Monday, February 28, 2011

Insurance commissioner: Premera is "stonewalling" on public disclosure of rate information

Washington State Insurance Commissioner Mike Kreidler today issued an open letter to health insurance consumers, calling for public disclosure of health insurers' rate requests.

"This is a critical week of the legislative session," Kreidler wrote. "Our biggest battle is still underway -- ending the secrecy of health insurance rates."

Under current law, the insurance commissioner's office is barred from disclosing virtually all the information submitted by insurers to justify health insurance rate requests. Kreidler wants to release those documents to the public, so they can see what’s driving health rates and comment on rate requests. Oregon and nearly a dozen other states have similar policies already.

Two of the state’s largest health insurers – Regence BlueShield and Group Health Cooperative – agree that rate information should be transparent. But a third – Premera Blue Cross – is balking, and only wants insurers to see the information once rates have been decided.

"I'm deeply troubled that Premera isn't willing to let you -- and their own policyholders -- see what's really driving health care premiums," Kreidler wrote, adding that he hopes they'll change their mind and help "put an end to the pointless secrecy of health insurance rates."

"We all know that health insurance rates have been rising dramatically in recent years," he wrote. "I believe that the people paying the premiums deserve to see why."

SUPERFOODS...What are they?

Superfoods are a class of the most potent, super-concentrated, and nutrient-rich foods on the planet. Extremely tasty and satisfying, superfoods have the ability to tremendously increase the vital force and energy of one's body, and are the optimum choice for improving over-all health, boosting the immune system, elevating serotonin production, enhancing sexuality, cleansing, and alkalizing the body. Nourishing us at the deepest level possible, they are the true fuel of today's “superhero.”

Top 10 Superfoods and Tonic Herbs
By David Wolfe

1. Cacao (Raw Chocolate) -- The seed of a fruit of an Amazonian tree, cacao is the highest
antioxidant food on the planet, the #1 source of magnesium, iron, chromium and is also extremely high in PEA, theobromine (cardiovascular support), and anandamide ("bliss chemical"). Raw Chocolate balances brain chemistry, builds strong bones, is a natural aphrodisiac, elevates your mood and energy.

2. Goji Berries (Wolfberries) -- Used in traditional Chinese medicine for over 5,000 years, goji berries are regarded as a longevity, strength-building, and potency food of the highest order. This superfood contains 18 kinds of amino acids, all 8 essential amino acids, up to 21 trace minerals, high amounts of antioxidants, iron, polysaccharides, B & E vitamins, and many other nutrients.

3. Maca -- A staple in the Peruvian Andes for thousands of years, this adaptogenic superfood increases energy, endurance, strength, and libido. Dried maca powder contains more than 10% protein, nearly 20 amino acids, and 7 essential amino acids. As a root crop, maca contains five times more protein than a potato and four times more fiber.

4. Hemp Products eaten their RAW form -- Packed with 33 % pure digestible protein, rich in iron, amino acids, and vitamin E as well as omega-3's and GLA. A perfect food.

5. Spirulina and Blue-Green Algae -- The world's highest source of complete protein (65%), spirulina provides a vast array of minerals, trace elements, phytonutrients and enzymes. Blue-green algae is a wild-grown superfood with a 60% protein percentage, but is equally or exceedingly higher in other components. Both are vital superfoods.

6. Bee Products (honey, pollen, and propolis) -- Bee pollen is the most complete food found in nature containing vitamin B-9 and all 21 essential amino acids, making it a complete protein. Honey, in its organic/wild, raw, unfiltered states is rich in minerals, antioxidants, probiotics, enzymes, and one of the highest vibration foods on the planet.

7. Camu Berry -- Highest Vitamin C source on planet. Great for rebuilding tissue, purifying blood, and enhancing immunity, and energy.

8. Sea Vegetables (seaweeds including: kelp, dulse, nori, hijiki, bladderwrack, chlorella, etc) -- Rich in life-giving nutrients drawn in from the ocean and sun, sea vegetables help remove heavy metals, detoxify the body, provide numerous trace minerals, regulate cholesterol, and decrease the risk of cancer. Seaweeds benefit the entire body, and are especially excellent for the thyroid (high iodine), immune system, adrenals, and hormone function.

9. Medicinal Mushrooms (Reishi, cordyceps, maitake, shiitake, lion's mane, etc.) -- High in polysaccharides and super immune enhancing components, medicinal mushrooms are one of the most intelligent adaptogenic herb/superfoods on the planet! They have also been proven effective in healing cancer and a variety of other ailments.

10. Powerful Supplements -- MSM, Beauty Enzymes, Blue Mangosteen, Marine Phytoplankton, Activated Liquid Zeolite, Ormus, MegaHydrate, Crystal Energy, Krill Oil.

Keep it fresh!
- Lauren

Why We Do What We Do: Rex Wong

About 20 years ago, Rex Wong visited Egypt for the first time. He didn’t know anything  about Egyptian health care, but he was intrigued by the country’s history and culture. Now, as director of hospital strengthening for the GHLI’s Egypt program, Rex has been a resident of Egypt since April 2010 and says it’s been, “A dream come true.” 

Rex came on board to the GHLI program in Egypt about a year ago,   to assess both public and private hospitals. A patient scheduling system that reduced waiting time by about 33 percent and cut hospital crowding by 45 percent were just a few of the successes he shared with me. The Ministry of Health in Egypt also supported GHLI’s program and recently expressed interest in expanding this program to other hospitals.

Rex described living in Egypt and working with GHLI “like a dream" because he’s wanted to work in developing countries for a while. “Since I was a kid, I’ve lived in multiple countries. It’s a part of my personal goals to work internationally,” explained Rex. He was already involved with GHLI after graduating from Yale and was approached by Elizabeth Bradley, the faculty director of GHLI, when the Egypt project presented itself.

Rex was the ideal candidate to the GHLI team because his personal ideology shaped his passion for work. “I like Yale and this program. Most other companies would charge fees to other countries. Instead, Yale is not trying to make a profit. Helping developing countries isn’t about making a profit,” explained Rex. The turning point in his ideology was shaped during his first volunteering experience in South Africa. “I saw the need in terms of health care and even necessities such as clean water and shelter.”

Working internationally, improving education and hospital management are the three things Rex cares about most. He’s doing all three things and says he has no complaints.

Amanda Sorrentino, GHLI Intern

GHLI Continues Strong Relations with Egypt Program

The political unrest and protests were more than a news story for Rex Wong. He was living in it. Rex recently had to leave his home in Egypt – where he works as part of a GHLI at Yale program – and return to the U.S. “I was not seen as an outsider, since I had been living there, so the environment did not feel threatening to me,” says Wong.  “It was actually more of an emotional experience to witness such a historical time in the country.”

As director of hospital strengthening for the GHLI’s Egypt program, Wong has been building relationships with government officials and with the National Bank in Egypt since April 2010. The National Bank has shown great interest in improving health care systems in Egypt by donating hospital equipment and initiating the partnership with GHLI in 2009. In collaboration with GHLI, they’ve created a more sustainable program to improve country-wide health care systems over the long term. Improving patient records, creating a more efficient method for patients to be seen and more effective payment systems are just a few of the GHLI’s accomplishments in the Egypt.

