Food Reward: a Dominant Factor in Obesity, Part I

A Curious Finding

It all started with one little sentence buried in a paper about obese rats. I was reading about how rats become obese when they're given chocolate Ensure, the "meal replacement drink", when I came across this:

...neither [obesity-prone] nor [obesity-resistant] rats will overeat on either vanilla- or strawberry-flavored Ensure.

The only meaningful difference between chocolate, vanilla and strawberry Ensure is the flavor, yet rats eating the chocolate variety overate, rapidly gained fat and became metabolically ill, while rats eating the other flavors didn't (1). Furthermore, the study suggested that the food's flavor determined, in part, what amount of fatness the rats' bodies "defended."

As I explained in previous posts, the human (and rodent) brain regulates the amount of fat the body carries, in a manner similar to how the brain regulates blood pressure, body temperature, blood oxygenation and blood pH (2). That fact, in addition to several other lines of evidence, suggests that obesity probably results from a change in this regulatory system. I refer to the amount of body fat that the brain defends as the "body fat setpoint", however it's clear that the setpoint is dependent on diet and lifestyle factors. The implication of this paper that I could not escape is that a food's flavor influences body fatness and probably the body fat setpoint.

An Introduction to Food Reward

The brain contains a sophisticated system that assigns a value judgment to everything we experience, integrating a vast amount of information into a one-dimensional rating system that labels things from awesome to terrible. This is the system that decides whether we should seek out a particular experience, or avoid it. For example, if you burn yourself each time you touch the burner on your stove, your brain will label that action as bad and it will discourage you from touching it again. On the other hand, if you feel good every time you're cold and put on a sweater, your brain will encourage that behavior. In the psychology literature, this phenomenon is called "reward," and it's critical to survival.

The brain assigns reward to, and seeks out, experiences that it perceives as positive, and discourages behaviors that it views as threatening. Drugs of abuse plug directly into reward pathways, bypassing the external routes that would typically trigger reward. Although this system has been studied most in the context of drug addiction, it evolved to deal with natural environmental stimuli, not drugs.

As food is one of the most important elements of survival, the brain's reward system is highly attuned to food's rewarding properties. The brain uses input from smell, taste, touch, social cues, and numerous signals from the digestive tract* to assign a reward value to foods. Experiments in rats and humans have outlined some of the qualities of food that are inherently rewarding:

• Fat
• Starch
• Sugar
• Salt
• Meatiness (glutamate)
• The absence of bitterness
  
• Certain textures (e.g., soft or liquid calories, crunchy foods)
• Certain aromas (e.g., esters found in many fruits)
• Calorie density ("heavy" food)
  

We are generally born liking the qualities listed above, and aromas and flavors that are associated with these qualities become rewarding over time. For example, beer tastes terrible the first time you drink it because it's bitter, but after you drink it a few times and your brain catches wind that there are calories and a drug in there, it often begins tasting good. The same applies to many vegetables. Children are generally not fond of vegetables, but if you serve them spinach smothered in butter enough times, they'll learn to like it by the time they're adults.

The human brain evolved to deal with a certain range of rewarding experiences. It didn't evolve to constructively manage strong drugs of abuse such as heroin and crack cocaine, which overstimulate reward pathways, leading to the pathological drug seeking behaviors that characterize addiction. These drugs are "superstimuli" that exceed our reward system's normal operating parameters. Over the next few posts, I'll try to convince you that in a similar manner, industrially processed food, which has been professionally crafted to maximize its rewarding properties, is a superstimulus that exceeds the brain's normal operating parameters, leading to an increase in body fatness and other negative consequences.


* Nerves measure stomach distension. A number of of gut-derived paracrine and endocrine signals, including CCK, PYY, ghrelin, GLP-1 and many others potentially participate in food reward sensing, some by acting directly on the brain via the circulation, and others by signaling indirectly via the vagus nerve. More on this later.

Washington state to bar insurer from writing new coverage

(Updated -- see note at bottom of this post.)

Washington State Insurance Commissioner Mike Kreidler has issued an order barring Ability Insurance Company, of Omaha, Neb., from writing new policies in Washington for the next six months.

The order, issued Wednesday, takes effect in 10 days.

The order stems from the company’s failure to honor long-term care coverage that lapsed after a senior citizen with dementia failed to make her payments. In such situations, state law allows a consumer to reinstate coverage within five months of the policy’s lapse.

“Situations like this are exactly why we have this law,” said Kreidler. “It protects people who, through no fault of their own, have lost the ability to keep up with their financial records.”

The suspension does not affect the company’s duties under current policies. The company can also continue to renew existing policies.

In this case, the company on March 20, 2009 sent the woman a notice of non-payment, warning that her policy would lapse unless paid within the next 35 days.

When her daughter called the company about a claim on Aug. 4, 2009 – well within the five-month period – the company failed to tell her that the policy had lapsed. The daughter didn’t learn of the lapsed policy until she checked her mother’s mail in September. This was still well within the five-month period.

Nonetheless, the company refused to reinstate the coverage. It contended that the five-month window started the day the premium was due, not at the end of the 35-day period mentioned in its March 20 letter.

Also Wednesday, Kreidler issued a cease-and-desist order telling the company to stop violating state law in such cases. He is also imposing a $10,000 fine on the company.

The company has the right to demand a hearing.

Update on May 4, 2011: Ability has requested a hearing, which automatically stays the suspension pending the outcome of the hearing.

Second update: On June 6, 2012, Kreidler's order was upheld, meaning that the company's authority to write new business was suspended for six months. The company was also fined $10,000.

The Impact of Prenatal Exposure to Pollutants: The China Initiative

Taiyaun City

The Columbia Center for Children’s Environmental Health (CCCEH) launched its first China study in 2001. The study was conducted in Tongliang, China, where a coal-fired power plant located in the center of town was the major source of ambient air pollution. In 2004, local officials shut down the power plant, creating a unique opportunity to study the effects of energy-related air pollution on children’s health before and after the plant’s closure.

Researchers specifically documented the impact of in utero exposure to polycyclic aromatic hydrocarbon (PAHs), a carcinogenic pollutant emitted from fossil fuel burning. The study tracked two cohorts of pregnant women and their children: the first was enrolled while the plant was still operational, and the second was enrolled after government authorities shut the facility down.

The study found that prenatal exposures to coal-related air pollutants adversely affected children’s health and neurodevelopment. Analyses showed that children born in 2002 when the power plant was still operating had higher levels of exposure to combustion-related PAH (measured by PAH-DNA adducts in cord blood) compared to the later cohort. Children with higher levels of prenatal exposure to PAHs had reduced head circumference at birth and a lower growth rate in childhood.

It was also shown that children who had higher levels of prenatal exposure to PAHs scored lower on the Gesell Scales of Child Development at age 2 and had more developmental delays than children who were less exposed in utero. Children born in 2005 by contrast, just a year after the plant was closed, had significantly lower levels of PAH-DNA adducts in cord blood, and did not show significant associations between PAHs and growth and developmental effects.

Tongliang power plant.

Building on this strong foundation in Tongliang, CCCEH launched a new serial prospective cohort study in Taiyuan and Changzhi, China. Taiyuan is the capital of the coal-rich Shanxi Province and is one of the most polluted areas of the country. This unfortunate distinction has been recognized by the Chinese government and the region is beginning to implement strong new policy measures to reduce air pollution over time.

