Real progress, but must stay the course

By Rik Ganderton
President & CEO, RVHS


We are making real progress in improving Rouge Valley Health System (RVHS) for our patients and all staff. I say that with caution, because RVHS is still early in our transformation journey.
Now, here comes the “but” of this message.
But, we need to ensure that our mutual focus on transformation, and the Deficit Elimination Plan, does not waiver or slip. The transformation of our culture into a hospital that is delivering top-quartile health care, safe, connected to its communities, accountable, transparent and united has only begun.
For getting our positive improvements underway, I thank all staff, physicians and volunteers for their growing engagement.

Transformation
My perception is that there are “sighs of relief” starting to echo around some tables. We need to be cautious as we have not yet won the first battle and are nowhere near declaring victory in the war!
We have made positive strides as we deploy Lean methodology, but our culture has not yet changed. At best, we can say we have woken ourselves up to see what is possible and also that there is a vast amount of hard work that has to be done to deploy and sustain change for many years to come.
Use of Lean methodology is moving us toward engraining a systematic, continuous improvement approach; we are focusing our many and broad activities on reducing waste, improving care and our workplace while aligning all of our efforts to become the best at what we do for our patients.

Four Transformation Themes
We must continue to focus our efforts on our four transformation themes:
1. Patients first — providing the best patient/family experience
2. Earn our reputation as the best everyday
3. No waste
4. We are one team, inspired and involved

Deficit Elimination Plan
On the financial front, we have achieved some early successes. We had a balanced run rate (spending within our funding) in November and December. At the end of December we have a small surplus on a year to date basis.
But again, I say that with caution. We have our busiest months ahead of us. Assuming we achieve out targets (and I believe we will), we must remember that success this year is just a one-year event. It does not address the magnitude of what we have to fix and improve. As a reminder:
* We need to generate significant surpluses to -
- Maintain required infrastructure. Thanks to many years of capital starvation, our buildings, our infrastructure and our capital equipment are woefully inadequate. We have already agreed to add $3.5 million to our long-term-debt to deal with potentially catastrophic failures of boilers and roofs. These are the tip of the iceberg.
Rebuild our working capital and fund our capital needs. Our working capital deficit is $39.5 million.
- Find two to three per cent compounded efficiency every year based on shortfalls of funding increases provided by government each year. This means $5 million to $7.5 million in efficiency every year.
* In late February the Board will be presented with our 09/10 operating plan and multi-year capital plan. Operationally we have had to squeeze very hard to achieve our Hospital Service Accountability Agreement (H-SAA) committed targets to the government. Our capital needs are huge and many are vital to the safe and efficient functioning of our workplaces and the safety and standards of care for our patients.

Patient volumes
Essentially we continue to be on target in all areas for meeting our H-SAA commitments within the performance corridors, meaning we are treating the same number of patients this year as we did last. Maintaining patient volumes and improving quality of care are among the key commitments we made in our Deficit Elimination Plan, back in March of 2008.

Community Outreach
We continue to meet with our communities, through the many health care and community organizations in west Durham and east Toronto. Our running list of presentations is available at www.rougevalley.ca/community_outreach.
Keep up your commitment and enthusiasm for positive improvement at Rouge. We will succeed as a team. Thank you all.

Exercise and Bodyfat

I'm a firm believer that exercise is part of a healthy pattern of living. Hunter-gatherers had a word for exercise: "life". Getting outdoors and moving is one of the few things that differentiate modern humans from lab rats.

That being said, there are some common misconceptions about the activity patterns of hunter-gatherers and healthy non-industrial groups. They aren't (usually) couch potatoes, but they don't necessarily exercise a lot either. They range from very active to positively lazy, depending on the culture, the season and the gender concerned. Yet overweight is rare in all of them.

