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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2012


The clock is running on implementation of federal health reform. Health care providers and payers are jockeying to position themselves for the impending changes in health care coverage, delivery and reimbursement. Who will survive the demands of the new marketplace? Who will prosper?

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Sierra Sacramento Valley

MEDICINE 3

PRESIDENT’S MESSAGE To NG, or Not to NG

18

Is it Time to Tax Soda?

Adam Dougherty, MPH, MS II

David Herbert, MD

4

EDITOR’S MESSAGE Let Food Be Thy Medicine

Ann Gerhardt, MD, Co-Editor

23

Book Reviews

6

Childhood Obesity and School Lunch Programs

Ann Gerhardt, MD

26

California Won’t License Dietitians!??

Joanne Graham, Ph.D., RD and Nathan Hitzeman, MD

Judy Gould, MA, MS, RD

28

How to Eat

10

An Acquired Taste

Ann Gerhardt, MD

Lydia M. Wytrzes, MD

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Board Briefs

12

Eating on $5 a Day

George W. Meyer, MD, FACP

15

EXECUTIVE DIRECTOR’S MESSAGE Together We Can Make a Difference

20 BagOfLife

John Loofbourow, MD

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Through the Aether

Bob LaPerriere, MD

33

Glossary of Fats and Oils

Aileen Wetzel, Executive Director

Denette J. Dengler, MD, MS

16

Can You TRACE Sacramento’s Place in Our Nation’s Food Economy?

35

Meet the Applicants

Bob LaPerriere, MD

36

Classified ads

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

SSV Medicine is online at www.ssvms.org/magazine.asp The contiguous United States visualized by distance to the nearest McDonald’s restaurant. Cruising down the I-5 through California’s Central Valley one summer, artist and scientist Stephen Von Worley began to wonder just how far away we could get from our world of generic convenience. And how would you figure that out? As he hurtled down the highway, a pair of golden arches crept over the horizon. Aha! He would set out to determine the farthest point from a Micky Dee’s — in the lower 48 states, at least. This endeavor incorporated information from www.aggdata.com, whose owners were kind enough to provide him with a complete list of all McDonald’s restaurants in the United States (14,058 as of Dec. 2011), geolocated for maximum convenience. From there, with a bit of software engineering gymnastics, behold — a visualization of the contiguous United States, colored by distance to the nearest McDonald’s! This issue’s cover image is used with permission from Stephen Von Worley, www.datapointed.net.

March/April 2012

Volume 63/Number 2 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

Position Available:

2012 Officers & Board of Directors David Herbert, MD President Demetrios Simopoulos, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD, Secretary District 2 Jose Arevalo, MD Ann Gerhardt, MD Lorenzo Rossaro, MD District 3 Bhaskara Reddy, MD, Treasurer District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristin Robinson, MD District 6 J. Dale Smith, MD

mmended By re Doctors.

2012 CMA Delegation Delegates Alternate-Delegates District 1 District 1 Robert Kahle, MD Reinhart Hilzinger, MD District 2 District 2 Lydia Wytrzes, MD Margaret Parsons, MD District 3 District 3 Katherine Gillogley, MD Ruenell Adams, MD District 4 District 4 Earl Washburn, MD Russell Jacoby, MD District 5 District 5 Elisabeth Mathew, MD Anthony Russell, MD District 6 District 6 Marcia Gollober, MD Karen Hopp, MD At-Large At-Large Alicia Abels, MD Robert Forster, MD Richard Gray, MD Maynard Johnston, MD David Herbert, MD Alexis Lieser, MD Richard Jones, MD Robert Madrigal, MD Norman Label, MD Rajan Merchant, MD Charles McDonnell, MD Richard Pan, MD, Stephen Melcher, MD Assemblyman Janet O’Brien, MD Vacant Kuldip Sandhu, MD Vacant Boone Seto, MD Vacant Demetrios Vacant Simopoulos, MD CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD

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CMA President-Elect Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair Sandra Hand, MD George Meyer, MD Albert Kahane, MD John Ostrich, MD Robert LaPerriere, MD Gerald Rogan, MD John Loofbourow, MD Gilbert Wright, MD John McCarthy, MD Adam Dougherty, MS II Managing Editor Webmaster Graphic Design

Nan Nichols Crussell Melissa Darling Planet Kelly

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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2012 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.

Sierra Sacramento Valley Medicine


PRESIDENT’S MESSAGE

To NG, or Not to NG An Intensivist’s View

By David Herbert, MD THIS ISSUE OF THE JOURNAL HAS a great deal of useful information about nutrition! But what about people who have more than a shortterm inability to eat? I’m not referring to those hospitalized for an acute illness where recovery is expected and for whom NG feeding or even TPN can be appropriate. And those who have an isolated inability to eat because of esophageal or laryngeal disease, but are otherwise fairly functional, often receive long-term benefit from a feeding gastrostomy. But what about the patient with advancing dementia who can no longer swallow without choking, or who no longer attempts to swallow when fed? Or the patient with a stroke who can’t swallow safely even though they have recovered awareness? Or the elderly patient who has survived intubation, but post-extubation remains weak, confused, and can’t swallow safely? And finally, there is the patient with advancing malignancy, CHF, or COPD who no longer eats much and is losing weight and energy. In all of these scenarios, tube feeding via NG or PEG is sometimes used. But is this really useful or appropriate? In many cases, the discussion simply boils down to a family’s belief that providing nutrition is a necessity. However, this belief is often based upon their misunderstanding that withholding artificial nutrition will cause hunger and suffering. Patients with advanced dementia do not appear to suffer when they can’t eat, but they very often become agitated and clearly distressed when a feeding tube is placed, especially since this often requires that they be restrained to keep the tube in place. There is also now abundant evidence that patients in the final stages of cancer or organ

failure do not experience hunger as they are losing weight, and that increasing their caloric intake with tube feeding neither makes them feel better, slows weight loss, nor prolongs their life. For these groups of patients, we can reassure families that there is no reduction in suffering to be achieved by providing artificial nutrition. The awake but confused patient who can no longer swallow safely is a more difficult challenge. They may want to eat, but this will cause recurrent aspiration pneumonia, often requiring intubation which they may have already experienced and do not wish to repeat. Even with a PEG, aspiration is inevitable. A tracheostomy plus a PEG is sometimes considered, which may decrease but not prevent aspiration at the cost of a further decrement in swallowing and speech. Additionally, this creates increased care requirements and usually results in transfer to a skilled nursing facility instead of home. We can help these families by identifying what is most important to the patient, and working to accomplish this. Often this will be to maximize comfort for whatever time remains, and thus allow eating for pleasure, to avoid tubes and restraints, and to manage the expected aspiration with comfort measures rather than antibiotics and intubation. There will certainly be some families who still choose artificial nutrition in these situations, but we have an obligation to ensure that they are making a choice based upon accurate information. And now I think I’ll go enjoy a veggie burger (no mayo) and a glass of wine (red) while I peruse this issue of our journal. dherbert@pol.net

March/April 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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EDITOR’S MESSAGE

“Let Food Be Thy Medicine” By Ann Gerhardt, MD, Co-Editor EVERYONE CAN RELATE TO FOOD, so we’ve cooked up a food-related issue of SSV Medicine to lift you out of the winter doldrums. Long ago Hippocrates recognized the integral relationship of food and medicine when he opined, “Let food be thy medicine and medicine be thy food.” Contributors came up with a widely-varied menu of items that speak to the role of nutrition in our region. Whether you care about food for purely hedonistic, purist, public policy, scientific or entertainment purposes, I hope you will find something of relevance and inspiration in this issue. And if we missed a topic or forgot to add a seasoning, please write us an e.Letter to let us know your tastes. Bon appetite!

Food Bills in the California Legislature

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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Editorial Committee member, Dr. Al Kahane, wondered how many bills dealing with food or nutrition were introduced this year. Former SSVMS Executive Director, Bill Sandberg, did the leg work and discovered a website that keeps track of all legislation in any given session of the legislature. You can search for legislation at http://www.leginfo.ca.gov/bilinfo. html. In the current session 2011–2012, there are 58 bills containing the word “nutrition.” Searching with the word “food,” there are 273 bills. Searching with the word “health,” there are 1254 bills.

Unusual Foods From Around the World We asked Editorial Committee members, “What is the most unusual food you have ever eaten?” From Gerald Rogan, MD: Brebis du cerveau sur la plat — un goût non Sierra Sacramento Valley Medicine

aquire, which means sheep brains on the plate. A non-acquired taste. From George Meyer, MD: Natto: Curdled tofu from Japan. It is a stringy, sticky, slimy, chunky fermented soybean dish that the Japanese regularly eat for breakfast. It has been described as smelling like “a marriage of ammonia and a tire fire.” Saumagen: A German dish of sow’s stomach, popular in the Palatinate. The dish is similar to a sausage in that it consists of a stuffed casing; however, the stomach itself is integral to the dish. It isn’t as thin as a typical sausage casing (intestines or artificial casing). Rather, it is meat-like, being a strong muscular organ, and when the dish is finished by being pan-fried or roasted in the oven, it becomes crisp. The dish is somewhat similar to the Scottish haggis, although the stuffing is quite different. Haggis: A dish containing sheep’s “pluck” (heart, liver and lungs), minced with onion, oatmeal, suet, spices, and salt, mixed with stock, and traditionally simmered in the animal’s stomach for approximately three hours. Most modern commercial haggis is prepared in a casing rather than an actual stomach.  Balut: A Philippine delicacy that is a fertilized duck embryo which is boiled alive and eaten in the shell. It is commonly sold as street food in


the Philippines. They are common, everyday food in countries in Southeast Asia, as well, and are often served with beer. From Ann Gerhardt, MD: You can find unusual foods right here in the U.S. In Ohio, Jeni’s Splendid Ice Cream makes ice creams like Golden Ale and Apricot, Cumin and Honey Butterscotch Cake, Whiskey and Pecans, Queen City Cayenne, Frankincense and Almond Cake, Salty Caramel, Smoked Tea and Plum Pudding, Goat Cheese with Cognac Figs, Brambleberry Crisp, and Scarlett and Earl Grey. Their most interesting frozen yogurt is Honeydew, Cucumber and Cayenne. They even have sorbets, including Riesling-Poached Pear and Influenza varieties. Cuy: Guinea pig, which is mostly bones, and revives lost surgical skills. Tastes good, if you can forget how cute guinea pigs are. Cau Cau: Tripe, with potatoes and spices. Tripes are not going to become extinct anytime soon. From Nan Crussell, Managing Editor: Though I have not tried the following, I have read about or seen these: Hákari: A fermented Icelandic delicacy made from Greenland shark. It is prepared by beheading and gutting the shark and then burying the carcass in a shallow pit covered with gravelly sand. The corpse is then left to decompose in its silty grave for two to five months. Once the shark is removed from its crypt, the flesh is cut into strips and hung to dry for several more months. Hákari is said to have a pungent, urinous, fishy odor that causes most newbies to gag. Casu Marzu: A sheep cheese popular on the Italian island of Sardinia. The name means “rotten cheese,” or, as it is known colloquially, “maggot cheese,” since it is literally riddled with live insect larvae. During the fermentation process, the larvae of the cheese fly (Piophila casei) are added to the cheese, and the acid from their digestive systems breaks down the cheese’s fats, making the final product soft and liquidy. By the time it is ready to eat, a typical casu marzu contains thousands of larvae. McLobster: Lobsters were once considered

the vermin of the deep, as early American colonists saw them, and not food fit for kings. Today, in Nova Scotia, Canada, they receive top billing at McDonald’s! Those of us with more delicate tastes might do well to invest in travel guide Rick Steves’ books of basic foreign language phrases. In his dining out section, my favorite phrase that appears in several languages is, “Nothing with eyeballs, please.”