Changzhi, also located in Shanxi Province, was selected for its lower pollution levels and thus serves as the concurrent control for the study. CCCEH’s goal is to document the direct benefits of these government policies in Taiyuan in terms of air quality, biomarkers of exposure in cord blood, and health and developmental outcomes in the children. These study findings, in conjunction with the findings from the Mothers and Newborn Studies in Tongliang, Krakow and New York City, have implications for future energy and public health policies in China and other coal-dependent nations.


Deliang Tang, MD, DrPH
Department of Environmental Health Sciences
Mailman School of Public Health

Other Investigators on the China Initiative: Frederica Perera, DrPH, and Julie Herbstman, PhD.

*Columbia University’s Mailman School of Public Health is pleased to announce a new practicum opportunity for MPH students at Fudan University’s School of Public Health (FUSPH) in Shanghai. FUSPH is offering a unique 3-6 month internship for students interested in international research. Two students will be selected to participate each year. The program is headed by Dr. Zhijun Zhou, Vice Dean of FUSPH.

Passover reflections from Beersheva, by May blogger of the month Talie Lewis

Hello Blog followers,

My name is Talie and I am excited to be typing up my thoughts in this way for the first time.

We first years have officially been on vacation for the past 10 days. This break began right after we took our Microbiology shelf exam, which tested us on all small things in the world that can cause infection.....and there are a lot. I'm including this in my post because I feel obligated to write something medical school-y. If I only included the text to come, you could easily assume I was just in Israel for a visit.

As many of my classmates boarded flights to the States, Europe and some other exciting locations two Thursdays ago, I began cleaning my apartment for Passover. A few months ago, when I found out my sister Rachie was going to be visiting Israel during this time, we decided that we would host two traditional Passover seders (ritual feasts that mark the beginning of Passover...according to wikipedia) for friends and family in my apartment in Beersheva. While I have always been an active participant in seders, I have never been a host and was excited for the opportunity.

I came to Israel knowing some people who were already living here or who had decided to spend this year in Israel. Hosting these seders gave me the opportunity to bring them, as well as some of my wonderful classmates who I have gotten to know over the past 9 months, together for two nights of traditional Passover foods, enlightening discussions and spirited singing.   

The two groups that ended up coming to these seders were both composed of an extremely interesting mix of people. My father and his wife, who live in Jersualem, two cousins, one of whom also lives in Jerusalem and the other of whom is studying in a Jewish learning institution for 10 months before he starts college next year. There were friends from college, a brother of a friend from college, a friend from summer camp, one of my sister's former housemates and of course, MSIH classmates. The range of experiences and world views that were present was pretty wide and I think that through our discussions about the Jewish people's exodus from Egypt many years ago (which is the central theme of Passover seders) and the various directions in which those discussions went, that range manifested itself in some pretty cool ways. Many old and many new questions were asked. Very traditional Jewish interpretations of the passover texts were offered as were interpretations that incorporated modern day examples of oppression, freedom and revolutions.

After reflecting on the mixture of ideas that came up over the course of those two nights, I realize that many of the thoughts I have had regarding Israel and the ways in which it relates to different populations, since arriving in Beersheva last July were expressed by a bunch of individuals; from questions of what role a nation's history should play in modern decision making, to the tensions that arise from ensuring that Israel remain a Jewish state, to questions of who should have rights and what rights should they have. I don't bring these up with the intention of sounding political but rather to point out that I think part of living in Israel, especially in a medical school for international health context, is dealing with, or at least just thinking about, questions regarding the rights of different populations and more specifically how they affect health care access and cultural sensitivity. Having thought these thoughts on a regular basis, it seems appropriate that they played a significant role in my Passover seder experience.


On that note, I bid anyone who is reading this farewell and wish you a lovely day :)  - May blogger of the month Talie Lewis

How to file an appeal when a health insurer denies your claim

Picture this: Your 24-year-old daughter is seriously injured in a snowboarding accident. She suffered head injuries. She's heavily sedated. Your doctor wants to do urgent surgery to stem internal bleeding. It will be costly. But your health insurer refuses to authorize the surgery.

What do you do?

In the past, your options were to pay for the procedure yourself, get another opinion that will be less costly or do nothing. All are bad choices and time is critical.

We've posted a new "appeals kit" designed to help when insurers deny requests to authorize a particular service -- or to pay a claim afterward. The site can help you challenge decisions and appeal denials. We're one of the first states to compile this information into a one-stop, consumer-focused site.

In the case above, you'd have several choices:

• File an urgent appeal with your health insurer.
• If the insurer still says no, you can appeal to an independent third-party group made up of health care professionals. They can overrule your insurance company and make it pay. (Over the last three years, nearly 1 in 4 appeals that were sent to an independent review organization by a health plan ruled in favor of Washington consumers.)
• You can sue.
• Or you can file a complaint with our office. 

All this can be complicated, depending on your type of coverage, type of appeal, and the timeline. But the online guide walks you through those options, with a handy worksheet to keep track of key information, etc.

Check it out.
(Corrected two links. Thanks to Public Data Ferret for the heads-up.)

Building Relationships for Stronger Health Care in Liberia and Ghana

After working with representatives of Liberia and Ghana for three years, Gabe Forrey, GHLI Conference Project Manager, finally made his first trip to these countries visiting the delegates who will be attending the GHLI Conference in June. “After meeting in person to understand problems and discussing next steps, I heard a change in their voice, and saw them take ownership over the process to create their own strategic plan of the process to create a feasible plan to reduce maternal mortality during my visit,” explains Gabe.

Gabe’s visit focused on building personal and professional relationships with delegates -- beyond the confines of email -- to confirm respective delegations and confirm logistics for GHLI fellows in the summer.

Gabe shared one of his most memorable experiences talking to Dr. Camara, who is an advisor to student fellows. Although visibly busy, when he sat down to discuss the conference with Gabe, they talked for almost three hours. Gabe explained, “He’s now invested, we can grow and continue to see success and it’s an exciting feeling.”

Gabe described how inspiring it was when all six delegates rearranged their schedules for a group meeting, to meet, illustrating their commitment to taking the conference seriously. “Sitting face-to-face with the delegates helped me bring a new level of energy and excitement to them about the conference,” says Gabe. “I was able to answer questions, clarify details and address any concerns for them immediately.”

Gabe shared his hopes for the future of Liberia’s health outcomes by breaking away from content with the status quo. “If they can elevate quality of care while also improving trust in the community,” he explains. “They could start out small and build.”

Liberia’s 2011 country delegations are as follows: Gregory Walker, Margibi County health services administrator; Vivian Cherue, deputy minister of health; Aribella Greaves, former assistant minister of planning, r&d, Ministry of Health & former technical officer, World Health Organization; Ansumana Camara, Montserrado County health officer; Satta Mckay, Montserrado County health services administrator and Hawa Kromah, Margibi County health officer.

Amanda Sorrentino, GHLI Intern

Alcohol consumption, gender, and type 2 diabetes: Strange … but true

Let me start this post with a warning about spirits (hard liquor). Taken on an empty stomach, they cause an acute suppression of liver glycogenesis. In other words, your liver becomes acutely insulin resistant for a while. How long? It depends on how much you drink; possibly as long as a few hours. So it is not a very good idea to consume them immediately before eating carbohydrate-rich foods, natural or not, or as part of sweet drinks. You may end up with near diabetic blood sugar levels, even if your liver is insulin sensitive under normal circumstances.

