Food Reward: a Dominant Factor in Obesity, Part VII

Now that I've explained the importance of food reward to obesity, and you're tired of reading about it, it's time to share my ideas on how to prevent and perhaps reverse fat gain.  First, I want to point out that although food reward is important, it's not the only factor.  Heritable factors (genetics and epigenetics), developmental factors (uterine environment, childhood diet), lifestyle factors (exercise, sleep, stress) and dietary factors besides reward also play a role.  That's why I called this series "a dominant factor in obesity", rather than "the dominant factor in obesity".
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Full Circle, by blogger of the month Renata Mazurek

Vendors setting up for Friday morning
market in the Old City.

It’s just us again. The other class years have finished, and while not everyone else has left Be’er Sheva, it reminds me of when we were basically the only ones late last July. Not tremendously though. That time seems so distant. I smile at conscientiously thinking of things have become commonplace in my mind. Approaching a gate or entrance, I find my ID card and open to show my bag. Walking up the stairs in the hospital, I excuse myself past large gatherings of people sitting across the steps. I don’t expect to buy 2% milk, but I make sure I select the right percentage in yogurt. I never put my laundry in a dryer. Basics. One occurrence that caught me off guard was when I stopped at a crosswalk of a one-way lane for a car to pass and instead of continuing, the driver stood blocking the turn. For a second I thought, What is he doing? because he started honking and there were no cars in front. That’s when a person passing out newspapers on the corner came up and handed one to the driver, who after accepting it then drove on. Oh, I see, I thought, and kept going. That is how it is. It’s mentally convenient to have gotten the hang of most things and not be distracted by making adjustments– particularly during weeks that end in exams. With the last exam and the end of our first year, after the last day of classes, the remainder of the week will be devoted to studying. That said, I don’t have much by way of news-flash events to report, though from the point-of-view of focusing on endocrinology, it might actually be better for us.

The University and Soroka Medical Center juxtaposed.

This past weekend I also realized that it was my last Shabbat in Israel this year. On Friday evening, I was with the family with whom I spent the first Shabbat here! They have been very welcoming people from the start and have always been willing to accommodate anytime during the year. And now being left with less than a week to go struck me of how preoccupying it gets over the year as each semester picks up speed. Not surprisingly, finishing first year and preparing to leave for the summer has culminated in making sure that all is in order. Therefore, as I have been fine-tuning and settling what needs to be taken care of, it was pleasant (and fitting) to just be able to pause and begin this “closing” Shabbat in the same home where the “opening” one began.  (As an aside for incoming students, I would recommend signing up to go to a family for the first Shabbat – it is a great to be able to connect at the start of coming to Be’er Sheva).

Aview on my walk back home. 

Since then, I have passed almost all Shabbats in Be’er Sheva. These have been the days that I have most appreciated living here. In addition to the break from the motion of daily life, there is also a certain calm that is a part of this city. It is distinct from the serenity that one might describe especially of land in northern Israel, and it transitions into Shabbat more discreetly than in other major cities.

Over my final Shabbat, I assessed that even during weekdays, as hectic as it might become at the personal level, the overall environment in Be’er Sheva is more easy-going, making it conducive to study and establish a nice rhythm in spite of being an atypical region. That is the balance. There are opportunities to be as involved as one decides to be with the area and populations, as much as with partaking in one’s own pastimes. People seek out ways to follow their interests, and at MSIH, there is always a good possibility of finding other people that share interests. It can be anything, from piloting a major initiative to a student group to a hobby. I’ve determined that there is an abundance of ways to be sufficiently occupied on a usual basis.

Of course, the main reason I am here to learn to practice medicine. With classes and studying taking up almost all of the day, there is not so much time to contemplate the place I study in as if I were planning a vacation. It’s great that already in the first year, students take opportunities to travel and engage in other places in and outside of the country. Besides this though, I’ve revisited the thought of taking advantage of being exactly where I am. One year down and I haven’t even exhausted seeing all of Be’er Sheva. On the day-to-day basis, it might not come to mind that this city has a long history, to recognize how it has built up and changed over time.  And maybe the aspects for which it is a unique will not be as imprinted until a few more years down the line.  Regardless, the present importance has been about being content in the pace of everyday – it is getting together with friends to share meals; having access to fresh seasonal produce (at good prices!); talking with little kids in the neighborhood who inquire about what it is like in the U.S.; discovering that, as much as I enjoy walking everywhere, acquiring a bike (a couple of weeks ago) can improve the quality of my life… Not to mention that my course of study is international health and medicine, in Israel! Not many people can make that claim. At various times before, I’ve mentioned that I would not trade the experiences of going here for any other school, and most of them have not even happened yet! There has never been a day that I wished I wasn’t here (and I cannot just say that on account of flying out soon, because I will undoubtedly be returning).

A park in Beer-Sheva. 

As my attention now turns to successfully completing the year, I tell myself to remember that my context sets up a baseline, and from there, my experience is what I choose to make of it. - blogger of the month, Renata Mazurek

Boring is another word for satiating

Satiety is a common topic of discussion on this blog. In the last few posts it came up several times in the comments’ sections. Also, in my interview with Jimmy Moore, we did talk a bit about satiety. I told him what has been my perception and that of many people I know, which is that the least satiating foods tend to be foods engineered by humans.

(Source: Wellnessuncovered.com)

There is another component to satiety, which applies to natural foods, or foods that are not man-made. That other component is the nutrition value of those foods, and whether they meet our nutrition needs at a given point in time. If our body needs certain essential amino acids for tissue repair, subconscious mechanisms will make us crave those foods from which those amino acids can be extracted. In this context, eating is generally a good idea.