McLobster, above, tickles the imagination in Nova Scotia (Photo by Nan Crussell). Goat brains with goat head garnish, below, are enticing in Morocco (Photo by Dr. Gerald Rogan). Balut, far left, is popular in the Philippines.

algerhardt@sbcglobal.net

March/April 2012

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Childhood Obesity and School Lunch Programs By Joanne Graham, Ph.D., R.D. and Nathan Hitzeman, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

ONE WOULD THINK THAT SCHOOL lunches in California would be healthy. After all, we live in the agricultural hub of the nation. We pride ourselves on farmers’ markets, co-ops, and farm fresh deliveries to our doorsteps. In some states, “local produce” may mean purchasing from up to 400 miles away. Here, we practically have tomatoes growing in our back pocket! Yet, through a perverse agribusiness industrial complex, our school lunches remain a dumping ground for processed food and ultra-sweetened chocolate milk. Berkeley health activist Georgeanne Brennan related this observation in a recent Sacramento Bee article:1 “I’ve eaten dozens of school lunches of every kind from corn dogs, packaged burritos, crispy drumsticks, chicken burgers, egg rolls, peanut butter and jelly sandwiches, to chicken teriyaki rice bowls and tortilla soup. Most of the entree items are prepared, packaged, frozen, frequently hundreds, if not thousands of miles away, and then shipped to California schools to be reheated and finally served.” Her conclusion: “Our children do not need to be served reheated processed food manufactured in Kentucky or Missouri when they are surrounded by some of the most, if not the most, productive orchards, fields, farms, ranches and dairies in the world. Let’s reconnect our children and ourselves to our rich agricultural landscape through creating a true California school lunch.” Why has school lunch become so complicated, what positive changes have been made locally, and how can we advocate for the health and longevity of our children? Fortunately, change is afoot. Both the State

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Meal and the National School Lunch Programs must comply by the USDA Nutrient Standard for menu planning if they are to be eligible for reimbursement. The lunch menu plan requires five components to be offered daily: meat/meat alternative, vegetable, fruit, grain, and dairy. In January 2011, the Food and Nutrition Service proposed standards for menu planning to better align with the 2009 Institute of Medicine report and 2005 Dietary Guidelines.2 The plan promotes a wider variety of vegetables, limits starchy vegetables (think French fries), requires at least half the grains to be whole, and reduces sodium by more than half. The final ruling on these new standards occurred on January 26, 2012, and they will be implemented in 2012-2013.3 Why are these changes so long in coming? Well, the food service directors at our schools are not necessarily to blame for the current predicament. They are caught in the middle of loopholes in government guidelines, an aggressive multibillion dollar processed food industry, and having to meet requirements with a relative pittance of funding. Nonetheless, the school districts in the Sacramento Sierra region are doing what they can to make positive changes. “We’ve implemented much of the new guidelines since its proposal last year. But it hasn’t happened overnight,” says Jill Van Dyke, Food Services Director of the Twin Rivers Unified School District (TRUSD). Over the last year, districts like Twin Rivers have been moving toward healthy changes, like cutting back on convenience foods which are higher in fat, sodium and sugars and emphasizing fresh fruits and vegetables in attempts to meet the


new guidelines. Currently, 80 percent of TRUSD students are eligible for free or reduced-price lunch. Van Dyke serves over 30,000 students every day and receives $3.01 from the government for each free lunch. Could any parent easily provide one-third of their child’s nutritional needs for that cost? It truly seems like a mission impossible, or “meal impossible,” if you will. School districts are expected to meet the new guidelines, but were only given six cents more per meal to do so. This is the first increase for the school lunch program in 30 years.4 How’s that for a challenge! In addition to limited budgets, there is a shortage of equipment that is needed to enable more scratch-cooking. Furthermore, children are typically given only 15 to 20 minutes to be served and eat lunch. Despite this “meal impossible,” local districts have seen the introduction of salad bars into school cafeterias — and not just the iceberg lettuce and Jello kind. These salad bars have been a big hit, especially when they are coupled with nutrition education in the classroom. Sacramento City Unified, Natomas Unified, Twin Rivers Unified and Elk Grove Unified are offering a variety of fresh fruits and vegetables daily through this venue. These bars are placed in schools when funds allow; otherwise, districts depend on grant funding, the PTA/PTSA, or generous donors. For example, ProPacific Fresh — a California-based fresh produce vendor — donated $12,000 to Twin Rivers which enabled them to purchase six salad bars. Some students actually want to eat healthier too. Students of Kohler Elementary in Twin Rivers wanted a fresh food bar and started a recycling program to raise money. “After two years they only raised a few hundred dollars. The students worked so hard. The opportunity came to apply for a grant, I did, and it was awarded!” said Van Dyke. The Food and Nutrition Service, through the California Department of Education, runs the Fresh Fruit and Vegetable Program in efforts to expand access to fresh fruits and vegetables in low-income elementary schools. California was allocated $10.8 million for this program in the

2011-12 school year.5 Twin Rivers Unified has participated in this program since its launch, and seven of its schools have received awards. “We are looking forward and want to offer the best nutritious food we can for our children,” said Van Dyke who recently received approval for a new hire of a registered dietitian for her district. Moving beyond the salad bar, Winters and Davis Joint Unified help bring school children food from local farms through the California Farm to School program. This program has educational components on waste management and composting, but its main goal is to help kids understand where fresh food comes from and the impact that food has on their body, the environment, and the community. Theodore Judah Elementary in Folsom also has a school garden project incorporated into their curriculum. Check it out at http:// sciencealive.net. Despite these changes, poor nutrition at school remains a contributor to the childhood obesity epidemic. Seventeen percent of our children and teens are now obese, according to a recent Bloomberg News report.6 The authors quote the yearly healthcare costs of obesity to be $147 billion, and they point to a 2009 Lancet study that correlates obesity with two to ten years of reduced life expectancy.7 As doctors and educators, how can we address childhood obesity with families in our offices? Telling them to “eat better and exercise” is simply not enough. We need to impress upon kids and parents how good nutrition matters. Point out the health problems associated with obesity.

…poor nutrition at school remains a contributor to the childhood obesity epidemic. Seventeen percent of our children and teens are now obese…

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March/April 2012

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Encourage families to cook together and pack healthy items to supplement their school lunches. Encourage them to “shop the periphery” of the grocery store…

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I often tell smokers the statistic that they will live 13-14 years less than their non-smoking counterparts.8 The Lancet data allows us to use similar language for obese children. After a family recognizes that there is a problem and that changes early in life are their child’s best chance for good health and longevity, create an action plan. Focus on at least one positive change, and provide for follow up to build on that change. Encourage the whole family to participate. Possible scenarios include going to the farmers’ market, eating breakfast to avoid overeating later in the day, choosing fresh snacks like veggies instead of chips, eating at the table without a TV on, limiting fast food to a certain number of times a week, packing half of their restaurant meals to go, or limiting sweetened beverages. Offer this website which has schedules and locations of our local farmers’ markets: http:// www.california-grown.com/Market-times.html. Learn how to do diet recalls and how to teach patients to read nutrition labels. Better yet, if available, refer to dietitians within your organization to educate families and provide follow up. Encourage families to cook together and pack healthy items to supplement their school lunches. Encourage them to “shop the periphery” of the grocery store and buy real, identifiable foods like fruit and vegetables, healthy types of dairy, whole grains, and lean meats. Suggest that they plant a garden at home or participate in a community garden. Encourage routine physical activity, even if it is something as simple as a family walk or bike ride. Organized sports have the advantage of keeping participants engaged and accountable. When the family is active, it not only burns calories, but also competes with mindless eating habits. How can we further change a school lunch program that is contributing to childhood obesity? Check out www.onetray.org, a non-profit organization advocating for healthier school lunches. Get involved with your kids’ school to encourage healthier options on their menus. (And don’t assume that your kids’ private school necessarily has healthier lunches either.) School menus are often available online by looking at

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your district’s or school’s web page. Every district should have a Wellness Policy posted on their website. (The Berkeley Unified School District was in the forefront in child nutrition advocacy by drafting the first Wellness Policy of its kind in the nation in 1999.) Alternatively, consider getting involved with the Wellness Committee itself which drafted your district’s policy. And make sure the policy is being followed. Sometimes the policy may be in place, but the districts may not be abiding by it. On a political level, get to know our legislators and support sweetened beverage taxes. We are lucky to have pediatrician Dr. Richard Pan in our State Assembly, and he is well aware of the childhood obesity problem. Internist Dr. Ami Bera is running for Congress again this year and may become a valuable voice at the federal level. We can support the CMA which at its October 2011 House of Delegates meeting voted overwhelmingly for healthier food marketing for children, especially for meals that include toys. A success story for all these elements coming together can be found at Grant Union High School (http://www.eatfromthegarden.org/). The students maintain a school garden and learn environmental sciences, horticulture, landscape design, and sustainable communities. They produce salsa with their crop and sell it at farmers’ markets such as Davis and Soil Born Farms. Students become invested in the work, and work together for a common goal. Berkeley chef Alice Walker has pioneered the idea of the edible schoolyard. Read more about it at http://edibleschoolyard.org. The alternative is to let the system continue down a path of processed foods. A somewhat telling study was published in 2010 by Scripps scientist Paul Kenny.9 Rats were allowed to eat Hormel bacon, Sara Lee pound cake, and Pillsbury cake frosting. Tiny rat-sized brain electrodes demonstrated neurological responses similar to cocaine addiction. The rats got fat and couldn’t control their intake. If you are like me and don’t want our kids to become junk food addicts while caged half of their waking hours at our publically/privatelycontinued on page 11


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March/April 2012

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An Acquired Taste By Lydia M. Wytrzes, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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LET’S JUST SAY THAT GROWING UP in Cleveland, Ohio circa 1960, did not lend itself to the development of a particularly sophisticated palate. My mother, a dedicated Polish cook, viewed pepper as an exotic spice. Sometime in my twenties, I figured out which part of the artichoke one actually eats, was shocked to find that beets were tasty and learned that pistachios are only stained red at the Nut Huts of most Midwestern shopping malls. So what I call my medicallyrelated food “adventures” did not come as any great surprise. The first dates to my fourth year of college when, while interviewing for medical school in New York City, my roommate and I decided to go out for “Chinese” before taking the train back to Boston. We went to a just-opened joint serving Szechuan food, which failed to register because who doesn’t like chop suey? We were dining unfashionably early, meaning it was just us, the waiters and one other (probably Cleveland) couple. The food was a bit spicy for us sweet-and-sour pork lovers, but I did know I liked mushrooms, which seemed scattered around an otherwise odd dish. After spearing three or four, I popped them in my mouth and experienced a momentary pleasurable sensation before the blow torch went off. Unfortunately, these “morels” were the evil kind, the peppers that Szechuan grandmothers teach Szechuan grandkids to never, ever, under any possible circumstance, eat. As my uvula was undergoing palatoplasty without the anesthetic, the only residual functioning part of my autonomic nervous system was screaming, “water!” Sized up appropriately as low-tippers, our waiter hadn’t bothered to bring any, but there

