What sets this report apart from the previous 6 is the inclusion of guest authors on a variety of relevant issues including communities’ access to affordable healthy foods, and steps food manufacturers are taking to improve the nutritional quality of their products. It also looks at ways to ensure that disease-prevention methods are included in the new health reform law and are implemented in strategic, cost-effective ways.

The major findings include:

• Adult obesity rates rose in 28 states over the past year (only the District of Columbia had a decline)
• 38 states now have adult obesity rates over 25%
• 8 states have adult obesity rates over 30% (in 1991 no state had an obesity rate above 20%)
• Mississippi had the highest rate of obese adults at 33.8% with Colorado having the lowest rate at 19.1%
• Blacks and Latinos have higher obesity rates than whites in at least 40 states and in DC.
• Latino adult obesity rates are 30% of more in 19 states
• Only West Virginia has an adult obesity rate for whites greater than 30%
• In 9 states, obesity rates for Blacks exceed 40%.

The major findings for child and adolescent obesity are:

• 9 out of 10 states with the highest childhood obesity rates are in the South. This correlates with 9 out of 10 states in the South having the highest rates of poverty.
• 8 states plus DC have childhood obesity rates greater than 20%
• Mississippi has the highest percentage of obese children at 21.9%

80% of Americans view childhood obesity as a serious problem, a view that cut across all demographics. Although there is controversy over how much of a role government should play in reducing this trend, 73% felt that it was an important goal for the government to focus on. In addition, 56% felt that government programs that dealt with reducing these rates were worth the financial investment even at the cost of billions of dollars a year. The majority of voters see that reducing childhood obesity rates will ultimately save taxpayers money.

For an executive summary of the report, entitled F as in Fat: 2010 How Obesity Threatens America’s Future can be read by following this link. The full report can be accessed here.

To find out how your state is doing, the executive summary provides charts that look at obesity rates for Blacks, Latinos, and obesity related standards in schools.

I am always aware that what I write is a legal document that can be viewed by anyone (who is authorized to do so by the patient that is) but like any field which has its own particular jargon and abbreviations, providers develop their own style in how the note is written – which is usually a balance between brevity and density, ie, how to pack as much information into the note using the fewest words possible.

But not all notes are dry descriptions of a medical problem. Many of my patients suffer from depression or anxiety and I like to add a few notes that help me remember their particular issues when I review the note when they come in for a follow-up visit months later. With my younger, healthier patients, it’s not unusual to have several years go by before I see them again so I like to jot something that might help me remember them. It might be anything like the school they go to or a particular struggle the patient is having with a child,  job, or relationship or simply where they’re going for vacation.

I remember many years ago reading an xray report about my back – this was before I was in the business. The technical terms made everything seem so much worse – phrases like “mild degenerative changes”.  I could only see the word “degenerative”  and imagine the worst. The physician’s note used the word “acute” to differentiate the problem from a chronic process. I misunderstood and thought he was describing something that represented an emergency. I would have needed hours of explanation to feel reassured that I was truly all right.

And then there are the lab values, minor variations of normal or transient elevations that to the unfamiliar eye might cause alarm. In many ways, part of my job is to explain, as simply as possible, what something means and so I may choose to avoid complicated details. So what would happen if patients could read their notes? Would they become unnecessarily frightened? Would it lead to excessive amounts of time trying to explain something that was essentially normal?

I don’t treat my patients paternalistically, nor am I condescending but I do have to edit what I say because I have a limited amount of time to spend in the exam room. I wouldn’t want to spend a lot of that time explaining why I wrote a particular phrase nor would I want to leave out those personal identifiable details that help me remember that patient. When this particular study concludes in a year, I’ll be curious to see what patients and providers decide.

While all this has been playing out in academia and the media, an excellent editorial appeared in the International Herald Tribune this weekend that raises thoughtful ethical questions about the consequences of testing for this gene. Amy Boesky, an associate professor of English at Boston College, herself a carrier of the BRCA (breast cancer) gene, has thought a lot about what it means to know you have a genetic predisposition for a particular illness. In this guest editorial, she asks:

• What happens to us when we begin to see each other’s futures in terms of our DNA?
• Should we test for this gene?
• Should genes be patented?
• Should personal genetic test kits be regulated?
• How and where should these tests be made available?

Given the field I’m in, a key issue for me is what happens when insurance companies get ahold of this information – how will this impact the cost of health care premiums? What about the costs of long-term health insurance?

For more information about the “longevity gene” controversy, Newsweek published a good article about how a “good study became bad science”. Unfortunately, despite the International Herald Tribune being a part of the New York Times, I have not been able to find a link to Ms. Boesky’s article.

So aside from the technical

from cookingontheside.com

Let’s see – there are:

• low-fat/high carb diets
• low carb/high protein diets
• moderate fat Mediterranean diets
• low fat diets
• low carb diets and
• calorie restricted diets (any combination of fat/protein/carbs)

And there are variations of each (Pritikin, Atkins, Zone etc) but which studies can you trust?