The other day I was thinking about this, and the title of this article caught my attention: Alcohol Consumption and the Risk of Type 2 Diabetes Mellitus. This article is available here in full text. In it, Kao and colleagues show us a very interesting table (Table 4), relating alcohol consumption in men and women with incidence of type 2 diabetes. I charted the data from Model 3 in that table, and here is what I got:

I used the data from Model 3 because it adjusted for a lot of things: age, race, education, family history of diabetes, body mass index, waist/hip ratio, physical activity, total energy intake, smoking history, history of hypertension, fasting serum insulin, and fasting serum glucose. Whoa! As you can see, Model 3 even adjusted for preexisting insulin resistance and impaired glucose metabolism.

So, according to the charts, the more women drink, the lower is the risk of developing type 2 diabetes, even if they drink more than 21 drinks per week. For men, the sweet spot is 7-14 drinks per week; after 21 drinks per week the risk goes up significantly.

A drink is defined as: a 4-ounce glass of wine, a 12-ounce bottle or can of beer, or a 1.5-ounce shot of hard liquor. The amounts of ethanol vary, with more in hard liquor: 4 ounces of wine = 10.8 g of ethanol, 12 ounces of beer = 13.2 g of ethanol, and 1.5 ounces of spirits = 15.1 g of ethanol.

Initially I thought that these results were due to measurement error, particularly because the study relies on questionnaires. But I did some digging and checking, and now think they are not. In fact, there are plausible explanations for them. Here is what I think, and it has to do with a fundamental difference between men and women – sex hormones.

In men, alcohol consumption, particularly in large quantities, suppresses testosterone production. And testosterone levels are inversely associated with diabetes in men. Heavy alcohol consumption also increases estrogen production in men, which is not good news either.

In women, alcohol consumption, particularly in large quantities, increases estrogen production. And estrogen levels are (you guessed it) inversely associated with diabetes in women. Unnatural suppression of testosterone levels in women is not good either, as this hormone also plays important roles in women; e.g., it influences mood and bone density.

What if we were to disregard the possible negative health effects of suppressing testosterone production in women; should women start downing 21 drinks or more per week? The answer is “no”, because alcohol consumption, particularly in large quantities, increases the risk of breast cancer in women. So, for women, alcohol consumption in moderation may also provide overall health benefits, as it does for men; but for different reasons.

A few favorite things: Live Jolly and Russell James!

I think it’s safe to say at this point that I have been obsessed with raw foods lately. While I have learned a lot from starting our raw cleanse and have been maintaining a mostly raw diet, I am still very far from being a raw chef. Mainly because raw food prep generally requires some equipment in lieu of a stove, including a high-speed blender, a good food processor and a dehydrator, of which I only have one. But, my goal is to own the other two and make good use of them, which means I need and want to continue to learn as much as I can about making raw foods.

That being said, this past week has been full of opportunities to do that. Starting with last week when I had the opportunity to meet up with Chris Jolly, raw chef and owner of Live Jolly foods and I have to give him a shout out. Chris is a New Jersey native who works out of Avon and Red Bank to prepare raw entrees and desserts that can be found at health food stores throughout the area. If you have ever been to Dean’s in Ocean and Shrewsbury or Nature’s Corner in Spring Lake, you may have seen or even tried his raw pizza, pad thai or ‘cheese’cakes, to name a few. Chris’s foods are so good and so popular that he will soon be selling in Whole Foods and is working on a bunch of new products, including kale chips, flax crackers and granola which will be available in stores soon. Which will make it much more convenient for those of us who don’t have a dehydrator at home, all while supporting a local and health-inspired business!

I hope to learn more from Chris in the next few months and can’t wait to try his new items! That being said, Live Jolly needs our help to ensure that his new products hit the shelves. They started a crowd funding project to help fund the new products and make sure that we all get to sample them. You can learn more about the project here: http://www.indiegogo.com/Granola-its-not-just-for-hippies-anymore. Unlike many crowd funding projects, this is not a donation or handout. Instead by contributing what you like, you get some of the new products in return. So it’s basically like ordering the product on line and getting a chance to taste them before anyone else, without ever having to leave your home! Live Jolly has a month left to reach their goal, so lets help them out and eat some yummy raw foods!

Next up was a trip into Manhattan with my friend Nancy to a place called Organic Avenue, a small boutique specializing in raw foods where I had the most amazing ‘Mint Chip’ smoothie. This place was a great resource for raw food products from nut cheese bags, raw chocolates, a variety of snacks and some of the harder to find products like alkalizing water drops and liquid chlorophyll. Yeah, I have no idea what I’d do with the latter, either. Anyway, the reason we ventured all the way to Organic Avenue was not to spend too much money on a some raw chocolate, snacks and a smoothie (which I did), but rather to see The Raw Chef, Russell James demo some of his recipes. If you are at all interested in raw foods, I suggest you google him. He is a wealth of knowledge and has tons of amazing recipes and how-to videos, and he has a way of making things a lot less intimidating. In a mere two hours he whipped up some falafel, flax crackers, nut ‘cheese’ and hummus... all of which were delicious!

Lastly, on the raw journey: In order to put some of this new knowledge to the test, Terra and I decided to tackle one of Russell’s recipes - an insanely rich chocolate torte with strawberry sauce and cashew/ginger cream, for Nancy for her birthday. We may not have done it as easily, or as pretty, as Russell, but I think we did a pretty darn good job, and Nancy loved it! However, as you will see from the recipe below, I will admit that it did take some time to prepare and while we had a blast doing it, it did make me thankful that we have some amazing local raw chefs, like Chris Jolly, to do the work for us!

If you are so bold to try a hand at it yourself, the following is Russell's recipe for the Chocolate Torte (most of the ingredients will be found in any good health food/natural food store. This is a very intense and rich dark chocolate torte... but free of dairy, flour and refined sugar!).

Russell James' Chocolate Torte:


The Crust:
1 1/2 cups raw pecans
3/4 raisins roughly chopped
2 Tbsn softened raw coconut oil*
1 tsp vanilla extract
1 tsp cinnamon
pinch of sea salt

Process pecans, raisins, cinnamon and salt in a food processor. Add coconut oil and vanilla and process again until pastey. Press mixture into the bottom of a 9" springform pan or pie plate. (You can sprinkle the bottom of the pie plate with a little bit of dried coconut to prevent the crust from sticking). Place in the fridge.

The Filling:
2 cups raw cashews
1 cup water
2 cups raw cacao powder
1 1/2 cups cacao butter*
2 Tbsn vanilla extract
1/2 cup agave nectar
1/2 Tbsn lemon juice

Blend cashews, water, vanilla, agave and lemon juice in a high speed blender until smooth. Add cacao butter and powder and blend again. You may need to add more water to get the desired consistency (similar to a thick pudding). Pour mixture into pie crust and smooth evenly. Return to fridge to set for 2-3 hours.

The Ginger Cream:
1 cup raw cashews
2 Tbsn coconut oil
1/4 cup raw agave nectar
1 Tbsn fresh grated ginger
pinch of ground clove
2 tspn vanilla extract

Blend all ingredients in a food processor or blender until smooth and creamy. You want a creamy sauce-like consistency. If it is too thick to "drizzle", you may need to add some water and blend again until you reach the desired consistency.

Strawberry Sauce:
1 cup fresh chopped strawberries
3 Tbsn agave nectar
2 Tbsn lemon juice
1/2 tspn cinnamon
1/4 tspn nutmeg

Blend all ingredients in a food processor or blender.