Sierra Sacramento Valley Medicine

was a large pitcher on our fellow diners’ table. No longer in control of my limbs, I jumped up, knocked over a few random chairs, grabbed the pitcher from the startled couple and waited in vain for the relief that only came 24 hours later with re-epithelialization. What the Clevelanders thought beyond why anyone would visit NYC in the 70s remains unrecorded. The second occurred during my fourth year of medical school when my classmate, Andy Bone, (who became an orthopedist, by the way), received a gift certificate to the Maisonette, a very chic French restaurant in Cincinnati that no selfrespecting medical student could ever afford. Having no special girlfriend, he invited me as his “date” for lunch. We were seated in elegant surroundings and, with appropriate finesse, we opened our menus and blanched, both at the prices as well as the hieroglyphics. Too embarrassed to ask for the English translation, we scrounged around for the only two vaguely recognizable words, which turned out to be soufflé and veau (veal, right?). The soufflé was “parfait,” but the “veau” did not look like any animal part either of us had seen or eaten before. Andy, with appropriate surgical gusto, attacked it with his knife and realized there was something very familiar about the ducts and vessels he was demolishing. Too bad the one French word we didn’t know was pancreas, since we were now blowing megabucks on veal “sweetmeats.” Our gross anatomy professor, however, would have been proud. The last episode occurred four years later in Calais, a city in France that may have evaporated with the opening of the “Chunnel.” I was in my residency and traveling with another doctor, ready to try that famous French cuisine on which a nation’s reputation had been built. To this day, I have no idea what I ordered,


but immediately knew from an olfactory and “morning sickness,” that apparently is the only gustatory standpoint that there was no way any solution to a bad meal in France. of it was going down my throat. The moral of the story: food is like life. It can Since I have been on flights to Europe shorter be good, bad, spicy, nauseating or downright than most French meals, it became ever harder mysterious. And though we sometimes can’t to hide from our waiter that the volume of food stomach it, we wake up hungry for more the on my plate was not decreasing. About every ten next day. minutes he would come over, glare at me and ask “en français” if there was anything I needed. snoozedoc@surewest.net Within the hour our table was surrounded by several waiters, the chef, sous chef and probably random people from the ANNE E. FERGUSON street, waiving Michelin A PROFESSIONAL LAW CORPORATION red guides in a menacing fashion.    Physician IPA & health plan contracts As the threat of interProviding legal   national incident grew, my  Medical group organizations, operations & s e r v i c e s   to     other business matters friend racked his brain in physicians &   desperation until, with a medical groups for   Practice management, governance & buymore than 20 years  sell agreements smile, he said something. There was immediate  Physician employment agreements consternation from the Anne E. Ferguson   Practice sales, acquisitions & mergers 655 University Avenue  crowd, punctuated by a Suite 110   Medical director, hospital-physician, series of “oo-la-las.” My Sacramento, CA 95825  recruitment, call-coverage & other plate was whisked away, Telephone:  (916) 488‐5388  contracts Facsimile:  (916) 488‐5387  a glass of fizzy water  Medical Records, HIPAA & EHRs   appeared and gendarmes website:      Regulatory compliance, compliance www.fergusonlawcorp.com  began dismantling crowdprograms, Stark and Anti-Kickback     control barriers. Mystified,    Medical office leases, ASC investments & This is attorney advertising.  it was only later that I other business matters discovered my salvation had been attributed to

continued from page 8 funded schools, join the cause, value your food and your body, and teach them to do the same. Help our schools move in the right direction! hitzemn@sutterhealth.org 1 Brennan G. California Authors: Connecting the dots from California fields to our dinner tables. The Sacramento Bee. July 24, 2011. p.1E 2 http://www.gpo.gov/fdsys/pkg/FR-2011-01-13/pdf/2011-485.pdf 3 http://www.gpo.gov/fdsys/pkg/FR-2012-01-26/pdf/2012-1010.pdf 4 http://frac.org/wp-content/uploads/2010/08/fedrates.pdf. Accessed 1/5/2012

5 USDA Expands Access to Fresh Fruits and Vegetables for Schools Across the Nation. Press Release No. 0133.11. http:// www.fns.usda.gov/cga/PressReleases/2011/0133.htm. Accessed 1/5/2012 6 Langreth R and Stanford D, 2011. Soda, fatty foods may spur addiction. The Sacramento Bee. November 6, 2011. p.1A. 7 Whitlock G et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. The Lancet 2009;373(9669):1083-96 8 Annual smoking-attributable mortality, years of potential life lost, and economic costs — United States, 1995–1999. MMWR 2002;51:300-3 9 Kenny P, Johnson PM. Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats. Nature Neuroscience. 2010(13):635-41

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Eating on $5 a Day By George W. Meyer, MD, FACP RECENTLY, WHEN VISITING OUR California legislators, I was chatting with Assemblywoman Mariko Yamada, a social worker by training, about eating for a month on $4.33 per day. Ms. Yamada, I understand, does this for one week each June for National Hunger Awareness Month (this was her 4th consecutive year) to understand what it is like for the two million Californians who are currently on food stamps. Being a gastroenterologist, I was intrigued, and made the mistake of mentioning it to the editor of this edition, who encouraged me to try to eat on $4.33 per day. I first assumed that I would consume no alcoholic drinks and no desserts. Although I explored trying to get by eating at fast food places, I ended up doing the experiment assuming I would use a kitchen, a slow cooking device and a refrigerator with space to freeze some food.

Government Assistant Programs

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

There are two programs for people needing government assistance for food: Food Stamps: The CalFresh Program, formerly known as Food Stamps and federally known as the Supplemental Nutrition Assistance Program (SNAP), can add to your food budget to put healthy and nutritious food on the table. The program issues monthly electronic benefits that can be used to buy most foods at many markets and food stores (http://www.calfresh. ca.gov/). Women, Infants and Children (WIC): WIC provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk (http://www.fns.usda.gov/wic/).

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The GWMeyer $4.33 a day plan: I must be truthful. Since being asked to do this, my schedule has been busy. I returned from a trip in mid-September and was busy attending meetings, or I was away for the weekends, so I was not able to observe this pattern for a whole month. We also had planted a garden, so we had the ability to eat beans, beets, cantaloupe, some lettuce and tomatoes from the garden. (By the way, seeds for planting are valid purchases for persons receiving food stamps). I did attempt to give value to the vegetables harvested from our garden. For some reason our medical group had lots of potluck lunches for baby showers or farewell parties; these were tempting, but I tried to remain loyal to the plan. I still get the occasional comment from a co-worker asking if I am still eating on $5 per day. I enjoy cooking and often share the cooking duties at home. My wife enjoys my cooking, but does not enjoy the mess I make when doing so. I do attempt to clean as I go, but she often follows behind to redo (according to me) and finish the job (according to her). Upon returning from my trip in mid-September, I visited two local grocery outlets, one a well-known, family-owned store, and the other a store which accepts payment only in cash. I compared prices for many items. In general, the prices at the cash-only store were 10-50 percent less expensive, but on the day I made my purchase, hamburger and spaghetti were less expensive at the other store. I purchased 1.5 pounds of stew meat and the same amount of ground beef as well as a large package of frozen chicken pieces along with frozen vegetables, kidney beans, and spaghetti. It became clear that to give volume I would have to use complex carbohydrates such as potatoes,


rice and spaghetti. My bill was for $49.99. I then added additional charges for eggs, milk, nuts, strawberries, and raisins; a friend dropped by some corn so I adjusted for that. The cost for the month was under $100.00. I first made stew in the slow cooker with lots of potatoes and frozen vegetables, then froze about half of it and put the rest in the fridge. I took about one pound of hamburger and made spaghetti sauce, then froze five small patties for hamburgers. I then made a large batch of red beans and rice (I grew up in New Orleans and hated the traditional Monday public school lunch alleged to have been red beans and rice, but this was much better). The plan was to also make a chicken and rice casserole (or a chicken and vegetable curry stew), but we never got around to it, so the chicken remained in the freezer. Although my purchases were to be for my food, I was able to feed my wife as well. She actually liked it and ate with me. Breakfasts always included orange juice. Then I usually alternated days between a couple of pieces of toast and granola with some strawberries purchased from the local growers (they are so much tastier than the unripe ones we get at the store). I would have an egg once or twice a week. Lunches were often food left over from the night before which I took to work and warmed in the microwave. I would occasionally bring a PB&J or cheese sandwich to work.

Options I didn’t end up using: Fast Food Establishments: I did explore some fast food restaurants in an effort to see if someone could survive on $5 per day using these establishments. I tried a Panda Express, but could not find any combination for less than $5. At KFC, I could purchase a BBQ sandwich for $1.39; a chicken pot pie or a mashed potato bowl would cost $2.99. At Del Taco, I could have purchased a veggie or spicy chicken burrito for $2.49 or 12 tacos for $5.88. McDonald’s offered a double cheeseburger for $1.19, a chicken sandwich for $1.59 or a McRib sandwich for $2.99.

Coupons: I did not use coupons, but many foods are available at decreased cost by going online and printing out coupons. (If a person does not have a computer, the various local libraries provide this capability). I have been interested in reviewing the success some people have while using coupons. There was an interesting article in one of the October 2011 Time magazines about extreme couponing. The subject of the article cut the weekly shopping budget of her family from $250 to $50. In one shopping adventure, the subject bought 92 items, used 76 coupons, spent 2.5 hours in the store, fought with management twice, but was able to purchase $293.82 retail value food purchases for $38.04. Many heavy couponers need an extra room to store the volume of purchases they acquire. One online site mentioned in the article is “For the Mommas” (www.forthemommas.com). The Sacramento Bee has been inviting its customers to couponing classes. I found the following coupon apps in Consumer Reports: The Coupons App; Cellfire; Foursquare; Grocery IQ; Pushpins; and Where. The Dollar Store: I also made a run through the Dollar Store. On the shelves, I found lots of cans of soups, some with well-known brands, for $1. I could also have purchased pre-packaged Chow Mein, tuna, cans of fruit, and cookies for $1. Then there is always Ramen. To summarize, I think it is possible to eat on $5 a day if a kitchen, slow cooker, and fridge with freezer are available. Costs can be minimized by using coupons. Clearly, alcohol and tobacco do not fit into this program. Cooking in volume, freezing part of the meal, and filling up on complex carbohydrates such as potatoes, rice, and pasta, were key to making the GWMeyer plan work. Other than a bit of monotony, the food wasn’t half bad, and I neither gained nor lost weight during this trial!

Although my purchases were to be for my food, I was able to feed my wife as well. She actually liked it and ate with me.

geowmeyer1@earthlink.net

March/April 2012

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2012

You still need to make important decisions now about rising health insurance premiums. So what can you do? • Enroll in a qualified High-Deductible Health Plan and open a Health Savings Account. This provides significant premium savings that can help fund your HSA account. With individualonly coverage, you are eligible to contribute up to $3,100 to your account or $6,250 with family coverage, on a tax-deductible* basis (members age 55–64 are eligible to contribute another $1,000). • Investigate RAF Sales Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health

plans. Instead of your medical rates increasing this year, we might be able to help you offset some of that increase. • Mercer Select HRKnowHow If you play a role in your medical group’s health care and benefit plan decisions, stay current on challenging issues. Access is included at no charge for all members who purchase group health insurance through Marsh. Includes: • News and analysis of important benefit issues. • Compliance Link tool to assist with health care and group benefit plan administration.

