The Doctor Weighs In

Gestational diabetes: Everything (well, almost everything) you ever wanted to know

2006-10-11T14:09:00Z

Gestational diabetes, or GDM, occurs because pregnancy hormones increase resistance to the hormone insulin. Because insulin does not work as well during pregnancy, the pancreas must produce more of it to keep up with the body’s demand. For many pregnant women, this is not a problem. However, in some women, the pancreas is unable to produce as much insulin as the body needs to keep blood sugars in the normal range. As a result, blood sugar levels rise (hyperglycemia) and gestational diabetes may develop.

It is important to diagnose and treat GDM as it can have serious short and long term health consequences for both you and your baby. Don’t worry needlessly, however, if you have been told you have gestational diabetes. There are a lot of things you and your doctor and/or health team can do to keep you and your baby healthy both during the pregnancy and afterwards.

Gestational diabetes is common. GDM occurs is about 4-7% of pregnancies in the United States. It is one of the most common health problems in pregnancy. The incidence appears to be increasing as well, most likely due to the increase in the prevalence of overweight and obesity.

Risk factors. You are at high risk for GDM if you have any of the following:

Obesity (BMI over 30)
Prior history of gestational diabetes
Strong family history of diabetes

These are all reasons to have early screening for gestational diabetes. Some health professionals will also screen early if you have any of the following:

You test positive for glucose in your urine at a prenatal visit
You have given birth to a big baby (9 pounds or greater)
You have had an unexplained still birth
You have had a baby with a birth defect
You have high blood pressure

Because many women who develop GDM do not have any of these risk factors, most practitioners screen all pregnant women for GDM at 24 to 28 weeks of pregnancy.

I am healthy. Do I really need to have this screening test? Some practitioners will not screen for GDM if the woman is at very low risk. To fall into this category, you must meet all of the following:

You are younger than 25
Your weight is in a healthy range
You are not a member of a racial or ethnic group that has a high prevalence of diabetes, such as Native American, African American, Latino, Asian American, Pacific Islander
None of your close relatives have diabetes
You have never had a high blood sugar on testing
You have never had a baby over 9 pounds or any other pregnancy complication that is associated with gestational diabetes

Only a small percentage of pregnant women will meet all of these criteria. Therefore, most obstetricians/gynecologists prefer to screen all pregnant women for GDM because the consequences of missing the diagnosis are serious.

Testing for GDM. In the United States, most ob-gyns and family physicians caring for pregnant women prefer to use a 50 gram, 1 hour “glucose challenge test” as the initial screening test. The test is administered between the 24^th and 28^th week of pregnancy. This test involves drinking a standardized 50 gram load of glucose dissolved in water. If the test is positive, you will be asked to come back for a longer, but more definitive test as described below. Two different cut-off values for a positive test have been proposed: 130 mg/dL and 140 mg/dL. Ninety percent of pregnant women with GDM will have one hour plasma glucose values that exceed 130 mg/dL. However, 20-25% twenty-five percent of pregnant women will have a positive screening test with this cut-off. Many of these women will fail to meet the criteria for GDM once they have the more definitive test (this is known as a “false positive” test).

The “gold standard” test for gestational diabetes in the US is the 100 gram, 3 hour oral glucose tolerance test. You will drink a standardized 100 gram load of glucose dissolved in water. Blood is drawn before you drink the glucose and hourly for the next 3 hours. Criteria for diagnosing GDM are as follows:

Fasting plasma glucose 95 mg/dl or higher

1 hour plasma glucose 180 mg/dl or higher

2 hour plasma glucose 155 mg/dl or higher

3 hour plasma glucose 140 mg or higher.

Two or more of the plasma glucose levels listed above must be met or exceeded to make the diagnosis of gestational diabetes. The test should be done in the morning after an overnight fast of 8-14 hours and after at least 3 days of unrestricted diet (150 grams or more of carbohydrate per day) and unlimited physical activity. You should remain seated during the test. Also, you should not smoke during the test, but you should not smoke at all during your pregnancy, in fact you should not smoke at all.

Outside of the United States, many clinicians follow the screening approach recommended by the World Health Organization: a 75 gram, 2 hour glucose tolerance test used as a one-step screening and diagnostic test. The test is considered positive if the fasting plasma glucose is 126 mg/dL and/or the 2 hour test is 140 mg/dL or higher.

In medicine, whenever there is disagreement about what is the best test or the best way of interpreting a test, it means that we don’t really know which approach is optimal. You should follow the recommendations of your clinician.

If I have it once, will I get it again? A woman who had gestational diabetes in one pregnancy has a 43% chance that it will recur with the next pregnancy. Lifestyle changes, such as weight loss, improved nutrition, and regular exercise should be initiated in all women with a history of GDM before they conceive again. Prior to conception, fasting blood glucose and Hemoglobin A1c testing (a test of glucose levels over the previous 2-3 months) should be obtained. If they are abnormal, every effort should be made to get your glucose levels in good control prior to becoming pregnant again.

Does GDM harm my baby? Poorly controlled gestational diabetes can lead to serious consequences for your baby. When your glucose levels are high, too much glucose can end up in your baby’s blood. Your baby’s pancreas will need to produce more insulin in order process this extra glucose. The excess insulin can cause your baby to get fat, particularly in the upper part of the body. When a baby is bigger than normal, we say the baby has macrosomia (macro=big, somia=body). Macrosomic babies may not pass easily through the birth canal, causing difficult deliveries, complications such as shoulder damage during delivery (shoulder dystocia), nerve damage, or even a fractured bone. If your health provider suspects you are going to have a macrosomic baby, she will probably recommend you have a cesarean section.

After delivery, the baby is at risk for developing low blood sugar (hypoglycemia) because of the extra insulin baby’s pancreas is producing. The baby’s blood sugar will be tested right after delivery. If it is low, you will be encouraged to feed him/her as soon as possible. If it is extremely low, the baby may require an intravenous (IV) glucose solution. Other complications for babies born to mom’s with uncontrolled gestational diabetes include jaundice (yellowing of the skin), low blood calcium and high red blood cell counts. If control was especially poor, the baby’s heart function could be affected. Women with severe gestational diabetes have an increased risk of having a stillbirth in the last two months of pregnancy. Finally, babies born to women with GDM may be at increased risk for obesity and type 2 diabetes later in life.