Drizzle both the ginger cream and strawberry sauce over the torte when ready to serve!
*Note: Both the cacao butter and coconut oil should be softened by placing in a bowl over hot water. It is easiest to do this with the cacao if it is finely grated first. You do not want to heat these too high though so be careful about heating them on the stove.

If you decide to attempt this or any of Russell's recipes, or get to taste some of Live Jolly's new products, you will have to let us know what you think!

Keep it fresh and local!
-Jill

Upcoming Talks

I'll be giving at least two talks at conferences this year:

Ancestral Health Symposium; "The Human Ecological Niche and Modern Health"; August 5-6 in Los Angeles. This is going to be a great conference. Many of my favorite health/nutrition writers will be presenting. Organizer Brent Pottenger and I collaborated on designing the symposium's name so I hope you like it.

My talk will be titled "Obesity; Old Solutions to a New Problem." I'll be presenting some of my emerging thoughts on obesity. I expect to ruffle some feathers!

Tickets are going fast so reserve one today! I doubt there will be any left two weeks from now.


TEDx Harvard Law; "Food Policy and Public Health"; Oct 21 at Harvard. My talk is tentatively titled "The American Diet: a Historical Perspective." This topic interests me because it helps us frame the discussion on why chronic disease is so prevalent today, and what are the appropriate public health measures to combat it. This should also be a great conference.

How to find old life insurance policies (and other unclaimed property)

The case: A woman recently called us, trying to track down a life insurance policy that her grandmother had bought in 1971. The policy had been sold by one company to another.

"Makes me wonder how many policies go unclaimed," she said.

A lot. According to the New York Times, hundreds of millions of dollars each year.

So how do you track down a relative's old policy?

• Gather as much information as possible: name, insurer and any relevant documents. Try to find the policy itself, which will have a number on it. Make sure you have a copy of the death certificate.

• Tip: If you can't find the company, try going through the person's financial records, looking for payments made to an insurer. Also, look through old mail -- the company may have sent periodic statements or billing reminders. If you know which company they had their auto= or homeowners coverage with, consider contacting that company. People often use the same insurer for life insurance.

• Then, make sure the company still exists, or if it merged with another company. If you live in Washington state, we can help with this, for free. Call us at 1-800-562-6900. If you live in another state, call your state's insurance regulator for help.

• If you can't find any information, even the name of the company, you may want to pay a search company to run your relative's name against insurance industry databases or to contact a large number of insurers directly. Examples include companies like MIB Solutions or The Lost Life Insurance Finder Expert. (Note: mentioning a company or product on this blog ≠ endorsement.)

• If the policy goes unclaimed for a long time, insurers are supposed to turn the money over to state unclaimed property funds. Run your relative's name through these free, state-run online search sites. Here's Washington state's official unclaimed property site. And here's a list of similar official unclaimed property sites in other states.

• Tip: Online companies can also search for unclaimed property for you, but with a little time at your computer and the sites listed above, you can do the same thing, for free, yourself.

As for that life insurance case, we helped the woman figure out the current company holding the policy and file a claim.

"This is incredible," she wrote. "We can't thank you enough."

Bonus round: Here are our tips if you're buying life insurance or an annuity.

Building on Success in South Africa

Erika Linnander’s face lights up as she talks about her recent GHLI trip to Ethiopia.  “It was fantastic,” she says.  “There’s such diverse leadership within the programs.”

During her two weeks immersed in Ethiopian health clinics and hospitals, she worked on developing GHLI’s Ethiopian Hospital Management Initiative (EHMI) and Ethiopian Millennium Rural Initiative (EMRI) programs.

Erika spent her first week working with the first cohort of students in the Master’s of Hospital Administration program at Addis Ababa University (AAU), where she was teaching financial management. This program is similar to the successful three year program established by Yale at Jimma University, which now fully functions on its own.

 “It was a mark of success to see Jimma University’s program sustained without GHLI,” shared Erika, after visiting this program during her second week. Erika expressed her hope for the same success at Addis Ababa University.

During the second week of her visit, Erika visited two EMRI health centers.  Yale, working together with the Clinton Health Access Initiative seeks to strengthen health outcomes in rural areas by using quantitative and qualitative data to evaluate and improve program design. Erika said she feels personally invested in the quality of this data and said she was also excited for the potential to use the data in  future collaboration in Ethiopia, such as an emerging initiative that will focus on maternal and child health.

As for her future ideas for these programs, Erika says she hopes the first cohort at AAU will join with other hospital CEOs in Ethiopia in a quality alliance, a network that will foster the sharing and blending of local solutions and global best practices to improving hospital quality.  She also emphasized how the creation of clinical blueprints, which is in the works between GHLI and CHAI, has the potential to serve as a bridge between ministry standards and guidelines and actual improvements in provider practices. 

Amanda Sorrentino, GHLI Intern

Low bone mineral content in older Eskimos: Meat-eating or shrinking?

Mazess & Mather (1974) is probably the most widely cited article summarizing evidence that bone mineral content in older North Alaskan Eskimos was lower (10 to 15 percent) than that of United States whites. Their finding has been widely attributed to the diet of the Eskimos, which is very high in animal protein. Here is what they say:

“The sample consisted of 217 children, 89 adults, and 107 elderly (over 50 years). Eskimo children had a lower bone mineral content than United States whites by 5 to 10% but this was consistent with their smaller body and bone size. Young Eskimo adults (20 to 39 years) of both sexes were similar to whites, but after age 40 the Eskimos of both sexes had a deficit of from 10 to 15% relative to white standards.”

Note that their findings refer strictly to Eskimos older than 40, not Eskimo children or even young adults. If a diet very high in animal protein were to cause significant bone loss, one would expect that diet to cause significant bone loss in children and young adults as well. Not only in those older than 40.

So what may be the actual reason behind this reduced bone mineral content in older Eskimos?

Let me make a small digression here. If you want to meet quite a few anthropologists who are conducting, or have conducted, field research with isolated or semi-isolated hunter-gatherers, you should consider attending the annual Human Behavior and Evolution Society (HBES) conference. I have attended this conference in the past, several times, as a presenter. That gave me the opportunity to listen to some very interesting presentations and poster sessions, and talk with many anthropologists.

Often anthropologists will tell you that, as hunter-gatherers age, they sort of “shrink”. They lose lean body mass, frequently to the point of becoming quite frail in as early as their 60s and 70s. They tend to gain body fat, but not to the point of becoming obese, with that fat replacing lean body mass yet not forming major visceral deposits. Degenerative diseases are not a big problem when you “shrink” in this way; bigger problems are  accidents (e.g., falls) and opportunistic infections. Often older hunter-gatherers have low blood pressure, no sign of diabetes or cancer, and no heart disease. Still, they frequently die younger than one would expect in the absence of degenerative diseases.

A problem normally faced by older hunter-gatherers is poor nutrition, which is both partially caused and compounded by lack of exercise. Hunter-gatherers usually perceive the Western idea of exercise as plain stupidity. If older hunter-gatherers can get youngsters in their prime to do physically demanding work for them, they typically will not do it themselves. Appetite seems to be negatively affected, leading to poor nutrition; dehydration often is a problem as well.

Now, we know from this post that animal protein consumption does not lead to bone loss. In fact, it seems to increase bone mineral content. But there is something that decreases bone mineral content, as well as muscle mass, like nothing else – lack of physical activity. And there is something that increases bone mineral content, as well as muscle mass, in a significant way – vigorous weight-bearing exercise.

