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.

There is also an excellent interview that you can access on this site, by Terri Gross from Fresh Air, a radio program on NPR. In it she talks to Dr. Carolyn Bernstein, a neurologist who started a migraine clinic in the Boston area.

Finally, for those interested in a herbal approach to treatment, check out this article, Feverview for Migraine Prevention.

What bears explaining is that I couldn’t give blood the last time I tried either. My hospital’s blood bank uses an automated hemoglobin machine that reads a drop of blood that comes from a quick finger prick. My hemoglobin read around 11. Because of medications I’m on I get my blood checked every three months so the next day I decided to get a venous blood draw – that is, blood that comes from a vein rather than a finger stick. The results were decidedly better and showed that I wasn’t anemic at all. Technology being what it is though, the hospital computer kicked me out of donating until 1 week had passed – it couldn’t be manually overridden.

Capillary blood testing (finger sticks) have shown equivalency when testing using either capillary or venous blood on such measures as blood sugar levels and cholesterol and I wasn’t able to find anything that suggested that measuring hemoglobin using finger stick rather than a venous blood draw would be any different.

Nonetheless, the hemoglobin machine results read 11 and I needed 12.5 in order to donate – so I decided to double check the foods I had remembered to be high in iron. As I thought, dark, green leafy vegetables are high in iron but what I didn’t know was that the iron from plant based foods, are less readily absorbed unlike animal based sources of iron (ie, red meat, chicken, pork etc) which is more readily absorbed.

Called non-heme iron, the iron found in plant foods, is what our foods tend to be enriched with, as in iron-enriched cereal for example. Yet as I mentioned above, this is the iron that is harder for the body to absorb. In fact, 15-35% of iron from animal meat will be absorbed but astonishingly, only 2-20% of non-heme iron get absorbed by our bodies and that will depend on the type of protein consumed with the meal as well as other food components.

Vitamin C greatly enhances the absorption of iron so citrus fruits consumed with your meal will help your body boost iron absorption. Foods that negatively impact iron absorption include tannins (found in tea), calcium, phytates (found in legumes and whole grains) and polyphenols (found in wine, beer, chocolate, walnuts, peanuts… sigh, the list goes on). And as a vegetarian, I consume a lot of tofu but it turns out that some of the proteins found in soybeans actually inhibit iron absorption.

So I will be much more mindful of the combinations of foods I eat in order to maximize the absorption of vitamins and minerals. I found two excellent sources of information – one is a dietary supplement fact sheet on iron that includes 2 tables, one for animal sources of iron, the other for plant based sources of iron.

The other source I found very useful is a web page called Natural Food Hub. It had an excellent page on the Vitamin C content of many fruits including lots of interesting side facts. Happy reading!

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.

This is a great short video about ringworm, a very common fungal infection of the skin. Dr. David Hill (love that bow-tie) discusses over-the-counter preparations used to treat ringworm (tinea) on the body and on surfaces.

Key points:

• continue to treat 1 wk after rash disappears because the fungus is still present, just not seen
• treat an area approximately 1 inch wider that the margins of the ringworm
• ringworm is NOT a worm – it’s just a fungal infection

Treating her was a real challenge. She was elderly and very debilitated as a result. Anything she ate passed right through her. Protecting her skin from further breakdown was paramount. If we couldn’t stop the diarrhea and prevent further skin breakdown, she would die.

I can’t remember now how we were able to stop the diarrhea – presumably we used stool bulking agents as well as metronidazole to stop the infection. I called a friend who worked in wound care, and she proposed a unique regimen of a thick layer of a zinc based cream (the white cream you used to see life guards use on their noses) topped off with an equally thick layer of vaseline. Whenever she stooled, the aides were instructed to clean her by gently wiping away the layer of vaseline but not the underlying layer of zinc. In this way we managed to protect her skin from the burning effects of the stool.

She eventually healed but I never forgot how potentially deadly C diff can be. C diff is a bacteria that is found in the environment – in stool, soil, air, or water. Healthy people don’t normally get the disease because our gut has many more colonies of good bacteria that keep C. diff. in check. When we take antibiotics however, the medication indiscriminately kills the good and the bad bacteria and in some people, especially the elderly, C. diff. out numbers the good bacteria causing inflammation of the colon, which leads to chronic watery stools. There are some particularly vicious strains of C. diff. that can kill.