Well researchers from the Department of Nutrition at Harvard School of Public Health teamed up with researchers at Brigham and Women’s Hospital and Pennington Biomedical Research Center of Louisiana State University to try answer this question. Their results were published in the New England Journal of Medicine.

811 overweight and obese adults were randomized into 4 different diets that restricted either protein, fats or carbohydrates. The subjects were followed for 2 years and all groups were offered group and individual instructional sessions for 2 years. The major differences between this study and preceding ones were the length of time that subjects were followed – 2 years vs 1, larger sample sizes (the number of people in the study -  not the food portions), the inclusion of more men and the ability to keep researchers and  study subjects unaware of the type of diet they were on. This was done by having similar foods chosen and ensuring that all of the diets met the guidelines for cardiovascular health.

The diets consisted of varying percentages of fat, protein and carbohydrates. The breakdown for each diet was:

• Diet 1:   20% fat, 15% protein, 65% carbs
• Diet 2: 20% fat, 25% protein, 55% carbs
• Diet 3: 40% fat, 15% protein, 45% carbs
• Diet 4: 40% fat, 25% protein, 35% carbs

Thus there were 2 low fat diets, 2 high fat diets, 2 moderate protein and 2 high protein. The one constant throughout was that each participant had their calories reduced by 750/day which was based on the individual’s resting metabolic rate.

All subjects participated in 90 minutes of moderate activity/wk and participated in various group and individual sessions.

So which diet was better? None of them – it didn’t matter which diet was followed – rather weight loss resulted from a reduction in caloric intake. So next time you read about the latest fad diet, don’t bother. If you reduce your intake by 514 calories a day (1 kid size chocolate chip cookie is 180 calories), you’ll lose a pound a wk or 52 pounds a year.

Think about that next time you want to reach for that bedtime snack…..

Some people might find this approach to health care cost containment a little extreme – after all, if someone chooses not to take medications, why should we care? Besides, won’t this in fact reward negative behavior?

It might if we respond emotionally rather than rationally. I’m reminded of one diabetic patient whose A1c is back up to 12% from 9.3%. Given what lies in store for her if she doesn’t get her numbers better controlled (blindness, kidney failure, MI or stroke), I would totally support rewarding her for taking her meds regularly.

To read more about this novel approach, follow this link to the New York Times article by Pam Belluck.

Peter Ghoroghchian from the Department of Bioengineering, embedded these flourescent porphyrins in a tumor located one centimeter beneath the skin of  a mouse. He then shone near-infrared light onto the skin which  triggered the flourescent materials, illuminating the tumour. Using near-infrared wavelengths enables these signals to pass through water, blood cells and other compounds that make up tissue. In other words, the signals are able to be detected up to 10 to 12 cms through breast tissue and 5 to 6 cm through muscle tissue. Because the polymersomes are made of nontoxic materials they differ from other contrast agents  currently used in imaging for CT and MRI.

The application of this technique is quite far reaching. Think of these polymere chains as a train that is able to carry the porphyrins (to light up and identify the cancer cells) and carry the chemotherapy agents to destroy the cancer cells. Because cancer cells have specific chemical markers on their outer membrane, specific chemical substances can be developed that will attach  to the cancer cell’s  outer membrane. Current chemotherapy is non-selective meaning that it targets all cells that are rapidly growing, killing good and bad cells alike.  This new technology will enable doctors to find cancer cells that are too small to be detected  and deliver chemotherapy to the site leaving healthy tissues intact.

For more information about this fascinating research, follow this link to the National Institue of Biomedical Imaging and Bioengineering. More information about  the use of porphyrins in cancer treatment can be found at this link.

Vincent Tuohy, M.D., a medical researcher at The Cleveland Clinic, has found just the target and he and his group are hoping to test this vaccine in women as early as 2011. In the case of breast cancer, the team discovered a protein that is secreted in women during two conditions: during lactation (breast-feeding)  and during cancer cell proliferation.

Since the protein, alpha-lactalbumin, is secreted in large amounts from breast tumors, Dr. Tuohy’s team decided to target this. Lab mice were genetically bred to be prone to breast cancer and some mice had active breast tumors. Half the mice were then given the vaccine with alpha-lactalbumin while the other half did not. Test results showed that all mice who received alpha-lactalbumin did not develop breast cancer and among those that did, the cancer inhibited the growth of the tumors. Those mice that didn’t receive the vaccine developed breast cancer.

Two Phase I clinical trials are proposed. The first one would be for women with advanced breast cancer and would test for dosage, toxicity and immune response while the second phase would be tested on women who have the genetic markers for breast cancer and who have elected to undergo prophylactic mastectomies. In this group, the amputated breasts would be examined for damage.