Take a look at the figure below, which I already discussed on a previous post. It shows a clear pattern of benign ventricular hypertrophy in Eskimos aged 30-39. That goes down dramatically after age 40. Remember what Mazess & Mather (1974) said in their article: “… after age 40 the Eskimos of both sexes had a deficit of from 10 to 15% relative to white standards”.

Benign ventricular hypertrophy is also known as athlete's heart, because it is common among athletes, and caused by vigorous physical activity. A prevalence of ventricular hypertrophy at a relatively young age, and declining with age, would suggest benign hypertrophy. The opposite would suggest pathological hypertrophy, which is normally induced by obesity and chronic hypertension.

So there you have it. The reason older Eskimos were found to have lower bone mineral content after 40 is likely not due to their diet.  It is likely due to the same reasons why they "shrink", and also in part because they "shrink". Not only does physical activity decrease dramatically as Eskimos age, but so does lean body mass.

Obese Westerners tend to have higher bone density on average, because they frequently have to carry their own excess body weight around, which can be seen as a form of weight-bearing exercise. They pay the price by having a higher incidence of degenerative diseases, which probably end up killing them earlier, on average, than osteoporosis complications.

Reference

Mazess R.B., & Mather, W.W. (1974). Bone mineral content of North Alaskan Eskimos. American Journal of Clinical Nutrition, 27(9), 916-925.

Obesity and the Fluid-in, Fluid-out Therapy for Edema

I recently attended a lecture by Dr. Arya M. Sharma here at the University of Washington. Dr. Sharma is a Canadian clinician who specializes in the treatment of obesity. He gave the UW Science in Medicine lecture, which is a prestigious invited lecture.

He spent a little bit of time pointing out the fallacy behind conventional obesity treatment. He used the analogy of edema, which is an abnormal accumulation of fluid in the body.

Since we know that the amount of fluid contained in the body depends on the amount of fluid entering the body and the amount of fluid leaving the body, the treatment for edema is obvious: drink less, pee more.

Of course, this makes no sense. It doesn't address the underlying cause of edema and it will not help the patient. Yet we apply that exact same logic to fat loss. Since the amount of energy contained in the body (in the form of fat) depends on the amount entering and the amount leaving, the solution is easy: eat less, move more. Well, yes, if you can stick to that program it will cause fat loss. But that's equivalent to telling someone with edema to drink less water. It will cause a loss of fluid, but it won't correct the underlying problem that caused excessive fluid retention in the first place.

For example, if you have edema because your heart isn't pumping effectively (cardiac insufficiency), the heart is the problem that must be addressed. Any other treatment is purely symptomatic and is not a cure.

The same applies to obesity. If you don't correct the alteration in the system that causes an obese person to 'defend' his elevated fat mass against changes*, anything you do is symptomatic treatment and is unlikely to be very effective in the long term. My goal is to develop a method that goes beyond symptomatic treatment and allows the body to naturally return to a lower fat mass. I've been doing a lot of reading and I have a simple new idea that I feel confident in. It also neatly explains the results of a variety of weight loss diets. I've dropped a few hints here and there, but I'll be formally unveiling it in the next couple of months. Stay tuned.


* The body fat homeostasis system. The core element appears to be a negative feedback loop between body fat (via leptin, and insulin to a lesser degree) and the brain (primarily the hypothalamus, but other regions are involved). There are many other elements in the system, but that one seems to set the 'gain' on all the others and guides long-term fat mass homeostasis. The brain is the gatekeeper of both energy intake and energy expenditure, and unconscious processes strongly suggest appropriate levels for both factors according to the brain's perceived homeostatic needs. Those suggestions can be overridden consciously, but it requires a perpetual high degree of discipline, whereas someone who has been lean all her life doesn't require discipline to remain lean because her brain is suggesting behaviors that naturally defend leanness. I know what I'm saying here may seem controversial to some people reading this, because it's contrary to what they've read on the internet or in the popular press, but it's not particularly controversial in my field. In fact, you'll find most of this stuff in general neuroscience textbooks dating back more than 10 years (e.g., Eric Kandel and colleagues, Principles of Neuroscience).

Our team is ready to make the plan work for patients

By Rik Ganderton, 

President and CEO

Thanks to staff, physicians, volunteers and the community our new Strategic Plan On-A-Page is done. Our 2011 – 2014 Strategic Plan was developed with robust participation from all interested stakeholders.

The content of the final strategic plan was created as a result of information collected during almost a year of consultations with community members, political leaders, RVHS Board members, the Community Advisory Group, staff, physicians and volunteers.

Now what?

Now we must put this exciting plan to work for our patients and their families. Our team has proven itself adept at leading and implementing change so I have great confidence in our ability to put this plan into action quickly and effectively.

As a next step there are 19 program and service teams that are creating their own specific strategic sub-plans fully aligned to deliver on the hospital’s corporate plan. Work on this will be ongoing throughout the spring with our sub-plans to be completed by early June.

We currently have teams visiting each department on all shifts sharing the strategic plan and the draft Patient Declaration of Values with front-line staff. Thank you to our staff involved and those participating. The response has already been very positive.

RVHS’ Strategic Plan On-A-Page is again on one page. It’s concise, clear and easily communicated so that we can all focus on the three main strategic directions:

* We will focus on what is important to our patients;

* We will help to build a system of care that meets the needs of our community;

* We will strengthen our organization to be the best at what we do.

The essential question each of us must answer individually, in our teams, our departments or our areas of the hospital, is:

How do I personally, and as a part of my team, ensure that our patients and their families see that we are delivering on our strategic commitments?

To put it another way: How do we each walk our talk?

Everyone is asked to keep each sub-plan to one page. This is no easy feat. But I remind everyone that you have done a lot of great work in the last four years. Delivering this new plan is a continuation of your successes for our patients and our community.

I know we can deliver this new plan because, quite simply, we are a dedicated team always planning, managing and working to be the best at what we do for our patients and their families.

To read our RVHS Strategic Plan On-A-Page 2011-2014 please visit

http://www.rougevalley.ca/strategic_plan .  

Benefits of Ginger

Ginger is known for its tremendous healing benefits. It's a powerful natural health food and remedy. Historically, ginger is one of the best herbs for joint health due to its powerful anti-inflammatory properties. In addition to protecting the joints, ginger also has many other health benefits. I first began using ginger when I was diagnosed with IBS, back in 2000. I drank ginger tea and would chew on a yummy piece of crystallized ginger to calm my stomach. I still use it to this day on a consistent basis to help my belly. As spicy as it may be, its taste has become so comforting to me because I know how much it's going to help warm and heal my tummy!

It is known to:

- treat nausea

- aid digestion

- relieve spasms and menstrual cramps

- regulate blood sugar by stimulating the pancreas

- increase circulation (so its great for cold hands and feet!)

- reduce inflammation

How to incorporate ginger into diet:

- The ginger root can be freshly grated and used in cooking.

- Grated ginger root mixed with diluted lime juice can help to soothe the digestive tract and treat stomach pain.

- To treat arthritis, ginger oil can be massaged into the area of pain.

- Steep fresh ginger tea.

FRESH GINGER TEA:

Ingredients:

4 cups of water

2-inch piece of fresh ginger root

honey (optional)

dash of cardamom

Directions:

Peel the ginger root and slice it into thin slices. Bring the water to a boil in a saucepan. Once it is boiling, add the ginger. Cover it and reduce to a simmer for 15-20 minutes. Strain the tea. Add honey if you prefer a sweeter taste.

Enjoy!