The problem is that we have not evolved mechanisms to differentiate “true” from “fake” nutrient starvation; one example of the latter would be fat starvation due to transient hyperinsulinemia induced by refined carbohydrate-rich foods.

Foods engineered by humans tend to lead to overeating because humans are good engineers. In modern society, business drives everything. Food business is predicated on consumption, so engineered foods are designed so that one person will want to consume many units of a food item – typically something that will come in a box or a plastic bag. There is no conspiracy involved; the underlying reason is profit maximization.

When we look at nature, we typically see the opposite. Prey animals do not want to be eaten; often they fight back. Eggs have to be stolen. Plants do not want their various parts, such as leaves and roots, to be eaten. Much less their seeds; so they have developed various defense mechanisms, including toxins. Fruits are exceptions to this rule; they are the only natural foods that are designed to be eaten by animals.

Plants want animals to eat their fruits so that they can disperse the plants’ seeds. So they must be somewhat alluring to animals. Sugar plays a role here, but it certainly is not the only factor. The chemical composition of fruits is quite complex, and they usually contain a number of health-promoting substances, such as vitamins. For example, most fruits contain vitamin C, which happens to be a powerful antioxidant, and also has the ability to reversibly bind to proteins at the sites where sugar-induced glycation would occur.

Many modern fruits have been bred to be resistant to diseases, more palatable, and larger (usually due to more water retention). But, fundamentally, fruits are products of evolution. So how come we don’t see fruits that are pure sugar? Watermelons, for example, are often referred to as “bags of sugar”, but they are only 6 percent sugar. Ice cream is 25 percent sugar.

Two things must be kept in mind regarding fruits and their evolution. One is that dead animals do not eat fruit, and thus cannot disperse seeds. Sick animals would probably not be good candidates for fruit dispersion either. So the co-evolution of fruits and animals must have led fruits to incorporate many health-promoting attributes. The other is that seed dispersion success is correlated with the number of different animals that consume fruits from a plant. In other words, plants do not want all of their fruits to be eaten by one single animal, which must have led fruits to incorporate satiety-promoting attributes.

Often combining foods, adding spices, and so on, is perceived as making those foods exciting. That is so even with natural foods. If you read the descriptions of the foods consumed by healthy isolated populations in Weston Price’s Nutrition and Physical Degeneration, you will probably find them a bit boring. A few very nutritious food items, consumed day in and day out, frequently without heavy preparation. Exciting foods, requiring elaborate and time-consuming preparation, were consumed in special occasions. They were not eaten regularly.

The members of those healthy isolated populations were generally thin and yet lacked no important nutrients in their diet. They were generally free from degenerative diseases. Their teeth were normally strong and healthy.

Just before writing this post, I took six whole sardines out of the freezer to thaw. I will prepare them as discussed on this post, and eat them with a side of steamed vegetables for lunch. (I tend to eat fruits only on the days I exercise; typically 3 days out of 7.) This lunch will be very nutrient-dense. I will be very hungry before lunch, since I’ll have been fasting for 16 hours, and after I’ll not be hungry until dinner. Frankly, eating the sardines will not be very exciting, since I’ve been doing this for years.

Boring is another word for satiating.

Your homeowners policy probably does NOT cover flooding

Many residents of Minot, North Dakota believed they were safe from flooding due to a revised flood map and either canceled their flood insurance or failed to purchase a policy. Today, only one in ten residents have flood insurance.

A New York Times article today chronicles how the number of people in Minot with flood insurance was cut in half in just a year.

Most people know this, but your standard homeowners policy doesn't cover flooding. If you want coverage, you must buy a policy from the National Flood Insurance Program.

Get a flood map or learn more about flood insurance.

Drug Cessation and Weight Gain

Commenter "mem", who has been practicing healthcare for 30+ years, made an interesting remark that I think is relevant to this discussion:

Recovering substance dependent people often put on lots of weight and it is not uncommon for them to become obese or morbidly obese.

This relates to the question that commenter "Gunther Gatherer" and I have been pondering in the comments: can stimulating reward pathways through non-food stimuli influence body fatness?  

It's clear that smoking cigarettes, taking cocaine and certain other pleasure drugs suppress appetite and can prevent weight gain.  These drugs all activate dopamine-dependent reward centers, which is why they're addictive.  Cocaine in particular directly inhibits dopamine clearance from the synapse (neuron-neuron junction), increasing its availability for signaling.
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Job opening: Chief market conduct examiner

Due to a retirement, we have a job opening for a chief market conduct examiner in our Seattle office.

The person will supervise the market conduct team of examiners, who work directly with insurance companies to determine compliance with consumer protection laws and regulations.

For more details, salary info, and more about the agency, travel requirements, etc., please see the full job listing.

If you want to stay up to date on any future openings at the Insurance Commissioner's Office, here's our job opportunities page.

Insurance companies and agents fined more than $750,000 this year in WA

Washington State Insurance Commissioner Mike Kreidler has fined insurance companies, agents and brokers more than $750,000 this year. Violations included charging unapproved rates and submitting false documents.
“These fines are the `teeth’ that help us protect insurance consumers,” said Kreidler. “It’s our job to see that the insurance industry’s playing by the rules.”

From January through mid-June, the insurance commissioner’s office has imposed $787,815 in fines. The largest, by far, was a $534,000 fine issued in January. More recent fines are listed below.

The money does not go to the agency. It is deposited in the state’s general fund to pay for other state services.

Any Washingtonian with a complaint against an insurer, agent or broker can contact the office at 1-800-562-6900 or file a complaint online at http://www.insurance.wa.gov/.

For a list of companies fined recently, read the press release here.

