Happy New Year: Looking forward to more successes in 2011

By Rik Ganderton, President and CEO

Hello everyone and happy New Year to all!

Thank you to everyone for your dedication to our patients and all your hard work in 2010. The year marked another huge step in our progress to becoming the best community hospital in Canada. We again served and treated more patients than in the previous year.

Our emergency departments (ED) at both hospital campuses — Rouge Valley Ajax and Pickering (RVAP) in west Durham and Rouge Valley Centenary (RVC) in east Toronto — saw and treated record numbers of patients during the year. In fact, December was a record month for both sites. Thanks to all of you — whether in the ED, on an inpatient unit or providing support services — who showed up for work over the holiday season and contributed to managing this record patient load.

From a quality perspective, we maintained or improved our record of making Rouge as safe as possible for our patients, families and staff. We are still challenged to ensure that our hand hygiene habits are the best in the industry, and I look forward to relentlessly pursuing this goal with you in 2011!

Operationally, we had another successful year, and we anticipate — on a financial-year basis — that we will again achieve our budgeted surplus. This will mark the third year in a row of success in managing to a surplus, and will bring to a successful close our three-year deficit elimination plan. Achieving surpluses allows us to reinvest in our facilities and equipment that have been so neglected for so many years (see our previous blog on this). Behind the scenes we have completed major, multi-million dollar replacements of our boilers (at RVC), while more obvious items for frontline staff include new monitors and infusion pumps. At RVAP, our major redevelopment is almost complete and we have opened the new complex continuing care unit; the ED has been open for more than a year; and the new ambulatory care area, lab and diagnostic imaging space are in use.

People development is core to our success. We have been able to invest significantly in training and developing our people. We continue to invest in the Late Career Nursing Initiative, we are expanding our investment in training of frontline nurses and other clinicians, and we continue to provide training for our managers in the use and deployment of Lean tools (read how Lean helps our patients). We have also run a very successful (and ongoing) program for our managers and leaders, called Advanced Leadership Foundations (ALF). This program is aimed at equipping all our managers with the skills and competencies needed to lead our organization. (Read about the ALF program in one of earlier blog posts).

Operating efficiently and delivering on what we commit to also means growing credibility with our funders (the Central East Local Health Integration Network — and through them, the Ministry of Health and Long-Term Care). This translates into real and tangible benefits for our patients, our communities and our staff. Examples include new funding for 20 new transitional restorative care beds at RVAP (read more about this new unit in our December 2010 Echo newsletter), as well as the recent announcement of operational funding for a new MRI at RVAP as well (see news release from CE LHIN). At RVC, we have enjoyed significant funding increases for the Birthing and Newborn Centre; for additional surgical volumes in a variety of specialties; for additional MRI operational funding; for a new coronary care unit bed; and support for the very successful implementation of Code STEMI program, which fast-tracks emergency care for people who experience a heart attack in our communities (learn more about Code STEMI). In fact, as I write this, I am sure there are lots more successes — they are just too numerous to recall!!

I fully expect 2011 to be as busy and successful as 2010. We will publish our new strategic plan early in the new year, and we will be starting an ambitious major capital plan which will see us, amongst other things, replace the Siemens catheterization lab and install a third cath lab so that we can meet our regional commitments to cardiac EP. We will also try to do some visible sprucing up of our facilities, including a "lick of paint" here and there to make the place look better!

Of course, we will continue to drive innovation and operational excellence so that we can continue to benefit our communities, make RVHS a place where all of us are proud to work, and allow us to invest in our people so that we can be the best.

Again thank you all for a tremendous year in 2010, and I look forward to an even more success in 2011.

I wish you all a healthy, happy, safe and successful 2011.

Regards to all!

Consumer toolkit, online complaint filing, agent lookup: New tools for the New Year

We're rolling out new consumer tools for the new year, including an easy way to look up past violations and complaints against insurers and agents.
The insurance commissioner’s website now includes a “consumer toolkit” that offers:

• Easy-to understand information on different types of insurance.

• Online filing – and tracking – of complaints against an insurance company.

• Online filing of complaints against an insurance agent or broker.

• And a new system to look up contact information, licensing history, past violations and consumer complaints against agents or companies.

The agency also continues to expand its website and its social media presence, including a new page on Facebook.

How much protein does one need to be in nitrogen balance?

The figure below, from Brooks et al. (2005), shows a graph relating nitrogen balance and protein intake. A nitrogen balance of zero is a state in which body protein mass is stable; that is, it is neither increasing nor decreasing. The graph was taken from this classic study by Meredith et al. The participants in the study were endurance exercisers. As you can see, age is not much of a factor for nitrogen balance in this group.

Nitrogen balance is greater than zero (i.e., an anabolic state) for the vast majority of the participants at 1.2 g of protein per kg of body weight per day. To convert lbs to kg, divide by 2.2. A person weighing 100 lbs (45 kg) would need 55 g/d of protein; a person weighing 155 lbs (70 kg) would need 84 g/d; someone weighing 200 lbs (91 kg) would need 109 g/d.

The above numbers are overestimations of the amounts needed by people not doing endurance exercise, because endurance exercise tends to lead to muscle loss more than rest or moderate strength training. One way to understand this is compensatory adaptation; the body adapts to endurance exercise by shedding off muscle, as muscle is more of a hindrance than an asset for this type of exercise.

Total calorie intake has a dramatic effect on protein requirements. The above numbers assume that a person is getting just enough calories from other sources to meet daily caloric needs. If a person is in caloric deficit, protein requirements go up. If in caloric surplus, protein requirements go down. Other factors that increase protein requirements are stress and wasting diseases (e.g., cancer).

But what if you want to gain muscle?

Wilson & Wilson (2006) conducted an extensive review of the literature on protein intake and nitrogen balance. That review suggests that a protein intake beyond 25 percent of what is necessary to achieve a nitrogen balance of zero would have no effect on muscle gain. That would be 69 g/d for a person weighing 100 lbs (45 kg); 105 g/d for a person weighing 155 lbs (70 kg); and 136 g/d for someone weighing 200 lbs (91 kg). For the reasons explained above, these are also overestimations.

What if you go well beyond these numbers?