Consider the Kitavans. According to Dr. Staffan Lindeberg, the only overweight person on the whole island is someone who left for several years to live in a city. An average Kitavan man has a BMI of 20, which is very lean. Women have an average BMI of 18! A BMI of 25 is considered overweight and 30 is obese. The average Swede has a BMI of 25, the average American, 28. Kitavans have the activity level of a moderately active Swede, nothing more. They do the minimum amount of work required to grow their starchy tubers and fruit, and catch fish, all of which are abundant year-round. They are not restricted in calories.

Then there are the Tokelauans. Between 1968 and 1982, residents of the Pacific atolls of Tokelau gained roughly 11 pounds (5 kg) on average. This corresponded with a shift in diet from traditional Polynesian foods to a partial reliance on white flour, sugar and other processed foods. During this period, men exercised progressively less due to the introduction of the outboard motor, but the activity level of women stayed roughly the same. Both genders gained weight. Calorie intake didn't trend in any particular direction during the same time period.

Tokelauans who migrated to New Zealand saw a particularly large weight gain, gaining 22 pounds (10 kg) over the same time period. Their diet became even more Westernized than their relatives who remained on Tokelau. The authors of the Tokelau Island Migrant study felt that "most of the migrants expend greater energy in their work than is currently the case in Tokelau."

The "paradoxes" keep rolling in. In this recent study, investigators compared the energy expenditure of Nigerian and African-American women, using direct measurement (respiratory gas exchange and doubly labeled water) rather than questionnaires and observation. Here's what they found:

Mean body mass index (in kg/m(2)) was 23 among the Nigerians and 31 among the African Americans; the prevalences of obesity were 7% and 50%, respectively. After adjustment for body size, no differences in mean activity energy expenditure or physical activity level were observed between the 2 cohorts.

Are you bored yet? Here's another one, just in case your eyes are still open. I'll quote from Stefansson's Cancer, Disease of Civilization, referring to traditional point Barrow Inuit women in wintertime. The section in quotes comes from the anthropologist Dr. John Murdoch:

"They are large eaters, some of them, especially the women, eating all the time..." ...during the winter the Barrow women stirred around very little, did little heavy work, and yet "inclined more to be sparse than corpulent"

One last example. Americans have gained weight continually over the last 40 years, despite increasing leisure-time exercise and an increased energy expenditure. Our calorie intake has increased over the same time period, and the quality of our diet has deteriorated.

I think it's clear that the relationship between exercise and weight is not very tight. In my opinion, diet has a much larger influence on weight than exercise. Doing low-intensity "cardio" on a treadmill is almost totally ineffective for weight loss.

So can exercise help a person reach or maintain a healthy weight? Absolutely, but the type of exercise is critical. Exercise plugs into some of the same metabolic pathways as a healthy diet, normalizing hormone levels and increasing stress resitance. All you have to do is pop over to Chris's Conditioning Research to see a number of studies that compared chronic cardio (as Mark Sisson would say) to high-intensity, intermittent training (HIIT). HIIT is the winner every time by virtually every measure. Even though a person burns fewer calories sprinting on and off for five minutes than she does running for 30, she will still lose more fat and gain more muscle sprinting because of the metabolic shift that type of training produces.

In one study Chris posted, investigators compared the effect of two different exercise styles on fat loss and metabolic parameters. One group was assigned to low-intensity steady-state exercise, while the other was assigned to short 8-second sprints (called HIIE in this study). Here's what they found after 15 weeks:

Both exercise groups demonstrated a significant improvement (P less than 0.05) in cardiovascular fitness. However, only the HIIE group had a significant reduction in total body mass (TBM), fat mass (FM), trunk fat and fasting plasma insulin levels.

I think exercise is part of the fat loss / maintenance toolkit, along with intermittent fasting. But nothing beats a good diet.

Seafood and Vitamin K2

In his travels around the globe, Dr. Weston Price found that the most robust groups were often those who had access to marine and freshwater foods. For example, Polynesian groups had a tooth decay prevalence as low as 0.6% of teeth. That's roughly one in 5 people with even a single cavity, in a population that doesn't brush its teeth, drink fluoridated water or go to the dentist. These individuals had broad dental arches, straight teeth, and fully erupted wisdom teeth as well.