Uphill, both ways, by blogger of the month Renata Mazurek

 If nighttime in Be’er Sheva makes it feel like a different place, so does sunrise. Admittedly, I’ve only started getting up at sunrise in the last month, but for some reason the contrast of the city at that hour is startling. Of course, the stillness of morning disrupted by movement as part of the transition into the day is nothing new – whether it’s rush hour in a city or just that most people are starting their day –though it seems so sudden here. Stepping out, the landscape is dim and there is hardly a sound. Barely two hours later, any visible trace of dew just prior is negligible as the heat sets in along with what looks like an exponential rise in activity. A few days ago I woke up late (a little after seven) and my immediate thought in deciding to abandon going for a run that morning was that I wouldn’t make it to avoid the heat, right before applying the fact that I wouldn’t make it in order to get to the first class. I do not even mind the rush of traffic and people; it just comes through as an altogether different setting. I suppose I’ve encountered similar atmospheres as far as both sides of the transition, although I’d never before passed a construction site in a desert first thing in the morning, and never been in a city where, behind a constant flow of people out and about, I see the borders taper off. It’s not as if the awareness of being in a desert isn’t apparent during the day, but somehow the emptiness that is met with early on brings that awareness forward, still maintaining the city environment.  

The other aspect drawn forth is the variability of the terrain. I sense the incline below me just going to and from school, and still sometimes there is a misconception that being as it is a desert, I would expect one flat and expanse area. Running throughout Be’er Sheva quickly underscores that this is not true. Some time ago, I was running (not on purpose) because I had mistaken my direction getting to a meeting place and ended up at the edge of Be’er Sheva. Tracking back, I had to scale a hill along the path. Having finally gotten the correct orientation, the last section to arrive to where I needed to be was… a hill. Didn’t I just run up a hill? I was beginning to be out of breath. The brink of Be’er Sheva was a lot farther out than I had imagined, and I was grateful to the person who knew which direction I had to turn because I had already asked three other people. Tired and becoming dehydrated, I was still in a rush, so I sprinted (as much as I could) the rest of the way. At that moment, it was anything but easy.

Being out on a run one morning at the same place last week, on a return route, I came to the one of the hills and briefly preparing myself mentally as I came closer, pressed up to the top, where to my astonishment, I wasn’t quite feeling the physical impact that I was expecting. Putting aside that I’ve been trying to improve my breathing capacity over the last few years, to this day by no means would I consider myself a runner. Maybe it had been my approach this time around. I had not mapped out a plan to run these hills as part of my route, but when it came to it, I made the snap decision that I had the energy for it and to follow through. The context was different, but the challenge was essentially the same. I assessed that a can-do approach could entirely transform an experience for the better.  

It’s a nice perspective to bear in mind. Though when having to draw on that perspective, it also may not come through as intended, regardless of best efforts. It is like taking a bus to Jerusalem- you can arrive well ahead of schedule, place yourself in ‘line’, even manage to actually get on the bus before the driver limits the capacity of people pushing in, and still wind up standing in the aisle the whole way. Uphill struggles can present in different manners whether occurring as relatively minor or major incidences, and success measured by achieving a desired result could be not what was hoped even if upholding a can-do approach. It can be disheartening. I’ve often told myself when such cases arise, that as a future doctor I’m supposed to be better than that. People count on me. Once in a while I will think, ‘Why am I not allowed to get aggravated?’, as if it was a matter of fairness between myself and other people. If I re-evaluate, the end result may be the most important but it does not detract from the process and putting in the effort. Of course, the effort might seem to be for nothing, too, but it can also be an indicator of how I am setting my expectations. When I go out to practice medicine, aggravation or discouragement can be part of it, but there is merit in acknowledging how much of it is due to the difference in what I was expecting and what happened. It is not necessarily lowering the bar just to feel that every uphill battle is a success; it is going back to knowing how to be flexible. All it takes sometimes is a moment of mental preparedness, and being ready to expect that even in less than two hours, one’s atmosphere can look entirely different.  - blogger of the month Renata Mazurek

Maybe you should stop trying to be someone you are not

Many people struggle to lose body fat, and never quite make it to their optimal. Fewer people manage to do so successfully, and, as soon as they do, they want more. It is human nature. Often they will start trying to become someone they are not, or cannot be. That may lead to a lot of stress and frustration, and also health problems.

Some women have an idealized look in mind, and keep losing weight well beyond their ideal, down to anorexic levels. That leads to a number of health problems. For example, hormones approach starvation levels, causing fatigue and mood swings; susceptibility to infectious diseases increases significantly; and the low weight leads to osteopenia, which is a precursor to osteoporosis.

In men, often what happens is the opposite. Guys who are successful getting body fat to healthy levels next want to become very muscular, and fast. They have an idealized look in mind, and think they know how much they should weigh to get there. Sometimes they want to keep losing body fat and gaining muscle at the same time.

I frequently see men who already look very healthy, but who think that they should weigh more than they do. Since muscle gain is typically very slow, they start eating more and simply gain body fat. The reality is that people have different body frames, and their muscles are built slightly differently; these are things that influence body weight.

There are many other things that also influence body weight, such as the length of arms and legs, bone density, organ mass, as well as the amount of glycogen and water stored throughout the body. As a result, you can weigh a lot less than you think you should weigh, and look very good. The photo below (from MMAjunkie.com) is of Donald Cerrone, weighing in at 145 lbs. He is 6 ft (183 cm) tall.

Mr. Cerrone is a professional mixed martial arts (MMA) fighter from Texas; one of the best in professional MMA at the moment. Yes, he is a bit dehydrated on the photo above. But also keep in mind that his bone density is probably well above that of the average person, like that of most MMA fighters, which pushes his weight up.