The excess protein will be used primarily as fuel; that is, it will be oxidized. In fact, a large proportion of all the protein consumed on a daily basis is used as fuel, and does not become muscle. This happens even if you are a gifted bodybuilder that can add 1 lb of protein to muscle tissue per month. So excess protein can make you gain body fat, but not by protein becoming body fat.

Dietary protein does not normally become body fat, but will typically be used in place of dietary fat as fuel. This will allow dietary fat to be stored. Dietary protein also leads to an insulin response, which causes less body fat to be released. In this sense, protein has a fat-sparing effect, preventing it from being used to supply the energy needs of the body. As long as it is available, dietary protein will be favored over dietary or body fat as a fuel source.

Having said that, if you were to overeat anything, the best choice would be protein, in the absence of any disease that would be aggravated by this. Why? Protein contributes fewer calories per gram than carbohydrates; many fewer when compared with dietary fat. Unlike carbohydrates or fat, protein almost never becomes body fat under normal circumstances. Dietary fat is very easily converted to body fat; and carbohydrates become body fat when glycogen stores are full. Finally, protein seems to be the most satiating of all macronutrients, perhaps because natural protein-rich foods are also very nutrient-dense.

It is not very easy to eat a lot of protein without getting also a lot of fat if you get your protein from natural foods; as opposed to things like refined seed/grain products or protein supplements. Exceptions are organ meats and seafood, which generally tend to be quite lean and protein-rich.

References

Brooks, G.A., Fahey, T.D., & Baldwin, K.M. (2005). Exercise physiology: Human bioenergetics and its applications. Boston, MA: McGraw-Hill.

Wilson, J., & Wilson, G.J. (2006). Contemporary issues in protein requirements and consumption for resistance trained athletes. Journal of the International Society of Sports Nutrition, 3(1), 7-27.

Job opening: Financial examiner

We're looking for a person to fill a financial examiner 3 position in our company supervision division, which is located in Seattle. Applications must be received by 5 p.m. on Friday.

The successful applicant will plan, conduct, and lead in-the-field financial examinations of insurance companies and other entities that our agency regulates. Duties include:

Examines and analyzes annual financial statements, actuarial opinions, management discussions and analyses, audited financial statements, holding company statements, quarterly financial statements, financial ratios, and other sources of information to discern financial condition, difficulties, trends, statutory compliance, accuracy, and completeness.

For more details, please see the job announcement.

How much dietary protein can you store in muscle? About 15 g/d if you are a gifted bodybuilder

Let us say you are one of the gifted few who are able to put on 1 lb of pure muscle per month, or 12 lbs per year, by combining strength training with a reasonable protein intake. Let us go even further and assume that the 1 lb of muscle that we are talking about is due to muscle protein gain, not glycogen or water. This is very uncommon; one has to really be genetically gifted to achieve that.

And you do that by eating a measly 80 g of protein per day. That is little more than 0.5 g of protein per lb of body weight if you weigh 155 lbs; or 0.4 per lb if you weigh 200 lbs. At the end of the year you are much more muscular. People even think that you’ve been taking steroids; but that just came naturally. The figure below shows what happened with the 80 g of protein you consumed every day. About 15 g became muscle (that is 1 lb divided by 30) … and 65 g “disappeared”!

Is that an amazing feat? Yes, it is an amazing feat of waste, if you think that the primary role of protein is to build muscle. More than 80 percent of the protein consumed was used for something else, notably to keep your metabolic engine running.

A significant proportion of dietary protein also goes into the synthesis of albumin, to which free fatty acids bind in the blood. (Albumin is necessary for the proper use of fat as fuel.) Dietary protein is also used in the synthesis of various body tissues and hormones.

Dietary protein does not normally become body fat, but can be used in place of fat as fuel and thus allow more dietary fat to be stored. It leads to an insulin response, which causes less body fat to be released. In this sense, dietary protein has a fat-sparing effect, preventing it from being used to supply the energy needs of the body.

Nevertheless, the fat-sparing effect of protein is lower than that of another "macronutrient" – alcohol. That is, alcohol takes precedence over carbohydrates for use as fuel. However, protein takes precedence over carbohydrates. Neither alcohol nor protein typically becomes body fat. Carbohydrates can become body fat, but only when glycogen stores are full.

What does this mean?

As it turns out, a reasonably high protein intake seems to be quite healthy, and there is nothing wrong with the body using protein to feed its metabolism.

Having said that, one does not need enormous amounts of protein to keep or even build muscle if one is getting enough calories from other sources.

In my next post I’ll talk a little bit more about that.

Stranded traveler? Here are some things to check

The weather on the East Coast has clearly scrambled plans for a lot of travelers this holiday; here are some tips that might help as you sort out your plans for getting home.

If you're wondering what your rights are, do an online search for the name of your airline and the words "contract of carriage." (Here, for example, is a summary of United's.) This is your contract with the carrier. If you feel they're violating it, you can file a complaint here. The bad news: Travel experts say that airlines generally aren't obligated to provide meals or a hotel if the problem is weather-related.

Also, if you used a credit card to buy the ticket, check with your credit card company. Cards come with a variety of perks, and you may have trip coverage without knowing it. Mastercard, for example, offers many cardholders reimbursement for lost or delayed baggage and trip cancellation insurance, as long as the tickets were paid for with an eligible MasterCard card.

For general information on travel insurance, see our page on this topic, which spells out the types of coverage and what they mean, in plain language. We're not trying to sell you anything; we're the state agency that regulates insurance in Washington state.

Lastly, here's the list of toll-free numbers for airlines.

Good luck.

Tool to compare insurance companies by the number of complaints

One of the most-used features of our website is our "Complaint Comparison Tool," a free and simple online tool that lets you compare the number of complaints filed by consumers against different insurance companies.

The information's broken down by year and by type of insurance (health, life, homeowners, auto, etc.). It also compares the number of complaints to an insurer's market share, which makes for easy apples-to-apples comparisons with other companies.

Take a look. We've posted 5 years' worth of data, and should be posting more soon.