* Marsh and the Society do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.

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EXECUTIVE DIRECTOR’S MESSAGE

Together We Can Make a Difference By Aileen Wetzel, Executive Director LAST SPRING, THE CALIFORNIA Legislature passed, and Governor Jerry Brown signed, Assembly Bill 97, which authorized a 10 percent Medi-Cal reimbursement rate cut for physicians, hospitals, dentists, pharmacists and other Medi-Cal providers. Federal approval was required before the state could implement its proposed cuts. The Centers for Medicare and Medicaid Services (CMS) approved the state plan amendment in December 2011. The California Medical Association (CMA) led a coalition that filed a lawsuit against the U.S. Department of Health and Human Services and the California Department of Health Care Services in November 2011, arguing that if the cuts went through, access to care for Medi-Cal patients would be eroded or cut off completely. U.S. District Court Judge Christina Snyder agreed with CMA and on February 1, 2012 issued a final order prohibiting the state of California from implementing the 10 percent cut to the Medi-Cal reimbursement rate. Five days later, on February 6, 2012, CMA advocacy again paid off when CMS rejected California’s request to impose mandatory co-payments for Medi-Cal patients. The co-pays, which would have included physician office and clinic visits, emergency room visits and inpatient hospital stays, was another attempt by the state to balance the budget by slashing Medi-Cal. Most recently, CMA advocacy was instrumental in stopping the 27.4 percent Medicare fee-for-service cut for physicians. While the payment cuts were halted, Congress failed to adopt a permanent solution to repeal the flawed SGR payment formula that imposes annual payment cuts on physicians. Physicians

are now faced with an even larger 35 percent Medicare fee schedule cut in 2013. CMA/SSVMS members — your membership made it possible for us to stop the 10 percent Medi-Cal cut, prevented mandatory Medi-Cal co-payments from being implemented, and stopped the crippling Medicare fee schedule cut. But we must continue fighting to protect physicians from the 35 percent decrease to Medicare payments scheduled to take place in less than 10 months. Our advocacy benefits all physicians. If you are not a member, we need you on board. Please support our advocacy efforts by joining SSVMS/ CMA today. Together we can make a difference. awetzel@ssvms.org or 916-452-2671

How to Submit an Article to SSVM SSV Medicine is the official publication of the Sierra Sacramento Valley Medical Society. Our focus is the life of physicians in the broadest sense. Our bi-monthly magazine offers members an opportunity to express a personal opinion, to describe an experience in the practice of medicine, to relate a travel or volunteer story, to comment on professional, political, or legislative matters, or to vent, and we occasionally accept articles of interest to members from non-physicians or non-members. If space allows, photographs are welcome. To request a copy of our Authors’ Guidelines, send an email to Nan Crussell, our Managing Editor, at crussell.nan@gmail.com, or to Nate Hitzeman, our Editor, at hitzemn@sutterhealth.org.

March/April 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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TomatoesRiceAlmondsCaviarEndive Can you TRACE Sacramento’s Place in our Nation’s Food Economy?

By Bob LaPerriere, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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WHEN YOU THINK ABOUT SACRAMENTO’S role in food production, what comes to your mind first? Maybe tomatoes…Sacratomato is a common nickname for Sacramento, though most of the tomato production is not in Sacramento County but in the surrounding, particularly southern, areas. California rates second for tomato production in the United States, having produced close to one billion dollars worth in 2010. Sacramento was a very prominent site of tomato processing, though many of the processing plants have closed over the past decades. Maybe rice…The Sacramento Valley is the heart of rice growing, and produced 4.5 billion pounds of rice in 2010, rating California as the second largest rice-producing state. Almost all was grown within a 100-mile radius of Sacramento. Maybe almonds…In 2010-11, 1.668 billion pounds of almonds were produced in California, over 70 percent being exported internationally to more than 90 countries. Nearly 80 percent of the global supply and 100 percent of the domestic supply of almonds is produced by California’s 6,500 almond farms. Though Sacramento is not a significant producer of almonds, Blue Diamond Growers, headquartered in Sacramento, is the world’s largest tree nut processing and marketing company. But how many people realize there are two other major food producers right here in Sacramento County, one that grows the entire U.S. supply and another that produces 80 percent of the domestic supply!

Sierra Sacramento Valley Medicine

CAVIAR Few locals are aware that 80 percent of the caviar for the United States is produced right here in three sites in the Elverta/Wilton/Elk Grove area by Sterling Caviar. Caviar, when there is no other descriptive term, by definition is from the sturgeon. Other caviars (roe) require the source of the eggs be included in the name, such as Salmon Caviar (roe) and Lumpfish Caviar (roe). Native sturgeon in California are the white and the less common green. The local caviar is produced from white sturgeon farmed for this purpose. This caviar is equal or superior to the wild caviar from the Caspian Sea. Individual sturgeon can live over 100 years and have probably been around, virtually unchanged, for over 200 million years. They are truly a prehistoric animal. The most familiar sturgeon is the large Beluga, found in the Caspian Sea, the largest one weighing in at 4,350 pounds. Also found in the Caspian Sea, and of caviar importance, is the Russian sturgeon (Osetra caviar) and the stellate sturgeon (Sevruga caviar). Since the 1970s, with improvement in aquaculture, caviar from farmed sturgeon has become common and offers the most sustainable


means for production. In the U.S., only salt is added to the sturgeon eggs, though in Europe borax may also be added to extend the shelf life. Caviar needs to be aged for 30-90 days to develop the best flavor and, once opened, kept chilled and consumed within hours. It should also be consumed shortly after purchasing, as home refrigerators are not cold enough for good preservation. Metal implements should never be used to serve or eat caviar. Caviar is high in fat, protein, cholesterol and also in many essential vitamins and minerals. In addition to our four basic “tastes” (sweet, sour, bitter and salt) there is a fifth taste, umami, discovered by the Japanese in 1908, which is particularly sensitive to glutamate and described as a savory or meaty taste. Caviar is high in glutamate as are foie gras, truffles, shitake mushrooms and fresh clams. There may be a relation between umami and the acquired taste for products such as caviar. Caviar, at $60-80 per ounce is probably enjoyed best with not much surrounding it, commonly served on a small dollop of creme fraiche on a blini (a small Russian pancake). A representative from Sterling recommended pressing the caviar with your tongue to the roof of your mouth so you can enjoy the eggs popping.  The Sterling Caviar website is http://www. sterlingcaviar.com/. A nice review of umami can be found at http://www.umamiinfo.com/. And an interesting discussion of umami can be found at http://sharpiron.wordpress. com/2007/08/07/umami-knows-best/.

ENDIVE (“ON-DEEV”) From the famed New Orleans coffee ingredient, chicory, through darkness, sprouts a vegetable favored by gourmets worldwide. And where else but Sacramento would the United States’ supply of endive be produced? Endive is in the same family as radicchio, escarole and curly endive and is often called the queen of vegetables, prized the world over. It is available in both white and red varieties.

Since 1983 Rich Collins and his company, California Vegetable Specialties in Rio Vista, is the only producer of endive in the United States. This is one of the rare culinary situations where pronunciation is critical. We are talking here about endive (pronounced “on-deev”) which is what people generally recognize as “Belgian endive.” Endive (pronounced “n-dive”) refers to curly endive, which is not limited to California. Endive’s claims are that it is low in calories, fat and sodium. It is loaded with vitamins B and C, calcium, magnesium, iron, zinc, folate, selenium and beta-carotene. High in complex fibers, it helps prevent the absorption of cholesterol into the blood stream and slows food metabolism. In a study of more than 62,000 women in the Netherlands, those who ate endive had a 75 percent reduction in the risk of ovarian cancer. Two steps are required for production of endive. The first takes 150 days in the field, where the chicory plant grows from seed into a deep root, which is then dug up and placed in cold storage. As demand necessitates, roots are removed from cold storage for their second growth, which takes 20 to 28 days in dark, cool, and humid forcing rooms, similar to mushroom growing, making it available year-round. Endive makes a nice appetizer with a bit of smoked fish and a dollop of creme fraiche or sour cream on the broad end which makes a pretty arrangement on a plate. California Vegetable Specialties’ website is http://endive.com.

80 percent of the caviar for the United States is produced right here in three sites in the Elverta/ Wilton/Elk Grove area…

drbob40@gmail.com

March/April 2012

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Is it Time to Tax Soda? By Adam Dougherty, MPH, MSII

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

IN THE LAST LEGISLATIVE SESSION, Assembly member Bill Monning (D-27) introduced AB669, a bill that would have imposed a one-cent-per-ounce surcharge on every soda and sugar-sweetened beverage sold in California. The revenue generated would have created the Children’s Health Promotion Fund, raising a projected $1.7 billion a year for programs that have suffered from the state budget crisis — like school lunch programs and physical education programs. Funds could also have been used to develop new programs targeting obesity prevention in children and enhancing community parks and other targeted endeavors. While the bill ultimately died in Committee, the concept may gain traction over the next several years. Is a soda tax a realistic solution? Here are some numbers to consider from the California Center for Public Health Advocacy (CCPHA), as well as from Michael Pollan, a 2010 member of the TIME 100 Most Influential People roster: • Per capita soda consumption has increased nearly 250 percent over the last 30 years. • Added sweeteners represent 16 percent of the average daily dietary intake. • Since 1985 the percent of personal income spent on food has decreased from 15 percent to 10 percent. Conversely, the real price of fruits and vegetables has increased by 40 percent while the real price of packaged food and soft drinks has decreased by 25 percent. • In California, 56 percent of adults and 28 percent of children are obese or overweight. • An estimated $41 billion is spent every year in California as a result of chronic disease costs in the obese, most notably diabetes. It is hard to argue against the fact that obesity rates have reached epidemic proportions. Skeptics of a new levy may see this as just

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another “tax and spend” maneuver, but it is important to understand that the health and productivity costs associated with complications from obesity are astronomical. Since the beverage industry has benefited significantly from a rise in consumption, the argument goes that they should pay their fair share to address the epidemic. More so, a concerted effort to target this risk factor would likely pay off in savings in the long term — both in community ratings for health insurance (your premiums) and in Medicare costs (your taxes). Authors of a recent Health Affairs study found that a penny-per-ounce Sugar-Sweetened Beverage Tax would lead to significant reductions in morbidity, mortality, and health care costs, estimating that an ensuing 15 percent decrease in consumption annually would prevent 2.4 million diabetes person-years, 95,000 coronary heart events, 8,000 strokes, and 26,000 premature deaths, while avoiding more than $17 billion in medical costs.1

Food Costs Play a Role in Diet Also worth exploring is the following premise: Food prices are a significant contributing factor in regard to the above trends; and people, especially low-income individuals, are cost-conscious in what they purchase. Research has shown that food costs play a significant role in diet and consumer behavior, and overall economic factors may be a much larger influence than lifestyle or personal will.2 Simply put, the current system is geared to make the unhealthiest calories in the marketplace “the most-bang-for-your-buck” for the bottom half of all income earners. This is the group who already has the highest obesity rates. Consider this relationship between energy density of selected foods and energy costs (in $/


Megajoule) in the image below. The question of whether a soda tax is “the right answer” or “another horrible idea” will continue to be debated, but it is difficult to contest that the status quo is unacceptable. Already, tax dollars subsidize an unhealthy system, which public health departments are trying desperately to combat. Specifically, taxpayer-supported agricultural subsidies for products such as corn, soybeans, and wheat have decreased the price of energy-dense foods. As a result, we receive cheaper, ultra-sweetened but lower quality food such as manufactured high fructose corn syrup. The Farm Bill thus subsidizes obesity to the tune of $25 billion a year.