Keep it fresh!
- Lauren

The Healer's Art......by blogger of the month Irene Koplinka-Loehr

This entry was a reply to a written request to students to submit a brief paragraph about their experiences while taking The Healer's Art, a course now offered at more than seventy medical schools in the world.

My heart began beating faster. Just six of us, in a small room, masks covering one wall, framing the only window. I was supposed to say something profound, to make some over arching comment on myself, on my past experiences with loss. Push our group deeper into this investigation. This was the first meeting, the first time our group was placed together. I had been journaling, making note of what surprised me, what inspired me, and what moved me throughout the day, something that they recommended. I found myself becoming more present in daily time, searching for little moments to track my existence. We didn't share our journals, but we did share our thoughts, and after two achingly long sessions, I began to feel comfortable, the silence was no longer a call for me to speak but rather a moment for me to think. An opportunity to envision myself extending a similar silence to a patient some day. 

Each evening I felt lighter upon leaving. An odd giddiness set in as the group of us tromped up the hill to get back to the main part of town. Perhaps it was the chocolate filled pastries that they pumped into us as soon as we arrived, or the silence that inevitably set in when we were thinking--waiting for someone to begin speaking, or maybe it was the space, the sharing of thoughts, the listening to pain and joy and amazement. Maybe it came from removing ourselves from the general flow of our lives, getting away from the hospital, the library, our apartments; walking into a multi-storied community living space with elderly people looking quizzically at you as you enter. Every time though, walking back through the night, I couldn't stop smiling. 

The course was surface level. I tried to think of what I would change, and I think I would have done more trust building activities at the beginning. To get past that initial hump of trust so that we could have optimized our time otherwise, or just added on a few more sessions. We hit on important topics but never jumped into them, did not immerse ourselves in the challenge of these topics, while after each session I felt cleansed after the entire course I felt unsatisfied. - first year medical student Irene Koplinka-Loehr

Why We Do What We Do: Jeannie Mantopoulos

Jeannie Mantopoulous was an undergraduate sitting in an economics class when she first became interested by the success of public health programs. She went on to intern with the New York City Department of Health and Mental Hygiene in Intergovernmental Affairs. Jeannie expressed to me how important she felt these issues were, and how they made her want to get involved with public health. “It’s powerful to know that public health programs have the potential to have a significant impact on so many lives,” explained Jeannie.

Jeannie’s involvement with GHLI started after graduating from the Yale School of Public Health in 2008. In collaboration with Elizabeth Bradley, faculty director of GHLI, Jeannie was a project manager for the Ethiopia Hospital Management Initiative. Now, after three years, Jeannie has become the assistant director of GHLI.

Jeannie has thrived from collaborating with country partners and being able to share GHLI’s work with the Yale community. She shared how increased student engagement at GHLI makes her very proud of the opportunity to work on campus. She also described her accomplishments with GHLI as a collective effort to implement important programs in management and leadership. “We work as a team and I love it because it gives me the opportunity to learn so much from everyone and from the GHLI projects.” explained Jeannie.

Jeannie and her colleague, Gabe Forrey, have recently traveled to Ghana, Liberia, Rwanda, and South Africa working with country delegations that will attend GHLI’s third annual conference in June. “The conference gives senior health practitioners from different countries the time, space, and support to focus in on a particular health system issue with their respective team, while also learning from other country experiences; it’s really a unique opportunity.”

Amanda Sorrentino, GHLI Intern

Beef meatballs, with no spaghetti

There are pizza restaurants, whose specialty is pizza, even though they usually have a few side dishes. Not healthy enough?

Well, don’t despair, there are meatball restaurants too. I know of at least one, The Meatball Shop, on 84 Stanton Street, in New York City.

Finally a restaurant that elevates the "lowly" meatball to its well deserved place!

Meatballs are delicious, easy to prepare, and you can use quite a variety of meats to do them. Below is a simple recipe. We used ground grass-fed beef, not because of omega-6 concerns (see this post), but because of the different taste.

- Prepare some dry seasoning powder by mixing sea salt, parsley, garlic power, chili powder, and a small amount of cayenne pepper.
- Thoroughly mix 1 pound of ground beef, one or two eggs, and the seasoning powder.
- Make about 10 meatballs, and place them in a frying pan with a small amount of water (see picture below).
- Cover the pan and cook on low fire for about 1 hour.

There is no need for any oil in the pan. On a low fire the small amount of water at the bottom will heat up, circulate, and essentially steam the meatballs. The water will also prevent the meatballs from sticking to the pan. Some moisture will also be released by the meat.

Part of the fat from the meat will be released and accumulate at the bottom of the pan. If you add tomato sauce and mix, the fat will become part of the resulting red sauce. This sauce will add moisture back to the dish, as the meatballs sometimes get a bit dry from the cooking.

Five meatballs of the type that we used (about 15 percent fat) will have about 57 g of protein and 32 g of fat; the latter mostly saturated and monounsaturated (both healthy). They will also be a good source of vitamins B12 and B6, niacin, zinc, selenium, and phosphorus.

Add a fruit or a sweet potato as a side dish to 3-5 meatballs and you have a delicious and nutritious meal that may eve impress some people!

US Omega-6 and Omega-3 Fat Consumption over the Last Century

Omega-6 and omega-3 polyunsaturated fats (PUFA) are essential nutrients that play many important roles in the body. They are highly bioactive, and so any deviation from ancestral intake norms should probably be viewed with suspicion. I've expressed my opinion many times on this blog that omega-6 consumption is currently too high due to our high intake of refined seed oils (corn, soybean, sunflower, etc.) in industrial nations. Although it's clear that the quantity of omega-6 and omega-3 polyunsaturated fat have changed over the last century, no one had ever published a paper that attempted to systematically quantify it until last month (1).

Drs. Chris Ramsden and Joseph Hibbeln worked on this paper (the first author was Dr. Tanya Blasbalg and the senior author was Dr. Robert Rawlings)-- they were the first and second authors of a different review article I reviewed recently (2). Their new paper is a great reference that I'm sure I'll cite many times. I'm going to briefly review it and highlight a few key points.

1. The intake of omega-6 linoleic acid has increased quite a bit since 1909. It would have been roughly 2.3% of calories in 1909, while in 1999 it was 7.2%. That represents an increase of 213%. Linoleic acid is the form of omega-6 that predominates in seed oils.

2. The intake of omega-3 alpha-linolenic acid has also increased, for reasons that I'll explain below. It changed from 0.35% of calories to 0.72%, an increase of 109%.

3. The intake of long-chain omega-6 and omega-3 fats have decreased. These are the highly bioactive fats for which linoleic acid and alpha-linolenic acid are precursors. Arachidonic acid, DHA, DPA and EPA intakes have declined. This mostly has to do with changing husbandry practices and the replacement of animal fats with seed oils in the diet.

4. The ratio of omega-6 to omega-3 fats has increased. There is still quite a bit of debate over whether the ratios matter, or simply the absolute amount of each. I maintain that there is enough evidence from highly controlled animal studies and the basic biochemistry of PUFAs to tentatively conclude that the ratio is important. At a minimum, we know that excess linoleic acid inhibits omega-3 metabolism (3, 4, 5, 6). The omega-6:3 ratio increased from 5.4:1 to 9.6:1 between 1909 and 2009, a 78% increase.