38 g of sardines or 2 fish oil softgels? Let us look at the numbers

The bar chart below shows the fat content of 1 sardine (38 g) canned in tomato sauce, and 2 fish oil softgels of the Nature Made brand. (The sardine is about 1/3 of the content of a typical can, and the data is from Nutritiondata.com. The two softgels are listed as the “serving size” on the Nature Made bottle.) Both the sardine and softgels have some vegetable oil added; presumably to increase their vitamin E content and form a more stable oil mix. This chart is a good reminder that looking at actual numbers can be quite instructive sometimes. Even though the chart focuses on fat content, it is worth noting that the 38 g sardine also contains 8 g of high quality protein.

If your goal with the fish oil is to “neutralize” the omega-6 fat content of your diet, which is most people’s main goal, you should consider this. A rough measure of the omega-6 neutralization “power” of a food portion is, by definition, its omega-3 minus omega-6 content. For the 1 canned sardine, this difference is 596 mg; for the 2 fish oil softgels, 440 mg. The reason is that the two softgels have more omega-6 than the sardine.

In case you are wondering, the canning process does not seem to have much of an effect on the nutrient composition of the sardine. There is some research suggesting that adding vegetable oil (e.g., soy) helps preserve the omega-3 content during the canning process. There is also research suggesting that not much is lost even without any vegetable oil being added.

Fish oil softgels, when taken in moderation (e.g., two of the type discussed in this post, per day), are probably okay as “neutralizers” of omega-6 fats in the diet, and sources of a minimum amount of omega-3 fats for those who do not like seafood. For those who can consume 1 canned sardine per day, which is only 1/3 of a typical can of sardines, the sardine is not only a more effective source of omega-3, but also a good source of protein and many other nutrients.

As far as balancing dietary omega-6 fats is concerned, you are much better off reducing your consumption of foods rich in omega-6 fats in the first place. Apparently nothing beats avoiding industrial seed oils in that respect. It is also advisable to eat certain types of nuts with high omega-6 content, like walnuts, in moderation.

Both omega-6 and omega-3 fats are essential; they must be part of one’s diet. The actual minimum required amounts are fairly small, probably much lower than the officially recommended amounts. Chances are they would be met by anyone on a balanced diet of whole foods. Too much of either type of fat in synthetic or industrialized form can cause problems. A couple of instructive posts on this topic are this post by Chris Masterjohn, and this one by Chris Kresser.

Even if you don’t like canned sardines, it is not much harder to gulp down 38 g of sardines than it is to gulp down 2 fish oil softgels. You can get the fish oil for $12 per bottle with 300 softgels; or 8 cents per serving. You can get a can of sardines for 50 cents; which gives 16.6 cents per serving. The sardine is twice as expensive, but carries a lot more nutritional value.

You can also buy wild caught sardines, like I do. I also eat canned sardines. Wild caught sardines cost about $2 per lb, and are among the least expensive fish variety. They are not difficult to prepare; see this post for a recipe.

I don’t know how many sardines go into the industrial process of making 2 fish oil softgels, but I suspect that it is more than one. So it is also probably more ecologically sound to eat the sardine.

Job opening: Chief market analyst

Our office is looking for a chief market analyst to fill an opening at our Tumwater office.

The person will manage staff performing market analysis, and help ensure that companies are acting within the scope of their license and are complying with laws and regulations.

Here's the job listing, which has much more detail about qualifications, salary, etc.

The critical part: Applications are due by 5 p.m. on Dec. 31, 2010.

Also, here's a handy online tool from careers.wa.gov that can e-mail you information about any job openings at state agencies, universities, etc.

A Gluten-free January

Are You Gluten Sensitive?

Many people are totally unaware of the fact that they react poorly to gluten. Because they've been eating wheat, barley and/or rye products every day for virtually their entire lives, they don't know what their bodies feel like without gluten. In susceptible people, eating gluten is linked to a dizzying array of health problems that stem from an immune reaction to gliadins and other proteins in gluten (1). Are you a susceptible person? How do you know?

The gold standard way to detect a gluten sensitivity is to do a gluten "challenge" after a period of avoidance and see how you feel. People who react poorly to gluten may feel better after a period of avoidance. After a gluten challenge, symptoms can range from digestive upset, to skin symptoms, to fatigue or irritability within minutes to days of the gluten challenge.

With 2011 approaching, why not make your new year's resolution to go gluten-free for a month? A man named Matt Lentzner e-mailed me this week to ask if I would help with his (non-commercial) project, "A Gluten-free January". I said I'd be delighted. Although I don't typically eat much gluten, this January I'm going 100% gluten-free. Are you on board? Read on.

A Message from Matt Lentzner

Hi There.

My name is Matt Lentzner. I'm just some guy who lifts weights on his patio and tries to eat healthy. That's not important, but I have an idea that just might be.

I am trying to get as many people as possible to go gluten-free for one month - this January 2011.

I've considered this whole ancestral diet thing and I've come to a conclusion. If you could only do just one thing to improve your health then not eating gluten would be it. This is not to say that avoiding other nasty things like fructose or industrial vegetable oil is not important. They are, but you'd get the most bang for your buck from not eating gluten.

"Eat No Gluten" is simple and easy to remember. I think that sometimes the rules get so complicated and overwhelming and people just give up on it. We're keeping it simple here. Even at this simplified level I see that it's difficult for a lot of folks. I think people, Americans especially, tend not to pay much attention to what they're eating - what it is, where it came from, etc.

Getting people to get out of their eating ruts and think a little about what goes into their mouths is a valuable exercise. It sets the stage for better choices in the future. I hope that some success with the simple step will encourage people to further improve their diets.

I have a website at www.glutenfreejan.com. If you want to sign up just send an email with your first name, last initial, and town of residence to glutenfreejan@gmail.com. If you are on Facebook there's a community you can 'Like' called: Gluten Free January. So far I have over 120 people all over the world signed up. If you are already gluten-free then I still want you to sign up - the more the merrier. You can also use this opportunity to spread the word and sign up your family and friends.

Merry Christmas - Looking forward to a gluten-free New Year.

Matt

We're expanding our social media presence

As a small agency with a broad consumer-protection mission, one of our hardest jobs is simply getting the word out to consumers that we can help them. Increasingly, we're turning to social media tools to help spread the word.

In the summer of 2009, we launched this blog, which is getting thousands of visitors a month. Shortly thereafter, we set up a Twitter feed, which we believe is now the second-largest among state insurance departments nationwide. From what we can tell, the blog tends to attract consumers Googling around for information. Our Twitter followers tend to be industry folks: agents, brokers and insurers.

