to do: Switch from refined to whole grains. Brown rice may protect against diabetes because it has more fiber, vitamins, and magnesium and other minerals than white rice, and because it raises blood sugar less than white rice does. However, other whole grains, like bulgur and whole-grain pasta, raise blood sugar even less than brown rice. Arch Intern Med. 2010; 170:961 and Circulation 2010; 121:2162. Reprinted from the Center for Science in the Public Interest’s Nutrition Action Health Letter, July/August 2010. November 2010 San Francisco Medicine 39

Food for Thought Benefits of Mushrooms At the most recent FASEB meetings, in Anaheim this past April, one of many exhibits promoted the medicinal characteristics of mushrooms. This particular group, located in Santa Rosa, is headed by David Law and calls itself Gourmet Mushrooms, Inc. Scientists have analyzed an array of characteristics of various mushrooms; most of these fungi, however, are relatively unavailable to most people. I have thus listed those mushrooms, with common and Latin names as well as characteristics, in the following groups: Gilled: Enoki, Shiitake, and Oyster Jelly: Woodear Polypores: Maitake and Reishi Common Name







Latin Name

Flamulina Velutipes

Lentinula Edodes

Plurotus Ostreatus

Auricularia Auricula

Grifola Frondos

Ganoderma Lucidum








Remediates Fatigue

x x



Mutagen Reduction










Lowers BP






Coronary Artery Dilation


Supports Bone Marrow


Cholesterol Reduction


Immune Support


Cytokine Mediation



x x

Increased Endurance


O2 Update Increase


x x

Liver Protection


Increased Lymphocyte Production


T Lymphocyte Increase


See for more information.

Resources: Nutrition Information Monthly Newsletters Subscribe to these newsletters to stay up on the latest in nutrition and related topics to better serve your patients, your family, and yourself the proper dosage of healthy food. Center for the Science in the Public Interest Nutrition Action Cornell Medical College Food and Fitness Advisor

Environmental Nutrition

Harvard Medical School Harvard Health Letter

Harvard Womanâ&#x20AC;&#x2122;s Health Watch

Integrative Medicine Communications Herb and Dietary Supplement Report

40 San Francisco Medicine November 2010 41 San Francisco Medicine November

Massachusetts General Hospital Mind, Mood, and Memory The Medical Letter, Inc. The Medical Letter Tufts University Health and Nutrition Letter

Food for Thought Weekly Calorie-Burning Worksheet Activity

Fun Activities Dancing (ballroom) Dancing (modern) Golf (walking) Hiking (hilly) Horseback riding (trot) Racquetball Scuba Diving Skating (ice) Skiing (cross-country) Skiing (downhill) Snowshoeing Squash Soccer Table tennis Tennis (singles) Tennis (doubles) Volleyball

Exercise Bicycling (10 mph) Jogging (6 mph) Jumping rope Rowing machine Swimming (slow crawl) Walking (2–2.5 mph) Walking (3.5 mph) Weight training Domestic Chores Carpentry Chopping wood (ax) Farming (light) Farming (heavy) Gardening (dig, hoe) Hedge trimming House cleaning Mopping Mowing lawn (power) Painting (outside) Plastering Raking Sawing (by hand) Sawing (power saw) Scrubbing floors Snow shoveling (light) Tree pruning Washing/polishing car Weeding Window cleaning Weekly Total

Vitamin K

H o u r s C a l o r i e s C a l o r i e s C a l o r i e s Total per week per hour per hour per hour (@180 Lbs) (@130 Lbs) per pound

288 468 411 648 504 738 684 468 666 468 810 774 666 342 522 324 396 486 756 684 558 630 288 432 342 270 414 414 576 576 378 288 306 486 378 378 270 594 360 522 702 630 270 360 288

208 338 299 468 364 533 494 338 481 338 585 559 481 247 377 234 286 351 546 494 403 355 208 312 247 195 299 299 416 416 273 208 221 351 273 273 195 429 260 377 507 455 195 260 208