A man can be 6 ft tall, weigh 145 lbs, and be very healthy and look very good. That may well be his ideal weight. A woman may be 5’5”, weigh 145 lbs, and also be very healthy and look very good. Figuring out the optimal is not easy, but trying to be someone you are not will probably be a losing battle.

Food Reward: a Dominant Factor in Obesity, Part VI

Reward Centers can Modify the Body Fat Setpoint

Dopamine is a neurotransmitter (chemical that signals between neurons) that is a central mediator of reward and motivation in the brain.  It has been known for decades that dopamine injections into the brain suppress food intake, and that this is due primarily to its action in the hypothalamus, which is the main region that regulates body fatness (1).  Dopamine-producing neurons from reward centers contact neurons in the hypothalamus that regulate body fatness (2).  I recently came across a paper by a researcher named Dr. Hanno Pijl, from Leiden University in the Netherlands (3).  The paper is a nice overview of the evidence linking dopamine signaling with body fatness via its effects on the hypothalamus, and I recommend it to any scientists out there who want to read more about the concept.
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GHLI Conference Visited by Ghana Dignitary

His Excellency John Dramani Mahama (center); Yale University President Richard Levin (far left); and Dr. Elizabeth Bradley, faculty director of the Yale Global Health Leadership Institute (far right), join 2011 Global Health Leadership Institute Conference delegates from Ghana.

Last Thursday, the GHLI Conference opened with a talk from GHLI research scientist Leslie Curry, who presented on the importance of evaluation and learning in health care leadership roles. She focused specifically on the power of positive deviation -- the idea that solutions to a problem facing a community, often reside within that community.  “We have adapted this approach to study health care organizations. Because the solutions are developed by peers, they are more credible, feasible and likely to be adopted and sustained over time,” explains Curry.  “This approach offers great promise in our efforts to identify and spread best practices in health care and ultimately to improve health care and health systems globally.”  Curry later opened the floor to delegates who shared their experiences with evaluation and learning in the health sectors of their own countries.

The visit of Vice President John Dramani Mahama from Ghana was a highlight of the day.  Mr. Mahama first met privately with Yale President Richard Levin and then with Ghana delegates, Yale faculty and representatives from South Essex Partnership Trust to discuss the treatment and perception of mental health in his country. He explained that currently, one out of four residents in Ghana is affected by some form of mental illness.  And, due to the lack of physicians and clinical care facilities, most of these people are ostracized from society and their families.  “I hope with Yale’s help, we can begin to erase the stigma associated with mental illness and provide quality care for those who are suffering,” he stated.  When Mr. Mahama addressed all conference participants at lunch, he commented on how pleased he was that delegates from Ghana were addressing the topic of mental health care needs and said he hoped Conference participants  "go back home more confused" because that means they are looking at the issues in new and different ways. The Vice President also mentioned that he is eager to work together with the Ghana delegates to get a mental health bill passed.

President Levin offered a toast at lunch applauding the delegates’ deep commitment to health care and thanked them for "bringing ideas and energy to Yale." President Levin went on to say that the GHLI Conference underscores Yale's long standing commitment to educating our students for service and leadership. He then asked all to raise their glass to "all those bettering the lives of people around the world through the Yale Global Health Leadership Institute."

The day ended with a ceremony in which the delegates from all five countries were presented with certificates for their participation in this conference.


Nina Gumkowski, GHLI Intern

Pierce County man charged in insurance fraud case

A Tacoma man faces multiple charges after allegedly filing forged documents in an auto theft claim.

Cash B. Knott, 45, has been charged in Pierce County Superior Court with three counts of forgery, one count of insurance fraud, and one count of attempted 2nd degree theft.

On Nov. 6th, less than a month after getting coverage from Progressive Direct Insurance Co. for his 1992 Ford Ranger pickup, Knott filed a $5,674 insurance claim with Progressive. He said someone had scratched the paint, stolen his chrome wheels and tires, and stolen his navigation and entertainment system, 1,000 watt amplifier and other electronic components.

He provided Progressive with a Sept. 2 stereo shop invoice for $4,547.84 worth of stereo equipment, a copy of his check, and a bank statement showing the withdrawal from his checking account.

The problem: When contacted by an insurance adjuster, the stereo shop said it had no record of such a purchase. All they could find was that Knott had bought an amplifier -- for $109 -- on Sept. 2.

Insurance Commissioner Mike Kreidler's Special Investigations Unit obtained a search warrant for Knott's bank records. The bank found no checks written to the stereo shop, and none whatsoever for $4,547.84.

The upshot: The investigators believe that Knott altered the invoice, forged a check, and created a phony bank statement.

He's scheduled for arraignment on June 27th.

Protecting your skin is key to enjoying your summer

By Dr. Mansour Bendago, Division Head of Plastic Surgery, Rouge Valley Health System

Seeing the beautiful sunshine and feeling those warm rays on our skin is a welcome change from the cold harsh winter, and long wet spring. But in order to get the most out of the summer season, it’s important that we always make protecting our skin a priority. 

Not protecting your skin can make it more susceptible to ultra violet (UV) damage, which can result in skin cancer. And this is possible whether your skin is light or dark. You even need sun protection when the skies are overcast.

Preventing Skin Damage  

Skin is divided into six categories, ranging from one (no pigmentation) to six (very dark). People whose skin ranges between one and three are more susceptible to skin damage from the sun, although those with darker skin are not exempt.

What you need to protect your skin   

Take great care in protecting your skin from sun’s harsh UV rays, especially areas that are typically more exposed to the sun, like the face, shoulders, arms, and legs, especially below the knees. You should use a sun screen that is sun protection factor (SPF) 30 or greater. Wear a hat with a brim to give your face added UV protection. Be sure to wear sunglasses that offer UV protection.