If the clinical trials are successful, the vaccine would be given to women over 40 as well as younger women who have the  BRCA1 or BRACA2 gene which predisposes them to breast cancer.  Women who become pregnant after receiving the vaccine would experience breast soreness and probably would not be able to breast feed.

The possiblity of cancer prevention and/or treatment using targeted vaccines remains very promising as long as the tumor expressed particular proteins not found in otherwise healthy individuals. In this particular case, Dr. Tuohy feels that if his vaccine works, breast cancer “will go the way of polio”.

For more information about the study, follow this link. You can also read the press release published by the Cleveland Clinic Lerner Research Institute.

Called remote controlled capsules (RCCs), these tiny devices consist of a drug reservoir and a mechanism to release the medication. RCCs are known as “site specific” meaning that the capsule’s movements can be precisely controlled from outside the body to ensure that the medication reaches a specific location. Using these devices, researchers are able to study how medications are broken down and absorbed in the GI tract. This information helps pharmaceutical scientists gather data for oral drug formulations.

In case the concept of remotely controlling the delivery of medication in the GI tract doesn’t seem like science fiction to you, research on the best way to discharge the medication once it arrives might make you shake your head in wonder and amazement.

One of the most recent methods reported  in the journal Sensors and Actuators (a journal devoted to materials research) is the use of a micro-fabricated thruster that houses a detonating agent and a propellant – in other words this is a microscopic-sized rocket. The thruster produced enough force to completely and rapidly expel the contents of the drug reservoir.

Other novel methods of releasing the medication from RCCs use high frequency energy waves. In this example, researchers used a capsule consisting of a drug reservoir, a high frequency receiver, a gas generating reactor and a piston to pump the medication out of the reservoir.

Another experimental method to discharge medication used rotating magnetic spheres approximately 5 mm round located inside a capsule. The magnetism generated enough heat to theoretically release drugs in the GI tract.

Does delivering a medication in this new way actually make a difference in how the medication works in the body? Possibly. It used to be that medications needed to be taken multiple times throughout the day because there was no way to delay the breakdown of medication in the GI tract – in other words there was no way to control the rate at which the medication was absorbed in the system. Today however, we have controlled release, sustained release, and long-acting formulations. This allows a more steady-state dose to be achieved in the body which can lead to better blood pressure control or pain relief or relief from acid indigestion just to name a few.

Hopefully, novel ways to administer medication will help improve treatments related to cancer as well as improve treatments for disorders of the endocrine, cardiovascular, neurological and GI  systems.

The process involves tailoring the the vaccine to each individual. Specifically, some white blood cells, (the cells responsible for our immune system), are removed from the patient’s body and exposed to a protein found on  prostate cancer cells. This primes the white blood cells to recognize and attack this specific protein  when the vaccine is reinjected into the patient’s body. Then the patient receives a series of 3 injections in a one month period.

This treatment  is referred to as “autologous (awe-TALL-o-gus) cellular immunotherapy”. Autologous simply means “coming from the same person” and in this case it refers to therapy/treatment derived from the patient’s own immune cells. This treatment is not meant to replace other treatments for advanced prostate cancer but to support other treatments the patient may be receiving.  As mentioned, the treatment is reserved for metastatic prostate cancer but it may be that the drug can be administered sooner in the disease process to more quickly harness the body’s immune system.

So how effective is the vaccine? Well Phase III trials (see my article on melanoma that explains the 4 phases of clinical trials ) conducted at cancer treatment centers across the country showed patients survived an average of 4.1months longer, had an improved 3 year survival rate of 38% and had a reduction in the overall risk of death of 22.5%. Because the injections are tailored to each individual, the cost of the treatment will be about $50,000 to $100,000.

Here’s a link to the FDA article about Provenge’s approval . In addition, the FDA has written a handy Q&A sheet about Provenge.

Until recently, few studies have been done to see if GR alone or in combination works. An Australian and New Zealand research team recruited 103 recreational athletes 18-40, which included 63 men and 33 women with the average age of 27.9 years. Their objective was to see if GR alone or combined with testosterone improved body composition and performance. The results were published in the Annals of Internal Medicine, May 2010.

Men were randomly selected to receive GH, testosterone, placebo or a combination of GH and T and women were randomly selected to receive placebo or GH. Subjects were then measured on their power, strength, endurance and sprint capacities. Study results showed that GH “significantly reduced fat mass, increased lean body mass…and increased body cell mass in men when combined with testosterone.” In addition, GH improved sprint capacity in both men and women but not power, strength or endurance. Muscle mass was not increased when taking GH however, athletes did suffer from more joint pain and swelling while also retaining fluid

Limitations of the study included the fact that the dosages administered of growth hormone (2mg/d subcutaneously) and testosterone (250 mg/wk intramuscularly) may underrepresent the actual doses taken covertly by athletes and thus, the side effects would also be underrepresented.

Annals of Internal Medicine published a summary of this study in layman’s terms and is an excellent read. This version is printed below in its entirety.