Treating C. diff. by taking antibiotics (yes, antibiotics do cause C. diff. but it’s also treated by taking antibiotics) can take many weeks but there are new treatments being used in dire circumstances: fecal transplantation.

Since the colon is lined with healthy bacteria, some specialists are now treating difficult cases of C. diff. with stool specimens given by family members and mixing it with normal saline. In one particularly horrendous case, a patient had lost 60 pounds in 8 months until one gastroenterologist mixed a small amount of her husband’s stool with normal saline and delivered it in her colon. Within 1 day, her diarrhea had stopped. Within 2 weeks, her gut was populated with normal bacteria.

The procedure is known as bacteriotherapy or fecal transplantation, and involves using bacteria normally found in the body to combat certain bacterial overgrowth that is detrimental to the body. In fact, scientists have calculated that there are more than 10x more microbes in our bodies than human cells and a new field of treatment is developing around this.

To read more about the fascinating use of microbes to treat illness, read the NY Times article entitled, “How Microbes Defend and Define Us“.

What I wanted first and foremost was a hospital that specializes in this type of surgery or at least does a large volume of this type of surgery. US World and News Report is a great place to start and their results are published on line. The report is separated into specialty areas, so in this case I chose orthopedics.

The hospitals reviewed are  all experienced in treating difficult cases and qualify for inclusion in the report only if a certain volume is reached or if surveyed specialists recommended the hospital.

The rankings are based on the following:

1. Reputation with physicians
2. Relative death rate
3. Patient safety
4. Patient volume
5. Level of nurse staffing
6. Nurse magnet status
7. Technology score
8. Patient services score
9. Trauma center

The relative death rate is a ratio that compares the number of medically complicated patients who died within 30 days of their  hospital stay with the number of deaths expected after adjusting for severity and other risk factors. The lower the better.

Patient safety rates the number of medical errors and accidents from 1 to 5. Again, the lower the better.

Patient volume is important because again, you want a hospital that has a high volume of the type of surgery you need. This number is derived by looking at the number of patient discharges in the particular medical speciality (in our example, orthopedics). Anything greater than 2000 is considered high volume.

Level of nurse staffing is actually the patient to nurse ratio – again the lower the ratio, the better patient care you can expect.

Nurse magnet status is a sign of excellence awarded to a hospital by the American Nurse Credentialing Center.

Technology score denotes whether the hospital uses the up-to-date technology for orthopedic surgery.

Patient services score denotes the number of other ancillary services available for this particular specialty – the higher the number the better.

How to Select a Surgeon

Once you’ve narrowed down the hospital, the  next thing is to find a good surgeon. Essentially, you want someone who specializes in the type of surgery you need. I usually recommend that people talk to their friends, relatives and other medical providers. When you ask a medical professional, ask him or her who they would want to operate on their own family member.

Don’t be afraid when meeting with the surgeon to specifically ask how many surgeries s/he has performed in the past year. Studies show that surgeons who do 50 or more replacement surgeries a year generally  have fewer post-op complications.

Some hospitals keep registries that track knee and hip implants that are associated with  higher than average revision rates. Talk to your surgeon about the kind of implant that would best serve you and what problems are associated with that particular device.

The NYTimes published a great article entitled, “Getting a New Hip or Knee? Do It Right the First Time” by Leslie Alderman. I highly recommend reading it for further tips on selecting a surgeon.

As for my dear friend, the hospital I recommended to her was Hospital for Special Surgery, in NY, NY. It’s an orthopedic hospital close to her family and is rated #2 in the country (Mayo Clinic was #1). I wasn’t able to recommend a surgeon – that’ll require some interviewing on her part, but the hospital publishes a list of ortho surgeons who specialize in knee replacement.

Tamoxifen is known to prevent a recurrence of breast cancer by suppressing endogenous estrogen. You take it every day for 5 years. In fact, it’s even given to young women who have not been diagnosed with breast cancer but who have a strong family history of breast cancer. It’s well tolerated and has a great track record in preventing a recurrence. It’s a great drug to use in our arsenal of medication to treat the # 2 cancer killer of women (lung cancer is #1).