Wong explained how important GHLI’s relationship with the National Bank of Egypt has been during the past few weeks to ensure stability for their program. He’s positive the program will continue, but he noted a lot is uncertain because the health care system relies on the Ministry of Health. GHLI had strong relations with the Ministry of Health, and Wong said he’s committed to reestablishing relationships with the new members of the Ministry now and after their September election’s.

“The more I stay in the country [Egypt], the more I realize the importance of the program. The people I work with are amazing; they are willing to learn, hardworking and committed,” explained Wong. He added he cannot wait to go back to Egypt and continue his work there.

Amanda Sorrentino, GHLI Intern

Vitamin D production from UV radiation: The effects of total cholesterol and skin pigmentation

Our body naturally produces as much as 10,000 IU of vitamin D based on a few minutes of sun exposure when the sun is high. Getting that much vitamin D from dietary sources is very difficult, even after “fortification”.

The above refers to pre-sunburn exposure. Sunburn is not associated with increased vitamin D production; it is associated with skin damage and cancer.

Solar ultraviolet (UV) radiation is generally divided into two main types: UVB (wavelength: 280–320 nm) and UVA (320–400 nm). Vitamin D is produced primarily based on UVB radiation. Nevertheless, UVA is much more abundant, amounting to about 90 percent of the sun’s UV radiation.

UVA seems to cause the most skin damage, although there is some debate on this. If this is correct, one would expect skin pigmentation to be our body’s defense primarily against UVA radiation, not UVB radiation. If so, one’s ability to produce vitamin D based on UVB should not go down significantly as one’s skin becomes darker.

Also, vitamin D and cholesterol seem to be closely linked. Some argue that one is produced based on the other; others that they have the same precursor substance(s). Whatever the case may be, if vitamin D and cholesterol are indeed closely linked, one would expect low cholesterol levels to be associated with low vitamin D production based on sunlight.

Bogh et al. (2010) recently published a very interesting study. The link to the study was provided by Ted Hutchinson in the comments sections of a previous post on vitamin D. (Thanks Ted!) The study was published in a refereed journal with a solid reputation, the Journal of Investigative Dermatology.

The study by Bogh et al. (2010) is particularly interesting because it investigates a few issues on which there is a lot of speculation. Among the issues investigated are the effects of total cholesterol and skin pigmentation on the production of vitamin D from UVB radiation.

The figure below depicts the relationship between total cholesterol and vitamin D production based on UVB radiation. Vitamin D production is referred to as “delta 25(OH)D”. The univariate correlation is a fairly high and significant 0.51.

25(OH)D is the abbreviation for calcidiol, a prehormone that is produced in the liver based on vitamin D3 (cholecalciferol), and then converted in the kidneys into calcitriol, which is usually abbreviated as 1,25-(OH)2D3. The latter is the active form of vitamin D.

The table below shows 9 columns; the most relevant ones are the last pair at the right. They are the delta 25(OH)D levels for individuals with dark and fair skin after exposure to the same amount of UVB radiation. The difference in vitamin D production between the two groups is statistically indistinguishable from zero.

So there you have it. According to this study, low total cholesterol seems to be associated with impaired ability to produce vitamin D from UVB radiation. And skin pigmentation appears to have little  effect on the amount of vitamin D produced.

I hope that there will be more research in the future investigating this study’s claims, as the study has a few weaknesses. For example, if you take a look at the second pair of columns from the right on the table above, you’ll notice that the baseline 25(OH)D is lower for individuals with dark skin. The difference was just short of being significant at the 0.05 level.

What is the problem with that? Well, one of the findings of the study was that lower baseline 25(OH)D levels were significantly associated with higher delta 25(OH)D levels. Still, the baseline difference does not seem to be large enough to fully explain the lack of difference in delta 25(OH)D levels for individuals with dark and fair skin.

A widely cited dermatology researcher, Antony Young, published an invited commentary on this study in the same journal issue (Young, 2010). The commentary points out some weaknesses in the study, but is generally favorable. The weaknesses include the use of small sub-samples.


Bogh, M.K.B., Schmedes, A.V., Philipsen, P.A., Thieden, E., & Wulf, H.C. (2010). Vitamin D production after UVB exposure depends on baseline vitamin D and total cholesterol but not on skin pigmentation. Journal of Investigative Dermatology, 130(2), 546–553.

Young, A.R. (2010). Some light on the photobiology of vitamin D. Journal of Investigative Dermatology, 130(2), 346–348.

Friday, February 25, 2011

Should children run marathons - something every runner should consider reading

 Post has moved to

Pet insurance tips

We're hearing more from consumers about pet insurance, which will come as no surprise to anyone who's paid a vet bill lately.

To help, we put together a pet insurance tips page, with advice on:
-what to look for when comparing coverage
-how to find out how many complaints have been made about a pet insurer
-and questions to ask (such as "Do you give discounts for multiple pets?")

Job openings: market analyst and market conduct examiner

We have a couple of job openings:

Senior Market Conduct Examiner: Among other tasks, this person will review and analyze insurance company records and procedures, including advertising, agency activity, complaint/grievance procedures, corporate structure, rate and form filings, provider networks, underwriting and claim administration. The application period ends March 2 at 5 p.m.

Senior Market Analyst: This person will plan, coordinate and perform market analysis of insurers and other regulated entities, reviewing company data statements and assisting in the design of audit programs. Applications are due by March 9 at 5 p.m.

The links have much more information about duties, qualifications, education, etc., as well as information on how to apply.

Thursday, February 24, 2011

Polyphenols, Hormesis and Disease: Part II

In the last post, I explained that the body treats polyphenols as potentially harmful foreign chemicals, or "xenobiotics". How can we reconcile this with the growing evidence that at least a subset of polyphenols have health benefits?

Clues from Ionizing Radiation

One of the more curious things that has been reported in the scientific literature is that although high-dose ionizing radiation (such as X-rays) is clearly harmful, leading to cancer, premature aging and other problems, under some conditions low-dose ionizing radiation can actually decrease cancer risk and increase resistance to other stressors (1, 2, 3, 4, 5). It does so by triggering a protective cellular response, increasing cellular defenses out of proportion to the minor threat posed by the radiation itself. The ability of mild stressors to increase stress resistance is called "hormesis." Exercise is a common example. I've written about this phenomenon in the past (6).

The Case of Resveratrol

Resveratrol is perhaps the most widely known polyphenol, available in supplement stores nationwide. It's seen a lot of hype, being hailed as a "calorie restriction mimetic" and the reason for the "French paradox."* But there is quite a large body of evidence suggesting that resveratrol functions in the same manner as low-dose ionizing radiation and other bioactive polyphenols: by acting as a mild toxin that triggers a hormetic response (7). Just as in the case of radiation, high doses of resveratrol are harmful rather than helpful. This has obvious implications for the supplementation of resveratrol and other polyphenols. A recent review article on polyphenols stated that while dietary polyphenols may be protective, "high-dose fortified foods or dietary supplements are of unproven efficacy and possibly harmful" (8).