What can I do to prevent any harm to my baby? Luckily, there are a lot of things you can do to keep gestational diabetes in good control while you are pregnant. You will need to monitor your glucose using a home glucose meter (glucometer) and blood glucose testing strips. And, you will need to watch your diet. Many experts recommend you get nutritional counseling from a registered dietician so that you can develop specific meal and snack plans tailored to your height, weight, activity level, and food preferences. Regular exercise also helps because it increases sensitivity to insulin. In some cases, you will need to take insulin shots to keep your glucoses in the normal range, as recommended by your doctor. Most women with gestational diabetes who keep their glucose in good control will go on to deliver a healthy baby.

Do I need to do anything special after I deliver the baby? The American Diabetes Association suggests that you should have your glycemic status checked about 6 weeks after delivery. Two tests are commonly used to test for postpartum glucose problems. One test is the fasting plasma glucose (blood is drawn in a laboratory after an overnight fast or no caloric intake for at least 8 hours). The other test is a 2-hour oral glucose tolerance test (GTT) that checks glucose levels 2 hours after you drink a standardized glucose drink (75 grams of anhydrous glucose dissolved in water). If the fasting plasma glucose is above 100 mg/dl but below 126 mg/dl, you have impaired fasting glucose. If it is 126 mg/dl or higher on two different blood tests, you have type 2 diabetes. If the 2 hour plasma glucose is between 140 and 199 mg/dl, you have impaired glucose tolerance. If it is 200 mg/dl or higher, you have type 2 diabetes.

If, at the 6 week postpartum visit, you find out you have impaired fasting glucose or impaired glucose tolerance, you should have your glycemic status checked every year. If glucose levels are normal at the 6 week visit, you should be retested at least every 3 years.

Are their any long term effects of GDM? Women who develop gestational diabetes have an increased risk of developing type 2 diabetes at some time in their lives. Overall the risk is increased about 63%. However, if you have more than one pregnancy with GDM, your risk increases. It approaches 100% if you have had three pregnancies with GDM.

Certain indicators are associated with an increase in the risk of developing type 2 diabetes within 5 years of a GDM pregnancy, including the following:

Development of GDM before the 24^th week of pregnancy
Plasma glucose levels remaining at the high end of normal or frankly elevated postpartum
Impaired glucose tolerance (abnormal glucose tolerance test)
Obesity
Family history of diabetes

It is important to have regular follow-up, for the rest of your life, to assess whether you have developed prediabetes or diabetes or linked conditions, including high blood pressure and abnormal lipids. All women with a history of GDM should maintain a healthy weight and follow a regular program of physical activity.

If I want more information on gestational diabetes, where should I go? The American Diabetes Association is an excellent source for information about gestational diabetes. (www.diabetes.org/gestational-diabetes.jsp). You can obtain a copy of “Gestational Diabetes: What to Expect” via a hyperlink on the ADA gestational diabetes website. Other books available online or at your local bookstore include the following:

Managing Your Gestational Diabetes: A Guide for You and Your Baby’s Good Health by Lois Jovanovic-Peterson

The Official Patient's Sourcebook on Gestational Diabetes by James N. Parker, MD and Philip M. Parker PhD

Fructose and Fat

2006-10-03T23:00:00Z

Fructose is a dietary sugar that is found in a number of naturally occurring foods, most particularly, fruit. Eaten in moderation, especially when ingested as a complex foodstuff (e.g., an apple), it is not harmful. On the other hand, high fructose ingestion appears to have a number of adverse health effects, including obesity and high triglyceride levels. Several recent scientific publications* have suggested that high fructose consumption may be a major contributor to the global epidemic of obesity.

You are probably thinking: “How can that be…no one could eat enough apples to get fat!” But did you know that high-fructose corn syrup (HFCS) is the sweetener used in most (non-diet) soda pop? It is also used to sweeten jams, jellies, candies and other ingestible goodies. Writing about this topic motivated me to rummage through my fridge to read the ingredient labels…my favorite raspberry jam listed HFCS second only to raspberries as the major ingredients of the product.

As you probably know, soft drinks are the beverage of choice for many people. We consume these drinks more often and in greater quantities than ever before. Because of that, the consumption of HFCS has increased more than 1000% since 1970. According to a study published in 2004 by George Bray and colleagues in the American Journal of Clinical Nutrition, HFCS now represents more than 40% of caloric sweeteners added to foods and beverages. It is the sole caloric sweetener in soft drinks in the US. These researchers estimate that the top 20% of consumers of caloric sweeteners ingest more than 300 calories per day as HFCS. That, for many folks, is about 15% of their recommended caloric intake. Since most soft drinks have no nutritional redeeming features, such as vitamins, minerals, protein, or fiber, HFCS sweetened soda pops bring a whole new level of meaning to the term “empty calories.”

Fructose has a number of effects that make it a likely candidate to fuel the growth of obesity when consumed excessively. Besides being a significant source of calories, HFCS soft drinks have important metabolic effects that contribute to its impact on obesity.

Regulation of eating and body weight is complex. Sensory cues, hormonal signals, and biochemical processes interact to help ensure living things take in enough food to survive. For example, the ingestion of glucose-containing carbohydrates leads to the secretion of the hormone insulin.

Insulin has many different effects on our metabolism, but one that is relevant to obesity is its effect on appetite. Insulin acts on the brain to reduce food intake.

Insulin also stimulates fat cells to increase production (about four hours after a meal) of another substance, called leptin. Leptin also acts on the brain to reduce appetite.

A third hormone, ghrelin is produced by the stomach and small intestine. It stimulates hunger and ad lib food intake. Circulating ghrelin levels are inversely related to body weight and increase after diet-induced weight loss. Ghrelin seems to play an important role in weight regain after weight loss.

So you can see that ingestion of certain foodstuffs, such as glucose-containing carbohydrates, trigger a number of responses that help to balance food seeking behaviors with whether an individual is fed or fasting. These complex processes interact to help us maintain weight over both the short and the long run. Fructose, unlike glucose, does not turn on these regulatory mechanisms, leaving individuals with high fructose ingestion vulnerable to overeating and weight gain.

High fructose ingestion has other adverse health effects as well, including elevation of triglycerides (a coronary heart disease risk factor for some people), and an association with development of insulin resistance and metabolic syndrome (high blood pressure, abnormal lipids, glucose intolerance, and central obesity).