Now we've launched an agency Facebook page. We're hardly the first Washington state agency to do so (Here's the list, put together by the good people at access.wa.gov), but surprisingly few insurance departments are using this tool. We'll see how it goes.

Where to look if you can't afford health coverage

We've put together a list of resources, suggestions and alternatives for folks who cannot find affordable health coverage. Our "can't afford health care coverage" page includes links and information about:

• community clinics and local free clinics,
• state-offered health coverage,
• free cancer screenings
• hospital charity care
• dental exams and treatment
• and specific programs for certain diseases or disabilities.

Dairy Fat and Diabetes

Introduction

Having access to embargoed news from the Annals of Internal Medicine is really fun. I get to report on important studies at the same time as the news media. But this week, I got my hands on a study that I'm not sure will be widely reported (Mozaffarian et al. Trans-palmitoleic Acid, Metabolic Risk Factors, and New-Onset Diabetes in US Adults. Ann Internal Med. 2010). Why? Because it suggests that dairy fat may protect against diabetes.

The lead author is Dr. Dariush Mozaffarian, whose meta-analysis of diet-heart controlled trials I recently criticized (1). I think this is a good opportunity for me to acknowledge that Dr. Mozaffarian and his colleagues have published some brave papers in the past that challenged conventional wisdom. For example, in a 2005 study, they found that postmenopausal women who ate the most saturated fat had the slowest rate of narrowing of their coronary arteries over time (2). It wasn't a popular finding but he has defended it. His colleague Dr. Walter Willett thinks dietary fat is fine (although he favors corn oil), whole eggs can be part of a healthy diet, and there are worse things than eating coconut from time to time. Dr. Willett is also a strong advocate of unrefined foods and home cooking, which I believe are two of the main pillars of healthy eating.

Let's hit the data

Investigators collected two measures of dairy fat intake in 3,736 Americans:

1. 24 hour dietary recall questionnaires, six times. This records volunteers' food intake at the beginning of the study.
2. Blood (plasma phospholipid) content of trans-palmitoleate. Dairy fat and red meat fat are virtually the only sources of this fatty acid, so it reflects the intake of these foods. Most of the trans-palmitoleate came from dairy in this study, although red meat was also a significant source.

After adjustment for confounding factors, trans-palmitoleate levels were associated with a smaller waist circumference, higher HDL cholesterol, lower serum triglycerides, lower C-reactive protein, lower fasting insulin and lower calculated insulin resistance. Furthermore, people with the highest trans-palmitoleate levels had 1/3 the risk of developing diabetes over the three years volunteers were followed. Keep in mind, however, that this is an observational study and does not prove that dairy fat prevents diabetes.

Even though certain blood fatty acids partially represent food intake, they can also represent metabolic conditions. For example, people on their way to type II diabetes tend to have more saturated blood lipids, independent of diet (3, 4)*. So it's reassuring to see that dietary trans-palmitoleate intake was closely related to the serum level. The investigators also noted that "greater whole-fat dairy consumption was associated with lower risk for diabetes," which increases my confidence that serum trans-palmitoleate is actually measuring dairy fat intake to some degree. However, in the end, I think the striking association they observed was partially due to dairy fat intake, but mostly due to metabolic factors that had nothing to do with dairy fat**.

Here's a nice quote:

Our findings support potential metabolic benefits of dairy consumption and suggest that trans-palmitoleate may mediate these effects***. They also suggest that efforts to promote exclusive consumption of low-fat and nonfat dairy products, which would lower population exposure to trans-palmitoleate, may be premature until the mediators of the health effects of dairy consumption are better established.

Never thought I'd see the day! Not bad, but I can do better:

Our findings support eating as much butter as possible****. Don't waste your money on low-fat cream, either (half-n-half). We're sorry that public health authorities have spent 30 years telling you to eat low-fat dairy when most studies are actually more consistent with the idea that dairy fat reduces the risk obesity and chronic disease.

What are these studies suggesting that dairy fat may be protective, you ask? That will be the topic of another post, my friends.


*Probably due to uncontrolled de novo lipogenesis because of insulin resistance. Many studies find that serum saturated fatty acids are higher in those with metabolic dysfunction, independent of diet. They sometimes interpret that as showing that people are lying about their diet, rather than that serum saturated fatty acids don't reflect diet very well. For example, in one study I cited, investigators found no relationship between dietary saturated fat and diabetes risk, but they did find a relationship between serum saturated fatty acids and diabetes risk (5). They then proceeded to refer to the serum measurements as "objective measurements" that can tease apart "important associations with diabetes incidence that may be missed when assessed by [food questionnaires]." They go on to say that serum fatty acids are "useful as biomarkers for fatty acid intake," which is true for some fatty acids but not remotely for most of the saturated ones, according to their own study. Basically, they try to insinuate that dietary saturated fat is the culprit, and the only reason they couldn't measure that association directly is that people who went on to develop diabetes inaccurately reported their diets! A more likely explanation is that elevated serum saturated fatty acids are simply a marker of insulin resistance (and thus uncontrolled de novo lipogenesis), and had nothing to do with diet.

**Why do I say that? Because mathematically adjusting for dairy and meat fat intake did not substantially weaken the association between phospholipid trans-palmitoleate and reduced diabetes risk (Table 4). In other words, if you believe their math, dairy/meat fat intake only accounted for a small part of the protective association. That implies that healthy people maintain a higher serum phospholipid trans-palmitoleate level than unhealthy people, even if both groups eat the same amount of trans-palmitoleate. If they hadn't mentioned that full-fat dairy fat intake was directly associated with a lower risk of diabetes, I would not find the study very interesting because I'd have my doubts that it was relevant to diet.

***I find it highly doubtful that trans-palmitoleate entirely mediates the positive health outcomes associated with dairy fat intake. I think it's more likely to simply be a marker of milk fat, which contains a number of potentially protective substances such as CLA, vitamin K2, butyric acid, and the natural trans fats including trans-palmitoleate. In addition, dairy fat is low in omega-6 polyunsaturated fat. I find it unlikely that their fancy math was able to tease those factors apart, because those substances all travel together in dairy fat. trans-palmitoleate pills are not going to replace butter.