Curbing the Obesity Epidemic In order to truly curb the obesity epidemic, it will be necessary to examine quality and health “costs” in addition to quantity and market costs in food production. The Farm Bill is up for reauthorization in 2012, and it would be smart to make food quality a bigger factor, nutritionally and fiscally. Shifting subsidies to healthier food products would not only promote better choices in the market as a whole, but would effectively link health to social productivity, efficiency, and a proper return on investment on public dollars. The long-term consequences of the obesity epidemic cannot be understated. The average life expectancy has stagnated for the first time since recording began, and health care costs continue to grow at an unsustainable pace. Strategies to combat the epidemic must be multi-factorial, and occur through strong publicprivate partnerships. A modest fee on one of the greatest culprits would not only help raise funds to better target obesity, but also justify the issue as a top priority to reduce future health care costs. The experiment in Denmark is worth watching, where the country recently implemented a surcharge on foods containing more than 2.3 percent saturated fat. At the very least, there should be recognition that today’s reality of public health dollars spent

on fighting an epidemic that is propped up by misguided publicly-funded food subsidies is irrational and wasteful. Consumers will continue to search for the best value (calorie) per dollar. Though ultimately personal choice decides what food is purchased, it is of the utmost importance for future policy to protect and promote our nation’s health and wellness, particularly through the nutritional value and affordability of our food products. apdougherty@gmail.com 1 Wang YC et al. (2012) A Penny-per-Ounce Tax on SugarSweetened Beverages Would Cut Health and Cost Burdens of Diabetes. Health Affairs 31(1):199-207. 2 Darmon, N., Ferguson, E., Briend, A. (2002). A Cost Constraint Alone Has Adverse Effects on Food Selection and Nutrient Density: An Analysis of Human Diets by Linear Programming. Journal of Nutrition. 132:3764-3771. 3 Drewnowski, A., Specter, S. (2004). Poverty and obesity: the role of energy density and energy costs. American Journal of Clinical Nutrition. 79: 6-16.

Attractively Dense Foods Are Also The Cheapest:3

March/April 2012

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BagOfLife The Kapurs and Rotary vs. a Malnourished USA

By John Loofbourow, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

GOPAL KAPUR HAS BEEN WIDELY regarded for his Center for Project Management (www. center4pm.com). But in recent years, he and his wife, Darlene, who live in Roseville, have devoted much of their energy to problems of malnutrition, and to Light1Candle, a program that supported a girls’ orphanage for a decade and now focuses on tuition for poor, bright children in Patiala, Punjab, India. Gopal’s hobby is cooking, dating back to a Punjabi childhood where his mother introduced him to an extensive variety of healthy vegetarian dishes. His food columns have appeared in three California newspapers. He and Darlene created www.familygreensurvival.com which has been featured in numerous newspaper and TV programs. They are working now with Roseville Rotary to begin a BagOfLife program, as reported recently in The Sacramento Bee1 and on Fox 40 News.2 Gopal graduated from Thapar University, Patiala, India with a diploma in civil engineering. He and Darlene, who is originally from Arkansas, met at CSU Fresno where he was pursuing engineering studies. But his fortune and name were ultimately made in management consulting. He has lectured at Harvard University, The Commonwealth Club, The National Press Club, UC Berkeley, UC Riverside, UC Davis, and The Brookings Institution. He received the Distinguished Achievement Award for his contributions to education by the president of India. He is a member of the Harvard Policy Group, and served as a trustee for the Charles Babbage Foundation, and much more. Gopal is a man of action, and when I email him, he responds immediately.

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We agree to meet in the Roseville Library on Pleasant Grove Blvd. When I arrive he is the only person in the elegant rotunda, seated at a small table, wearing a navy blue cap bearing the Rotary emblem. After polite introductions and the exchange of some personal history, I ask about the current project. He instantly morphs into the bigger-than-life man of worldwide interests, dynamic ideas, and the skills of an experienced executive. We waste little time on the well-known statistics of worldwide and U.S. problems of nutrition. There is clear evidence for at least two major kinds of malnutrition: — The malnourished people of the Third World who are thin, and calorie- and proteinstarved. — The malnourished people of the U.S. who are generally obese. Kapur enjoys a laugh even when dead serious, and speaks of one of those 4x4 ft. European hotel elevators where an adulterated sign reads: Occupancy 5, or 3 Americans! He holds that a spoonful of humor helps with children, as well as a forkful of persistence. On a family car ride, when a “Fastfat” restaurant is passed, all the car windows are rolled up and breath is held to avoid breathing the surrounding toxic gasses. In the malnutrition of famine, almost any food that can be made available is helpful. Yet the malnutrition of obesity is not so easy to reverse. While common among the poor, it is found along the entire socio-economic spectrum, including the shut-in or elderly. Kapur makes a number of points: 1. The most convenient, most advertised, most familiar foods are not nourishing;


they promote obesity, and related chronic diseases like hypertension, diabetes, and atherosclerosis. 2. For both the young and for busy and productive people, fast and convenient food has an obvious attraction. 3. Contrary to popular belief, high-quality, tasteful, nourishing food can be eminently affordable to anyone. 4. Taste is largely learned, so diet is largely habit; our national taste favors food high in sugar, salt, and fat. The food industry simply responds to our demands. To view a Gopal video effort to promote a healthier kind of demand, go to http://vimeo.com/35242209. 5. To address malnourishment obesity, we have to change our thinking, taste, and habit. He and Darlene have created a series of tasty, healthy and reasonable meals to meet the needs of various people in various circumstances, and they hope to address the following problems: 1. The elderly or shut-in often can’t travel easily to a store where healthy food is readily available. 2. Healthy foods are sometimes expensive, or thought to be so. 3. There are not often places where affordable small amounts of food can be purchased. (Local exceptions are the WinCo Foods with stores in Folsom, Elk Grove, and Roseville, where food and condiments can be bought by the ounce if desired.) 4. Some handicapped people have difficulty preparing meals. These considerations led the Kapurs to develop BagOfLife: packets of carefully-crafted, pre-mixed meals that can be simply cooked and eaten. Sutter Hospital provided nutrition advice and Roseville Rotary supports the effort. The recipes offer: 1. No refined carbohydrates 2. Primarily plant-based protein from whole grains, legumes, and raw nuts 3. Plentiful fiber from whole grains, legumes, dry vegetables, and raw nuts 4. Antioxidants from herbs and spices    5. Less than 8 grams of added sugar per day

Nutrition Consultant Gopal Kapur

6. Less than 1500 mg of sodium per day 7. No added oil Each bag holds 16 ready-to-cook servings, or four each of the following:

• • • • • •

Grand Hot Cereal Dried milk and cinnamon Flax seed, Oat bran, Quinoa, Rolled oats Turbinado sugar Sunflower seeds, Wheat bran Whey protein Textured Vegetable Protein

Soup Of Life • Dried onion, mushroom, bell pepper, tomato, and garlic • Italian seasonings, Salt, Paprika and cayenne • Fennel seeds • Great northern beans Lean Mean Bean Cuisine • Dried carrots, milk, mushrooms, bell pepper, tomato, and garlic March/April 2012

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• Lentils, Flax and fennel seed • Soy protein, Textured Vegetable protein, Whey protein • Turmeric, salt, pizza seasoning, paprika

• • • •

Nutty Quinoa Almond meal Dried onion, bell pepper Flax seed, Quinoa Salt, turmeric, pizza seasoning, paprika, and cinnamon

Each of the meals above costs about 75 cents. Will people eat these meals? Will children eat them? Apparently. They were market-tested in children and adults, and were well received. Gopal doesn’t hold hope for legislation about food; you simply cannot legislate behavior or nutrition successfully. But he believes we would all eat better if that became a priority for parents, for the average citizen, for schools, for business which profits by offering what people want.

I was as impressed with the presentation, the ideas, and the man, and used BagOfLife meals frequently during January. They are nutritious and easily prepared. Some ingredients and flavors were new to me, but nothing was too spicy. Favorite vegetables or fruits can be added readily. A crock pot is handy for the soups and hot dishes. The meals microwave nicely. The BagOfLife program is still in its very early stages, but Kapur Project Management principles apply: the plan is to donate 100,000 bags (1,600,000 meals) in 2012 to low-income families through social service organizations. Roseville Rotary is the first local sponsor. For information contact gkapur@ familygreensurvival.com. john@loofbourow.com 1 www.sacbee.com/2011/12/11/4112774/healthy-meals-are-in-thebag.html#storylink=misearch 2 http://www.fox40.com/videogallery/66919024/News/Bag-of-Lifefor-Needy-Families-Gopal-Kapur-FamilyGreenSurvival.

Your care makes all the difference. Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

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not-for-profit since 1948

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For every patient, like Roberta, who gratefully receives the gift of blood — and another day to be with family and friends — there are countless medical professionals whose care and support make all the difference. Thank you for the care you give to every man, woman and child whose life depends on the precious gift of blood. Yes, you do save lives.


Book Reviews Two Food Books by Michael Pollan

By Ann Gerhardt, MD THE CHARM OF MICHAEL POLLAN’S BOOKS lies in his writing style. He is a journalist by trade, backyard gardener by upbringing and lacto-ovo-vegetarian by inclination, without any special nutrition training. He gets away with writing nutrition-oriented best sellers by engaging in extensive research of agriculture, food biology and food manufacturing. Entertaining prose, coupled with real information, make for good reading and incidental education, if you can excuse the relatively biased research focus (see below) and occasional error. I’ll skip to Pollan’s third food book, Food Rules, An Eaters Manual, before I slash and burn his second book, In Defense of Food: An Eater’s Manifesto. Pollan’s most famous book, The Omnivore’s Dilemma, is a wonderful book, with an engaging premise and good information, but I’m going to review the two books that give flatout nutrition advice. Food Rules mixes one part cutesy rules to live by, one part blistering concise commentary and one part middle-finger to voluminous, gimmicky, diet books. It’s the book I’ve always wanted to write, but knew I wasn’t a good enough writer to make it sell. Just-plain-common-sense usually bombs at the bookstore… unless you are Michael Pollan. After reading the table of contents: Part I What Should I Eat? (Eat food); Part II - What Kind of Food Should I Eat? (Mostly plants), and Part III - How Should I Eat? (Not too much), you almost don’t need to read the book. If you stopped there, however, you’d miss the humor and a few details, most of which he has explained ad nauseum in previous books. With this book you can cut to the chase. Each section presents about 20 rules, none

of which last longer than two partial pages. Rules like number 19: “If it came from a plant, eat it; if it was made in a plant, don’t,” and number 20: “It’s not food if it arrived through the window of your car,” include no discussion, and move right on to the next page. Those, and ones like number 7: “Avoid food products containing ingredients that a third-grader cannot pronounce,” and number 36: “Don’t eat breakfast cereals that change the color of the milk” have tongue-in-cheek points, but don’t beat you over the head. The rules’ catchy flavor takes the preachiness out of the book’s overall message, which may be, “Don’t eat like a typical American.” He’s not a food-Nazi, though. He acknowledges that humans are omnivores, and suggests that we try new foods, enjoy treats, and eat meat from healthy animals. The last rule, “Break the rules once in a while,” speaks to food’s happiness factor, recognizing that strict dietary regimentation makes for miserable lives. In Defense of Food: An Eater’s Manifesto is Pollan’s attempt to scientifically justify his food rules. The vast majority of Pollan’s readers are not trained to critically analyze scientific data. Neither is Pollan. He’s a writer. While his books are reasonably well-referenced, for lay-person diet books, he necessarily picks and chooses studies that make his point. It made reading the book a chore for me. As a clinical nutrition specialist, I was irritated a few too many times as I read his clearly biased, and at times misleading, “scientific” analysis. For example, he quotes Bruce Ames, famous for devising a test for carcinogen-induced mutations in bacteria, saying that numerous vitamin and mineral deficiencies mimic DNA

March/April 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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How many can remember what they ate last week, let alone arrive at an accurate estimate of how often they ate cruciferous vegetables last year?