Bray and colleagues point out that the rapid rise in the rates of obesity since 1970 mirror the rapid increase in the consumption of HFCS. This does not prove that fructose is the cause of the obesity epidemic. However, when combined with our current understanding of the metabolic effects of fructose, it strongly suggest HFCS-sweetened soft drinks are contributing to the problem.

*If you want to read more:

“Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity” by George Bray, Samara Joy Nielsen and Barry M. Popkin (American Journal of Clinical Nutrition, 2004)

“Adverse effects of dietary fructose” by Alan R. Gaby (Alternative Medicine Review, 2005)

“Dietary fructose: implications for dysregulation of energy homeostatis and lipid/carbohydrate metabolism by Peter J. Havel, Nutrition Reviews, 2005)

Talk? Or Text? What works best for you?

2006-09-22T17:25:00Z

According to a front page article in the San Francisco Chronicle, a growing number of teens and twenty-somethings prefer text messaging to talking. The article describes the findings from the “Silicon Valley Cultures Project” being conducted by San Jose State University Anthropology Professors, Jan English-Lueck and Chuck Darrah.

The Chronicle describes the view of 23 year old Stanford administrative assistant, Hana Xu who says,“It’s easier to say what you really want to say online because you don’t get cut off or interrupted.”

Texting, it seems creates an emotional distance as well as a feeling of control that is much harder when conversing face-to-face.

Some people in health care are trying to adopt and adapt on-line communication technologies to deliver more efficient and effective services. One area in which this is happening is the field of mental health. The Chronicle article describes the practice of a California psychologist, Ofer Zur, who regularly uses the telephone, the Internet and email to communicate with some of his patients. He says, “We need to move away from the tyranny of therapists who believe only in face-to-face conversation.”

The article lists a number on online group therapy organizations, such as FamilyTherapyNet.com and eGetgoing.com. [I have not checked this out so don’t view this as an endorsement of these organizations.] The American Psychiatric Association posts answers to FAQs about e-therapy. And a new professional organization, the International Society for Mental Health Online has developed guidelines for ethical e-therapy practices.

I believe going forward we will see more and more healthcare delivered over the Internet and via electronic communication technologies, whether email or text messaging. There are a number of reasons why this makes sense. First, this is how a significant subset of the population wants to communicate. Second, people are just too busy to take a day or half-day off of work to go to a doctor’s office. Third, there are some issues people are more comfortable discussing anonymously or at least not in person. And, finally, these types of communications are much less costly than traditional office based health care.

Now if we can only get doctors and health insurance companies to agree that this is something that should be provided and paid for, it would be great.

Do school lunches make you sick?

2006-09-21T16:57:00Z

No time to make lunch for your kids? If you are like many parents, there is no time to do anything in the morning besides getting everyone some form of breakfast, gathering up the kids and their backpacks, and hustling them off to school as quickly as possible. You get no slack if you are late to work.

The children can get lunch in the cafeteria, you reason. After all, that’s what you did when you were in school and you survived. The lunch choices in your day weren’t perfect (mashed potatoes, canned green beans, and meatloaf), but weren’t they more or less nutritious? Would the schools have served them if they weren’t?

Sadly, you are probably wrong about how healthy lunches are in your youngsters’ schools. Things have changed a lot since you were a kid. Even if there are healthy choices available in some of the more enlightened school districts, by and large “Vending Machines Rule!" Yes, many school districts have taken on the issue of sweetened soda pop in school vending machines. But many more still offer not only sodas, but also Pop Tarts, fudge brownies, and Rice Krispie Treats.

And what about the choices in the cafeteria proper? Christopher Kimball, founder and editor of Cook’s Illustrated Magazine and host of America’s Test Kitchen, a public television cooking show, tells us what his young children told him they are eating at school:

“Eggo waffles, reheated French toast with maple-flavored corn syrup, hot dogs, ersatz mac and cheese, and canned sweetened fruit for dessert.”

After he heard this, he sent some of his test kitchen staff to investigate the state of lunches in the Boston public schools. According to an editorial he wrote in the Boston Globe, this is what they found: The lunches often include "French toast sticks, egg rolls, and the famous Uncrustable prepackaged sandwiches." They did find some moderately good choices (pork in mushroom gravy, mashed potatoes and corn), but right next to the “healthy” choices were a la carte items such as Tater Tots, pizza, potato chips, and Cheetos.”

Cheetos? Can anything that is fluorescent orange really be good for your kids?

Chris was outraged. But he is turning his outrage into action. He has founded a non-profit, “Parents Against Junk Food.” This is a good old-fashioned call-to-action website that aims to get parents riled up about this issue.

Chris writes in his editorial:

““One day, mothers and fathers across America are going to wake up, throw open the window, and yell, “We’re mad, and we’re not going to take it anymore!””

Way to go, Chris! Yes, parents need to be responsible for their kids’ health and well-being, but we need to ask for, no demand, that the public institutions that we pay for with our hard-earned tax dollars, support us in our efforts keep our kids healthy and safe.

205 pounds lighter, Dario Wolfish is a most remarkable guy

2006-09-20T21:54:00Z

I want to share the story of my friend, Dario Wolfish. When I first met Dario, he was an applicant for a job opening that I had. He told me the odyssey of his 205 pound weight loss and the reversal of the obesity-related complications he had been diagnosed with—diabetes and high blood pressure. I was awed. 205 pounds in 13 months. But even more awesome, several years later he has kept it off. He has weathered stress, relocation, and all manner of things that could drive one to eat. But he has kept it off. Meet Dario Wolfish, a most remarkable guy, in his own words:

“Up to 2001, I had been severely overweight all of my life. I lost 205 pounds in 13 months, hence I have a personal understanding of the difficulty we all face to lose weight and keeping the weight off.

There is no question that proper diet and exercise are necessary to lose weight, but there needs to be a process. This was how I did it:

1) I went to the doctor and received a comprehensive checkup. This checkup diagnosed serious health problems as well as identified exercise limitations and specific diet factors that needed to be considered. For example, I was diagnosed with diabetes; thus, I needed to focus on reducing carbs in my diet.

2) I went to a nutritionist (and diabetes educator) who educated me on food, required nutrition, and disease specific diets. Three invaluable things that my nutritionist said to me in the first 5 minutes of our meeting were

a) This is not about dieting, it is about life style change

b) If it is in your home, you will eat it

c) Do not beat yourself up when you fall off your diet. Dust yourself off and get back on the horse.