1.6 2.6 2.3 3.6 2.8 4.1 3.8 2.6 3.7 2.6 4.5 4.3 3.7 1.9 2.9 1.8 2.2 2.7 4.2 3.8 3.1 3.5 1.6 2.4 1.9 1.5 2.3 2.3 3.2 3.2 2.1 1.6 1.7 2.7 2.1 2.1 1.5 3.3 2.0 2.9 3.9 3.5 1.5 2.0 1.6

(K1 – phylloquinone; from green plants, and K2 – manufactured by bacteria; menaquinones) K, synthesized, is menaquinone (menadione) Under normal circumstances, these all have metabolic activity, and in general each has a distinct type and degree of activity. Vitamin K, synthesized, is provided occasionally, via a prescription, as Mephyton, 5 mg., which is taken daily if people have any bruising and are elderly, but occasionally used by the young. Bruising may be following a long illness or prescription medicines, but it can also be seen in anorexic or restricting bulimic people. Vitamin K2 is the preferred form for those people needing assistance with osteoporosis. In addition to discussing ample calcium and magnesium from the diet, we normally would ask people to take Ca and Mg citrate, in capsule or powder form. Pills with hard coatings (like Citracal) may be harder to digest than capsules by about 20 percent. An indeterminate amount of vitamin K1 and K2 is provided via GI tract manufacture by microbes. Of note: Many people may produce insufficient Vitamin K2 via this gut source after antibiotics, especially if prolonged.

Food Sources of Vitamin K Sources of Vitamin K2 include: Pretin foods, eggs, egg whites, milk Spinach, broccoli, Brussels sprouts, kale, and turnip greens (1/2 c provides 2-300 mcg.) The other excellent option is fermented Asian foods. Liver outstrips them all, with very high Vitamin K levels. Adequate sources are lettuce, peas, green beans, and cabbage, at 10–100 mg/100mg. Since it’s difficult to estimate what one might get from the gut, the general aim would be to have at least three to five servings of the foods from first list per week; and the usual three to four regular servings of vegetables per day (a serving raw = 1 cup; cooked, 1/2 cup). This might usually include a food or two from the second list. The pill Mephyton is available, but this is K1 and of limited help with osteocalcin and gut (and later bone) absorption of calcium and mineral into bone. The role of K1 is mainly enhancing the coagulation process.

November 2010 San Francisco Medicine 41

Food for Thought Local Farmer’s Market Guide Those of us who live in the Bay Area are extremely fortunate to have access to a diverse array of fresh seasonal produce yearround. Shopping at the local farmer’s market has many benefits; you directly support local growers, you get fresher produce that is in season in your area, you cut down on fossil fuel use because your produce did not need a plane ticket to reach you, and oftentimes you also save money in the process. Use this guide to locate the market nearest you!

San Francisco

Alemany Saturdays, dawn to dusk 1000 Alemany Blvd. (junction 101 and 280) Bayview Wednesdays, 9:00 am to 1:00 pm Seasonal: May to October 3rd St. and Oakdale Ave. (Hunter’s Point) Castro Wednesdays, 4:00 pm to 8:00 pm Seasonal: April to October Market St. and Noe St. Crocker Galleria Thursdays, 11:00 am to 3:00 pm 50 Post (at Montgomery) Divisadero Sundays, 10:00 am to 2:00 pm Divisadero St. (at Grove St.)

Ferry Plaza Tuesdays and Thursdays, 10:00 am to 2:00 pm (30 vendors) Saturdays, 8:00 am to 2:00 pm (120 vendors) One Ferry Building Fillmore Saturdays, 9:00 am to 1:00 pm Seasonal: May through November Fillmore St. (at O’Farrell) Fort Mason Sundays, 9:30 am to 1:30 pm Seasonal: June to October Marina Blvd. at Buchanan St.