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radiation damage. While this is, at best, a stretch, Pollan stretches it further, asserting that this may be the reason that people who eat more fruits and vegetables seem to contract less cancer. He ignores the facts that the best sources for half of the implicated nutrients are not fruits and vegetables, and that most of these nutrients have been tested in randomized, controlled trials (RCTs), and don’t, by themselves, prevent cancer. The book progresses something like this: Nutrition research is flawed and deconstructs food into individual nutrients, which enables public health officials to make simplistic recommendations. These give food manufacturers impetus to refine out naturally healthy food components and add back the fashionable nutrient du jour. “Western” chronic diseases, like heart attacks and metabolic syndrome, are rampant, in part because of changes in the food supply and dietary patterns. If we stop deconstructing food, and instead eat non-manufactured food based mostly on plants, we would be healthier. I don’t disagree with any of these assertions. The path he lays out to justify them, however, is a little too sensationalist, using selective analysis of nutrition science to spew a non-selective path of destruction. Along with ridiculing public health recommendations, media and food manufacturers, he castigates scientists for just being scientists. Pollan does a reasonable job of explaining the inherent difficulties of nutritional science, but then calls it “bad science.” Research is research, and it is the nature of scientists to try to figure out why and how things work. To do this, one designs studies that reduce variables to one, in order to be able to make a conclusion. He criticizes this as “reductionism,” but he’s really criticizing the scientific method itself. He criticizes the fact that we study the nutrients we know. Duh. Yes, there are as-yetunidentified nutrients, evidenced by the fact that food is better for you than a pile of macronutrients, 13 vitamins and a few minerals. Parenteral nutrition (feeding a person intravenously, bypassing the usual process of eating and digestion) repeatedly proved that

Sierra Sacramento Valley Medicine

to us, as the nutrition knowledge of the time created essential fatty-acid-free, or biotin-free, or selenium-free formulae that caused deficiency symptoms. It’s not often that an Albert SzentGyorgyi (the discoverer of vitamin C) comes along to discover another vitamin. Bioflavonoids are the latest addition to the nutrition cadre. We have to ask questions of the science we know to discover the nuances, vagaries and substances we don’t know. Who knows which blip on a chromatography printout will be the next important nutrient? He, and every nutrition scientist, criticize the facts that, in nutrition research, 1) changing one variable necessarily changes another; 2) people lie (to themselves and/or the investigator) on their food-frequency surveys; and 3) people don’t follow exactly the dietary changes expected of them. That’s the way it is, and all of us who have ever done nutrition research rue those realities. Reducing dietary fat either reduces total calories or increases another calorie source (carbs, protein or alcohol), making two variables in the study. How many can remember what they ate last week, let alone arrive at an accurate estimate of how often they ate cruciferous vegetables last year? How many will admit to regularly devouring large bags of chips? Who of you, or anyone trying to follow a diet, can give up foods you like or whole food groups for more than a few weeks? Rather than criticizing the research itself, he should limit himself to criticizing the overreaching conclusions, premature publicity and overly zealous public health recommendations which result from it. He does these things exceedingly well, and, if he had stuck to these issues, it would be a much better book. He spends whole chapters, with cute titles like “The Melting of the Lipid Hypothesis” (which unfortunately has some erroneous statements), “Eat Right, Get Fatter,” and “The Elephant in the Room,” bemoaning the fact that scientists, food manufacturers and public health officials attempt to change whole cultural dietary patterns based on incomplete data. There is nothing wrong with eating oat bran instead of


Krispy Kreme donuts, but should it be in every food we eat? Should we eschew it just because it didn’t lower the already normal levels of cholesterol in a study of a few healthy dietitians? People embrace the concept of snake oil: Eat this one nutrient and you can compensate for your crappy lifestyle without having to change, reductionism in a nutshell. If you can buy it in a bottle, or get that marvel mineral in your sugar cereal, it’s much easier than a balanced variety of wholesome foods every day. News media feed into the snake oil mentality. They don’t want to hire scientists to help them sort through the literature or critique the science. They jump on single articles, giving the glowing author undue credit for breakthrough science, choosing to forget the studies that came before. The formula for a nutrition “news” article is to make an absurd populationwide pronouncement, briefly summarize the conclusions without giving the limitations of

study group and methods, interview the lead author and one other person in the field, and call it a wrap. Thus one out of millions of studies gets the circulation sufficient to either change people’s buying and eating habits or convince them that scientists can’t make up their minds about what’s right. I have no problem with his criticism of the “reigning nutritional orthodoxy,” which determines, for example, whether avocados are healthy (new school) or verboten high-fat balls of death (old school). We have suffered (or enjoyed, depending on your taste) cultural food shifts, with “experts” pushing low-fat, low-carb, high-fiber, fish oil, flax seed, walnuts, red wine, no-dairy, high-dairy and on and on. In the end, in spite of the less-than-perfect journey, his advice is good. We really should eat real food, mostly plants and not too much. algerhardt@sbcglobal.net

March/April 2012

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California Won’t License Dietitians!?? By Judy Gould, MA, MS, RD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

GOOD NUTRITION. WHO COULD BE against it? Good nutrition is right up there with motherhood and apple pie (low fat, of course).  But if 100 people were asked to define the term, they’d give 100 different answers. Googling “good nutrition” results in a list of 29,000,000 sites! With all those sources of “information,” how can consumers, government workers, and medical professionals separate fact from folklore and fabrication?    Registered dietitians (RDs) are specifically trained in this area. But right now, just about anyone can say they are nutrition experts and can dole out advice. The state government has chosen to license locksmiths, barbers, engineers and private investigators, but people who make nutrition recommendations that could help or hurt your health are completely unregulated. RD licensure in California would make dietitians’ services and expertise easier to access.    The Academy of Nutrition and Dietetics (formerly the American Dietetic Association) provides accurate and current  information about good nutrition and how to incorporate a healthy diet into any lifestyle. It also provides detailed information about the education and practice requirements for earning an RD credential. When it comes to supporting their expertise, it’s important to note some little-known history of RD involvement in pioneering nutrition advancements. 1939: Practicing RDs in Philadelphia established a bachelor’s degree and a supervised practice program as the requirements for entrylevel employment as a registered dietitian. 1947: The American Diabetes Association,

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the American Dietetic Association, and the U.S. Public Health Service collaborated to create the food exchange system for use in the management of patients with diabetes. The Exchange System serves as the cornerstone of diabetes management for Type I, Type 2, and gestational diabetes, and is routinely updated when research results indicate changes are necessary to bring the exchange system into line with current evidence. In 1994, members of the Diabetes Care and Education Practice Group of the ADA began writing an “Ethnic and Regional Food Practices” series which includes customs and holiday food traditions for 11 ethnicities.1 Practicing RDs and other professionals can use information from this series to easily incorporate ethnically-preferred foods into patients’ treatment plans.   1969: The American Dietetic Association created the Commission on Dietetic Registration (CDR) to establish continuing education requirements and to monitor RD compliance.  CDR also created standards for specialty nutrition credentials in diabetes, renal disease, pediatrics, and gerontology. The American Society of Parenteral and Enteral Nutrition (ASPEN) offers a specialty credential in nutrition support for RDs who meet the education and experience standards.   1998: Along with the California Diabetes Association, the California Dietetic Association and other professional groups lobbied to pass Senate Bill 64, requiring health insurance plans in California to cover the cost of diabetes supplies and treatment.       What could make the services of RDs in


California better utilized? It would be achieving RD licensure! Thirty-seven states in the U.S. have enacted licensure for RDs, and in California, RDs have sponsored legislation for licensure three times since 1988. But the legislative experience for RDs in California is proof positive that “there are 100 ways to kill a bill, but only one way to pass it.” The experiences have been as bizarre as they are varied, including opponents carrying picket signs into a capitol hearing room and sending vitriolic letters to the authors of licensure bills. First, let’s clarify the confusion between dietitian certification and licensure. The status of a dietitian’s credentials can be certified by the Commission on Dietetic Registration (CDR). CDR can refuse to renew an RD’s registration if s/he hasn’t completed the required continuing education hours and/or hasn’t paid the registration fee, but it has no authority to affect that RD’s practice except by notifying his/her employer, if known. Licensure is the responsibility of each state, which is why state legislatures must enact enabling legislation. And licensure is valid only in comparing practitioners  within the same profession, not between professions. How does licensure of RDs benefit the general public?   1. Licensure legislation establishes the minimum qualifications required for a practitioner and creates a specific scope of practice. It also creates an entity to oversee the licensed profession, a place where complaints can be collected and investigated. The oversight mechanism proposed in AB575, the RD licensure legislation introduced in 2011, was comprised of one employee from the Department of Consumer Affairs and an unpaid panel of three people, two RDs and one public representative.   2.  Licensure allows professionals to practice to the full extent of their education and training. It also qualifies them to receive direct

reimbursement, and reimbursement facilitates access. Of note is that acute care hospitals do not receive additional reimbursement for the patient/family education and/or the medical nutrition therapy  performed by RDs before the patient is discharged.    As part of health care reform, the Center for Medicare and Medicaid Services (CMS) requires participating medical professionals to be licensed. And The Institute of Medicine’s (IOM) report, The Future of Nursing: Focus on Scope of Practice, released January 26, 2011, states in its conclusion, “Scope of practice regulations in all states should reflect the full extent not only of nurses but of each profession’s education and training. Elimination of barriers for all professions with a focus on collaborative teamwork will maximize and improve care throughout the health care system.” We couldn’t have said it better! jaye43@gmail.com

March/April 2012

1 Chinese American, Mexican American, Hmong American, Filipino American, Navajo, Indian and Pakistani, Alaska Native, Jewish, Northern Plains Indians, Creole and Cajun, Soul and Traditional Southern

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How to Eat By Ann Gerhardt, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