3) I started to exercise slowly. My first exercise was parking my car 100 yards further away from the office door. It is important though to increase your exercise as you get in better shape but start slowly. I now ride my bicycle 200 miles a week up and down steep hills. The starting point though was walking 100 yards. Once I started losing weight, I joined a gym and worked with a personal trainer.

4) The HARDEST part of this process was dealing with the emotional elements. Getting started was most difficult since I believed (as many of us do) that profound weight loss was not a possibility. To emotionally believe that “change was POSSIBLE” was the toughest part of the process. Also, I went through therapy to understand my relationship to food with my emotions. I also tried overeaters anonymous but I responded better to one on one therapy.

My bottom line is that I want to encourage all of you who are struggling to lose weight. Feel free to email me at dariow@comcast.net if you would like to chat about this topic.”

If you want to read more about Dario, click on this link to the Oakland Tribune online. He is the cover guy of a great article on diabetes and diet.

This one is so good, I can't add a thing

2006-09-17T21:32:00Z

As a blogger, you always try to add something of your own to stories you get from the paper, magazines or from journals. But the editorial by William Saletan that first appeard in the Washington Post is so good, I feel compelled to pass it on to you unchanged. The article is wonderfully written, with some parts laugh out loud funny, but the overall message is very sobering.

I'll get you started and then you can click on the link to finish reading. (Do read all the way to the end, some of his funniest lines are there.)

Please Don't Feed the People

By William Saletan
WASHINGTON POST, Sunday, September 3, 2006

In 1894, Congress established a national Labor Day to honor those who "from rude nature have delved and carved all the grandeur we behold." In the century since, the grandeur of human achievement has multiplied. Over the past four decades, global population has doubled, but food output, driven by increases in productivity, has outpaced it. Poverty, infant mortality and hunger are receding. For the first time in our planet's history, a species no longer lives at the mercy of scarcity. We have learned to feed ourselves.

We've learned so well, in fact, that we're getting fat. Not just the United States or Europe, but the whole world. Egyptian, Mexican and South African women are now as fat as Americans. Far more Filipino adults are now overweight than underweight. In China, one in five adults is too heavy, and the rate of overweight children is 28 times higher than it was two decades ago. In Kuwait, Thailand and Tunisia, obesity, diabetes and heart disease are soaring.

Hunger is far from conquered. But since 1990, the global rate of malnutrition has declined an average of 1.7 percent a year. Based on data from the World Health Organization and the U.N. Food and Agriculture Organization, for every two people who are malnourished, three are now overweight or obese. Among women, even in most African countries, overweight has surpassed underweight . The balance of peril is shifting.

Fat is no longer a rich man's disease. For middle- and high-income Americans, the obesity rate is 29 percent. For low-income Americans, it's 35 percent . Fourteen percent of middle- and high-income kids age 15 to 17 are overweight. For low-income kids in the same age bracket, it's 23 percent . Globally, weight has tended to rise with income. But a recent study in Vancouver, Canada, found that preschoolers in "food-insecure" households were twice as likely as other kids to be overweight or obese. In Brazilian cities, the poor have become fatter than the rich .

Technologically, this is a triumph. In the early days of our species, even the rich starved. Barry Popkin, a nutritional epidemiologist at the University of North Carolina, divides history into several epochs. In the hunter-gatherer era, if we didn't find food, we died. In the agricultural era, if our crops perished, we died. In the industrial era, famine receded, but infectious diseases killed us. Now we've achieved such control over nature that we're dying not of starvation or infection, but of abundance. Nature isn't killing us. We're killing ourselves.

You don't have to go hungry anymore; we can fill you with fats and carbs more cheaply than ever. You don't have to chase your food; we can bring it to you. You don't have to cook it; we can deliver it ready to eat. You don't have to eat it before it spoils; we can pump it full of preservatives so it lasts forever. You don't even have to stop when you're full. We've got so much food to sell, we want you to keep eating.

Click here to finish reading the article.

How would you help this man lose weight?

2006-09-15T10:42:00Z

The cabbie who drove me from the airport to the hotel on my last business trip probably weighed 400 pounds. We made small talk during the trip. He told me he was hoping to leave Nevada soon and move to Oregon. But, he said, it was tough getting the time and resources to make the move.

He works 12 hours days, six days a week. The cab company deducts chunks of his pay for their share of his revenues and to cover his health insurance premium and a tax on his tips. His take home pay is $500 every two week pay period.

As we started talking about his health insurance, the conversation naturally drifted to health. He is prediabetic, he told me, and his brother is a type 2 diabetic who has already had some toes amputated. He knows he is facing the same future if he doesn't lose weight, but how can he do it?

When you drive a cab 12 hours a day, you often eat on the run. That means fast food, high fat, and lots of calories. Also, how do you fit in exercise? Should he try to walk before the 12 hour shift or, perhaps, go out in the middle of the night when his shift is over?

I found myself wondering what I would do if I were his doctor. Of course, I would recommend he lose weight, alot of it. And, I would tell him to get moderate to vigorous exercise 30 to 60 minutes a day. I would prescribe any needed medications. And, I would tell him to join PEERtrainer (www.peertrainer.com) (which, of course, I did).

Chances are, in my 15 minute office visit, I wouldn't have learned about the challenges presented by his daily schedule. I wouldn't understand that my recommendations were unlikely to be followed -- not because he wouldn't, but rather because he couldn't.

If something doesn't change, his prediabetes will most likely become diabetes. He will probably have a heart attack or stroke or maybe, like his brother, he will end up with toes or feet amputated -- all potentially preventable if he could change his lifestyle.

At the end of the ride, all I could think of to say was that he needed to get a new job -- one that is less stressful and would allow him to exercise and eat better. But I knew this too would be a daunting task given the long hours he already works and the meagerness of his financial resources.

I keep mulling over his story and wondering, how could you help this man? I haven't come up with an answer. Can you?

Are Parents Responsible for Kids Getting Fat?

2006-09-13T16:35:00Z

I just came across an article on childhood obesity in USA Today. The main thrust of the article is that overweight kids learn their bad habits from their parents.

Keith Ayoob, a registered dietician at Albert Einstein College of Medicine in New York is quoted as saying he has never met children who have better eating habits than their parents. "Parents are, hands down, the biggest influence on their kids. They need to be good role models"

While I agree, parents need to be good role models and set limits, I also believe that there are so many influences in kids lives today, ranging from TV, to the internet, to peers in play groups and day care, that placing all of the responsibility and blame on parents seems naive to me.