Sunscreen is a must for children above six months of age. And because their eye tissue is delicate and their pupils are larger, their eyes are more susceptible to UV damage than adults. So they should wear sunglasses when they’re outside. Wearing a hat can help to protect their face and eyes.

Adults and children alike should also keep themselves hydrated by drinking water, especially when they’re out in the sun.

Melanoma – What to Look For 

One of the reasons we should take great care in our skin is to prevent melanoma, a very aggressive form of skin cancer. Here are some signs to look for: 

- Moles become asymmetrical in appearance, where one half is unlike the other;

- Their normally well-defined borders become irregular in appearance;

- The colour of mole starts to change;

- Itchiness or bleeding of the mole;

- The mole appears like an ulcer or a scar.

If you notice these types of changes, contact your physician immediately.

So while you go out and enjoy your summer, please remember to always protect your body’s largest organ – your skin! 

............ .........  
Related news - 

Read an article about port-wine stain and how Rouge Valley is treating children with this serious skin condition. Rouge Valley is one of only two hospitals in Ontario, which treats this condition.

Job openings: Analyst and .NET developer

We have two job openings:

Functional Program Analyst 3 - The application period ends June 22.

.NET Application Developer - Open until filled. This is a limited-duration project, funded by a federal health care reform grant.

Note: The link to this post has been fixed. Sorry about that.

New free iPhone app guides you through steps after a car accident

AAA has released a new iPhone app that will walk you through the steps to take after an auto accident, including a list of information to gather for police and your insurers, photos to take, and a diagram of vehicle damage.

You don't have to be a AAA member. The app is free, and AAA says it's working on a version for other smartphones.

No smartphone? Here's a comprehensive auto accident checklist, put together by the National Association of Insurance Commissioners, that you should print out and keep in your car.

Here are the steps we recommend:

• Stay safe, but try to warn oncoming traffic of the danger at the scene. Turn on your hazard lights.
• If someone's hurt, give reasonable aid and call 911 immediately. Don't move them unless absolutely necessary.
• Notify the police.
• Give and get info for the accident report, including insurance information, license plates, names and contact information of those involved, including police and witnesses. Diagram the scene.
• If you can do it safely, take photos with a camera or phone.
• Call your agent or insurance company.
• Many experts advise not admitting fault or assigning blame, and only discussing the details of the accident with police or your insurer.

Things Hidden, by blogger of the month Renata Mazurek

Cutting up an apple this morning that I had just bought fresh, I was surprised to see that it was rotting from the inside out, and it looked like it had a giant pit in the middle instead of a core. There was no way to tell, of course, and this is the first time I had encountered this here (or anywhere). All I thought was, foiled again. While proceeding to cut out the rotted section, the next thing passing my mind was that at least I had decided to cut my apple in pieces today instead of biting into it. I have noticed this latter sort of non-intentional thought process a number of times now, where I only realize after the fact that it could have been worse if I made a different decision, which at the onset is not apparent, or not even a consideration, as being better or worse. It’s easy to develop a bitterness in an environment that seems to always be up against you, and then it becomes just as easy to blame it for every unfavorable episode. While I probably can complain about something each day that is a result of being here, it just cannot be accountable for everything that doesn’t go smoothly. Plus, it’s also not worth complaining at every opportunity. Going back a little, in what I’ve already mentioned, I’ve also developed more and more awareness over this year that often the decision that I made ends up being a better one in the long term, even if I felt at the time that I was getting the short end of the stick (usually because I had to make a decision and the option that I would have wanted wasn’t present or didn’t come together).

Certainly, I cannot suggest that each scenario resolves in this way, but sometime it is good to hold off on a reaction before waiting to see what will happen. An outcome may turn out to be inconsequential or reveal something. It just so happened that I had this apple; I didn’t know what would happen when I came to eat it – it could have not been rotten inside, and whether I sliced it or ate it whole likely would not have impacted my experience. Since it was, an already up-front negative experience, delaying the potential for having a bad mood about it, I realized that slicing ended up being a good decision though I didn’t know it yet. Even if the final outcome of an initial choice (selecting that apple) is not positive (getting rid of a lot of it), the recognition of having avoided a more negative experience (biting into the rotted part) can be positive itself (and from my experiences, is more often the case). Or if the final outcome is still negative (had I bitten into the apple instead of slicing) then there can still be a lesson learned (cut apples preferably before eating), whether or not having an idea beforehand that the decision could lead to the outcome, not to mention that the primary decision (taking the apple) may mean that someone else does not have potentially negative experience.

All of these considerations came to me as I continue to reflect on the past year at MSIH. My mentality of being open to the possibilities being presented in life has been applicable plenty of times, but I had not taken into account how applicable it could be on a daily level. Personally, I don’t think that every scenario can be positive, because while it is always subjective, it is not even always relatively positive and I might be fooling myself if I thought that I felt good in any way about the situation. I’ve found this out from experiences where I’d like to think that anything can become meaningfully positive, but realistically and perceptually, it doesn’t play out. However, also being conscious of this approach, it has made me acknowledge that it is how I react and my next step that counts. Hearing from graduates about their own experiences at this school, there is the sense that the overarching picture is genuinely positive, and that taking all the phases together, including those that might have felt unequivocally negative, there is something good to be said at the outcome. And I feel that a lot of times, it’s out of not knowing yet what can make an influence and how things can change.

This past week during the holiday of Shavuot I was sparked with a lot of new insights and thoughts, as well as some recollections. I still remember the first time I learned about Shavuot and other than the main premises, one concept, if you will, that was brought up in the context of this holiday was that nighttime hides things, that they are unseen only because they are hidden and not because they are gone. I won’t go into the holiday significance of it now, but thinking about it again led me to another train of thought. At the close of the day, if I am focusing on studying, or brushing my teeth, or laying down to sleep, it sometimes almost doesn’t occur to me that I am in Be’er Sheva and all that I encounter being here and not anyplace else. And waking up, after a few seconds, I know that it’s still here, I’m still here, in Israel, at MSIH. But, although everything can clearly be seen again in the daylight, what may not be seen is what is waiting to happen on any given day.