****That's a joke. I think butter can be part of healthy diet, but that doesn't mean gorging on it is a good idea. This study does not prove that dairy fat prevents diabetes, it simply suggests that it may.

Dreaming of a White Christmas and Pitote, by blogger of the month Claire Gahm

Hold on, I'm actually only day dreaming about Christmas. But at night I dream about pitote and the Urea Cycle and Mallory stained Collagen Type I and Cytotoxic t cells.

This is break #570 of today, the 15th day of finals study period, and the night before our Cell & Molecular Biology exam. We'll have Immunology this coming Wednesday then most of us will dash through the desert sand to the airport to arrive home this weekend! My room is decked and our hall has homemade felt stockings I spent an evening making instead of studying. Christmas music has been floating through the air since the day of Thanksgiving and I've made every effort to convince myself ‘tis the season - But dreaming of Christmas is becoming hazardous for my mental health as I try to push through these last few days. :)

Irene next to the store we passed in Jerusalem;
please note those are Santa balloons (not shown:
life size Santa statues)

In case you haven't taken a semester of Hebrew, "pitote" is the plural of pita (a feminine word - masculine would be "pete" and "petim"). Only in Israel would a professor refer to the Golgi bodies as pitote pockets. And did you know that eating along with caffeine has an opposing effect? Eating stimulates insulin release from the beta-cells of the Pancreas while caffeine simulates epinephrine (or glucagon released from alpha-cells of the Pancreas). All of this to say - there is a reason black coffee sans food really gets people going in the morning. Prime caffeine working conditions.

Taking a break for sushi at Ishimoto
for Lisa's birthday (Lisa, Tali and Jonathan)

It's also amazing to me (as I study Molecular Biology to a degree that suggests I am not, in fact, an MD candidate, but a graduate Molecular Biologist student) that I hear the following phrase so often in class: "We don't know much about this yet, so just know the general idea". We've finally, truly reached the frontier of our education - yet it will continue for the rest of our lives. It's like the Cisternal Maturation Hypothesis - mark the information that needs to be sent back to the classroom with KDEL and keep pushing ahead for the output of some breakthrough research finding. Nerdspeak translation again: aside from the next year or two, our entire careers as physicians will be filled with not knowing, but adapting, learning, and constantly staying up-to-date in case someone solves the latest educational gap of knowledge.

Last Friday I visited Jerusalem with Irene (fellow 1st year) to peruse their Shukh and go

Whiteboard balagan for finals
studying.  Biochemistry, Immunonolgy
and Cell Biology.

Christmas shopping! It was the day after the end of Hanukkah and there were huge Menorahs all over the city. This was my 4th visit and I was hoping to hop over to Bethlehem in honor of the Christmas season, but we ran out of time (buses stop running around 3 now that it gets dark at 4:30).

Every time I go to Jerusalem it is physically and spiritually breathtaking. Living in Israel for this Christmas season - with the tangible hope in the coming Messiah - has forever changed Advent and Christmas for me. It is more hopeful, full of genuine preparation for Jesus' birth, more joyful, and more real than it has ever been.

Beer Sheva Blizzard - the recent three
day sandstorm termed "the
worst in forty years" by many
cab drivers and shop owners

Here are a few pictures from recent study and travel adventures - time is perpetually either moving too fast or too slow (a thought-provoking concept from C.S. Lewis mentions that humanity’s need to hold onto time lends itself to Someone timeless – I couldn’t agree more because I’m often one of those people trying to speed up or slow down life!). These past 5 months have been an incredible & unexpected adventure – not only am I living in ISRAEL but I am a medical student (my lifelong dream) – now 5 months are over and I have NO idea how! - Claire Gahm, MSIH first-year student

Nuts by numbers: Should you eat them, and how much?

Nuts are generally seen as good sources of protein and magnesium. The latter plays a number of roles in the human body, and is considered critical for bone health. Nuts are also believed to be good sources of vitamin E. While there is a lot of debate about vitamin E’s role in health, it is considered by many to be a powerful antioxidant. Other than in nuts, vitamin E is not easily found in foods other than seeds and seed oils.

Some of the foods that we call nuts are actually seeds; others are legumes. For simplification, in this post I am calling nuts those foods that are generally protected by shells (some harder than others). This protective layer is what makes most people call them nuts.

Let us see how different nuts stack up against each other in terms of key nutrients. The quantities listed below are per 1 oz (28 g), and are based on data from Nutritiondata.com. All are raw. Roasting tends to reduce the vitamin content of nuts, often by half, and has little effect on the mineral content. Protein and fat content are also reduced, but not as much as the vitamin content.

These two figures show the protein, fat, and carbohydrate content of nuts (on the left); and the omega-6 and omega-3 fat content (on the right).

When we talk about nuts, walnuts are frequently presented in a very positive light. The reason normally given is that walnuts have a high omega-3 content; the plant form of omega-3, alpha-linolenic acid (ALA). That is true. But look at the large amount of omega-6 in walnuts. The difference between the omega-6 and omega-3 content in walnuts is about 8 g! And this is in only 1 oz of walnuts. That is 8 g of possibly pro-inflammatory omega-6 fats to be “neutralized”. It would take many fish oil softgels to achieve that.

Walnuts should be eaten in moderation. Most studies looking at the health effects of nuts, including walnuts, show positive results in short-term interventions. But they usually involve moderate consumption, often of 1 oz per day. Eat several ounces of walnuts every day, and you are entering industrial see oil territory in terms of omega-6 fats consumption. Maybe other nutrients in walnuts have protective effects, but still, this looks like dangerous territory; “diseases of civilization” territory.

A side note. Focusing too much on the omega-6 to omega-3 ratio of individual foods can be quite misleading. The reason is that a food with a very small amount of omega-6 (e.g., 50 mg) but close to zero omega-3 will have a very high ratio. (Any number divided by zero yields infinity.) Yet, that food will contribute little omega-6 to a person’s diet. It is the ratio at the end of the day that matters, when all foods that have been eaten are considered.

The figures below show the magnesium content of nuts (on the left); and the vitamin E content (on the right).