I wrote a few weeks ago about Advergaming. The food industry's use of branded video games to engage kids around their products. I think it is a safe bet that they are not spending millions on these efforts because they merely want to entertain kids.

Yes, parents should prepare good meals for their kids. Yes, they should sit down and eat with them at least two meals a day. And yes, they need to control the amount of TV their kids watch and how much time they spend on the internet.

But alot of the parents I know are both working and can barely keep their heads above water financially and with respect to time.

Although I am a big proponent of healthy eating at home. I believe we need to take a broad view of how we are going to get a handle on the obesity epidemic. It will take personal and parental responsibility, but it is also going to take changes in food policy, school curriculae, and much more.

Elizabeth Ward sums it up nicely in the article when she says "Everyone needs to be aware that the deck is stacked against children for having a healthy weight. Our society is set up to have our kids grow up overweight, which is why we need to be vigilant.....All of us need to do something about it. When it comes to this issue, we cannot put a Band-Aid on it anymore."

The article closes on a hopeful note with pediatrician Marc Jacobsen, a member of the American Academy of Pediatrics' task force on obesity saying: It's on the front of everybody's radar screen. There is a huge outpouring of commitment from schools, government, public health agencies, private industry, medical groups and parents....It's something we've caused...I don't see any reason why we can't make the changes needed to reverse it.

I hope he is right.

Even kings can lose weight

2006-09-11T04:26:00Z

I was lucky to visit the magical Kingdom of Tonga about 25 years ago. It was a beautiful Pacific Ocean island country. The people were friendly, the islands were lovely, the rulers were accessible. It was a memorable vacation.

On the day my friends and I left Tonga, our flight was delayed because the King of Tonga was traveling at the same time. We got to see the King's suit being loaded onto his jet. I have never forgotten that his suit jacket looked like a tent. He was huge.

In fact, at that time, King Taufa'ahau Tupou IV was listed in the Guiness Book of Records as "The Fattest Monarch in the World." He weighted 209.5 kilograms (462 pounds). But. to his royal credit, he decided to make a change and eventually was able to lose 70 kilograms (154 pounds) to end up at about 130 kilograms (or 286 pounds). Quite a credible weight loss.

Tonight online news services are carrying news of his death at the age of 88. Like other prominent world leaders (Bill Clinton and Mike Huckabee come to mind), he managed to parlay his weight loss into an experience that would motivate other people to follow his example.

Here is the story of his life, his weight gain, weight loss, and death as reported on CNN.com/

NUKU'ALOFA, Tonga (AP) -- Tonga's King Taufa'ahau Tupou IV, a towering figure in the tiny Pacific Island nation for four decades, died in a New Zealand hospital, the Tongan government announced Monday, ending one of the world's longest reigns by a monarch in modern times. He was 88.

His death came at the end of a long but unspecified illness in a hospital where the king had spent most of the past several months, and plunged the remote country into a mourning period expected to last for months.

Tonga's acting Prime Minister Viliami Tangi said on radio and television broadcasts that the king passed away shortly before midnight New Zealand time (1200 GMT Sunday). The nation's Lord Chamberlain, Hon. Fielakepa, was expected to formally announce the death later Monday. The lord chamberlain is a government minister assigned to serve the monarch.

The end of Tupou IV's reign is likely to fuel a push for more democracy in the near-feudal kingdom, where the royal family has ruled with absolute power since tribal groups on more than 170 Polynesian islands united into a single kingdom in 1845.

Tupou IV benefited from a historical reverence for the monarchy, which has waned in recent years as most people languished in poverty even as the royal family enriched themselves from the nation's meager resources, fell prey to scam artists and oversaw bad economic decisions.

Tupou IV ascended the throne in 1967 after his mother, Queen Salote, died in 1965 and a long mourning period. Another long grieving period is expected this time, when villagers traditionally wear black and grass-weave mats wrapped around their waists.

Before his death, Tupou IV's 41-year reign made him one of the world's longest-serving sovereigns, after Thailand's King Bhumibol Adulyadej, Britain's Queen Elizabeth II and Samoa's King Malietoa Tanumafili II.

At age 14, the future king was one of Tonga's top athletes; he could pole vault more than three meters (10 feet), played tennis, cricket, rugby and also rowed competitively in a racing skiff.

But like many of his countrymen he became obese, and remained so for most of his adult life.

In the 1990s, Tupou IV led his 108,000 people on a diet and exercise regime aimed at cutting the levels of fat in a nation where coconut flesh and mutton flaps are dietary staples.

From a weight listed in the Guinness Book of Records as the heaviest for any monarch, 209.5 kilograms (462 pounds), the king shed around 70 kilograms (154 pounds) to top the scales at about 130 kilograms (286 pounds).

In his later years, the king divided his time between Tonga and New Zealand. In his last days, the government didn't release details of his malaise but informed Tongans he was gravely ill and asked them to pray and otherwise prepare "if the sun should fall."

Tupou IV was held in enormous esteem and affection by most Tongans, though the reverence waned toward the end of his rule.

Under the 150-year-old Tongan Constitution the king appoints the government and all but nine of the nation's 32 lawmakers. The royal family controls most state assets.

In recent years he became increasingly autocratic, and a pro-democracy movement strengthened. Thousands rallied last year calling for constitutional reform to curb the royals' power.

Reportedly worth tens of millions of dollars, part of the king's fortune came from the many monopoly businesses that his family runs across the Tongan economy. Meanwhile, a quarter of his subjects lived in poverty, according to the Asian Development Bank.

Businesses and scams the late king and his children were involved with in recent years included taking ownership of the privatized monopoly Tongan power and telecommunications companies, satellite communications systems and ".to" Internet domain.

The king authorized taxpayer money to be used to start Royal Tongan Airlines, which failed, then gave the only license for a replacement airline to a prince, creating a lucrative monopoly. He was also implicated in Tonga's giving a self-styled court jester and con man more than US$60 million to invest in U.S. death "futures" -- only to lose it all.

The first Tongan to graduate from university, he won Bachelor of Arts and Bachelor of Laws degrees from the University of Sydney, Australia.

In 1947 he married Halaevalu Mata'aho, the daughter of a high chief, in an unprecedented double wedding with his younger brother, Prince Tu'ipelehake, who married Melenaite Vaikune, niece of the Speaker of Tonga's Parliament.