Inner Sunset Sundays, 9:00 am to 1:00 pm 9th and Irving

Center St. (between Milvia and Martin Luther King)

Mission Bay Wednesdays, 10:00 am to 2:00 pm Seasonal: April to November Gene Friend Way, between 3rd and 4th

Oakland Grand Lake Saturdays, 9:00 am to 2:00 pm Splashpad Park (at Grand Ave. and Lakepark Way)

Kaiser Permanente Wednesdays, 10:00 am to 2:00 pm Geary (at St. Joseph’s Street)

Jack London Square, Oakland Sundays, 10:00 am to 2:00 pm Water St. from Webster to Broadway (west of Embarcadero)

Noe Valley Saturdays, 8:00 am to 1:00 pm 3861 24th Street (between Sanchez and Vicksburg)

Old Oakland Fridays, 8:00 am to 2:00 pm 9th St. in Old Oakland (between Broadway and Clay)

U.N. Plaza Wednesdays, 7:00 am to 5:30 pm Sundays, 7:00 am to 5:00 pm 1182 Market St. (at 8th Street and Grove)

Park Merced Saturdays, 10:00 am to 2:00 pm Seasonal: May to December The Meadow (at Serrano Dr. and Arballa Dr.) Stonestown Galleria Sundays, 9:00 am to 1:00 pm 3251 20th Ave.

UCSF Parnassus Wednesdays, 10:00 am to 3:00 pm 505 Parnassus Ave. Upper Haight Wednesdays, 4:00 pm to 8:00 pm Waller St. at Stanyan St.

East Bay

Alameda Tuesdays, 9:30 am to 1:00 pm Thursdays, 4:00 pm to 8:00 pm Seasonal: May to September Taylor St. and Webster St.

Berkeley Tuesdays, 2:00 pm to 7:00 pm Thursdays, 3:00 pm to 7:00 pm Saturdays, 10:00 am to 3:00 pm

42 San Francisco Medicine November 43 San Francisco Medicine November 2010 42 San Francisco Medicine october 2010


Belmont Sundays, 9:00 am to 1:00 pm Seasonal: May to November Caltrain Parking Lot (at El Camino Real and O’Neill) Palo Alto Saturdays, 8:00 am to 12:00 pm Seasonal: mid-May to mid-December Gilman St. (at Hamilton)

San Mateo Wednesdays and Saturdays, 9:00 am to 1:00 pm College of San Mateo 1700 W. Hillsdale Blvd.

North Bay

Point Reyes Station Saturdays 9:00 am to 1:00 pm Seasonal: June to November Toby’s Feed Barn Highway One

San Rafael Civic Center Sundays, 8:00 am to 1:00 pm 3501 Civic Center Dr. (at N. San Pedro Rd.) Downtown San Rafael Thursdays, 5:00 pm to 8:00 pm Seasonal: April to September 4th St. (between Lincoln and B St.)

Food for Thought

Still Sour Health Policy Perspective: Sugar Politics Versus Health

Shannon Udovic-Constant, MD, and Steve Heilig, MPH


hen San Francisco officials floated the idea of a soft drink fee last year, some reactions were predictable, especially denunciations by the soda beverage industry and at least one so-called “consumer” group funded by them. For many of us in the health field, however, there was another reaction to the proposal: “What has taken so long?” Ideologies aside, the rise in obesity presents a looming health and economic disaster. As noted by UCLA and California Center for Public Health Advocacy researchers, whose 2009 study provoked the proposal, $41 billion is spent treating obesity in our state annually. There are many reasons for increased weight, but there’s no denying that childhood consumption of sugar can play a significant role. More than half of teens drink at least one soda per day. Overall, soda accounts for almost half of the increased calories Americans take in daily compared to thirty years ago. At the same time the California study was released, a team of leading figures in food and nutrition published a paper titled, “The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages” in the New England Journal of Medicine. These physicians and other researchers, from Yale, Harvard, and elsewhere, produced a document that should be required reading for anybody interested in this topic—perhaps before they post comments online or send angry letters to newspapers. The health aspects of overconsumption are now obvious, including not just obesity but diabetes and heart disease, two of our leading and increasing killers. The NEJM paper convincingly outlines “sugar science” but also provides an equally important look at the financial side of the issue.