Let us say that you are looking for the best combination of protein, magnesium, and vitamin E. And you also want to limit your intake of omega-6 fats, which is a very wise thing to do. Then what is the best choice? It looks like it is almonds. And even they should be eaten in small amounts, as 1 oz has more than 3 g of omega-6 fats.

Macadamia nuts don’t have much omega-6; their fats are mostly monounsaturated, which are very good. Their protein to fat ratio is very low, and they don’t have much magnesium or vitamin E. Coconuts (i.e., their meat) have mostly medium-chain saturated fats, which are also very good. Coconuts have little protein, magnesium, and vitamin E. If you want to increase your intake of healthy fats, both macadamia nuts and coconuts are good choices, with macadamia nuts providing about 3 times more fat.

There are many other dietary sources of magnesium around. In fact, magnesium is found in many foods. Examples are, in approximate descending order of content: salmon, spinach, sardine, cod, halibut, banana, white potato, sweet potato, beef, chicken, pork, liver, and cabbage. This is by no means a comprehensive list.

As for vitamin E, it likes to hide in seeds. While it may be a powerful antioxidant, I wonder whether Mother Nature really had it “in mind” as she tinkered with our DNA for the last few million years.

Potato Diet Interpretation

If you read my post on December 16th, you know that Chris Voigt saw remarkable fat loss and improvements in health markers as a result of two months of eating almost nothing but potatoes. This has left many people scratching their heads, because potatoes are not generally viewed as a healthy food. This is partially due to the fact that potatoes are very rich in carbohydrate, which also happens to be a quickly digested type, resulting in a high glycemic index. The glycemic index refers to the degree to which a particular food increases blood glucose when it's eaten, and I've questioned the relevance of this concept to health outcomes in the past (1, 2, 3). I think Mr. Voigt's results once again argue against the importance of the glycemic index as a diet-health concept.

It's often pointed out that potatoes are low in vitamins and minerals compared to vegetables on a per-calorie basis, but I think it's a misleading comparison because potatoes are much more calorie-dense than most vegetables. Potatoes compare favorably to other starchy staples such as bread, rice and taro.

Over the course of two months, Mr. Voigt lost 21 pounds. No one knows exactly how much of that weight came out of fat and how much out of lean mass, but the fact that he reported a decrease in waist and neck circumference indicates that most of it probably came out of fat. Previous long-term potato feeding experiments have indicated that it's possible to maintain an athletic muscle mass on the amount of protein in whole potatoes alone (4). So yes, Mr. Voigt lost fat on a very high-carbohydrate diet (75-80% carbohydrate, up to 440g per day).

On to the most interesting question: why did he lose fat? Losing fat requires that energy leaving the body exceed energy entering the body. But as Gary Taubes would say, that's obvious but it doesn't get us anywhere. In the first three weeks of his diet, Mr. Voigt estimates that he was only eating 1,600 calories per day. Aha! That's why he lost weight! Well, yes. But let's look into this more deeply. Mr. Voigt was not deliberately restricting his calorie intake at all, and he did not intend this as a weight loss diet. In my interview, I asked him if he was hungry during the diet. He said that he was not hungry, and that he ate to appetite during this period, realizing only after three weeks that he was not eating nearly enough calories to maintain his weight*. I also asked him how his energy level was, and he said repeatedly that it was very good, perhaps even better than usual. Those were not idle questions.

Calorie restriction causes a predictable physiological response in humans that includes hunger and decreased energy. It's the starvation response, and it's powerful in both lean and overweight people, as anyone knows who has tried to lose fat by decreasing calorie intake alone. The fact that he didn't experience hunger or fatigue implies that his body did not think it was starving. Why would that be?

I believe Mr. Voigt's diet lowered his fat mass 'setpoint'. In other words, for whatever reason, the diet made his body 'want' to be leaner that it already was. His body began releasing stored fat that it considered excess, and therefore he had to eat less food to complete his energy needs. You see this same phenomenon very clearly in rodent feeding studies. Changes in diet composition/quality can cause dramatic shifts in the fat mass setpoint (5, 6). Mr. Voigt's appetite would eventually have returned to normal once he had stabilized at a lower body fat mass, just as rodents do.

Rodent studies have made it clear that diet composition has a massive effect on the level of fat mass that the body will 'defend' against changes in calorie intake (5, 6). Human studies have shown similar effects from changes in diet composition/quality. For example, in controlled diet trials, low-carbohydrate dieters spontaneously reduce their calorie intake quite significantly and lose body fat, without being asked to restrict calories (7). In Dr. Staffan Lindeberg's Paleolithic diet trials, participants lost a remarkable amount of fat, yet a recent publication from his group shows that the satiety (fullness) level of the Paleolithic group was not different from a non-Paleolithic comparison group despite a considerably lower calorie intake over 12 weeks (8, 9). I'll discuss this important new paper soon. Together, this suggests that diet composition/quality can have a dominant impact on the fat mass setpoint.

One possibility is that cutting the wheat, sugar, most vegetable oil and other processed food out of Mr. Voigt's diet was responsible for the fat loss. I think that's likely to have contributed. Many people find, for example, that they lose fat simply by eliminating wheat from their diet.

Another possibility that I've been exploring recently is that changes in palatability (pleasantness of flavor) influence the fat mass setpoint. There is evidence in rodents that it does, although it's not entirely consistent. For example, rats will become massively obese if you provide them with chocolate flavored Ensure (a meal replacement drink), but not with vanilla or strawberry Ensure (10). They will defend their elevated fat mass against calorie restriction (i.e. they show a physiological starvation response when you try to bring them down to a lower weight by feeding them less chocolate Ensure) while they're eating chocolate Ensure, but as soon as you put them back on unpurified rodent pellets, they will lose fat and defend the lower fat mass. Giving them food in liquid or paste form often causes obesity, while the same food in solid pellet form will not. Eating nothing but potatoes is obviously a diet with a low overall palatability.

So I think that both a change in diet composition/quality and a decrease in palatability probably contributed to a decrease in Mr. Voigt's fat mass setpoint, which allowed him to lose fat mass without triggering a starvation response (hunger, fatigue).