5. The biggest factor in both linoleic acid and alpha-linolenic acid intake changes was the astonishing rise in soybean oil consumption. Soybean oil consumption increased from virtually nothing to 7.4% of total calories, eclipsing all sources of calories besides sugar, dairy and grains! That's because processed food is stuffed with it. It's essentially a byproduct of defatted soybean meal-- the second most important animal feed after corn. Check out this graph from the paper:

I think this paper is an important piece of the puzzle as we try to figure out what happened to nutrition and health in the US over the last century.

8 things to know about pet insurance -- and what's it cost?

1) What's it cost? Here in Washington, according to rates filed with our office:

• Coverage for cats ranges from $83 to $926 a year; most policies are $150-$250 annually.
• Coverage for a dog ranges from $107 to $1,059 a year, but most coverage is between $225 and $400 annually.

2) Coverage varies a lot. Some policies cover a broad range of things: accidents, sickness, surgery, x-rays, drugs, hospitalization, cancer treatment, etc. Others are much narrower, covering accidents and illness after a waiting period.

3) Look for exclusions. Insurers consider hereditary conditions pre-existing conditions and may exclude them or limit coverage. They may also exclude or limit coverage for incurable conditions like diabetes or cancer.

4) Qualifying: A vet may have to examine your pet and certify its health before you can insure it.

5) The rules can change when the policy renews. If your pet's treated for something, some insurers may consider that a pre-existing condition when the policy renews, meaning they'll exclude coverage for it.

6) And they can change based on your type of pet. Exclusions may vary by type of pet and breed.

7) Who pays the bills? Some companies will pay the vet directly, but often you'll be responsible for the full amount at the time of treatment.

8) Which vet? Some insurers will require you to use a specific network of vets.

For more specifics, please see our pet insurance page.

Two agents lose their licenses for misappropriating clients' money

Insurance Commissioner Mike Kreidler has taken action against two insurance agents who misappropriated thousands of dollars from their clients.

• Nancy M. Bishop, of Puyallup, has been notified that the insurance commissioner’s office refuses to renew her insurance license. She has been barred from doing insurance business in Washington and ordered to repay consumers more than $131,000.

A state examination of Bishop’s business records revealed that she violated state insurance laws in dozens of instances, including repeatedly accepting premium payments for policies that did not exist, and keeping the money herself. She also wrongly kept some clients’ refunds and issued false certificates of coverage.

The examination found that Bishop owes dozens of Washington consumers more than $131,000, including overcharges and misappropriated funds.

The violations, according to Kreidler’s order, show Bishop to be “untrustworthy and a source of injury and loss to the public and not qualified to be an insurance producer in the state of Washington.”

• Isaac Mayanja, an agent in Redmond, has had his insurance license revoked.
In 2010, a state investigation determined that Mayanja sold at least 19 unapproved annuities to Washington residents. He also repeatedly engaged in the unauthorized withdrawal of clients’ funds, including forgery and misappropriation of their money.

Specifically, he submitted withdrawal forms totaling $15,570 for several clients’ annuities, changing their addresses on the forms to his own address and then transferring the money to his own personal bank accounts.

In both cases, the agents have the right to demand a hearing. The orders take effect immediately.

Come join us this Friday, April 8th from 7-9 at The Downtown in Red Bank for healthy happy hour! We will have a table reserved upstairs.. just look for our logo. Hope to see you there!

Fat-ten-u

I recently bought the book Food in the United States, 1820s-1890. I came across an ad for an interesting product that was sold in the late 1800s called Fat-ten-u. Check your calendars, it's not April fools day anymore; this is for real. Fat-ten-u was a dietary supplement guaranteed to "make the thin plump and rosy with honest fleshiness of form." I found several more ads for it online, and they feature drawings of despondent, lean women and drawings of happy overweight women accompanied by enthusiastic testimonials such as this:

"FAT-TEN-U FOODS increased my weight 39 pounds, gave me new womanly vigor and developed me finely. My two sisters also use FAT-TEN-U and because of our newly found vigor we have taken up Grecian dancing and have roles in all local productions."

I'm dying to know what was in this stuff, but I can't find the ingredients anywhere.

I find this rather extraordinary, for two reasons:

• Social norms have clearly changed since the late 1800s. Today, leanness is typically considered more attractive than plumpness.
• Women had to make an effort to become overweight in the late 1800s. In 2011, roughly two-thirds of US women are considered overweight or obese, despite the fact that most of them would rather be lean.

A rhetorical question: did everyone count calories in the 1800s, or did their diet and lifestyle naturally promote leanness? The existence of Fat-ten-u is consistent with the idea that our bodies naturally "defended" a lean body composition more effectively in the late 1800s, when our diets were less industrialized. This is supported by the only reliable data on obesity prevalence in the 1890s I'm aware of: body height and weight measurements from over 35,000 Union civil war veterans aged 40-69 years old (1). In that group of Caucasian men, obesity was about 10% of what it is today in the same age group. Whether or not you believe that this sample was representative of the population at large, I can't imagine any demographic in the modern US with an obesity prevalence of 3 percent (certainly not 60 year old war veterans).

Here are two more ads for Fat-ten-u and "Corpula foods" for your viewing pleasure:

Important: Open enrollment for many kids ends April 30th

We cannot say this enough: If you want to buy an individual health plan for your child or enroll them in your individual health plan, you have until April 30 to do it. Do not delay.

Individual coverage is typically bought by people who don't have access to employer-sponsored coverage, or whose employer doesn't cover dependents.

The next open-enrollment period for kids this year won't be until Sept. 15 through Oct. 31.

For more on this, please see our March 14 news release.

Seattle couple pleads guilty in storm-damage insurance scheme

The owners of a Seattle construction company have pleaded guilty to attempted theft for an insurance-billing scheme based on inflated storm-cleanup bills.

James and Cheryl-Lin Philo pleaded guilty March 25th in King County Superior Court to two counts of second-degree attempted theft. In addition, their company, Philo Construction Co., of Seattle, is guilty of one count of first-degree theft.

An investigation by Insurance Commissioner's Mike Kreidler's anti-fraud unit found dozens of cases of apparent fraudulent billing by the company.

Here's what happened: In December 2006, a major windstorm swept across Washington, knocking down trees and causing substantial damage to a numerous homes. The Philos hired subcontractors to remove many of those trees from customers’ homes.


In March 2007, a former employee contacted our office, saying that Philo was submitting inflated invoices to insurers. Other workers provided information as well.

An investigation by the agency’s Special Investigations Unit, working with more than 15 insurance companies, found that the Philos had been asking their subcontractors for two invoices for each job. The Philos paid the subcontractors the smaller amount, and then submitted the larger invoice to their customers’ insurance companies for reimbursement.

The markup averaged close to 30 percent, plus another 20 percent that insurers allow for profit and overhead. For example, a $2,150 bill from a tree service company was reported to the insurer as a $2,795 job. Once profit, overhead and sales tax were added, the Philos were paid a total of $3,649.

The Philos also created a fictitious company, Pro Line Construction Resources, to act as a subcontractor when they needed to support a particularly high estimate.

The Philos were each assessed a $500 victim penalty assessment. They'll also pay restitution totalling $19,849.15, and $220 in court costs.

GHLI Prepares for Upcoming Annual Conference: South Africa and Rwanda

Jeannie Mantopoulos, assistant director at GHLI, recently returned from a visit to South Africa and Rwanda where she worked in each country for a week in anticipation of GHLI’s upcoming third annual conference to take place June 6-10, 2011. South Africa and Rwanda will participate in this year’s conference, along with Ethiopia, Ghana and Liberia. 