As has now been learned from long experience with tobacco, by taxing sodas we can not only generate much-needed revenue for health services but also discourage consumption, particularly by children and teens. Although a majority of states already have a soda tax in some form, the NEJM authors propose a national tax of one cent per ounce, which would generate around $15 billion per year—$1.8 billion in California—and also lead to weight loss among soda drinkers. The revenue should be used for child nutrition and obesity education and treatment programs, they propose. Dental care might logically be thrown into the mix as well. The proposal makes economic sense, even for those who might consider themselves “conservative” in financial policy matters. In fact, Adam Smith, figurehead of modern free-market theory, held that sugar was “an extremely proper subject of taxation.” Economists identify some costs of a product or transaction as “externalities” when those costs are borne by third parties. Pollution has long been cited as an example of an externality cost, which is one reason why environmental regulations exist. Obesity and other attendant health costs are externalities of the sugar market. We all pay, or will pay, ever-increasing amounts for those costs via tax-funded health care, education, and other expenses—and we even subsidize the production of sugar and its evil twin, high fructose corn syrup, to the tune of $3 billion annually. Why not have the producers and consumers cover more of their fair share? One answer is that such a tax would likely produce the desired effect of reduced consumption, and thus the appearance of new beverage-industry lob-

bying groups such as “Americans Against Food Taxes”—something similar to the now-defunct Tobacco Institute. So far, expensive lobbying has gutted such tax proposals from public budgetary proposals, including those for health system reform. Proposals to reduce subsidies for sugar have also been killed politically. Thus, even though the CMA—thanks to a policy originating at the SFMS—favors increased sugar taxes and advises that high fructose corn syrup consumption “threatens the health of Californians,” legislation to increase such taxes is killed due to lobbying and a general “no new taxes” sentiment. We are left with worthy but piecemeal approaches such as the recently enacted restriction on artificially sweetened drinks in children’s daycare centers. Also, legislation passed recognizing the last week of September as Childhood Obesity Prevention and Fitness Week in California. This is all to the good, but hardly sufficient given the magnitude of the problem. Leading nutrition expert Dr. Marion Nestle, author of a number of landmark books on food policy, recently noted that our national sugar policy is “ripe for satire.” Of course she also succinctly advises everyone to “eat less sugar.” That will be a long, but worthy, battle. Polls show that a majority of Americans support sugar taxes, especially if the revenue is used for related health programs. It’s time to vote with science, economics, and what is increasingly seen as common sense, and increase taxes on sugar, high fructose corn syrup, and sweeteners in whatever guise they are marketed, especially to young people. The alternative is the increasingly bitter—and overweight— status quo.

November 2010 San Francisco Medicine 43

Food for Thought

Inspiring Physicians to Make a Difference CMA Foundation Partners with Physicians and Communities to Fight Childhood Obesity

Carol A. Lee, Esq.


he purpose of the CMA Foundation’s Obesity Prevention Project is to reduce the prevalence of overweight and obesity in children and their families. The Project carries out its mission by working with “Regional Physician Champions” and giving them access to and assistance with education and community outreach, policy advocacy, and provider resources. “Research tells us that Californians want physicians to be their primary source of information about nutrition, physical activity, and other issues associated with obesity,” stated CMA Foundation Board Chair and Physician Champion Dexter Louie, MD. “Through a partnership with the Foundation and a true desire to change society’s outlook on nutrition and physical activity for the better, everyday physicians can become ‘champions’ in the effort to curb the obesity epidemic.”

The Importance of Daily Physical Activity

A goal of the Obesity Prevention Project is to facilitate partnerships between schools and physicians for ongoing collaborations in support of the Safe Routes to School (SRTS) Program. The most recent California Health Interview Survey found that nearly 30 percent of Bay Area children and teens ages five to seventeen are overweight or obese. Another 23.8 percent of them are at risk of being overweight. In addition, only 27 percent of Bay Area children ages five to eleven years old, and 13.9 percent of teens ages twelve to seventeen, are getting the recommended sixty minutes of physical activity each day. Walking and bicycling to school is an easy and effective way for children to get their daily physical activity. Unfortunately, only 30 percent of