The Cellular Response to Oxidants

Although it may not be obvious, radiation and polyphenols activate a cellular response that is similar in many ways. Both activate the transcription factor Nrf2, which activates genes that are involved in detoxification of chemicals and antioxidant defense**(9, 10, 11, 12). This is thought to be due to the fact that polyphenols, just like radiation, may temporarily increase the level of oxidative stress inside cells. Here's a quote from the polyphenol review article quoted above (13):
We have found that [polyphenols] are potentially far more than 'just antioxidants', but that they are probably insignificant players as 'conventional' antioxidants. They appear, under most circumstances, to be just the opposite, i.e. prooxidants, that nevertheless appear to contribute strongly to protection from oxidative stress by inducing cellular endogenous enzymic protective mechanisms. They appear to be able to regulate not only antioxidant gene transcription but also numerous aspects of intracellular signaling cascades involved in the regulation of cell growth, inflammation and many other processes.
It's worth noting that this is essentially the opposite of what you'll hear on the evening news, that polyphenols are direct antioxidants. The scientific cutting edge has largely discarded that hypothesis, but the mainstream has not yet caught on.

Nrf2 is one of the main pathways by which polyphenols increase stress resistance and antioxidant defenses, including the key cellular antioxidant glutathione (14). Nrf2 activity is correlated with longevity across species (15). Inducing Nrf2 activity via polyphenols or by other means substantially reduces the risk of common lifestyle disorders in animal models, including cardiovascular disease, diabetes and cancer (16, 17, 18), although Nrf2 isn't necessarily the only mechanism. The human evidence is broadly consistent with the studies in animals, although not as well developed.

One of the most interesting effects of hormesis is that exposure to one stressor can increase resistance to other stressors. For example, long-term consumption of high-polyphenol chocolate increases sunburn resistance in humans, implying that it induces a hormetic response in skin (19). Polyphenol-rich foods such as green tea reduce sunburn and skin cancer development in animals (20, 21).

Chris Masterjohn first introduced me to Nrf2 and the idea that polyphenols act through hormesis. Chris studies the effects of green tea on health, which seem to be mediated by polyphenols.

A Second Mechanism

There is a place in the body where polyphenols are concentrated enough to be direct antioxidants: in the digestive tract after consuming polyphenol-rich foods. Digestion is a chemically harsh process that readily oxidizes ingested substances such as polyunsaturated fats (22). Oxidized fat is neither healthy when it's formed in the deep fryer, nor when it's formed in the digestive tract (23, 24). Eating polyphenol-rich foods effectively prevents these fats from being oxidized during digestion (25). One consequence of this appears to be better absorption and assimilation of the exceptionally fragile omega-3 polyunsaturated fatty acids (26).

What does it all Mean?

I think that overall, the evidence suggests that polyphenol-rich foods are healthy in moderation, and eating them on a regular basis is generally a good idea. Certain other plant chemicals, such as suforaphane found in cruciferous vegetables, and allicin found in garlic, exhibit similar effects and may also act by hormesis (27). Some of the best-studied polyphenol-rich foods are tea (particularly green tea), blueberries, extra-virgin olive oil, red wine, citrus fruits, hibiscus tea, soy, dark chocolate, coffee, turmeric and other herbs and spices, and a number of traditional medicinal herbs. A good rule of thumb is to "eat the rainbow", choosing foods with a variety of colors.

Supplementing with polyphenols and other plant chemicals in amounts that would not be achievable by eating food is probably not a good idea.

* The "paradox" whereby the French eat a diet rich in saturated fat, yet have a low heart attack risk compared to other affluent Western nations.

** Genes containing an antioxidant response element (ARE) in the promoter region. ARE is also sometimes called the electrophile response element (EpRE).

Car accident? How to file an insurance claim

Lots of snow, packed snow and ice on roads in Puget Sound this morning, which likely means a lot of fender benders. Here are some tips on filing an insurance claim and key information to know.

First: try to warn oncoming traffic, if it can be done safely. Give reasonable aid to the injured. Call police and, if necessary, an ambulance. If property damage exceeds $700 -- which is very often the case -- you must notify law enforcement.

Then: call your insurer. They can start the claims process and talk you through the details.

Who was at fault? Insurance adjusters typically gather information from the drivers and passengers, any witnesses, and accident reports filed with the state patrol or local law enforcement. If fault isn't clear, adjusters may decide that the fault is shared between drivers.

Which auto body shop to go to? In Washington state, unless you signed a contract with an insurer to take your car only to a specified repair shop, you can choose where to take it. But the shop still needs to work with the insurer to agree on a price. If they don't, and the car's repaired, you may be responsible for costs not covered by the insurer.

What if my car was totaled? We get this question all the time, and have a lot of information available about how to determine the vehicle's value (be ready to negotiate), how to keep your damaged vehicle, etc.

Check if your policy -- or the at-fault driver's -- covers "diminished value." This is the difference between the value of an undamaged vehicle and what it's worth after repairs are made.

Rental car? If the other driver was at fault, his or her insurer will negotiate with you for rental car payment. If you were hit by an uninsured driver, your insurance may pay for a rental.

Finally, what's "subrogation?" Subrogation allows your insurer to recover its costs from the person legally responsible for the accident. In other words, they seek reimbursement from the at-fault person.

Wednesday, February 23, 2011

Different Syles of Yoga

Vinyasa, ashtanga, kundalini, hatha, many styles of yoga, but what is best for you?

There are so many different lineages and styles of yoga that it can be pretty overwhelming, especially as a beginner. Here is a brief breakdown of the most popular styles of yoga out there for your convenience. See which style best resonates with you and then attend a class in your area!

All styles of yoga stem from the same basic principles. Each style is based on the same physical postures (called asanas) with particular emphasis.

Hatha is a very general term that can encompass many of the physical types of yoga. If a class is described as Hatha style, it is probably going to be slow-paced and gentle and provide a good introduction to the basic yoga poses.

Like Hatha, Vinyasa is a general term that is used to describe many different types of classes. Vinyasa, which means breath-synchronized movement, tends to be a more vigorous style based on the performance of a series of poses called Sun Salutations, in which movement is matched to the breath. A Vinyasa class will typically start with a number of Sun Salutations to warm up the body for more intense stretching that's done at the end of class.

Ashtanga, which means "eight limbs" in Sanskrit, is a fast-paced, intense style of yoga. A set series of poses is performed, always in the same order. Ashtanga practice is very physically demanding because of the constant movement from one pose to the next. In yoga terminology, this movement is called flow. Ashtanga is also the inspiration for what is often called Power Yoga. If a class is described as Power Yoga, it will be based on the flowing style of Ashtanga, but not necessarily keep strictly to the set Ashtanga series of poses.

Based on the teachings of the yogi B.K.S Iyengar, this style of practice is most concerned with bodily alignment. In yoga, the word alignment is used to describe the precise way in which your body should be positioned in each pose in order to obtain the maximum benefits and avoid injury. Iyengar practice usually emphasizes holding poses over long periods versus moving quickly from one pose to the next (flow). Also, Iyengar practice encourages the use of props, such as yoga blankets, blocks and straps, in order to bring the body into alignment.