The rest of his improvements in health markers were partially due to the fat loss, including his decreased fasting glucose, decreased triglycerides, and presumably increased insulin sensitivity. They may also have been partially due to a lack of industrial food and increased intake of certain micronutrients such as magnesium.

One of the most striking changes was in his calculated LDL cholesterol ("bad" cholesterol), which decreased by 41%, putting him in a range that's more typical of healthy non-industrial cultures including hunter-gatherers. Yet hunter-gatherers didn't eat nothing but potatoes, often didn't eat much starch, and in some cases had a high intake of fat and saturated fat, so what gives? It's possible that a reduced saturated fat intake had an impact on his LDL, given the relatively short timescale of the diet. But I think there's something mysterious about this setpoint mechanism that has a much broader impact on metabolism than is generally appreciated. For example, calorie restriction in humans has a massive impact on LDL, much larger than the impact of saturated fat (11). And in any case, the latter appears to be a short-term phenomenon (12). It's just beginning to be appreciated that energy balance control systems in the brain influence cholesterol metabolism.

Mr. Voigt's digestion appeared to be just fine on his potato diet, even though he generally ate the skins. This makes me even more skeptical of the idea that potato glycoalkaloids in common potato varieties are a health concern, especially if you were to eliminate most of the glycoalkaloids by peeling.

I asked Mr. Voigt about what foods he was craving during the diet to get an idea of whether he was experiencing any major deficiencies. The fact that Mr. Voigt did not mention craving meat or other high-protein foods reinforces the fact that potatoes are a reasonable source of complete protein. The only thing he craved was crunchy/juicy food, which I'm not sure how to interpret.

He also stopped snoring during the diet, and began again immediately upon resuming his normal diet, perhaps indicating that his potato diet reduced airway inflammation. This could be due to avoiding food allergies and irritants (wheat anyone?) and also fat loss.

Overall, a very informative experiment! Enjoy your potatoes.


*Until the last 5.5 weeks, when he deliberately stuffed himself beyond his appetite because his rapid weight loss worried him. Yet, even with deliberate overfeeding up to his estimated calorie requirement of 2,200 calories per day, he continued to lose weight. He probably was not quite reaching his calorie goal, or his requirement is higher than he thought.

Trouble With RSS Feed?

I've received several comments that my blog posts are no longer showing up in peoples' RSS feeds. I've gone into my settings, and the blog is still set to full feed mode, so I don't know why that would be. I'm trying to understand if the problem is widespread or only affects a few people. Please let me know in the comments section if new posts (since the potatoes and human health series) are not showing up in your reader. Also, please let me know if new posts are showing up. Thanks!

High wind warning for eastern Puget Sound

The National Weather Service is forecasting gusts of up to 60 miles per hour tonight and Saturday in the east Puget Sound lowlands, which includes Bellevue, Gold Bar, Enumclaw, North Bend and Buckley. The good news is that those are the gusts; the wind will generally be 20-30 miles per hour in the area.

Wet soil and high winds often mean tree damage, so here's our ever-popular winter storm guide, with common questions about insurance and storm damage.

Insurance survey ranks Olympia as the safest mid-sized U.S. city in America; a dozen other Washington cities also score well

Farmers Insurance Group has released its seventh annual list of the safest cities in America.

Scoring highest among mid-sized cities: Olympia, Wash. Also doing well: Seattle/Bellevue/Everett, Bellingham, Yakima, the Tri-Cities, Spokane, Bremerton-Silverdale, Wenatchee, and Mount Vernon-Anacortes. (Some areas are grouped into single statistical areas.)

How do they decide? Here's what their press release says:

The rankings, compiled by database experts at www.bestplaces.net, took into consideration crime statistics, extreme weather, risk of natural disasters, housing depreciation, foreclosures, air quality, terrorist threats, environmental hazards, life expectancy and job loss numbers in 379 U.S. municipalities.

Case closed: Man who claimed $33k tie collection had been stolen pays the money back, pleads guilty

A Lynnwood man who claimed that thieves had repeatedly made off with his collection of more than 200 silk neckties has paid back more than $33,000 and pleaded guilty to two counts of making a false insurance claim.

Under a diversion agreement, the felony charges will be dropped from his record if he complies with the agreement.

Carlton H. Wopperer, 50,  was charged with two counts of insurance fraud in Snohomish County Superior Court in July. Last week, he paid restitution of $33,370.67 and signed the diversion agreement.


Three times in 9 years, Wopperer claimed, thieves had stolen his collection of 212 silk neckties from his vehicle. But an investigation by the state insurance commissioner's office revealed that Wopperer had returned many of those ties within minutes of buying them.

On Jan. 5, 2009, Wopperer told the Mill Creek Police Department that his vehicle had been broken into while parked at a greeting card store. He said that four plastic containers containing 212 of his silk neckties had been stolen. He said that he’d taken the ties to a quilt shop to see about having them sewn onto a quilt for display.

Wopperer purchased replacement ties from Nordstrom, Butch Blum, Barneys New York and Mario’s of Seattle, submitting the receipts to his insurer. His insurer, PEMCO Insurance, paid him $33,370 under the terms of a provision allowing for replacement cost of stolen items.

Six months later, on June 9, 2009, Wopperer reported a very similar crime. He told the Everett Police Department that his vehicle had been broken into while he was moving. The 212 replacement ties that he’d purchased following the January theft had been stolen, he said. He subsequently filed an insurance claim for approximately $35,000.

But a PEMCO adjuster, checking with the retailers, learned that most of the ties purchased in January had been returned almost immediately. PEMCO denied Wopperer’s claim and reported the case to Insurance Commissioner Mike Kreidler’s Special Investigations Unit. State investigators interviewed store employees, documented the paper trail and referred the case to the Snohomish County Prosecutor’s Office.

(The investigation also revealed that there had been a third claim. Nine years earlier, on June 19, 2000, Wopperer told the Lynnwood Police Department that his collection of 212 silk ties had been stolen from his vehicle while parked at a mall. His insurer at the time paid his $16,900 claim.)

Nigerian Government Launches the National Strategic Health Development Plan (2010-2015) on December 16th 2010 in Abuja

Nigerian Government Launches the National Strategic Health Development Plan (2010-2015) on December 16^th 2010 in Abuja

The Government of Nigeria through its Federal Ministry of Health on Thursday, the 16^th of December officially launched the National Strategic Health Development Plan (2010-2015), as well as signed the Health Compact with Development Partners at the Transcorp Hilton Hotel in Abuja in a well-attended ceremony.