The king's nephew, Prince Tu'ipelehake, and his wife, Princess Kaimana Fielakepa, were killed in July in a car crash in California.

He was crowned Tupou IV on his birthday, July 4, 1967, in the palace's Royal Chapel in the capital Nuku'alofa in an elaborate ceremony wearing British-style regalia. The Duke and Duchess of Kent represented Britain's Queen Elizabeth II.

Tupou IV took the throne intent on the rapid and radical modernization of the kingdom, refusing to accept that Tonga's isolation and acute lack of resources meant it must remain a coconut- and banana-dependent backwater.

He launched plans for expanding technical education, improving land use and establishing new industries.

As the years went by, his schemes became bolder and more varied, but increasingly impractical. Most failed.

There are 26 heirs to the Tongan throne directly descended from Salote. Crown Prince Tupouto'a, 57, is expected to be named the new king.

Funeral arrangements were not immediately announced.

******

Like many other world leaders, the King of Tonga was neither all good nor all bad. This is not a political commentary. It is a health and weight loss blog, after all. The King of Tonga got very fat and he worked hard to lose the weight and tired to motivate people in his Kingdom to do the same. Amen.

Karen Michaeli: On food & class

2006-09-07T19:17:00Z

It is with great pleasure that I introduce my first guest blogger, Karen Michaeli, MSW. Karen is an expert in issues related to improving health for individuals living with chronic illness. She has also thought a great deal about the linkage between how we live (including what we eat) and how it impacts not just our individual health, but the health of our communities and, indeed, the health of the world.

Opinion: Healthy Food is a Class Issue

By Karen Michaeli, MSW

“How we eat determines to a considerable extent how the world is used.”

-Wendell Berry

If you subscribe to a Community Supported Agriculture (CSA) or shop at your local farmers’ market, you know what it’s like to eat fresh, organically-grown food during a growing season; you also know that you are supporting local farmers. What you may or may not know is that you are also supporting access for all people to healthy food.

Co-ops, during their golden age of the 1970s, were once also a way to buy affordable, locally grown produce. Since that time, however, these grocery stores have retained a minimal co-op structure with membership fees, but largely transformed themselves into boutique-style specialty food retailers. They continue to sell produce, but at a significant markup. The pricing belies the traditional marketing aesthetic of hand-drawn signs and a token bulk-foods aisle, and local agriculture is supported to a limited extent. An organic farmer near Iowa City, Iowa recently shared with me his observation of a woman buying a three-dollar tomato at a local co-op grocery!

Proponents of co-op grocery retailers argue that it’s worth paying a little more to buy organic. Co-op markups are far more than “a little”, however, and this is the point where sustainability and class issues converge: the excessive markup at co-ops is maintained by the mostly high-income customer base willing to pay the high prices. This boutique grocery model has inspired the proliferation of large chains such as Whole Foods, which cater to the same market. Like co-ops, these groceries support local farmers to a limited extent, which helps their popularity with sustainability-aware markets, but these stores also charge exorbitantly.

A deeper issue exists here in the lack of socioeconomic awareness among the sustainability community. Class and income are not necessarily associated in this context. Curiously, even some lower-income individuals among this group find the class dimensions of the issue not applicable to them: one mother very active in the natural parenting movement told me “we don’t make much money, but we manage to feed our family by shopping at the co-op. If we can do it, there’s no reason for anyone to support big corporate grocery stores.” More examples of the dissonance between environmental and economic awareness are vividly presented in the 2001 PBS documentary film “People Like Us: Social Class in America” which includes several segments on the politics of food. One segment titled “The Trouble with Tofu” focuses on Burlington, VT, where a culture war between the lower-income population of Burlington and “upper middle-class countercultureites” was waged over who would build a new downtown grocery: Shaw’s, a national supermarket chain, or the Onion River Co-op, a health food/specialty item grocery store. The classism of the faction supporting the co-op was evident in their paternalistic view that the poor needed more grocery-shopping options in order to broaden their tastes—never mind the fact that options without economic access would be useless.

Hiram Bonner and Meredith Taylor, who transformed a traditional community food pantry in Harlem, New York, describe the challenge of providing healthy food for the poor: “Fresh, healthy food is the most expensive, so it's the first to go when times get tough.” The reality is that healthy food is more expensive—expensive enough to make access a real issue, which belies the common sustainability sentiment that it’s worthwhile to pay more. The question is, “worthwhile” to whom? The only access to healthy food that is maintained by supporting the pricing at specialty grocery stores is access for people who can afford to pay more. Bonner and Taylor identify the health implications of this economic barrier: “Emergency programs get stuck with lower quality food, and some of that is so processed, it's not worth eating.” It would behoove those in the public health arena concerned with population characteristics of so-called “lifestyle diseases” such as diabetes or hypertension to support activism related to food politics.

A litmus test of political acceptability among the sustainability community is one’s attitude toward Wal-Mart, a commonly agreed-upon enemy for many good reasons (not the least among them, the company’s labor practices). Now, with its foray into the organic food market, Wal-Mart is identified by the New Yorker’s Field Maloney on Slate.com as an unlikely champion of access: “The organic-food movement is in danger of exacerbating the growing gap between rich and poor in this country by contributing to a two-tiered national food supply, with healthy food for the rich. Could Wal-Mart's populist strategy prove to be more ‘sustainable’ than Whole Foods? Stranger things have happened.” This said, and given the assumption that buying locally produced organic food is preferable, what can someone who is both sustainability-conscious and socioeconomically conscious do?

Shop at your local farmers’ market.

Farmer’s markets can be found in almost every community, though access issues exist for the poor here in terms of geographic access.

Join a CSA.

According to the Practical Farmers of Iowa, Community Supported Agriculture is a “relationship of mutual support…between local farmers and community members who pay the farmer an annual membership fee to cover the production costs of the farm. In turn, members receive a weekly share of the harvest during the local growing season.” The subscription fee is usually affordable for most incomes, $100 to $200 for the season roughly spanning May through October. Many farms provide sliding-scale fees or special discounted subscriptions as well, for low-income individuals or families (why don’t “community” co-op groceries do this?)

During the winter, choose lower-priced chain store organics when possible.