The emphasis in Kundalini is on the breath in conjunction with physical movement, with the purpose of freeing energy in the lower body and allowing it to move upwards. All asana practices make use of controlling the breath. But in Kundalini, the exploration of the effects of the breath (also called prana, meaning energy) on the postures is essential.

Pioneered by Bikram Choudhury, this style is more generally referred to as Hot Yoga. It is practiced in a 95 to 100 degree room, which allows for a loosening of tight muscles and profuse sweating, which is thought to be cleansing. The Bikram method is a set series of 26 poses, but not all hot classes make use of this series.

Founded in 1997 by John Friend, Anusara combines a strong emphasis on physical alignment with a positive philosophy derived from Tantra. The philosophy’s premise is belief in the intrinsic goodness of all beings. Anusara classes are usually light-hearted and accessible to students of differing abilities. Poses are taught in a way that opens the heart, both physically and mentally, and props are often used.

This style of yoga emerged from one of New York’s best-known yoga studios. Jivamukti founders David Life and Sharon Gannon take inspiration from Ashtanga yoga and emphasize chanting, meditation, and spiritual teachings. They have trained many teachers who have brought this style of yoga to studios and gyms, predominantly in the U.S. These classes are physically intense and often include some chanting.

Integral yoga follows the teachings of Sri Swami Sachidananda, who came to the U.S. in the 1960s and eventually founded many Integral Yoga Institutes and the famed Yogaville Ashram in Virginia. Integral is a gentle hatha practice, and classes often also include breathing exercises, chanting, kriyas, and meditation.

The first Sivananda Yoga Vedanta Center was founded in 1959 by Swami Vishnu-devananda, a disciple of Swami Sivananda. There are now close to 80 locations worldwide, including several ashram retreats. Sivananda yoga is based upon five principles:
1. Proper exercise (Asana, focusing on 12 poses in particular)
2. Proper breathing (Pranayama)
3. Proper relaxation (Savasana)
4. Proper diet (Vegetarian)
5. Positive thinking (Vedanta) and meditation (Dhyana)

I've been practicing yoga for over 18 years now and I've always been drawn to Hatha yoga. My teacher training was in classic Hatha yoga. However, I began studying and practicing Sivananda yoga about a decade ago on my own and it still is what resonates the most with me. As I'm progressing with my practice I do find myself designing more challenging Vinyasa flow classes because I enjoy the whole dance of yoga. It's so beautiful! Come try my class at the lovely Brahma Yoga Spa in Sea Bright on Friday nights at 5:30pm or Fair Haven Yoga Studio on Saturday mornings at 9am.

What is your favorite style of yoga?

Keep it fresh!
- Lauren

Information adapted from Ann Pizer's Yoga Style Guide

Tuesday, February 22, 2011

Winter storm watch -- and info on how to file auto insurance claims

A winter storm watch is in effect from Wednesday morning through Thursday morning for much of western Washington, with snow accumulations of up to 6 inches possible.

Anyone who lives in Puget Sound knows that much-feared snowstorms sometimes turn out to be, well, just more rain. But if this one turns out to be real, and west-siders are trying to drive around in it, here's a link to keep handy. It's our page about how auto insurance claims work -- diminished value, repairs using aftermarket parts,  rental cars, deciding who's at fault, etc.

Also: Many school districts in Washington state use to put out information on school closures.

Drive carefully.

Jack La Lane was a chiropractor. I didn't know that and more...

Monday, February 21, 2011

Why We Do What We Do: Michael Skonieczny

Michael Skonieczny is the executive director of the Global Health Leadership Institute (GHLI), at Yale University, where he directs the program’s operations. Skonieczny’s interest in health issues began from his previous work on domestic health policy issues with the Federal Drug Administration and Congresswoman Rosa L. DeLauro. When he began working for the Elizabeth Glaser Pediatric AIDS Foundation, Skonieczny’s interest expanded into the global arena.

Skonieczny became interested in GHLI after meeting with Elizabeth Bradley over two years ago. Her vision and work in Ethiopia around hospital management presented an exciting opportunity to create something new at Yale. GHLI also presented a new prospect to Skonieczny that was different than his work with health policy in Washington, D.C. He made the decision to join the GHLI team.  

Even though he’s only been at GHLI for a short period of time, Skonieczny said he thinks much has been accomplished. “We’ve created a fertile ground at Yale University for global health with tremendous support on campus from students, faculty and senior administration,” he explained. Since GHLI’s annual conference in 2009, the student course, variety of speakers and development of a potential Rwanda program are a few examples of why he feels the program has been a success. Skonieczny said his ultimate accomplishment at GHLI came from the delegation at the annual conference because it began the collaboration between GHLI and the Ministry of Health in Rwanda. 

Skonieczny expressed a similar sentiment as his fellow GHLI coworkers by saying, “My work makes excited because I believe we can contribute to make a difference. He added, “It’s great to be a part of a group that’s innovative and entrepreneurial.”

Amanda Sorrentino, GHLI Intern

Trip to China: Support from across the world creates success for 10,000 Women Program

Martha Dale, director for China Programs, and Lui Yu, program manager, shared their experiences after a recent trip to China. Martha and Lui’s work provides women in China with the opportunity to learn management and leadership skills that will improve their own health care systems. While Martha and Lui make several trips per year to China, much of their work is done providing support to the program from countries away. 

Both were able to reflect and share their most rewarding aspects of the overall program. Yu explains how he manages the program’s 60 students with regular phone calls and e-mails on a daily basis because he wants to make sure they’re not ignored and still feel a part of the program. Dale adds that watching the group dynamics, team roles and applicable skills develop is the most satisfying part of her trip.

Dale explains that the program began when Tsinghua University decided they wanted to do more work in health care and connected with Yale University because of their past work with China. After both universities connected, Elizabeth Bradley, faculty director at GHLI, took the lead to develop a proposal for funding the initiative.

The program focuses around a three week certificate class and a four month field assignment. Dale explained the main purpose of the program was to create a profession of health care managers and to increase the efficiency and quality of health provided. The program is funded by the Goldman Sachs Foundation, and provides women in lower category hospitals, but with a wide range of health care experience, the opportunity to improve their health care management outcomes. Students have been recruited thus far from 18 of China’s provinces.

Success in the program is measured through a series of complex monitoring evaluation systems consisting of competency, leadership, projects, promotion and gender roles. These five constructs involve evaluating skill sets before and after, how the project’s impact the community and if men or women are perceived to have more dominant roles in the workplace or home. Yu explained one example of success is measured by comparing the initial skill sets of students in the cohort to their present abilities at the conclusion of the program. Another measure is through field assignment work: one student’s project increased the recognition rate of diabetes within their community. Two classes of students have graduated and the program is currently working on their third. The certificate program aims to graduate eight groups in total.

Amanda Sorrentino, GHLI Intern

The China Study II: Wheat, dietary fat, and mortality

In this post on the China Study II data we have seen that wheat apparently displaces dietary fat a lot, primarily fat from animal sources. We have also seen in that post that wheat is strongly and positively associated with mortality in both the 35-69 and 70-79 age ranges, whereas dietary fat is strongly and negatively associated with mortality in those ranges.