As soon as they adopted white flour and sugar as dietary staples, the tooth decay prevalence of Polynesian groups went as high as 33.4% of teeth, or about 11 cavities per person. This represents a 5,600% increase in the prevalence of tooth decay. The next generation to be born also suffered from characteristic facial and skeletal abnormalities that are common in modern societies to varying degrees.

This leads me to ask the question, what is unique about seafood that allows it to support excellent development and maintenance of the human body? Seafood has a lot of advantages. It tends to be very rich in minerals, particularly iodine which can be lacking in land foods. It's also a good source of omega-3 fatty acids and low but adequate in linoleic acid (omega-6). This impacts development and maintenance in a number of ways, from fat mass to dental health.

As I wrote in the last post and others, I believe that one of the major determinants of proper development and continued health is the diet's content of the fat-soluble vitamins A, D and K2. K2 in particular is rare in the modern diet. We're also deficient in vitamin D because of our indoor lifestyles and use of sunscreen. Polynesians didn't have to worry about vitamin D because they spent much of the day outside half naked.

How about K2? Is seafood a good source? At first glance, it doesn't appear to be. Mackerel is the best source I came across on NutritionData, with one serving delivering 5.6 micrograms of vitamin K. It wasn't specified, but only a portion of that will be vitamin K2 MK-4, with the majority probably coming from K1. Most other types of fish have very low levels of vitamin K.

But we have to probe deeper. Nutrition information for fish refers to muscle tissue. Muscle is a poor source of K2 in mammals, could that be the case in fish as well? It turns out, the organs are the best source of K2 MK-4 in fish, just as they are in mammals. It's most concentrated in the liver, kidneys, heart and gonads. This loosely resembles the situation in mammals, which also retain MK-4 in their kidneys and gonads (along with pancreas, salivary glands, and brain).

I don't know how frequently traditional non-industrial cultures ate fish organs. My guess is they discarded most of them as do modern cultures, because they smell funny and putrefy rapidly. There are some exceptions, however. Certain traditional cultures ate fish livers, cod for example. Price described a dish eaten by a healthy, isolated Gaelic group in Nutrition and Physical Degeneration:

An important and highly relished article of diet has been baked cod's head stuffed with chopped cod's liver and oatmeal.

Gonads are one of the richest sources of K2 MK-4 in fish, containing 5-10 micrograms of MK-4 per kilogram of tissue in a few different species (according to this paper). Even that is not really an impressive concentration.

One thing that is universally relished by traditional groups is fish eggs, which of course develop from the gonads. A number of cultures dried fish eggs, sometimes trading them far into the interior. Although they haven't been analyzed for MK-4 content in modern times, Price found fish eggs to be a rich source of K2. Speaking of vitamin K2, he said: "its presence is demonstrated readily in the butterfat of milk of mammals, the eggs of fishes and the organs and fats of animals". Unfortunately, Price's assay was not quantitative so we don't have numbers.

As mainstream medicine slowly catches up to the importance of vitamin K2 MK-4 that Price described in the 1940s, more foods are being tested. I think we'll see values for fish eggs in the near future. This will allow us to discriminate between two possibilities: 1) seafood is a good source of K2, or 2) the human requirement for K2 is not particularly high in the context of an otherwise healthy diet.

Vitamin K2 and Cranial Development

One of the things Dr. Weston Price noticed about healthy traditional cultures worldwide is their characteristically broad faces, broad dental arches and wide nostrils. Due to the breadth of their dental arches, they invariably had straight teeth and enough room for wisdom teeth. As soon as these same groups adopted white flour and sugar, the next generation to be born grew up with narrow faces, narrow dental arches, crowded teeth, pinched nostrils and a characteristic underdevelopment of the middle third of the face.