…In fact, the day before the Shavuot, with respect to the holiday there was a cheesecake competition set up by the Israeli students- There is constantly some sort of event to be looking out for, whether it is one hour or one day, a small or a major event, or through BGU or MSIH. What takes on a meaning is one’s interactions and reactions. The second day of this month was Faculty Day (in the week after Student Day, but referring to faculty as in department, not specifically staff), including a series of sports matches; the students representing MSIH in volleyball won the championship, and with the prize money decided to throw a pool party for everyone at the end of this last week. It was another reminder to me of how much I can attribute positive experiences (and the anticipation of positive experiences) to my classmates. Nighttime does not make Be’er Sheva go away, but it also does not hide the great things about the people I share my time here with. Going along, I might expect an apple to be rotting inside, but maybe instead, learning from someone and cutting horizontally this time, find a star in the middle.  -blogger of the month Renata Mazurek

Alcohol intake increases LDL cholesterol, in some people

Occasionally I get emails from people experiencing odd fluctuations in health markers, and trying to figure out what is causing those fluctuations. Spikes in LDL cholesterol without any change in diet seem to be a common occurrence, especially in men.

LDL cholesterol is a reflection of many things. It is one of the least useful measures in standard lipid profiles, as a predictor of future health problems. Nevertheless, if one’s diet is not changing, whether it is high or low in fat, significant fluctuations in LDL cholesterol may signal a change in inflammatory status. Generally speaking, the more systemic inflammation, the higher is the measured LDL cholesterol.

Corella and colleagues (2001) looked into alcohol consumption and its effect on LDL cholesterol, as part of the Framingham Offspring Study. They split the data into three genotypes, which are allele combinations. Alleles are genes variations; that is, they are variations in the sections of DNA that have been identified as coding for observable traits. The table below summarizes what they have found. Take a look at the last two columns on the right.

As you can see, for men with the E2 genotype, alcohol consumption significantly decreases LDL cholesterol. For men with the E4 genotype, alcohol consumption significantly increases LDL cholesterol. No significant effects were observed in women. The figure below illustrates the magnitude of the effects observed in men.

On average, alcohol consumption was moderate, around 15 g per day, and did not vary significantly based on genotype. This is important. Otherwise one could argue that a particular genotype predisposed individuals to drink more, which would be a major confounder in this study. Other confounders were also ruled out through multivariate controls - e.g., fat and calorie intake, and smoking.

Alcohol consumption in moderation seems, on average, to be beneficial. But for some individuals, particularly men with a certain genotype, it may be advisable to completely abstain from alcohol consumption. Who are those folks? They are the ones for whom LDL cholesterol goes up significantly following moderate alcohol consumption.

Glamorous Hydration!!

There’s no ifs, ands or buts about it…you need to drink water to stay fit and healthy. It’s estimated that up to 70% of our body is made up of water! Our blood is mostly water and our muscles and brains contain lots of water. We need water to assimilate vitamins and nutrients into our body, to transport oxygen to nourish our cells, to remove waste and to protect our organs and joints! Without water our bodies cannot function properly. Water is also in our lymph (nodes and fluids) so the amount of water in our body directly affects our immune system. If you want to boost your immunity, stay hydrated!

Oftentimes we don’t realize that the symptoms we’re feeling are the result of dehydration. Symptoms of dehydration can include chronic joint and muscle pain, lower back pain, headaches and even constipation. If there is a strong odor or color to your urine it’s a big indication that we’re not giving our body enough water! Our bodies needed the water long before we started to feel thirsty.

For years people have followed the old adage that one should have 8, 16oz glasses of water per day. This may seem like a lot. For some it may be too much, for others too little, it all depends on the person. Size and activity levels should be taken into account. We lose water through every day activity including urination, sweating and even respiration. The more active you are, the more water you will lose, therefore the more water you need to take in!

We have found that a good estimate is to divide your weight by half to give you the number of ounces of water your body needs. For example, if you weigh 140 pounds, you should drink at least 70oz (around 8 glasses). The water equation is complicated by variables! For ever 20 minutes you exercise you should add another 8oz. If you’re having an adult alcoholic beverage, you should have at least equal the amount of water (hangover prevention!). If you live in a hot, dry climate, add another two glasses!

Up to 20% of your water intake will come from the foods you eat. The rest must come from the beverages you drink. If your head is spinning trying to figure out the perfect amount… take a breath. Better yet, take a sip of your water and relax! We have a few tips that will help you up your water intake without even realizing your doing it!

~ Ditch the soda pop and energy drinks. While carbonated beverages and energy drinks contain water, they also contain high levels of caffeine, sugar and sodium. Not only are these drinks packed with empty calories that we don’t need, but the high levels of caffeine causes dehydration! If you drink a caffeinated beverage, tack on another 2 glasses of water to make up for it!

~ Give it a kick! Spice up your water with a hint of flavor. Flavored waters are all the rage these days. We say, “why waste the money when you can make your own?” Fill up a pitcher with water and add orange, mint, cucumber, lemon or lime to give it a kick! Experiment with favor combinations! One of my favorites is orange and clove!

~ Switch out your java for herbal tea. I know this one may be tough for you die hard coffee drinkers….but again with the caffeine! There are so many great herbal tea flavor options out there. You can drink it hot with a lemon or steep the tea and pour it over ice! Just be sure that the herbal tea you choose isn’t a diuretic! Diuretics trick your body into thinking you have more water than we need…thus resulting in the need to drink more water!!