This opens the door for the hypothesis that wheat increased mortality in the China Study II sample mainly by displacing dietary fat, and not necessarily by being a primary cause of health problems. In fact, given the strong displacement effect discussed in the previous post, I thought that this hypothesis was quite compelling. I was partly wrong, as you’ll see below.

A counterintuitive hypothesis no doubt, given that wheat is unlikely to have been part of the diet of our Paleolithic ancestors, and thus the modern human digestive tract may be maladapted to it. Moreover, wheat’s main protein (gluten) is implicated in celiac disease, and wheat contains plant toxins such as wheat germ agglutinin.

Still, we cannot completely ignore this hypothesis because: (a) the data points in its general direction; and (b) wheat-based foods are found in way more than trivial amounts in the diets of populations that have relatively high longevity, such as the French.

Testing the hypothesis essentially amounts to testing the significance of two mediating effects; of fat as a mediator of the effects of wheat on mortality, in both the 35-69 and 70-79 age ranges. There are two main approaches for doing this. One is the classic test discussed by Baron & Kenny (1986). The other is the modern test discussed by Preacher & Hayes (2004), and extended by Hayes & Preacher (2010) for nonlinear relationships.

I tested the meditating effects using both approaches, including the nonlinear variation. I used the software WarpPLS for this; the results below are from WarpPLS outputs. Other analyses of the China Study data using WarpPLS can be found here (calorie restriction and longevity), and here (wheat, rice, and cardiovascular disease). For yet other studies, click here.

The graphs below show the path coefficients and chance probabilities of two models. The one at the top-left suggests that wheat flour consumption seems to be associated with a statistically significant increase in mortality in the 70-79 age range (beta=0.23; P=0.04). The effect in the 35-69 age range is almost statistically significant (beta=0.22; P=0.09); the likelihood that it is due to chance is 9 percent (this is the meaning of the P=0.09=9/100=9%).

The graph at the bottom-right suggests that the variable “FatCal”, which is the percentage of calories coming from dietary fat, is indeed a significant mediator of the relationships above between wheat and mortality, in both ranges. But “FatCal” is only a partial mediator.

The reason why “FatCal” is not a “perfect” mediator is that the direct effects of wheat on mortality in both ranges are still relatively strong after “FatCal” is added to the model (i.e., controlled for). In fact, the effects of wheat on mortality don’t change that much with the introduction of the variable “FatCal”.

This analysis suggests that, in the China Study II sample, one of wheat’s main sins might indeed have been to displace dietary fat from animal sources. Wheat consumption is strongly and negatively associated with dietary fat (beta=-0.37; P<0.01), and dietary fat is relatively strongly and negatively associated with mortality in both ranges (more in the 70-79 age range).

Why is dietary fat more protective in the 70-79 than in the 35-69 age range, with the latter effect only being significant at the P=0.10 level (a 10 percent chance probability)? My interpretation is that, as with almost any dietary habit, it takes years for a chronically low fat diet to lead to problems. See graph below; fat was not a huge contributor to the total calorie intake in this sample.

The analysis suggests that wheat also caused problems via other paths. What are them? We can’t say for sure based on this dataset. Perhaps the paths involve lectins and/or gluten. One way or another, the relationship is complex. As you can see from the graph below, the relationship between wheat consumption and mortality is nonlinear for the 70-79 age range, most likely due to confounding factors. The effect size is small for the 35-69 age range, even though it looks linear or quasi-linear in that range.

As you might recall from this post, rice does NOT displace dietary fat, and it seems to be associated with increased longevity. Carbohydrate content per se does not appear to be the problem here. Both rice and wheat foods are rich in them, and have a high glycemic index. Wheat products tend to have a higher glycemic load though.

And why is dietary fat so important as to be significantly associated with increased longevity? This is not a trivial question, because if too much of that fat is stored as body fat it will actually decrease longevity. Dietary fat is very calorie-dense, and can be easily stored as body fat.

Dietary fat is important for various reasons, and probably some that we don’t know about yet. It leads to the formation of body fat, which is not only found in adipocytes or used only as a store of energy. Fat is a key component of a number of important tissues, including 60 percent of our brain. Since fat in the human body undergoes constant turnover, more in some areas than others, lack of dietary fat may compromise the proper functioning of various organs.

Without dietary fat, the very important fat-soluble vitamins (A, D, E and K) cannot be properly absorbed. Taking these vitamins in supplemental form will not work if you don’t consume fat as well. A very low fat diet is almost by definition a diet deficient in fat-soluble vitamins, even if those vitamins are consumed in large amounts via supplements.

Moreover, animals store fat-soluble vitamins in their body fat (as well as in organs), so we get these vitamins in one of their most natural and potent forms when we consume animal fat. Consuming copious amounts of olive and/or coconut oil will not have just the same effect.


Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality & Social Psychology, 51(6), 1173-1182.

Preacher, K.J., & Hayes, A.F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36 (4), 717-731.

Hayes, A. F., & Preacher, K. J. (2010). Quantifying and testing indirect effects in simple mediation models when the constituent paths are nonlinear. Multivariate Behavioral Research, 45(4), 627-660.

Sunday, February 20, 2011

USA Track and Field NJ y Open & Masters Indoor Track & Field Championships

Today, 2-20-11 I was on the medical staff for the USATF open and masters indoor track and field championships at the John Bennett Indoor Athletic Complex in Toms River.  As many of my patients already know, I have been their medical director since 1992 and also do my best to make sure that their events have medical staffing which is typically all volunteer.  

This particular event features athletes who are at lease 18 years of age and some are in the 80's.  Pictured above was the start of the 50 yard dash.  Below to the left is one of our patients, Jane Vaneewan who got into track and field when her doctor told her she had some health issues.  Rather than take pills, she found track and field and on a given weekend, is a national competitor, often doing at least one if not more events,  To the right was an older high jumper. I was watching his jumps which were quite good for his age group.  Lastly, the bottom photo was of a high jumper.  

I was quite busy today, since we had one runner who I suspect fractured his ankle and another who severely pulled his hamstring.  Stuff happens but I was also able to help quite a few runners.  When I was packing up and leaving, one of the runners I worked on came over to thank me.  I turned out that he had some problems that continually were occurring and he had been through all sorts of therapies which did not work.  He ran after I taped his feet and worked on him free of pain for the first time in years. He is planning to visit and bring members of his team he trains with to the office from Pennsylvania because he believes he finally found someone who understands running problems. 

 It is nice to receive that type of endorsement.  I also met a number of coaches who brought over their team members because the liked the way I helped their athletes.I love working with runners and seeing them improve with my treatment.  It is quite rewarding which is why I will work for pizza and soda and the occasional T Shirt I receive at an event.

Friday, February 18, 2011

White Swan fire victims: We may be able to help you with insurance claims

On Saturday, a wind-whipped blaze tore through the town of White Swan, southwest of Yakima, torching 18 homes and leaving 120 people homeless.