California school children walk or bike to school in a typical week. San Francisco has been ranked one of the most walkable cities in the U.S., with transit-rich neighborhoods and homes, schools, shops, and parks all in close proximity to each other. Health care providers around the state can take steps to promote safe “walking and rolling” to school among their patients and their families. Providers can encourage parents to walk or bike to school with their children in order to ensure that both children and adults get their daily physical activity. Providers can also lend a strong and respected voice to community efforts to prevent pedestrian and bicycle injuries and deaths among children. For more information, please visit the San Francisco Safe Routes to School at To learn how you can become involved in the Safe Routes to School Program in San Francisco, please contact Ana Validzic of the San Francisco Department of Public Health, at or (415) 581-2478. Learn more about statewide efforts to promote Safe Routes to School and Walk to School at and www.

The Role of Nutrition in the Community’s Overall Health

The CMA Foundation’s Obesity Prevention Project recently launched a new resource to raise childhood obesity awareness. Titled Inspiring Change in our Communities: Physician Champions Making a Difference, the monograph provides a snapshot of the innovative programs implemented by Physician Champions throughout California. The work of each of

44 San Francisco Medicine November 2010

these physicians is aimed at serving their communities, particularly low-income and underserved communities, in a variety of settings. Each of these physicians was inspired by a patient, an incident, or a movement. Some have dedicated months and years while others could only spare a few hours; each has changed behavior to break the cycle of childhood obesity by empowering patients to take control of their health. “Community involvement reminds us that we are not alone in the fight against obesity, and together we will achieve success,” stated Dr. Louie, who is one of the physicians featured in the monograph. He developed a program to educate middle school students in the Moraga School District about the role of nutrition and physical activity in overall health and empowered them to become advocates and influence the decisions made about food choices at their schools. Students came together to conduct research, identify potential changes, and implement an action plan, which included the removal of soda machines, adding vegetarian lunch options to the cafeteria menu, producing a health-awareness newsletter, and developing noncompetitive physical activity programs. Inspiring Change in Our Communities: Physician Champions Making a Difference and additional resources can be accessed by visiting the Obesity Prevention Project website at projects/obesityProject.aspx. For more information, please contact or (916) 779-6620.

Food for Thought

Which Nutrition Services Are Covered? Medicare, Medicaid, and SCHIP

The American Dietetic Association


ection 105 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) permits Medicare coverage of medical nutrition therapy (MNT) services when furnished by a registered dietitian or nutrition professional meeting certain requirements. The benefit is available for beneficiaries with diabetes or renal disease, when a physician makes the referral. For the first time, it also allows registered dietitians and nutrition professionals to receive direct Medicare reimbursement. The benefit consists of an initial visit for an assessment, follow-up visits for interventions, and reassessments as necessary during the twelve-month period beginning with the initial assessment (“episode of care”) to assure compliance with the dietary plan. Three hours is the basic coverage of MNT for the first year that a beneficiary receives MNT with either a diagnosis of renal disease or diabetes. Basic coverage in subsequent years for renal disease is two hours. Additional covered hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary. For the purposes of this benefit, renal disease means chronic renal insufficiency or the medical condition of a beneficiary who has been discharged from the hospital after a successful renal transplant within the last six months. Chronic renal insufficiency means a reduction in renal function not severe enough to require dialysis or transplantation (glomerular filtration rate

[GFR] 13–50 ml/min/1.73m²). CMS defines diabetes as the following: Diabetes is defined as diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using a fasting blood sugar greater than or equal to 126 mg/dL on two different occasions, a two-hour post-glucose challenge greater than or equal to 200 mg/dL on two different occasions, or a random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes. The MNT benefit is a completely separate benefit from the diabetes selfmanagement training (DSMT) benefit. CMS had originally planned to limit how much of both benefits a beneficiary might receive in the same time period. However, the national coverage decision allows a beneficiary to receive the full amount of both benefits in the same period. Therefore, a beneficiary can receive the full ten hours of initial DSMT and the full three hours of MNT. However, providers are not allowed to bill for both DSMT and MNT on the same date of service for the same beneficiary.