~ Add some bubbly and feel like a rock star! Try sparkling water with a splash of juice (my favorite is pomegranate) with a twist of lime. This is a delicious bubbly daytime cocktail that will make you feel like a rock star!

~ Get funky with some sexy style! Seriously, ditch the plastic water bottles. They’re bad for the environment and how sexy is BPA? You got it, it’s not! BPA has been shown to interfere with reproductive development in animals and has been linked to diabetes in humans! But we still drink out of it? Preposterous! Shell out the $30 to buy a new Sigg bottle or other BPA free reusable bottle. I personally have a collection of Sigg bottles to choose from depending on my outfit and mood! You can even go to Café Press and design your own!

~ Get glamorous!!!!!!!!! If you are anything like 3 Healthy Chicks, you have cabinets filled with amazing stem ware. Beautiful wine goblets, snappy martini glasses and frosty pint glasses lifted from your favorite college joint. Who says they have to be filled with wine, vodka or beer? They’re fabulous glasses and there’s no reason for them to be collecting dust in your china cabinet! Dust off that hand painted (non-toxic!) martini glass and have some H2O on the rocks with a twist of lime and sprig of mint! Hell, put on your favorite Jersey Girl, Joan Rivers style sunglasses and embrace the healthy rock star that you are.

Cocktails before noon? Definitely!

Things that can affect your auto insurance rates

A new survey says that more than half of Americans have recently made an economic-driven change that may affect how much they pay for car insurance.

The National Association of Insurance Commissioners survey found that:

• nearly 40 percent of respondents were driving less or taking public transportation more
• nearly 20 percent traded in a vehicle for a lower-priced model or got rid of a second vehicle entirely
• and almost 20 percent of drivers reduced or canceled their car insurance to save money -- something we do not recommend. You'll almost certainly pay more to get coverage later, and if you continue to drive without coverage, you expose yourself to potentially devastating financial liability.

(Bonus round: Here's a long list of NAIC tips for lowering your auto insurance premiums.)

Here are some of the changes that can affect how much you pay for insurance:

• You moved: A change in zip code may affect your premium, depending on crime statistics in the area.
• You changed cars: A lower-value car, not surprisingly, is usually cheaper to insure. If you're car's paid off and not worth much, you might consider saving money by raising your deductible or canceling your collision coverage. But keep your liability coverage.
• A new job, or no job: These can affect whether you commute, and how far.
• Driving less: Almost 40 percent of consumers said they're driving less. Many are walking or taking public transportation more often. If this sounds like you, you should talk to your insurer and see if you qualify for a low-mileage discount.
• Bad credit score: The weak economy, layoffs and the collapse of the housing market have left many people with battered credit. Most states, including Washington, allow insurers to use your credit information to decide how much to charge you. (Here in Washington, we have successfully fought to limit this practice, but have not yet been able to convince lawmakers to ban it entirely.)

Also, if you're struggling to find coverage here in Washington, we maintain an online list of companies offering policies for hard-to-insure drivers.

Insurance investigators shot and killed in Louisiana

Our hearts go out to our colleagues in Louisiana, where yesterday two Louisiana Department of Insurance fraud investigators were shot and killed while trying to gather information from an insurance agent.

Here's the statement from Louisiana Insurance Commissioner Jim Donelon.

According to the New York Times, the agent was found dead by SWAT team members after barricading himself in his business, where the shootings happened.

GHLI Conference – in Progress

The second day of the 2011 GHLI Conference opened with Dr. Elizabeth Bradley providing an overview of the upcoming week's events to the delegates from the five countries and a keynote address by Yale University Provost Peter Salovey.  Provost Salovey discussed his research on emotional intelligence and how this type of intelligence affects interaction in leadership skills and among cultures.   His research outlines how to measure emotional intelligence by testing a person's ability to: perceive, express use, understand and manage emotions. This scoring system demonstrates that high emotional intelligence can be correlated with lower self destructive behavior and higher likability and job approval among colleagues. Partly due to the attention Provost Salovey’s research has brought to the topic, emotional intelligence has become a tool worldwide used both in business and educational settings.

Yale University Vice President and Secretary, Linda Lorimer, addressed the delegates to emphasis how important the GHLI and this Conference is to Yale.  “This is an amazing gathering of minds and our real hope is that, as the week proceeds, you all find ways to constructively contribute to the issues of your country.”  She also stressed to the crowd how Yale is invested in helping the next generation of leaders and is particularly interested in further developing relationships in South Africa.

Delegates representing five African countries gave presentations and led discussions about the health system and area of innovation on which they will focus during the conference. Ethiopia, the first country to present, focused on hospital management performance improvement; Ghana discussed mental health framework for implementation of a new mental health bill; Liberia and South Africa presented on maternal and child health and Rwanda delegates discussed human resources for health.

Nina Gumkowski, GHLI Intern

Chew Your Food

We live in a fast paced world. People are on the go, multi-tasking, planning and thinking ahead. In a busy world, people also eat on the go; in the car, at their desks, standing up, walking down the street, barely taking the time to enjoy their meal. When we eat quickly, we tend to eat more, therefore consuming more calories.

 Digestion begins in the mouth. Slowing down to completely chew your food, allows the release of digestive enzymes that break down food and greater assimilation of nutrients. Whole foods, especially whole grains, must be mixed with saliva and chewed until they become liquid to release their full nutritional value. Because digestion becomes so efficient when you chew your food thoroughly, your body will begin to feel wonderfully light. To get into the habit of chewing correctly, try counting the chews in each bite, aiming for 30 to 50 times. It helps if you put your fork down between bites.