If you're one of those families and you had insurance, our office may be able to help. We're the state agency that regulates insurance in Washington state, and we have a toll-free consumer hotline where analysts can help any Washingtonian with insurance questions or problems.

If claims are wrongly denied or delayed, we can contact insurers on your behalf and try to resolve the situation quickly.Call us at 1-800-562-6900 or send an e-mail to

If you'd like to help the White Swan families, MSNBC has put together a list of local donation sites. Any Bank of America branch can also accept donations in the name of the "White Swan Relief Fund."

Global Health Discussion on Innovation and Scale Up

During the first ever Global Health Faculty Symposium at Yale, expert faculty explored global health research puzzles in depth. Elizabeth Bradley, Linda Arnold, Mark Saltzman, Mushfiq Mobarak, and Nancy Reynolds were some of the faculty who participated in the innovation and scale up discussion group. Faculty, across various disciplines, were able to share more details about their specific research projects and discover additional information about their research endeavors.
The discussion began with Dr. Bradley identifying the different paths that can lead to product design adoption after innovation. The first path is when great technology stops dead in its tracks because of diffusion. An alternative is priming the political and economic environment. For example, lowering the price of complements and increasing the price of substitutes can make the benefits of diffusion outweigh the costs. Finally, the third pathway is engaging social norms and DNA fabrics of a community. This means the product may have to come from the community, rather than from outsiders. Dr. Bradley explained this through an example, “Like a virus moves through the cell, the virus has to embed into a cell to reproduce, this is how the community would reproduce an innovation. That’s how things diffuse.”

Mushfiq Mobarak explained how innovation and scale up is about more than just countries adopting technology to improve their health, but can help a researcher learn additional information about human behavior. For example, his research on a scale up for a government credit program to encourage seasonal migration away from famine in Bangladesh helped Dr. Mobarak learn availability of information, money or employee relationships, are different determining factors of migration.

Most faculty members agreed that Yale University’s involvement and advocacy of researchers are two necessary components for innovation and scale up. Finding a balance between faculty’s interests in global health could create opportunities for student involvement. Dealing with the unintended effects from innovation and scale up were harder to agree upon.

For example, Dr. Bradley explained how the world may adapt a product differently than it was intended, but how this isn’t necessarily a bad thing because communities can still maximize their welfare. Another faculty member thought, as a researcher, you are responsible for how an innovation is presented to the world and how it should be used. The interaction between two different innovations and designs should also be taken into account. Nancy Reynolds discussed how female condoms in Uganda may not be compatible with Mark Saltzman contraceptive design.

The discussion concluded with Lubna Pal asserting a needs assessment is necessary to help address and prioritize problems with vulnerable populations. Dr. Mobarak suggested potential next steps. Yet, no matter what the next steps are for innovation and scale up, the discussion is the main vehicle for faculty collaboration and understanding.

Amanda Sorrentino, GHLI Intern

Thursday, February 17, 2011

How to stay running injury free this spring

The weather is finally warming from this deplorable winter and many runners are testing out the roads during some of our warmer February days.  As many of our patients who run know, injuries tend to happen when you load up poorly functioning bodies with exercise.

Simple tests to screen yourself and see if your body may require some help before hitting the road.
1. Balance on one leg - This simple test where you balance on each leg, for 30 seconds will tell you if you are likely to have running problems.  Lift the leg until your thigh is perpendicular to your body (90 degrees).  If you lose your balance on one or both sides, you should visit your chiropractor or muscle therapist to have them find the muscular imbalance and correct it.  Often, problems in the back of the calf by the posterior knee are part of the problem as well as the gluteal muscles and the oblique muscles in the abdomen.  An imbalance of tension in these muscles will cause you to over and under stride with the net result being pain.  Get it checked out by a professional and then hit the road.
2. Crouch down slowly.  If you lose your balance or have a hard time getting up from this position unassisted, you are having problems and should have them checked out.  Imbalances such as the ones I spoke about in the first test will make it difficult to do this correctly.  What will likely happen if you run like this - pain in the hips, shins and the legs will tighten.  See a professional before running.

Great warm up exercises before your run
1. Hip Extensions - get on all fours and lift the right leg bent at 90 degrees 10 -20 times.  This will help warm up the gluts.
2. Lateral leg raises - While on your side, with the bottom leg bent, lift the top leg straight up for 10 - 20 repetitions.
3. Calf raises - Stand on the stoop on one foot with the ball of the foot on the edge.  Let the calf stretch out all the way and then slowly push off and lift your body.  Do these 10 -20 times.  These are great for warming up the front and the back of the lower leg.
4.  Balancing for 30 seconds on each leg - Essentially, this is the same as the test mentioned above.  This will help warm up the muscles and prepare them for exercises.

Avoid stretching - little evidence to support this unless we have a young growing child. Exercises is what you should do even if you grew up with the notion that you should stretch before the run.  Trust me, you will run stronger with exercises instead.

Other things that may help
1. Foam rollers - especially if the gluts and lateral legs are tight, this will perform a crude form of myofascial release and improve the way you feel during your run. Never do this after exercise, only before
2. Mild stretching after the run to ensure the muscles heal with more flexibility.  Gentle, not vigorous.

I hope you find this useful.  If you have any questions, or opinions, please forward them to

Important note to agents, brokers, insurers and insurance educators

Our office recently adopted new rules that  affect licensees (like agents and brokers), insurance companies, and people who provide insurance continuing education and pre-licensing education.

Under these new rules, licensing must be done online. Licensees must provide a valid e-mail address, which will be the point of contact for all communication from our office, including renewal notices. We will no longer be printing and mailing licensing documents, such as appointments, affliations, etc.

Here's the timeline:

  • For licensees (like agents and brokers, which are now known as producers), renewals and applications must be done online starting June 1, 2011.

  • For insurance companies, new appointments, appointment renewals and appointment terminations must be done online starting May 1, 2011.

  • For insurance education providers, all education courses submitted for our approval must be sent in electronic format (such as an e-mail attachment), starting Feb. 28, 2011.
For more details, please see our "new online licensing rules" page.

Tuesday, February 15, 2011

Job openings

We have three jobs -- two non-permanent positions, and one project position funded by a federal grant -- that we're trying to fill:

  • Communications Consultant 4: This is a project position funded by federal grant dollars from the U.S. Department of Health and Human Services. The project is expected to end on Oct. 15, 2011. The person will work with our consumer protection staffers to develop and manage communication strategies, techniques and tools. The work includes a variety of projects, all of which involve translating complicated health insurance information into materials that can be understood by an average consumers. For more information, see the job listing. Applications will be accepted through Feb. 28, 2011.

  • Health Insurance Advisor 1 - Regional Trainer (non-permanent): We're looking for someone who's bilingual in Korean and English to help provide training and technical assistance to volunteer health insurance benefit advisors in Clallam, Jefferson, King, Kitsap, Snohomish and Pierce counties. For details, here's the job listing. Note: The application period ends Friday afternoon.

  • Forms and Records Analyst 2 (non-permanent). Among other tasks, this person will act as a publications liaison between a health insurance advisory program and the state Department of Printing. For more details, salary information, etc., here's the job listing. Note: This application period also ends Friday afternoon.