Here's an excerpt from Nutrition and Physical Degeneration, about traditional and modernized Swiss groups. Keep in mind these are Europeans we're talking about (although he found the same thing in all the races he studied):

The reader will scarcely believe it possible that such marked differences in facial form, in the shape of the dental arches, and in the health condition of the teeth as are to be noted when passing from the highly modernized lower valleys and plains country in Switzerland to the isolated high valleys can exist. Fig. 3 shows four girls with typically broad dental arches and regular arrangement of the teeth. They have been born and raised in the Loetschental Valley or other isolated valleys of Switzerland which provide the excellent nutrition that we have been reviewing.

Another change that is seen in passing from the isolated groups with their more nearly normal facial developments, to the groups of the lower valleys, is the marked irregularity of the teeth with narrowing of the arches and other facial features... While in the isolated groups not a single case of a typical mouth breather was found, many were seen among the children of the lower-plains group. The children studied were from ten to sixteen years of age.

Price attributed this physical change to a lack of minerals and the fat-soluble vitamins necessary to make good use of them: vitamin A, vitamin D and what he called "activator X"-- now known to be vitamin K2 MK-4. The healthy cultures he studied all had an adequate source of vitamin K2, but many ate very little K1 (which comes mostly from vegetables). Inhabitants of the Loetschental valley ate green vegetables only in summer, due to the valley's harsh climate. The rest of the year, the diet was limited chiefly to whole grain sourdough rye bread and pastured dairy products.

The dietary transitions Price observed were typically from mineral- and vitamin-rich whole foods to refined modern foods, predominantly white flour and sugar. The villagers of the Loetschental valley obtained their fat-soluble vitamins from pastured dairy, which is particularly rich in vitamin K2 MK-4.

In a modern society like the U.S., most people exhibit signs of poor cranial development. How many people do you know with perfectly straight teeth who never required braces? How many people do you know whose wisdom teeth erupted normally?

The archaeological record shows that our hunter-gatherer ancestors generally didn't have crooked teeth. Humans evolved to have dental arches in proportion to their tooth size, like all animals. Take a look at these chompers. That skull is from an archaeological site in the Sahara desert that predates agriculture in the region. Those beautiful teeth are typical of paleolithic humans and modern hunter-gatherers. Crooked teeth and impacted wisdom teeth are only as old as agriculture. However, Price found that with care, certain traditional cultures were able to build well-formed skulls on an agricultural diet.

So was Price on to something, or was he just cherry picking individuals that supported his hypothesis? It turns out there's a developmental syndrome in the literature that might shed some light on this. It's called Binder's syndrome. Here's a description from a review paper about Binder's syndrome (emphasis mine):

The essential features of maxillo-nasal dysplasia were initially described by Noyes in 1939, although it was Binder who first defined it as a distinct clinical syndrome. He reported on three cases and recorded six specific characteristics:⁵

• Arhinoid face.
  
• Abnormal position of nasal bones.
  
• Inter-maxillary hypoplasia with associated malocclusion.
  
• Reduced or absent anterior nasal spine.
  
• Atrophy of nasal mucosa.
  
• Absence of frontal sinus (not obligatory).
  

Individuals with Binder's syndrome have a characteristic appearance that is easily recognizable.⁶ The mid-face profile is hypoplastic, the nose is flattened, the upper lip is convex with a broad philtrum, the nostrils are typically crescent or semi-lunar in shape due to the short collumela, and a deep fold or fossa occurs between the upper lip and the nose, resulting in an acute nasolabial angle.

Allow me to translate: in Binder's patients, the middle third of the face is underdeveloped, they have narrow dental arches and crowded teeth, small nostrils and abnormally small sinuses (sometimes resulting in mouth breathing). Sound familiar? So what causes Binder's syndrome? I'll give you a hint: it can be caused by prenatal exposure to warfarin (coumadin).

Warfarin is rat poison. It kills rats by causing them to lose their ability to form blood clots, resulting in massive hemmorhage. It does this by depleting vitamin K, which is necessary for the proper functioning of blood clotting factors. It's used (in small doses) in humans to thin the blood as a treatment for abnormal blood clots. As it turns out, Binder's syndrome can be caused by a number of things that interfere with vitamin K metabolism. The sensitive period for humans is the first trimester. I think we're getting warmer...