This advice is likely to be controversial, but voting with your dollars can help pressure specialty natural-foods stores to adapt their pricing to an increasingly socially conscious customer base. A Green Left review by Belinda Selke of Peter Singer and Jim Mason’s 2006 book The Ethics of What We Eat gives us something to think about, if you’re feeling guilty about not buying locally during part of the year:

…locally grown food is preferable because it keeps dollars in local communities, supports small-scale farming, and is better for the environment because it reduces carbon emissions and packaging waste. But when you live in one of the wealthiest countries on the planet, wouldn’t it be more ethical to support poor farmers in underdeveloped nations by purchasing their produce imported under fair trade conditions? And what if your local family farmer doesn’t pay award wages or let its workers join a union? Singer and Mason also show how buying distantly produced food can contribute less to global warming — for example, when it is grown seasonally, in soils and climates naturally suited for its production and transported by sea (which is very efficient in fossil fuel terms). Singer and Mason are not opposed to buying locally, but recognise that it is not automatically the more ethical choice.

Learn more about food and class, and educate others.

When you hear someone moralizing about healthy or responsible food choices, don’t be afraid to speak up: seek clarification by asking “healthy for whom?” or “environmentally or socially responsible?” This is an opportunity to help otherwise “aware” individuals learn about the socioeconomic dimension of food and environmental responsibility.

This article has also been published on www.gather.com

Staying fuller, longer: the role of protein meals and PYY

2006-09-07T00:15:00Z

Have you noticed that you are ravenously hungry an hour or two after certain meals? Or that you stay fuller, longer after others? Many people have learned that adding protein to their breakfast meal is the best insurance against the mid-morning munchies. And a bit of chicken in your lunchtime salad may help you make it to dinner without a trip to the vending machines.

Protein, it turns out, enhances satiety (the feeling of fullness) and helps you lose weight. Scientists from University College London think they know why. In a paper published in the September 2006 online journal, Cell Metabolism, Rachel Batterham and colleagues review the role of a gut hormone (peptide YY or PYY, for short) in mediating the sensation of satiety caused by ingestion of protein meals.

Hormonal control of appetite

PYY is a hormone that is released from the gut after eating a meal. It apparently acts on the brain to cause satiety. The amount of PYY released is dependent on the composition of the meal. High protein meals are associated with the greatest release of PYY compared to the amount of PYY released after high fat or high carbohydrate meals.

In experimental subjects, high protein meals also cause the greatest reduction in hunger, measured by a hunger score, in both normal weight and obese people. Plasma PYY levels, however, are lower in obese people compared to normal weight people.

Control of appetite is quite complex. Humans evolved in an environment where food was in short supply and required a lot of effort to obtain. Thus, the need to have interacting mechanisms to ensure we will go out and chase down the next meal in order to survive another day. Unfortunately, in this day of easy-to-obtain, energy dense food, these control mechanisms can make it hard to maintain a healthy weight.

Other gut hormones that are involved in appetite control include:

Ghrelin, a stomach hormone that increases hunger and food intake. Ghrelin is widely thought to be the hormonal mediator of weight regain after weight loss
Cholecystokinin (CCK) comes from the duodenum, the part of the intestinal tract that links to the stomach. CCK causes short term satiety.
Glucagon-like peptide 1 (GLP-1) and oxyntomodulin (don’t you just love these names?) also come from the gut. Both are associated with decreased food intake.

Leaning more from mice

In order to more fully understand the role of PYY in protein-mediated satiety, the researchers conducted several studies in mice. First, they determined that adding dietary protein to mouse meals was associated with an increase in PYY levels, decreased food intake, and reduced adiposity (fatness).

Next, the researchers developed a strain of mice that were unable to make PYY. They called these mice “PYY null mice.” These mice were resistant to both the satiating and weight-reducing effects of protein meals. They became very fat. When PYY was injected into the null mice, they lost the weight. This series of experiments suggests that PPY is the mediator of protein-induced satiety and weight loss.

What does this mean for humans?

Mice aren’t human and PYY null mice are not “normal” mice. Further, most people eat meals that vary in the mix of protein, carbohydrate, and fat. So it may turn out that these results cannot be simply translated into a definitive weight loss recommendation. We do know that people lose weight quicker on a high protein diet, such as the Atkins diet, but that this diet is no more effective than reduced calorie diets in the long run. It is also very difficult for people to stick with an Atkins-type diet for prolonged periods of time.

I think it is safe to say that if you find, by trial and error, that adding a little extra protein to your meals helps to keep you fuller longer, then, by all means, include it to your otherwise balanced diet. But be sure you watch your portion sizes and keep on counting those calories.

Big Meals Lead to Big Mistakes in Calorie Estimation

2006-09-05T22:47:00Z

How good are we at estimating the number of calories in the foods we eat? It turns out, if the meal is small, we are pretty good. But if the meal is large, we grossly underestimate the number of calories it contains.

Brian Wansink and Pierre Chandon, PhDs from New York and France respectively, designed two studies to look at how accurately people estimate the number of calories in fast food meals. They were also interested in whether overweight individuals differed from normal weight individuals in their ability to estimate calories in meals. The results are reported in an article, “Meal Size, Not Body Size, Explains Errors in Estimating the Calorie Content of Meals,” that appears in the September 2006 issue of the Annals of Internal Medicine.

In Study 1, the researchers sent trained interviewers to local fast-food restaurants. They asked 150 men and women who had just finished eating to estimate the number of calories in their meals and to provide their heights and weights. 105 people agreed to participate. A little more than half of the participants (59%) were normal weight (BMI less than 25). The rest were overweight. Men and women’s estimates of meal calories were similar as were estimates of normal and overweight individuals. What was significantly different was the calorie underestimation of different size meals. People underestimated small meals by an average of about 3%. However, they underestimated big meals by 38%.

In the second Study, the researchers asked 40 undergraduate students to estimate the number of calories in 15 different meals purchased from a local fast food restaurant. Each meal consisted of three items (chicken nuggets, French fries, and a regular cola drink). What differed was the portion size of each item. The smallest meal consisted of 3 nuggets, a small (1.45 oz) order of fries and a 10 oz cola. The largest meal was 12 nuggets, 5.8 oz of fries, and a 40 oz cola. The rest of the meals were different combinations of the different portion sizes of the same items. The meals ranged from 445 calories to a whopping 1780 calories.

Similar to Study 1, they found that the undergrads were very good at estimating calories of the small meals, but they underestimated the 7 largest meals by a mean of 23%. Again, there was no difference between normal and overweight people in their ability to estimate calories.