IT’S REALLY VERY NON-SEXY: Eat a balance of all the food groups. Emphasize plant foods, especially vegetables and whole grains. Avoid food that doesn’t have much in the way of natural foodstuffs in it (think soda or gummy bears), has had the nutrients refined out of it (like Cocoa Puffs or potato chips) or whose ingredients read like a chemistry experiment (like Coffee-mate and most salad dressings). Drink water. Minimize alcohol. Eat when you are stomach-hungry and stop when no longer hungry. Don’t eat because of boredom, fatigue, anger, joy, a TV ad or billboard, or because it’s there. There. Feel enlightened? And you thought it was hard. Too bad it is hard. It’s hard to turn such easy advice into healthy behavior in a society that has turned something as natural as eating on its ear. One almost has to be a crusader to adhere to down-to-earth dietary practices. “Yes, I really do want to order only from the ‘sides’ and appetizer portions of the menu.” “Please don’t super-size me.” “Where are the vegetables?” “Please leave off the sauce – I’d like to taste the food.” Sounds un-American, or at least kooky. Mom taught those of us of a certain age to eat. In the Western Pennsylvania version, circa 1950s, a normal diet equaled what she put on our plates. Meat, starch, vegetable. Peanut butter and jelly sandwich. Eggs and toast. Vegetables from the garden. Given a different locale and era, the details and balance might change. Coastal societies eat more fish. The Chinese culture seems to use every part of the animal, and every available animal, rather than waste food. Agrarian societies consume food that grows best in their local climate. What’s wrong with any of those dietary patterns? Nothing. The notion that societies

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somehow discover what works to sustain the population, and that Mom implements it, has worked for thousands of years. So why do we now need public health recommendations for dietary advice? Because we got off track. And getting off track ignited a burst of obesity and an epidemic of Western chronic diseases that has spread across the world, as other societies adopt the Western diet. People debate which factors created this dietary-health mess, but it boils down to a changed food supply and calorie imbalance: 1. TV created an avenue for food manufacturers to counter Mom’s supremacy over food choices. After all, advertising works. 2. Food manufacturers started making cheap “food” with long, chemical names. They developed biologic and chemical processes (think high-fructose corn syrup) to unbalance content, skewing towards extra fat, sugar, salt or all three, to alter taste expectations. Ditto fast food. 3. Food got cheaper, because of agricultural price supports and efficient manufacturing, so we can eat more for the same money. In medieval times, only the rich, like Henry VIII, got Western diseases. Poor people couldn’t afford to eat that much. Now poor people say they can’t afford to not eat cheap, calorie-dense food. 4. Transportation and automation obviated the need to burn calories. We started sitting at desks to work, instead of doing physical labor. Collectively, we slashed the expenditure side of the calorie balance equation. The current public health recommendations support the Mediterranean diet, but what keeps people from eating only the pasta and olive oil, and leaving out vegetables and fish? Increasing numbers of nutrition researchers focus on the


Board Briefs December 12, 2011 The Board: Extended appreciation to outgoing Directors Louise Glaser, MD; Robert Madrigal, MD; Stephen Melcher, MD and Anthony Russell, MD for their service on the Board of Directors. Serving as the Member Board of BloodSource, the Board received the annual BloodSource update from Michael Fuller, CEO. Also, Mr. Fuller presented Mr. Bill Sandberg, retiring executive director, with a resolution and a Bennett Sculpture.

The Member Board of BloodSource approved the following 2012 BloodSource Officers and incoming members to the Board of Directors: President, Keith McBride, Esq.; Vice President, Harry H. Lawrence, DDS; Secretary/ Treasurer, Paul Rosenberg, MD. Incoming Board Members, Mark Carter, MD; Michael Lucien, MD (SSVMS representative); Travis Miller, MD (SSVMS representative); Jim Schraith; and term renewals for George Chiu, MD; Angelo deMattos, MD; Sherri Kirk, Esq.; Harry Lawrence, DDS. continued on next page

continued from previous page “prudent” diet – a balanced diet of recognizable, whole, natural foods – but it really needs a much catchier name. “Prudent” won’t work in today’s society. As a physician who discusses this topic every day with patients, the problem is so obvious and yet so challenging. We don’t need diet books, which only succeed in making money for the authors and publishers. They certainly don’t solve the problem. Public health recommendations about specific nutrients haven’t worked so far. Some surgeons’ livelihoods now rest on girdling our stomachs or turning the intestines into a pretzel, but how practical or cost effective is that for widespread application? What we need is a magic wand that changes people’s food choices to those based only on physiologic need, makes kids and adults love vegetables, and makes it necessary to walk one-half mile to every meal. Or some common sense, an equally fanciful idea.

Fruit stand in Salamanca, Spain

algerhardt@sbcglobal.net Suggested Reference: www.healthychoicesformindandbody.org

March/April 2012

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Board Briefs continued from previous page Reconvening as the SSVMS Board of Directors, the Board: Approved the 2012 SSVMS Committee Appointments. Approved removing William Sandberg as Trustee to the SSVMS-Employee Money Purchase Plan because of retirement and adding Aileen Wetzel as his replacement effective January 1, 2012. Approved reducing the number of Board meetings from 11 to six. Issues requiring Board action during the months the Board is not scheduled to meet would be accomplished electronically. The Board also confirmed holding a Board Retreat in March 2012. Approved the Membership Report: For Active Membership — James D. Boone, MD; Petra Hoette, MD; Tariq A. Khawawinah, MD; Lenora W. Lee, MD; Elmo N. Orlino, Jr., MD; Bernard L. Ormsby, DO; Arvind Sonik, MD; Sarah E. Taylor, MD; Long E. Thao, DO. For Reinstatement to Active Membership — Katie C. Askew, MD; John Chin, MD; Stanley W. Leff, MD; Anne M. Prentice, MD; Francisco J. Prieto, MD; JaNahn C. Scalapino, MD. For a Membership Status Change from Active to Government — R. Steve Tharratt, MD; Mary Jess Wilson, MD. For a Membership Status Change from Active to Active-65/20 — Joanne Berkowitz, MD. For Retired Membership — John P. Roe, MD; Rajendrakumar N. Trivedi, MD. For Resignation — Benjamin T. Keh, MD; Todd D. Lasher, MD (moved to Virginia); Audrey Tague, MD (moved to Marin County); Christy S. Waters, MD (moved to San Francisco).

January 9, 2012 The Board: Welcomed the 2012 President, David

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Herbert, MD, and extended appreciation to outgoing President, Alicia Abels, MD for her leadership in 2011. Welcomed new Directors Paul T. Akins, MD, Jason P. Bynum, MD, Russell F. Jacoby, MD, Steven Kelly-Reif, MD and Kristen A. Robinson, MD. Continuing as Directors in 2012 are: Alicia Abels, MD, Immediate Past President, Jose A. Arevalo, MD, John Belko, MD, Ann L. Gerhardt, MD, Robert A. Kahle, MD, Bhaskara G. Reddy, MD, Lorenzo Rossaro, MD, Demetrios Simopoulos, MD, President-Elect and J. Dale Smith, MD. Elected Robert Kahle, MD, 2012 Secretary and Bhaskara Reddy, MD, 2012 Treasurer. Received a presentation from Peter Willson, Director of Development, and Raymond Burnell, Deputy Executive Director, for the Powerhouse Science Center. Sacramento’s 60-year-old Discovery Museum Science and Space Center will expand to a new location at the site of the historic PG&E building in downtown Sacramento and become the Powerhouse Science Center. Approved appointing Alexis Lieser, MD to Alternate-Delegate Office #8, moving Dr. Robert Kahle from Delegate At-Large Office 13 to Delegate Office #1 and moving Dr. Stephen Melcher from Alternate-Delegate Office 7 to Delegate At-Large Office 13. Approved the Membership Report: For Active Membership — Amit A. Raheja, MD. For Resident Membership — Charlene A. Hauser, MD. For Reinstatement to Active Membership — Cecilia M. Hernandez, MD. For Retired Membership — Anne Brennan, MD; David Naliboff, MD; Dennis Stobie, MD; Alton G. Wills, MD. For Resignation — Douglas E. Roberts, MD; Sultan A. Sultan, MD.


THE                      April

Art

29, 2012

OF

Medicine

 

Auction & Concert 5-9pm

The SSVMS Alliance is hosting an evening of fine art, fine wines, good food and wonderful music. The proceeds from the auction will go directly toward our Community Endowment Fund which is the sole source of funding for our annual community health grant and medical student and nursing scholarship programs.

SAVE THE DATE! April 29th, 2012 5:00-9:00pm

$75*pp Hors d'oeuvres and Host Bar Del Paso Country Club Music: Dan Katz, MD & the Festival Brass Quintet

Join our efforts to give back to the community. 1. Are you an artist, do you know one? Make or obtain a donation of artwork from an artist or gallery.* 2. Contribute to the SSVMSA Wine Auction*(Contributions can be dropped of at the SSVMS Medical Society Bldg. or contact Susan Brownridge at 916-955-7753 or sue_bee@surewest.net for pick up). 3. Join our current sponsors: Northern California Spine and Rehabilitation Assoc., Radiologic Associates of Sacramento(RAS) , Raleys/Bel-Air: Michael and Julie Teel, Sacramento Cardiovascular Surgeons, Spine and Neurosurgery Associates: Barry Chehrazi, MD Sean Minor Wines, Sierra Sacramento Valley Medical Society, Dr. & Mrs. Allan Morris, UC Davis Health Systems.

2011 Grant Recipients

Sacramento Child Abuse Prevention Council Childrens Receiving Home Society for the Blind Wellspring Womens Center Discovery Science Center Keaton Raphael Memorial Foundation

2011 Scholarships

$2,500 Nursing Scholarships : UC Davis, CSUS, American River College, Sacramento City College $2,970 SSVMS William E. Dochterman Medical Student Scholarship Fund $3,705 AMA Foundation Medical School Scholarship Fund

To make a donation or become a sponsor contact Gabby Neubuerger at gabby@surewest.net or (916) 736-1613. For reservations contact Ann Parsons at aparsons@surewest.net or 916-488-3534. *SSVMSA is a 501 (c) 3, Donations/Sponsorships are fully tax deductible. $25 of tickets to event tax deductible. 


Through the Aether By Bob LaPerriere, MD THIS WILL BE AN OCCASIONAL column featuring websites and/or “apps” of interest. Neither I nor this publication endorse or guarantee the accuracy of these sites and apps, but I do use them, and hopefully they are of interest to our readers. Both comments and contributions of your favorite apps are invited. Send them to me at drbob40@gmail.com.

Website http://www.medicalappjournal.com This is a peer-reviewed website listing almost 400 apps for the medical profession, organized by both topic and discipline. It contains apps for all four platforms: iOS (Apple), Android, Windows and Blackberry.