General Conditions on Medicare Coverage

The following are the general conditions of coverage: The treating physician must make a referral and indicate a diagnosis of diabetes or renal disease. As described above, a treating physician means the primary care physician or specialist coordinating care for the beneficiary with diabetes or renal disease. The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the

treating physician. Services may be provided either on an individual or group basis without restrictions. For a beneficiary with a diagnosis of diabetes, diabetes self-management training (DSMT) and MNT services can be provided within the same time period, and the maximum number of hours allowed under each benefit are covered. The only exception is that DSMT and MNT may not be provided on the same day to the same beneficiary. For a beneficiary with a diagnosis of diabetes who has received DSMT and is also diagnosed with renal disease in the same episode of care, the beneficiary may receive MNT services based on a change in medical condition, diagnosis, or treatment.


The contractor shall pay for MNT services under the physician fee schedule to a registered dietitian or nutrition professional who meets the requirements. Deductible and coinsurance apply.

Private Insurance

Private insurance coverage of nutrition services varies throughout the country and changes frequently. Providers can contact an insurance company’s provider relations department for details on the nutrition benefits offered. Reprinted with permission from the American Dietetic Association. Visit them online at

November 2010 San Francisco Medicine 45

Hospital News Kaiser

Robert Mithun, MD

At Kaiser Permanente we firmly believe you are what you eat. Using this basic premise to promote healthy eating (and physical activity) to our patients and the communities we serve, the San Francisco Medical Center has developed several programs to promote wellbeing through nutrition. One of our goals is to reduce debilitating chronic conditions, such as hypertension and diabetes, by advocating through Health Education programs and in exam rooms for whole, fresh foods versus processed; eating locally and seasonally; and aiming for fruits and vegetables on half the plate at each meal. Weekly farmers’ markets at every Northern California Kaiser Permanente facility, including San Francisco, help reinforce the message of local, sustainable, and seasonal. The Health Education Department is staffed with several health educators focused on nutrition and physical fitness, and it offers programs ranging from healthy grocery shopping tours to personal health coaches. The department is open to the public and nutrition information materials are available free of charge. A designated Nutrition Clinic within Health Education enables registered dieticians an opportunity to interface with individual clients and groups seeking information to improve eating habits and nutritional choices. A multi-disciplinary team of health care providers, including a physician champion, registered dieticians, health educators, and nurses, lead the nutritional advocacy efforts at the medical center. Thanks to Kaiser Permanente’s coordinated national, regional, and local efforts in nutrition advocacy, research is easily shared across the organization. For more information about Kaiser Permanente San Francisco’s nutritional programs, please contact the Health Education Department at (415) 833-3450.

Saint Francis

Patricia Galamba, MD

Many of you may have read that Saint Francis’s Bothin Burn Center is treating several of the survivors of the San Bruno gas explosion. Recently my colleague and medical director of our Psychiatric Unit, Dr. Mel Blaustein, was interviewed by KPIX Medical Reporter Dr. Kim Mulvihill on the subject of posttraumatic stress. Dr. Blaustein is an experienced psychiatrist who led the Psychiatric Society’s response to the Loma Prieta earthquake. He shared a few thoughts regarding what our patients may be experiencing. “Posttraumatic stress disorder (PTSD) is an anxiety disorder triggered by a traumatic event, such as the San Bruno explosion, the Oakland fires, the 1989 Earthquake, and the 101 California shootings. Experiencing this type of traumatic occurrence can be a lifechanging event. It is not uncommon for people to become overwhelmingly fearful, anxious, sad, irritable, and angry. These feelings are a normal response but can be accompanied by other signs, such as trouble sleeping, self-destructive behavior, flashbacks, and recurring nightmares. In the case of the Bothin Burn patients, the first phase of care is to stabilize the patient and begin the physical healing process. This can take weeks to months. At the point when the patient is ready to verbalize recollections of the traumatic event, a psychiatric evaluation is conducted. Some patients will have strong coping mechanisms, along with a strong family support system and the ability to handle the intense emotions that arise from traumatic events. Patients who are more vulnerable may not want to talk about their experience because it is just too painful, or they may even deny the event. Patients who have been pre-exposed to trauma are more vulnerable and have a sense of hopelessness, lack of control, and media overexposure. Mental health professionals can help patients deal with PTSD symptoms and alleviate the sequele that arise. As a psychiatrist, my goal is to reassure them and to normalize their responses as much as possible.”