Fewer scans recommended for lower back pain says a recent NY Times article

The other day I read about the American College of Physicians recent updated recommendations concerning ordering routine scans such as x rays and MRI for back pain (

The study states "Routinely ordering X-rays and CT orM.R.I. scans drives up health care costs, and does not help resolve the problem, the college’s “best practice advice” guidelines say. On the contrary, the guidelines suggest, the scans may pick up unrelated abnormalities, leading to additional tests or procedures that are of no benefit, and some scans expose patients to high levels of radiation. The recommendations are the first in a series of papers aimed at helping doctors and patients identify misused medical treatments."

On one hand, I totally agree because many physicians who do not have good evaluation skills for lower back problems will rely on scans that can be expensive in the case of an MRI or CT scan, and the tests either come back negative or show a lesion that may have nothing to do at all with why the person is in pain.  A proper evaluation is essential, and requires more than just feeling the muscles, checking reflexes and doing a straight leg raise test, which we are taught in school to do.  Many of the newer doctors who specialize in physical medicine such as chiropractors are now using active evaluation methods which tell us much more about what is going on functionally. We can then use a standing lumbar xray to deduce the overall condition of the structures.  Unlike many doctors who order lower back films taken on a table, standing films yield more useful information because it shows posture (a component of lower back pain in many cases), alignment as well as other useful information such as the quality of the hip sockets (which can be problematic in older patients).

The big question of course is when is it appropriate.  In our office, we typically do not taken plain films in children under 18, unless trauma was involved.  Over 18, if I deduce there was trauma or recurrent injuries, films are indicated to determine where the injuries occured and to what extent.  Most people over the mid 30's on will likely be candidates for x rays films with trauma or if the problem is recurrent.  While we do not perform blanket screenings, the use of plain films is quite helpful, especially in the chiropractic office since we are performing manual work and the films also alert us to anomalies.  Recently, an older patient we took films on looked to have a slight curvature in his back.  The films showed the curve to be over 30 degrees which is quite significant and alters the way we would treat him.  Obviously, this gives us medical necessity.

The article continues by saying "Most lower back pain is caused by strain on bones, muscles and ligaments. It can be treated with over-the-counter painkillers and usually abates within a few days, said an author of the practice guidelines, Dr. Amir Qaseem, director of clinical policy in medical education at the American College of Physicians." Personally, I think this shows the typical lack of true knowledge of what back pain is and why most people are not helped.  Pain killers may hide the pain, however, they never fix the body mechanics that create the problem. When you teach legions of primary care doctors that this is what back pain is, which is what typically happens, you get poor patient satisfaction, mediocre outcomes and people developing chronic back problems.

Lower back pain, especially chronic problems, most commonly start at the feet.  The more asymmetrical or inefficient your body is designed, the more you tend to suffer from back problems. Our patients know this because they see the results we get, and the way we are able to demonstrate to them where the problems are coming from and how quickly we often can turn these problems around.  To dismiss this as strain on bones, muscles and ligaments ignores that all structures against gravity experience this.  Not all structures have pain.  It is when these structures are overloaded by asymmetrical forces that the back breaks down and joints are damaged.  This is why we rarely perform tests such as MRI because 
1. most people improve from our care and not only feel better but function better too.
2. Those who do not improve after a reasonable course of care (2-3 weeks) are then referred for MRI or other advanced scans.  Since most people improve, few scans are ordered.

This is my opinion based on many years of experience.  Of course, I value your opinion too.  You can email any questions to

Monday, February 14, 2011

Wind gusts tonight in western WA

Weather Underground is predicting gusts of up to 45 miles an hour in Seattle this evening.

To answer common questions about what storm damage is covered by insurance, we built a web page largely devoted to wind damage and insurance.

Hope you don't need it, but if you do, it may help. (And yes, that ladder doesn't look too safe to us, either.)

Chronicles of Movement, by February blogger of the month Irene Koplinka-Loehr

A view of my apartment
from the road

 I woke up this morning to find my housemate in the bathroom and myself short on time. Lacing my key to my right running shoe I headed out the door with a full bladder and the hope of a pit stop within the first ten minutes. In the United States, amongst runners, gas stations are notorious for their lack of enthusiasm for the ‘non-paying’ bathroom frequenter, thus I felt a good deal of apprehension about receiving a friendly welcome at the nearby fuel stations, especially with my limited Hebrew skills (luckily the phrase, “Sherooteem, bavakasha” “Bathroom, Please” was mastered in the early days of my language acquisition). Normally, being that I hail from upstate New York, I would just peel off into a thickly forested area and be done with the whole issue,[1] unfortunately, subtly undulating desert is less conducive to such behavior. Thus with slight trepidation I began to case out the options, after a few minutes and accumulating pressure, I chanced it at the last station before wasteland. The sliding double doors opened, the cashiers looked up, I assertively used my phrase while simultaneously trying to hide the sweatier parts of me and, without a missed beat, they graciously directed me to the glistening, well-stocked relief zone. I left a minute later with their ‘Good Day’ echoing behind me, finding myself, once again, surprised by the duality of Israelis. While pushy and occasionally offensively frank, they are incredibly giving, helpful, and flexible in wonderful, unexpected ways; take a tip, US gas stations.

Earlier this week I came around the corner of the alleyway (perhaps that is a misnomer, small tunnel-like space between two larger houses) leading to my apartment and came face to face with a medium-sized black and white cat. Obviously well fed, it was balancing on the wall to the right of the path. What caught my eye—because, lets be honest, not-seeing a cat in Beer Sheva would be significantly more bizarre—was that it was staring directly at me. Cats in Beer Sheva are, in one, ridiculously curious, and supremely skittish; as such, they are often caught in a spread-leg state of paralysis, prepared to leave, but seemingly unwilling to miss whatever might come next. This cat, following suit, jumped off the wall and played the same game as I handily avoided it to go up to my apartment (I have been giving them a wider birth ever since one of them left a gash in a classmates foot last semester). As I was about to close the door I startled to see a small white head peeking around the doorframe, certainly the closest a cat has ever come to darting in; it was clear that this guy knew how to obtain food. It should be noted that there are three types of cats here: the scrawny ones that fly out of garbage disposals as you walk by, often, but not always, right into you; the plush, medium sized ones, typified by the above; and the cats that eat other cats. While the last has never been officially documented, it is more than clear that there is one, extremely large, fluffy, confident cat per neighborhood, best described as ‘harem leader’. Gimel’s has been dubbed: The Snow Leopard.

A recent trend in Israeli style was mentioned in our Anthro class this week: English phrases on clothing. Our Epidemiology professor, perpetually perky in the face of our obstinate early-morning silence and lateness, has been known to wear a long maternity shirt on which is printed, in English, I *heart* my Baby. This top, which is incidentally very flattering and a great color, causes a certain amount of amusement among those of us that make it at 8:15. Israelis, while they most probably know English well enough to be able to read the writing, do not care what the shirt says, rather, they care about the fit or the color—text is irrelevant. A classmate related to me that he had seen an older man on the lawn, just after prayers walking back toward the hospital with a pink knit hat reading ‘hot b**’ on the side. Awesome.