Now here is the punch line: Although normal and overweight individuals were similar in their ability to estimate the number of calories in food, the overweight individuals in Study 1, who had eaten a fast food meal, ate larger meals. Because everyone significantly underestimates the number of calories in large meals, these overweight people actually ate many more calories than they thought they had.

An analysis of the data in these two studies showed a meal that increased in calories by 100%, was only thought, by the participants, to have increased by 50%. Whew, that’s a big mistake that can really impact the bottom line – aka the “waistline.”

The authors had several suggestions on ways to improve an individual’s ability to estimate calories. One was to have fast food restaurants clearly post calorie content on the meal servings themselves, as opposed to just being available somewhere in the restaurant or on the company’s website. Another was to provide people with an idea of what a portion-size should be (e.g., 3 chicken nuggets or an amount of fries equal to the size of your fist).

An interesting option they propose takes advantage of what they learned from the data in this study. Since people can accurately estimate the calories in small amounts of food, they should estimate the amount of calories in a large meal by estimating the calories in each item (chicken nuggets, fries, cola) and then adding them up to get the total. Whether this works or not, of course, will have to be tested. But if it does, it will be one more tool that we can use to help us ensure that our daily calorie intake stays in a range that allows us to achieve and maintain a healthy weight.

Obesity in men linked to infertility

2006-09-02T18:47:00Z

It is known that obesity impacts fertility in women. The link between obesity, insulin resistance, and polycystic ovary syndrome (PCOS) is one example. According to an online report from the National Institute of Health (NIH), a new study, published in the September 2006 issue of journal Epidemiology suggests that men, too, may have more problems with infertility than men who are normal weight.

The research, lead by Markku Sallmen and funded by the NIH’s National Institute of Environmental Health Sciences (NIEHS) , analyzed data from questionnaires completed by 1468 farmers and their wives. The research is a part of an ongoing study started in 1993 called the Agricultural Health Study. That study examines factors that relate to the health of farmers and their families in agricultural communities

The wives completed a family health questionnaire, which included information about the couple's reproductive history. The men reported their weight and height on a questionnaire about their health. This allowed the researchers to calculate the men’s Body Mass Index (BMI), a measure of overweight or obesity.

The analysis was limited to couples that reported that they had tried to get pregnant in the four years before enrollment in the study. It was also limited to couples in which the woman was under the age of 40. The majority of participants were more than 30 years old.

The researchers divided the couples into infertile and fertile groups, defined as follows:

Fertile couples were those that conceived within a year
Infertile couples were those that tried for longer than a year to conceive

Using these definitions, the researchers found that twenty-eight percent of the couples had experienced infertility.

They also found that men’s BMI was an independent risk factor for fertility in both older and younger men. Even after adjustment for other factors that could affect fertility (high BMI of the woman, age, cigarette smoking, alcohol intake, and solvent and pesticide exposure) the researchers found that there was a general increase in infertility with increased BMI, reaching a nearly 2-fold increase among obese men.

"The data suggest that a 20-pound increase in men's weight may increase the chance of infertility by about 10 percent," says Markku Sallmen, lead author on the paper who is now at the Finnish Institute of Occupational Health.

The researchers did not have data on frequency of sexual intercourse, so it is possible that overweight men have less sexual intercourse than their normal weight counterparts and this could influence fertility. However, there have been recent studies looking at semen characteristics that show lower semen quality for overweight and obese men, as well as hormonal differences.

It is important to point out that this study is an epidemiologic study and therefore can only suggest, not prove, a causal link between obesity and male infertility. It, nevertheless, adds to a growing body of scientific literature that documents adverse impacts of overweight and obesity on health. Further research is needed to determine is the relationship between obesity and male infertility is real and whether it occurs in all men or only in some men who may have a genetic predisposition, such as a relative insensitivity to insulin, to become infertile when they gain weight.

Bad childhoods and adult health

2006-08-31T22:16:00Z

Vince and Rob’s research indicates that the ACE Score likely captures the cumulative biologic consequences of these exposures. Multiple, well done analyses of the ACE data have been published in good medical journals. They demonstrate that the ACE score has a strong graded relationship to: Obesity, diabetes, cardiovascular disease, liver disease and other leading causes of death in the United States Smoking, alcohol use and abuse, as well as illicit and IV drug use Early initiation of sexual intercourse, promiscuity, and sexually transmitted disease (STDs) Teen and unintended pregnancy, stillbirths, and spontaneous abortion Suicide attempts, depression and poor health-related quality of life ...(read more)

You Ate it, But Did the Nutrients Get Absorbed?

2006-08-29T15:02:00Z

When it comes to absorbing nutrients, it makes a difference how you prepare a food (cooked or raw) and what foods you eat with it. The science of understanding nutrient absorption is an area called “bioavailability.”

BBC NEWS online has an interesting, easy to read article, titled "Getting the Best Out of Your Food," that will help you understand the best ways to eat certain foods to maximize their nutritional value to you. Here are a few hints from the article.

Eat your spinach with a glass of orange juice.

We all know spinach is a good source of iron. It is an important source if you are a vegetarian. But did you know that the iron in spinach is in a form that is not readily absorbed? By drinking orange juice along with your spinach, you change the iron in spinach from an oxidized state to a more readily absorbed non-oxidized state.

You absorb more beta-carotene, an antioxidant, from cooked carrots than raw carrots. Cooking breaks down the carrot’s cell walls, allowing easier absorption of this important nutrient.

Canned tomatoes or cooked tomatoes are better than raw tomatoes when it comes to lycopene. Lycopene is another antioxidant. It is thought to halt cell damage. It is turned into a more readily absorbed form when tomatoes are cooked or canned.

Iron fortified cereals may not be the best way to get your daily dose of iron. Whole grain cereals contain phytates which inhibit the absorption of iron. Calcium in milk also inhibits iron absorption. And that cup of coffee you drink with your cereal…well, it contains phenols that inhibit iron absorption as well.

So it all gets pretty complicated. As scientists continue to study how nutrients are absorbed and how foods interact with each other, we are likely to get even more confused. For now, it is probably best to follow a diet that is varied in nutrient sources and varied in the ways the food is prepared. If you eat a diet that is rich in fruits and veggies and includes good sources of protein and fiber, you can feel confidant that you have optimized your chances of getting all the vitamins and minerals you need.