Jeannie explained GHLI invites countries to the conference by identifying significant health systems accomplishments despite limited resources. Jeannie explained how the conference gives countries the opportunity to focus on issues they feel are a priority with expertise from Yale and abroad.

Jeannie had previously traveled to Rwanda to work with its Ministry of Health on a maternal and child health project. However, the Rwandan delegation has identified human resource management as its focus for the conference. She described the delegation this year as, “Prepared and excited for the opportunity to get together in June.”

South Africa’s delegation from the National Department of Health will focus on quality measurement to track quality and safety related problems in maternal and child health.

During her travels to South Africa, Jeannie had the opportunity to visit an HIV clinic supported by the Foundation of Professional Development, which is a partner of GHLI. 

Jeannie explained how fantastic it was to see their electronic medical system because it ensured efficient operations. She also noted how effectively the clinic set up routine transportation for the local population and those in the surrounding rural areas to get HIV treatment. 

Jeannie expects that after GHLI’s conference this year, both the South African and Rwandan delegations, along with other participating delegations, will execute the plans developed at Yale when back in their country. To read more about the upcoming conference, visit our website at yale.edu/ghli

Amanda Sorrentino, GHLI Intern

The China Study II: Carbohydrates, fat, calories, insulin, and obesity

The “great blogosphere debate” rages on regarding the effects of carbohydrates and insulin on health. A lot of action has been happening recently on Peter’s blog, with knowledgeable folks chiming in, such as Peter himself, Dr. Harris, Dr. B.G. (my sista from anotha mista), John, Nigel, CarbSane, Gunther G., Ed, and many others.

I like to see open debate among people who hold different views consistently, are willing to back them up with at least some evidence, and keep on challenging each other’s views. It is very unlikely that any one person holds the whole truth regarding health matters. Unfortunately this type of debate also confuses a lot of people, particularly those blog lurkers who want to get all of their health information from one single source.

Part of that “great blogosphere debate” debate hinges on the effect of low or high carbohydrate dieting on total calorie consumption. Well, let us see what the China Study II data can tell us about that, and about a few other things.

WarpPLS was used to do the analyses below. For other China Study analyses, many using WarpPLS as well as HealthCorrelator for Excel, click here. For the dataset used here, visit the HealthCorrelator for Excel site and check under the sample datasets area.

The two graphs below show the relationships between various foods, carbohydrates as a percentage of total calories, and total calorie consumption. A basic linear analysis was employed here. As carbohydrates as a percentage of total calories go up, the diet generally becomes a high carbohydrate diet. As it goes down, we see a move to the low carbohydrate end of the scale.

The left parts of the two graphs above are very similar. They tell us that wheat flour consumption is very strongly and negatively associated with rice consumption; i.e., wheat flour displaces rice. They tell us that fruit consumption is positively associated with rice consumption. They also tell us that high wheat flour consumption is strongly and positively associated with being on a high carbohydrate diet.

Neither rice nor fruit consumption has a statistically significant influence on whether the diet is high or low in carbohydrates, with rice having some effect and fruit practically none. But wheat flour consumption does. Increases in wheat flour consumption lead to a clear move toward the high carbohydrate diet end of the scale.

People may find the above results odd, but they should realize that white glutinous rice is only 20 percent carbohydrate, whereas wheat flour products are usually 50 percent carbohydrate or more. Someone consuming 400 g of white rice per day, and no other carbohydrates, will be consuming only 80 g of carbohydrates per day. Someone consuming 400 g of wheat flour products will be consuming 200 g of carbohydrates per day or more.

Fruits generally have much less carbohydrate than white rice, even very sweet fruits. For example, an apple is about 12 percent carbohydrate.

There is a measure that reflects the above differences somewhat. That measure is the glycemic load of a food; not to be confused with the glycemic index.

The right parts of the graphs above tell us something else. They tell us that the percentage of carbohydrates in one’s diet is strongly associated with total calorie consumption, and that this is not the case with percentage of fat in one’s diet.

Given the above, one may be interested in looking at the contribution of individual foods to total calorie consumption. The graph below focuses on that. The results take nonlinearity into consideration; they were generated using the Warp3 algorithm option of WarpPLS.

As you can see, wheat flour consumption is more strongly associated with total calories than rice; both associations being positive. Animal food consumption is negatively associated, somewhat weakly but statistically significantly, with total calories. Let me repeat for emphasis: negatively associated. This means that, as animal food consumption goes up, total calories consumed go down.

These results may seem paradoxical, but keep in mind that animal foods displace wheat flour in this dataset. Note that I am not saying that wheat flour consumption is a confounder; it is controlled for in the model above.

What does this all mean?

Increases in both wheat flour and rice consumption lead to increases in total caloric intake in this dataset. Wheat has a stronger effect. One plausible mechanism for this is abnormally high blood glucose elevations promoting abnormally high insulin responses. Refined carbohydrate-rich foods are particularly good at raising blood glucose fast and keeping it elevated, because they usually contain a lot of easily digestible carbohydrates. The amounts here are significantly higher than anything our body is “designed” to handle.

In normoglycemic folks, that could lead to a “lite” version of reactive hypoglycemia, leading to hunger again after a few hours following food consumption. Insulin drives calories, as fat, into adipocytes. It also keeps those calories there. If insulin is abnormally elevated for longer than it should be, one becomes hungry while storing fat; the fat that should have been released to meet the energy needs of the body. Over time, more calories are consumed; and they add up.

The above interpretation is consistent with the result that the percentage of fat in one’s diet has a statistically non-significant effect on total calorie consumption. That association, although non-significant, is negative. Again, this looks paradoxical, but in this sample animal fat displaces wheat flour.

Moreover, fat leads to no insulin response. If it comes from animals foods, fat is satiating not only because so much in our body is made of fat and/or requires fat to run properly; but also because animal fat contains micronutrients, and helps with the absorption of those micronutrients.

Fats from oils, even the healthy ones like coconut oil, just do not have the latter properties to the same extent as unprocessed fats from animal foods. Think slow-cooking meat with some water, making it release its fat, and then consuming all that fat as a sauce together with the meat.

In the absence of industrialized foods, typically we feel hungry for those foods that contain nutrients that our body needs at a particular point in time. This is a subconscious mechanism, which I believe relies in part on past experience; the reason why we have “acquired tastes”.

Incidentally, fructose leads to no insulin response either. Fructose is naturally found mostly in fruits, in relatively small amounts when compared with industrial foods rich in refined sugars.

And no, the pancreas does not get “tired” from secreting insulin.

The more refined a carbohydrate-rich food is, the more carbohydrates it tends to pack per unit of weight. Carbohydrates also contribute calories; about 4 calories per g. Thus more carbohydrates should translate into more calories.

If someone consumes 50 g of carbohydrates per day in excess of caloric needs, that will translate into about 22.2 g of body fat being stored. Over a month, that will be approximately 666.7 g. Over a year, that will be 8 kg, or 17.6 lbs. Over 5 years, that will be 40 kg, or 88 lbs. This is only from carbohydrates; it does not consider other macronutrients.

There is no need to resort to the “tired pancreas” theory of late-onset insulin resistance to explain obesity in this context. Insulin resistance is, more often than not, a direct result of obesity. Type 2 diabetes is by far the most common type of diabetes; and most type 2 diabetics become obese or overweight before they become diabetic. There is clearly a genetic effect here as well, which seems to moderate the relationship between body fat gain and liver as well as pancreas dysfunction.

It is not that hard to become obese consuming refined carbohydrate-rich foods. It seems to be much harder to become obese consuming animal foods, or fruits.