So perhaps you can imagine my shock when I read the recent findings published online in the July 2010 issue of the  Journal of Clinical Oncology which reported that only 49% of women  (whose breast cancers were positive for the estrogen or progesterone receptors) completed the 5 years of therapy. The remaining women simply stopped taking the medication with a shocking 13% of patients nonadherent right from their first refill.

Even more shocking was that the age group most likely to stop taking tamoxifen were women under 40.

If you think that this study is an anomaly, you would be wrong. Two previous studies of tamoxifen also found that young women were likely to discontinue their medication. As the researchers reported, “young adults with cancer may be a particularly vulnerable group”. Other studies show discontinuation rates between 30%-50%. Why this occurs was not made clear in the study.

So please, if you know someone with breast cancer who has stopped taking tamoxifen or the other aromatase inhibitors, inquire why and urge them to speak with their oncologist.

For an abstract about the study, follow this link - from  here you can download the complete report in PDF format if desired.

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

We really don’t have enough data on the possible long term complications of this radical surgery in such a young population but with her abnormal blood sugars and elevated cholesterol, she was facing, in the very near future, a life filled with multiple medications and frequent medical visits.

 How did she get this way? As she exeplained it, she had always been a “little” overweight since childhood and over the years (not so many in her case), she had continued to gain weight – 30#s in the last year alone. She felt miserable about herself.

 Interestingly but not surprisingly, the markers for adult onset diabetes (DMII) are actually present in childhood/adolescence. Using only blood pressure readings and body mass index (BMI), the National Growth and Health Study (NGHS) followed 1,067 ten year old girls and 822 boys and girls aged 6-18 years in the Princeton Follow-up Study.

 The results showed that children in the top fifth percentile for BMI were 4 times more likely to develop diabetes in adolescence or adulthood. Additionally, an elevated systolic blood pressure (the top number) in the top fifth percentile increased the risk of diabetes 5.78 times.

 Given that the cost of treating diabetes and its complications (heart attacks, heart failure and kidney disease) will only continue to rise, we need to be hypervigilant about treating childhood obesity aggressively. The problem is, how?

 A recent study reported on by the National Institutes of Health, linked childhood obesity to the rise in working mothers – yet another hit on the chin for mothers – stating that these children were 48% more likely to be overweight or obese. Those percentages increased if both parents were obese/overweight.

 But obesity doesn’t happen in a vacuum and we can’t simply single out mothers to blame for increasing obesity rates. School lunches are often pre-packaged food high in sugar and salt. With a decrease in school funding, physical education classes are often cut back. Schools have been seduced into providing soda machines in exchange for a percentage of the money to help boost their falling coffers. Students now have less activity and easy access to junk food.

Some local school councils are under increasing pressure however to remove vending machines, or stock them with healthy snacks and drinks. There are also states who are closely examining the quality of the food served in schools and movement is underway to radically improve the quality of school food offering seasonal fresh fruit and incorporating fresh produce from local farms. 

Leisure time activities are more often sedentary – video games and TV predominate. Limiting TV/computer time and encouraging your child to be outside playing will help him/her burn more calories.

 Super-sized drinks and junk food advertisements are promoted everywhere as well as all-you-can-eat buffets. How about posting calorie counts on all food sold in the grocery-store bakery and take-out restaurants so that we can make informed choices? (I recently found out that the cinnamon scone I so enjoyed eating from Whole Foods actually had more calories than a donut – and here I thought I was choosing my food carefully). Although unpopular, we could apply a higher tax on foods we know are unhealthy – you know, those chocolate cereals, sodas, candies etc. After all, higher taxes on cigarettes has helped to reduce smoking rates.

 Truth is, obesity has many causes and as much as no one wants to be nagged about their eating and exercise habits, behaviors can change if there is a national will to do so – just consider how far we’ve come as a nation in decreasing smoking rates. With the same concerted efforts by public health officials as well as parental, local, state and federal involvement, we can reduce the rates of obesity in this country.