Present at the event were top government officials, members of the diplomatic corps, heads of donor agencies, NGOs, civil society organizations among others.Top Government officials that were present include the Representativ of the President of the Federal Republic of Nigeria ,Alhaji Yayale Ahmed,the Secretary to the Government of the Federation, Shamshudeeen Usman, the Minister of National Planning, Prof. Onyebuchi Nwosu, the Honourable Minister of Health, Hajia Amina Al-zubbair, the Senior Special Assistant to the President on MDGs, among other dignatories.

Alhaji Yayale Ahmed the Secretary to the Government of the Federation signed on behalf of the Government of Nigeria while the Development Partners Group on Health were represented by the Chair, Jane Miller (DFID) and co-chair, Dr Peter Eriki (out-going WHO Representative). The Donor Agencies that signed the compact or sent in letters of support include DFID, USG, JICA, CIDA, EU, GTZ, World Bank, AfDB, WHO, UNICEF, UNFPA, UNDP etc.

The NSHDP document was developed after series of consultations and engagement with stakeholders across Nigeria’s 36 States and the Directorate of Health Planning, Research and Statistics served as the coordinating secretariat. Technical and Funding support were provided by bilateral and multilateral agencies operating in Nigeria as well as the International Health Partners Plus (IHP+) which helped in developing the Health Compact.

The NSHDP which is a successor to the previous Health Sector Reform Program (2003-2007) aligns with health sector component of the newly developed Nigeria’s Vision 20:2020 Policy document. The document which is duly costed incorporates a clearly defined Results Framework with which to measure performance based on the outlined 8 priority areas to be given attention;

1. Leadership and Governance for Health
2. Health Services Delivery
3. Human Resources for Health
4. Financing for Health
5. National Health Information System
6. Community Participation and Ownership
7. Partnerships for Health
8. Research for Health

The NSHDP document was officially approved at the March 2010 National Council on Health which was held at Asaba Delta State and it essentially is encompasses the individual State Health Plans of the 36 states, as well as the Federal Plan to be directly implemented by the Federal Ministry of Health.

One major highlight of the NSHDP is the emphasis on Joint Annual Review (JAR) of the state of implementation by the combined evaluation team made up of the representatives of Health Ministry and its parastatals and agencies who were expected to work with a team of Independent Consultants. The first 2010 JAR on the level of implementation of the NSHDP was conducted in six States that were selected from the 6 geopolitical zones of Nigeria between October and November 2010. Preliminary findings from the review were presented to a well-attended stakeholder’s forum at Transcorp Hilton Hotel on Friday, 3^rd December 2010, and this would be shared widely during the National Council on Health in January 2011.

At the early stages of the development of the document, efforts were made to get the commitment and political will of the 36 State Governors. To ensure commitment from political office holders, the first Presidential Health Summit was held in Abuja in November 2009 during which Nigeria’s late leader, President Musa Yardua, the erstwhile Vice President, Goodluck Jonathan (Currently the President of Federal Republic of Nigeria) and the 36 State Governors signed a Health Compact; thus committing to provide support and funding for the provision of essential package of healthcare to the citizens of their respective states, nay Nigeria. At the summit the State Governors for the first time, were presented with a league table detailing the health indices of their respective states. In addition, a documentary on the dismal state of health care in Nigeria developed by the DFID-sponsored PATHS 2 Project was presented to the Governors and other stakeholders.

And with the official launch of the NSHDP and signing of IHP+ a major huddle has now been scaled in the drive to ensure alignment and harmonization of efforts between the government (federal and states) and development partners. In essence, the NSHDP is the only plan that would be implemented through the joint efforts of the government and partners, and this will be benchmarked annually using the one results framework and M&E framwork to be conducted by a joint team of government and development partners.

Health Economics and Policy Network in Africa (HEPNet) holds International Workshop in Abuja Nigeria

HPRG hosts Health Economics and Policy Network in Africa (HEPNet) 2010 International Workshop in Abuja 2010

The Health Policy Reseach Group (HPRG) Enugu successfully hosted the 2010 International Workshop of the Health Economics and Policy Network in Africa (HEPNET) for Africa in Abuja, the capital of Nigeria from November 29^th - December 1^st 2010. Delegates from Nigeria, Ghana, Zambia, Kenya, Tanzania, Zimbabwe, South Africa and Sweden were in attendance. Representatives of Nigeria’s Federal Ministry of Health, National Primary Health Care Development Agency, Donor Agencies, NGOs, Researchers, Policy Analysts, and Health Economists participated. The theme for the workshop was on the “National Responses to Communicable and Non-Communicable Diseases in Africa” and abstracts were received from over 20 participants who presented papers at the event.

The 2010 workshop was memorable in several ways. For instance, the meeting coincided with the 2010 Abuja Carnival which through which the culture of Nigeria is showcased in its diverse forms. The quality of papers presented was high and the social events introduced by the HPRG added spice to the program and this helped in strengthening the bond among the members. Participants from other African countries had the opportunity visiting some landmark places in Abuja as well experiencing the best of local Nigerian cuisine, cultural dances and folk drama in an ambient environment.

The international workshop in Nigeria would be the last in the series since HEPNET as an organization would be winding up by the end of 2010 having been active since 2000. HEPNet served as a network that brought together health economists and policy analysts from 37 institutions in Ghana, Kenya, Nigeria, South Africa, Tanzania, Uganda, Zambia and Zimbabwe and it was set up to build in-depth expertise in health economics and health policy analysis in order to improve health systems in Sub-Saharan Africa.

Though HEPNet as a network is winding up in the participating countries, some of its activities would continue in Nigeria. According to the HEPNet Secretariat at the Health Economics Unit of the University of Cape Town, a follow-up project may likely succeed HEPNet which was established through the funding support received from Swedish SIDA to develop local capacity in health economics and policy in the participating African countries.

HEPNet members were encouraged to maintain and sustain the already established networks among themselves, and it is instructive to note that some members of the network from different countries in Africa have started seeking for opportunities to collaborate in research projects in their respective countries.