47 San Francisco Medicine November 2010 46 San Francisco Medicine November 2010


David Eisele, MD

UCSF’s Weight Assessment for Teen and Child Health (WATCH) program has served 800 morbidly obese youth since 2003. The cornerstone of the program’s behavioral intervention is an evidence-based teaching breakfast. The interactive session takes advantage of the need for fasting labs and introduces healthy foods to hungry kids. Parents attend too and often are surprised to see their children enjoying plain yogurt with fruit. “Kids and parents model healthy behaviors together in the clinic and then practice them at home,” said Andrea Garber, chief nutritionist and assistant professor of pediatrics at UCSF. Positive results from WATCH were published last year. Vitamin D deficiency is making headlines, and more doctors are prescribing supplements. In addition to building strong bones, vitamin D could be tied to disease prevention. UCSF dental experts are looking into links between vitamin D deficiency and periodontal disease. “In periodontal diseases, loss of support around the teeth is due to both harmful effects of the bacterial plaque that accumulates around the teeth, and to the local destructive inflammatory reaction to this bacterial plaque. Vitamin D may help in two ways, by fighting bacterial infection and by reducing destructive inflammation,” said Mark Ryder, chair of periodontology, UCSF School of Dentistry. Proper nutrition is critical to helping cancer patients tolerate treatment and maintain strength and weight. Patients can be encouraged to be creative with whole foods and tasty recipes so they ingest enough calories. Many treatment symptoms, including nausea, vomiting, diarrhea or constipation, and decreased appetite and taste changes, may be helped with food and fluid choices in addition to appropriate medications. “Friends and family can assist the person with cancer by cooking nutritious, appealing soups and stews that support the patient through difficult posttreatment days,” said Theresa Koetters, codirector of the Oncology Master’s Program, UCSF School of Nursing.

Open Wide...

With Confidence!

It’s Open Enrollment time for the San Francisco Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees.

Sponsored by:

• Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on January 1, 2011. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit to download an enrollment kit.

Underwritten by:

Administered by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

46809 (11/10) © Seabury & Smith Insurance Program Management 2010 • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • Marsh is part of the family of MMC Companies, including Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

Which One?

Can you identify which of these people has the ventricular assist device (VAD)? The HeartMate® II VAD is the size of an egg, implanted alongside a patient’s weakened heart to take over pumping. The lightweight computer and batteries attached to the VAD are easily worn underneath clothing, allowing people to live active, normal lives. More importantly, VAD implementation is no longer used only for those waiting for a transplant. It is as much a therapy for heart failure as transplant, medica-

tion, bypass, biventricular pacing – anything – especially for younger patients with good immune systems that may reject a donor heart. Surgeons at CPMC have unparalleled experience – they’ve performed 200 VAD implantations as well as nearly 400 transplants since our program began. We are the only Northern California hospital to perform HeartMate® II implantations for destination therapy since 2006 – and one of the first to be CMS-approved. The old thought process was ‘Let’s get the patient the heart transplant ASAP.’ But the HeartMate II is as good an intervention for heart failure as a transplant. This is not your Mother’s VAD.

Our program offers: n

24/7 DIRECT PHYSICIAN ACCESS: 866-207-4417


Urgent outpatient consultations and evaluations of your patients – within 48 hours. We can also accommodate same-day hospital transfers.


Expert evaluation and treatment of patients with NYHA functional class III/ IV heart failure and AHA/ ACC stages C and D heart failure.

** All four of these people have VADs

November 2010  

San Francisco Medicine, November 2010. Food for Thought: Practical Nutrition for Physicians.

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