Apps Apps included are for the iOS (Apple-iPhone,

iPad) as this is what I use, but many are available for other platforms. • Scandit QR http://www.scandit.com/apps/scandit-qr-codescanner — A free, easy-to-use scanner app for reading QR codes such as the ones associated with this article. Especially for this food issue, the following may be of interest: • Fooducate http://www.fooducate.com — Available for Apple and Android products with cameras. The bar code is scanned, and product and related health information is displayed. There is a free version with ads or a paid version ($2.99 currently as a promotional price) for the iOS platform. Lots of great reviews for this app. • My Food-Nutrition Facts (iPad) http://www.pomapps.com/myfood/ — A free nutritional information app, though there are several “in app” purchases available to provide more functions. A nice feature is the choice of various serving sizes by volume, weight etc. • What’s On My Food http://whatsonmyfood.org/iphoneapp.jsp — A free app by the Pesticide Action Network listing potential toxic residues on over 60 food items. • Chemical Cuisine http://www.cspinet.org/reports/chemcuisine.htm — An app by the Center for Science in the Public Interest. It is a glossary of food additives with a description of them and safety ratings. • Nutrition Facts http://www.ihealthventures.com — A nicelyorganized program of nutrition facts, using the standard graphic format found on food labels. It is available only for iPad and Android platforms at the promotional price of $2.99. drbob40@gmail.com

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Sierra Sacramento Valley Medicine


Glossary of Fats and Oils By Denette J. Dengler MD, MS FATS USED TO BE EASY. THEY WERE a part of food, so you ate them. Then came knowledge that eating a low fat, low cholesterol diet was recommended for prevention of coronary artery disease. The bad news about trans fat and the confusion about omega-3 and omega-6 fatty acids ensued. Suddenly food fat became a chemistry experiment. How to interpret all that chemistry, as well as food labels??? Hope this helps. Fat/Oil: A food mixture of triglycerides, with other fat soluble substances. We all know that dietary fat is essential to health. It supplies essential fatty acids, fat soluble vitamins and other fats necessary for cell membrane function, steroid hormone synthesis, neurological integrity and prostaglandin synthesis, both pro- and anti-inflammatory. Fats are dense in calories (9 cal/gm) compared to proteins and carbohydrates (4cal/gm). Triglycerides: The major component of dietary fats and oils. They are triesters of glycerol and three fatty acids. Each type of triglyceride has a mixture of different fatty acids (of which there are at least 20 in food sources). The fatty acid content determines the triglyceride’s physical and biologic properties. Monoglycerides and diglycerides: Triglycerides missing two or one fatty acids, respectively. Often present in foods with “zero” fat, as a means to give a fatty texture. Caloric density is essentially the same as triglycerides. Manufacturers must list mono- and diglyceries under Ingredients on food labels, however, they usually exclude the fat (therefore calorie) content under Nutrition Facts (allowed by poor wording of the regulation defining fats). Medium chain triglycerides (caprylic, capric): Used in medicine for treating malabsorption disorders, among other

conditions. Fatty acids: Chains of carbon and hydrogen terminating an acid moiety. The fatty acid carbon chain length and configuration of the carbon bonds determines the stability and solidity of the fat at room temperature. Saturated fatty acid: Every carbon is bonded to as many hydrogens as possible (i.e., is saturated). They are solid at room temperature, improving shelf life and the desired consistency and flavor of baked goods. Some raise cholesterol and are more atherogenic. Unsaturated fatty acid: A fatty acid chain with one or more pairs of hydrogen atoms missing because of a double bond between two carbon atoms. The majority of unsaturated fats have double bonds in the cis-configuration (cis isomer), which makes it more liquid at room temperature. Trans fatty acids: Unsaturated fatty acids with at least one carbon to carbon double bond in the trans configuration (trans isomer), increasing the solidity and stability of the fat at room temperature. The majority of trans fat in our food supply is derived from liquid oils which have undergone a process of hydrogenation (saturating a previously double bond). Small amounts of naturally occurring trans fatty acids are present in meat, dairy products and eggs. The FDA mandated inclusion of trans fat in the Nutrition Facts section of food labels in 2006, but excluded the small amounts of trans fats occurring naturally in these foods. Debate continues on the health benefits of some trans fats. Trans fats include conjugated linoleic acids (CLA), vaccenic acid (from ruminant animals) and elaidic acid (the trans isomer of oleic acid in hydrogenated vegetable oils). Monounsaturated fatty acid (MUFA): A single double bond between carbon atoms

March/April 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

33


FAT CONTENT TABLE Percentages are based on grams per 100 grams of edible food product taken from the National Nutrient Data Bank for Standard Reference, United States Department of Agriculture.

Animal Fats Butter, Salted Bacon & Lard Beef Tallow Chicken Fat Turkey Fat Vegetable Fats Avocado Oil Cocoa Butter Canola Oil Coconut Oil Corn Oil Cottonseed Oil Flaxseed Oil Grapeseed Oil Olive Oil Palm Oil= Palm Fruit Oil Palm Kernal Oil= Palm Seed Oil Safflower Oil Sesame Seed Oil Soybean Oil Sunflower Oil Rice Bran Oil Nut Oils Almond Oil Hazel Nut Oil Macademia Nut Oil Peanut Oil Walnut Oil

%SAT

%MUFA

%PUFA

51 39 50 30 29

21 45 42 45 43

3 11 4 21 23

14 59 7 87 13 26 9 10 14

75 33 63 6 28 18 18 16 73

11 3 28 2 55 52 68 70 10

49

37

9

83 6 14 15 10 20

15 14 40 23 20 39

3 74 41 58 66 35

70 78 Not available 17 46 9 23

17 10

8 7

%TRANS*

32 63

* The %Trans Fatty Acids (TFA) content is really confusing. A blank space in the column under %Trans Fatty Acid means the information is unknown, and should not be interpreted as “zero.� TFA is not required or provided by the NFDB or on food labels of meat and dairy products and eggs which do contain some naturally occurring TFA. Refer to TRANS FATTY ACID section above. Plant seed oils contain some trans very long chain PUFA (trans polyenoic) and MUFA (trans monoenoic) fatty acids in small amounts, as listed above. Apparently, this content is increased by heat used in processing and the % does vary in the literature (often lower than the NNDB data).

34

Sierra Sacramento Valley Medicine

0.4 0.3 0.1

0.1 0.5

is present. Usually anti-inflammatory. Examples are oleic acid, a healthy but non-essential fatty acid, and palmitoleic acid, both in the cis-configuration. Polyunsaturated fatty acid (PUFA): More than one double bond exists in the carbon chain. Examples are linoleic, a- or y-linolenic, and eicosapentaenoic (EPA, an omega-3 fatty acid from fish oil) and docosahexaenoic acid (DHA, an omega-6 fatty acid from vegetable sources). PUFA can have healthy, vasodilatory effects, or unhealthy, proinflammatory effects, depending on fatty acid content (n3:n6 ratio, desirable lately = 4:1). Essential fatty acids: Unsaturated fatty acids, which cannot be synthesized by the body (linoleic and linolenic) or cannot be synthesized in adequate quantity for optimal health (EPA and DHA). Hydrogenation: The process of adding hydrogen atoms to unsaturated fats, eliminating double bonds between carbon atoms. In the process, some cis isomers are converted into trans isomers. Used to convert liquid oils to a more solid state at room temperature. Partial hydrogenation only saturates some of the double bonds. More complete hydrogenation results in a hard fat. More atherogenic. Nut and Vegetable fats: Tend to have more unsaturated fatty acids. Cholesterol content is so negligible, that it is zero for label requirements. Expeller pressed oil: The desired plant part is placed under pressure to extract the oil. Cold pressed oil: Expeller pressed with the temperature controlled to improve flavor and other qualities of delicate table oils, therefore more expensive. Leached oil: Extracted by dissolving the plant part(s) in water or another solvent, then separating and


Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Robert A. Kahle, MD, Secretary

Berna, Zoe D., Family Medicine, Hahnemann University 2001, Sutter Medical Group, 111 E. Grant Ave, Winters 95694 (530) 795-4591

Hauser, Charlene, Family Medicine, Tulane University 2008, UCDMC, 4860 Y St #1600, Sacramento 95817 (916) 734-2833 (Resident Member)

Raheja, Amit A., Radiology/Neuroradiology, UC Los Angeles 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Brogle, Elaine, Ophthalmology, Yale University 2003, The Permanente Medical Group, 7300 Wyndham Way, Sacramento 95823 (916) 525-6400

Lovell, Diane M., Radiology, Tulane University 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Walter, Marc C., Emergency Medicine/Internal Medicine, Georgetown University 1982, Emergency Medicine Physicians, 3300 Douglas Blvd., #405, Roseville 95661 (916) 960-2006

Fineberg, Annette E., OB-GYN, University of Maryland 1992, Sutter Medical Group, 2020 Sutter Place #203, Davis 95616 (530) 750-5880

Manshaii, Sapoora, Surgical Critical Care/General Surgery, Technical University of Munich, Germany 1991, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014

Grand, Alexander, Ophthalmology/Oculoplastics, Hahnemann/Drexel Medical School 2005, Medical Vision Technology, 1700 Alhambra Blvd., #202, Sacramento 95816 (916) 731-8040

Merchant, Deven B., Emergency Medicine, Wayne State University 1997, CEP/MedAmerica, Sutter Davis Hospital, 2000 Sutter Place, Davis 95616 (530) 757-5111

continued from previous page concentrating the extracted oil. Fractionation: Used to separate different fatty acids, usually by a process of heating and crystallization, for industrial and medical purposes. For more comprehensive information, I refer you to these excellent resources: — Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. Part D. Section 3: Fatty Acids and Cholesterol. — Diet and Lifestyle Recommendations. Revision 2006. A Scientific Statement from the American Heart Association. Nutrition Committee. — Position of the American Dietetic Association and Dietitians of Canada: Dietary Fatty Acids. J Am Diet Assoc.2007;107(9)15991611. — Astrup, A. The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010. Am J Clin Nutr. 2011;93(4):684-8. — P.W. Siri-Tarino, et al. Saturated fat,

carbohydrate and cardiovascular disease. Am.J Clin Nutr. 2010;91(3): 502-509, and editorial on page 497. denglerdj@comcast.net

Remember When?

March/April 2012

35


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36

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Sierra Sacramento Valley Medicine


Serotonin Surge Charities presents

Friday, March 30th, 6 : 30pm to 9 : 30pm at the Arden Hills Resort Club & Spa A food, wine and fashion show fundraiser for the following clinics and organizations that serve the medically uninsured: Bayanihan Clinic, Clinica Tepati, CommuniCare Health Centers, CSERF’s SPIRIT Project, The Effort, MercyClinic Folsom, Health & Life Organization (HALO), Imani Clinic, Joan Viteri Memorial Clinic, MercyClinic Loaves & Fishes, MercyClinic North Highlands, MercyClinic Norwood, Paul Hom Asian Clinic, MercyClinic White Rock, Willow Clinic.

Please join us and emcee Mark Kreidler as we learn more about safety net medical care, enjoy fine wines and sweet and savory foods, marvel at the fashion show some say rivals those in Paris and Milan, and recognize this year’s Safety Net Hero, Dr. Jack Rozance, Physician in Chief, Kaiser Permanente, Sacramento. Valet parking provided.

Sacramento Cal Expo

Senders Wines Fashion Show:

Graphics:

Photography:

Media Sponsors:

Signage:

Website:

Event Produced By:

For sponsorship and donor information, please contact John Chuck, M.D. at john.chuck @ kp.org or 530-757-4114. To register to attend, go to www.serotoninsurge.org or contact Tina Bozzini at tina.bozzini@ kp.org or 530-757-4121. Cost is $100 per person. Early bird registration by February 17th is $75. Serotonin Surge Charities is a 501(c)(3) public benefit non-profit organization (tax ID#68-0411254).


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Customers satisfied

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93%

To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.

strenghten your Practice at norcalMutual.coM Proud to be endorsed by the Sierra Sacramento Valley Medical Society.

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March/April 2012