 The New York Times reported on a few scientific studies to support the claim that eating slowly is a method for consuming fewer calories. Who could imagine that losing weight is as simple as taking a few more minutes to slow down and eat what is already on your plate?

5 Tips to Slow Down at Meal Time:

1. Take 3 deep breaths before your meal.

2. Place your fork down between each bite, or use chopsticks to eat.

3. Chew your food at least 30-50 times before swallowing.

4. Savor the flavors and textures that are happening in your mouth.

5. Eat in a calm, relaxed atmosphere as often as possible.

Keep it fresh!
- Lauren

Information adapted from the Institute for Integrative Nutrition.

Instant replay, by June blogger of the month Renata Mazurek

Across the hospital grounds, BGU main
campus

It’s June! I still haven’t quite taken it in. My usual first reaction to this month is that summer is well on its way. And somehow this year, it feels different… I have not been able to quite put my finger on it. I can’t exactly attribute it to the weather. Despite a popular notion that it is always hot and seems like summertime here, I have not forgotten about the amount of layers I would put on during the winter months (which, considering I grew up in upstate New York, was ridiculous for me). The second thing that comes to mind is just that I’ve been here for such a long time. Not having been back home since early last July, it’s been a long stretch. Besides the time off during holiday breaks, being in school for close to a full year maybe delays the feeling of getting into summer, especially since I’ve been used to the end of May as being finals period. That’s when I think, Well, welcome to medical school, or rather, Welcome to life. From now on, I should not expect to have a summer break of two and a half months. Then again, I recall that last year I hardly had a summer break at all, almost not at all, going right into beginning medical school. So, even though it has occurred to me that perhaps the most valuable thing I currently own is my return ticket, the anticipation for going back home does not entirely account for the difference I’ve sensed. And after all, I am in a completely different place like I hadn’t experienced before. I have begun to consider that maybe this has something to do with it…

the Pathology building (where we are when not\
on the sixth floor)

Thinking back from the beginning here, I admit that my view of Be’er Sheva has not changed that much. To be honest, I did not have a “culture shock” coming to Israel, even though this was my first time. Nonetheless, having to navigate within the mode of living has posed challenges (some of which have been illustrated by other bloggers) since the first day. One might think that the passage of time has a way of softening rough starts, but months and months later, I still find myself dealing with the same frustrations, inwardly disapproving every time I see that there does not appear to be a way around the inefficiencies. Frustration seems to come up as a common and frequent theme. This thought crossed my mind when I was waiting in the main post office yesterday. It’s not that I ever regret my trips there because I always am able to take care of what I need to, but I avoid having to go in there if I can, on account that the length of time spent is always undeterminable, even as one of the only places that actually has an orderly system (there are three different number series based on which service you are there for). Taking a ticket, I noticed that I was three numbers away from my turn. At one moment while waiting, I looked around and figured that with a total of about fifteen people there (as opposed to usually being packed), not all of them having come in before me, and not all of them there for the same reason as me, there was  a chance that it might be an easier in-and-out this time. I still ended up being at the post office for an hour. And yet I continue trying to comprehend these things. 

Faculty of Health Sciences (the Negev
brigade memorial is in the distance)

Then I thought about it again- why would it be any different this time or any other time? Things run as they do, so even after months, an expectation that they get “better” is not reasonable. If anything, the change that could make for a better experience is in my attitude. But my next immediate thought was, why should I just accept what I disagree with? I’ve not been considered to be an unreasonable nor intolerant person, but it does not seem justified to simply accept inefficiency- especially since I generally aim to make things efficient myself. Therefore, the position I’ve arrived at has been more along the lines of coming to terms with things, because I still have to work with the situations that are presenting. This has established an interesting personal dynamic from my point-of-view, in which I feel that I am constantly pushing back within also trying to integrate. I often need to remind myself that I live here now, even if temporarily. Some people have said that when they return to Be’er Sheva from traveling, it does carry some sense of “coming home”.  I have to say that while it’s been a relief to just get back sometimes, I cannot say that it’s ever had a “home” feeling, and maybe it never will. So often, I still feel very much like an outsider. I’ve noticed more and more especially with communication (the classic struggle) that when I’m not getting away with passing as native, people try to have me default to English, if they pick up on my accent in Hebrew. Mostly, it seems that it’s because I present an opportunity to use English, while to me, any encounter is an opportunity to practice proficiency in Hebrew… when this happens, I typically hear “you know you can just say it in English”, and each time I respond with “…I know, but I like to work on my Hebrew…” after which I am “allowed to” until I stumble across not knowing a particular word. I think these interactions often rub off as cordially amusing for the other person, and I’m not bothered by them, but they do have a way of reaffirming that I am a foreigner.

Initial glimpse of the Bet
neighborhood exiting the hospital
on Rager Blvd

But maybe that’s okay. From the 6^th floor of Soroka, where I’ve spent a considerable amount of time for about ten months, looking out on the familiar territory that I see on a daily basis, it may not be much more impressionable than it was on day one, but it’s certainly given me a lesson about what it means to learn to find my place.

(By the way, as a side note, a statement that is heard repeatedly by upperclassmen  is that at least within MSIH, it gets better and better with each year…although I haven’t doubted this statement, having just finished our first ‘second-year’ system in Hematology and starting Endocrinology, I would now say that this is, in fact, true)  - blogger of the month Renata Mazurek

Photo(s) caption: The four corners of my ‘world’ in the past year: the view from Soroka 6^th floor.

                Across the hospital grounds, Ben Gurion University main campus

                Faculty of Health Sciences (The Negev Brigade Memorial in the far distance)

                The Pathology building (where we are when not on the 6^th floor)

                Initial glimpse of the Bet neighborhood exiting the hospital onto Rager Blvd.