Sunset in the Negev.
On Tuesday, our clinical rotation morning, my group had the pleasure of joining a nurse to visit a patient in one of the recognized Bedouin villages. In plastic lawn chairs we sat around two large queen beds in an open, lowly lit room. One of the beds held the patient, survivor of a stroke, wrapped in blankets, slowly recovering. Minutes after we arrived the patient’s daughter brought in small glass cups with sweet tea, along with olive oil and zatar to eat with the flatbread we had picked up on our way. Many of the villages have minimal care facilities or only occasional care options (a maternal health clinic that comes to the villages every week or so). As such, having a nurse that checks on patients regularly is important both for continuing care and to build rapport with the communities. The nurse learned Arabic over her years of work and made the decision to go back to school for Anthropology after beginning her work with the villages to gain a more academic context for her work. She has discovered that, as both healthcare provider and ‘outsider,’ she is often privy to information and emotions that she would not see as a community member. As we were driving back to Beer Sheva, she said, “I know things about some of the women in these villages, that I will never tell anyone,” something which as we are discovering, is a necessity in the practice of medicine.  - blogger of the month, Irene Koplinka-Loehr

[1] In fact, in high school I ran a race where, after a mega-hill (dubbed Everest in team lore), I had to stop and jump off-trail into the woods. The following week, on the same course, my coach exclaimed loudly at the amount of time I cut off of my race. Truly, improvement is all about perception. 

Colts Neck Lunch N Learn: Sugar Blues

Have you had enough Valentine's Day candy to give you the Sugar Blues?
3HC will be holding a Lunch N' Learn workshop on how to beat those Sugar Blues this Saturday! Come join us and we will feed your brain with lots of yummy information. Bring a healthy (teehee) bagged lunch to feed your belly.Saturday, February 19th at 12pm at Colts Neck Recreation & Parks.

February Healthy Happy Hour: Teak, Red Bank

Come join 3HC this Friday night for Healthy Happy Hour, Japanese style! We will be having a couple of healthy cocktails at Teak in Red Bank, NJ from 7-9pm. Hope to see you there!

The Good News and the Bad News: Decreases in Maternal Deaths, But Not for Everyone

Mother and child in Ethiopia.
Over the past year, UNFPA and The Lancet released findings that offer a clear view of the maternal health interventions that save lives. This evidence affirms the efficacy of the most widely-used systems- and treatment-level interventions in the field. It clearly demonstrates good quality, comprehensive reproductive health services, including access to emergency obstetric care, family planning and antiretroviral (ARV) therapy, is key to reducing maternal mortality. And this complement of care must be delivered in strong, fully functional health systems.

Global reductions in maternal deaths are finally appearing at the population level, for the first time during my career. This holiday season, unlike any before, we can reflect on these accomplishments with renewed pride based on hard evidence, proof that our work is creating real global change.

However, the vast gains made in some countries, while great cause for optimism, must not be allowed to mask the much slower progress—even reversals—in others, most especially those experiencing conflict and crisis. Fragile states do not have the functional health systems and the necessary trained clinicians, medicines and equipment to reduce maternal death.

Now that we have the evidence to confirm that our interventions save lives, we must continue to apply this knowledge to those most in need. Women still become pregnant and experience life-threatening complications during war and in the aftermath of floods and earthquakes. They want to prevent pregnancy in these circumstances; they still want to space or limit their births. The proven interventions to prevent maternal death must be implemented or strengthened in countries experiencing or emerging from humanitarian emergencies.

Knowing what works isn’t enough. We’ll need the collective will and financial commitment to provide reproductive health care in crisis-affected countries that, to date, have been sorely lacking.

Women have a fundamental right to good quality care and a health system that can consistently provide it, no matter the crisis going on around them. When these are prioritized, we can expect an even more dramatic decline in women’s needless suffering and death.

Therese McGinn, DrPH, Director, The Reproductive Health Access, Information, and Services in Emergencies (RAISE) Initiative. The RAISE Initiative works to catalyze change in how reproductive health is addressed by all sectors involved in emergency response, from field services to advocacy, from local aid providers to global relief movements.

Sunday, February 13, 2011

Does protein leach calcium from the bones? Yes, but only if it is plant protein

The idea that protein leaches calcium from the bones has been around for a while. It is related to the notion that protein, especially from animal foods, increases blood acidity. The body then uses its main reservoir of calcium, the bones, to reduce blood acidity. Chris Masterjohn does not agree with this idea. This post generally supports Chris’s view, and adds a twist to it, related to plant protein consumption.

The “eat-meat-lose-bone” idea has apparently become popular due to the position taken by Loren Cordain on the topic. Dr. Cordain has also made several important and invaluable contributions to our understanding of the diets of our Paleolithic ancestors. He has argued in his book, The Paleo Diet, and elsewhere (see, e.g., here) that to counter the acid load of protein one should eat fruits and vegetables. The latter are believed to have an alkaline load.

If the idea that protein leaches calcium from the bones is correct, one would expect to see a negative association between protein consumption and bone mineral density (BMD). This negative association should be particularly strong in people aged 50 and older, who are more vulnerable to BMD losses.

As it turns out, this idea appears to be correct only for plant protein. Animal protein seems to be associated with an increase in BMD, at least according to a study by Promislow et al. (2002). The study shows that there is a positive multivariate association between animal protein consumption and BMD; an association that becomes negative when plant protein consumption is considered.

The study focused on 572 women and 388 men aged 55–92 years living in Rancho Bernardo, California. Food frequency questionnaires were administered in the 1988–1992 period, and BMD was measured 4 years later. The bar chart below shows the approximate increases in BMD (in g/cm^2) for each 15 g/d increment in protein intake.

The authors reported increments in BMD for different increments of protein (15 and 5 g/d), so the results above are adjusted somewhat from the original values reported in the article. Keeping that in mind, the increment in BMD for men due to animal protein was not statistically significant (P=0.20). That is the smallest bar on the left.

Does protein leach calcium from the bones? Based on this study, the reasonable answers to this question are yes for plant protein, and no for animal protein. For animal protein, it seems to be quite the opposite.

Even more interesting, calcium intake did not seem to be much of a factor. BMD gains due to animal protein seemed to converge to similar values whether calcium intake was high, medium or low. The convergence occurred as animal protein intake increased, and the point of convergence was between 85-90 g/d of animal protein intake.

And high calcium intakes did not seem to protect those whose plant protein consumption was high.

The authors do not discuss specific foods, but one can guess the main plant protein that those folks likely consumed. It was likely gluten from wheat products.

Are the associations above due to: (a) the folks eating animal protein consuming more fruits and vegetables than the folks eating plant protein; or (b) something inherent to animal foods that stimulates an increase in the absorption of dietary calcium, even in small amounts?

This question cannot be answered based on this study; it should have controlled for fruit and vegetable consumption for that.

But if I were to bet, I would bet on (b).


Promislow, J.H.E., Goodman-Gruen, D., Slymen, D.J., & Barrett-Connor, E. (2002). Protein consumption and bone mineral density in the elderly. American Journal of Epidemiology, 155(7), 636–644.