Another name for Binder's syndrome is "warfarin embryopathy". There happens to be a rat model of it. Dr. Bill Webster's group at the University of Sydney injected rats daily with warfarin for up to 12 weeks, beginning on the day they were born (rats have a different developmental timeline than humans). They also administered large doses of vitamin K1 along with it. This is to ensure the rats continue to clot normally, rather than hemorrhaging. Another notable property of warfarin that I've mentioned before is its ability to inhibit the conversion of vitamin K1 to vitamin K2 MK-4. Here's what they had to say about the rats:

The warfarin-treated rats developed a marked maxillonasal hypoplasia associated with a 11-13% reduction in the length of the nasal bones compared with controls... It is proposed that (1) the facial features of the human warfarin embryopathy are caused by reduced growth of the embryonic nasal septum, and (2) the septal growth retardation occurs because the warfarin-induced extrahepatic vitamin K deficiency prevents the normal formation of the vitamin K-dependent matrix gla protein in the embryo.

"Maxillonasal hypoplasia" means underdevelopment of the jaws and nasal region. Proper development of this region requires fully active matrix gla protein (MGP), which I've written about before in the context of vascular calcification. MGP requires vitamin K to activate it, and it seems to prefer K2 MK-4 to K1, at least in the vasculature. Administering K2 MK-4 along with warfarin prevents warfarin's ability to cause arterial calcification (thought to be an MGP-dependent mechanism), whereas administering K1 does not.

Here are a few quotes from a review paper by Dr. Webster's group. I have to post the whole abstract because it's a gem:

The normal vitamin K status of the human embryo appears to be close to deficiency [I would argue in most cases the embryo is actually deficient, as are most adults in industrial societies]. Maternal dietary deficiency or use of a number of therapeutic drugs during pregnancy, may result in frank vitamin K deficiency in the embryo. First trimester deficiency results in maxillonasal hypoplasia in the neonate with subsequent facial and orthodontic implications. A rat model of the vitamin K deficiency embryopathy shows that the facial dysmorphology is preceded by uncontrolled calcification in the normally uncalcified nasal septal cartilage, and decreased longitudinal growth of the cartilage, resulting in maxillonasal hypoplasia. The developing septal cartilage is normally rich in the vitamin K-dependent protein matrix gla protein (MGP). It is proposed that functional MGP is necessary to maintain growing cartilage in a non-calcified state. Developing teeth contain both MGP and a second vitamin K-dependent protein, bone gla protein (BGP). It has been postulated that these proteins have a functional role in tooth mineralization. As yet this function has not been established and abnormalities in tooth formation have not been observed under conditions where BGP and MGP should be formed in a non-functional form.

I think there's a good case to be made that most people in modern societies exhibit some degree of "Binder's syndrome" due to subclinical vitamin K2 deficiency during growth. I believe the evidence suggests that prenatal vitamin K2 MK-4 deficiency is behind narrow dental arches, crooked teeth, underdevelopment of the face and jaw, underdevelopment of the sinuses with mouth breathing in some cases, and poor tooth development resulting in a high susceptibility to dental cavities.

These symptoms are so common they are viewed as normal in industrial societies. There is no other single factor that so elegantly explains these characteristic changes in cranial form. Rickets (vitamin D deficiency during growth) also causes cranial malformations, but they are distinct from those caused by K2 deficiency.

Humans do not efficiently convert K1 into K2 MK-4 (unlike rats), so we require a ready source of K2 in the diet. Our hunter-gatherer ancestors had a relatively high intake of K2 MK-4 from the organs of wild animals (particularly brain, pancreas, and marrow), insects and seafood. Our food supply today is depleted of K2, due to our avoidance of organ meats and poor animal husbandry practices. K2 MK-4 is found only in animal products. Pastured dairy is the most convenient source of K2 MK-4 in the modern diet, just as it was for the villagers of the Loetschental valley when Dr. Price visited them. Dairy from grain-fed cows contains much less K2.

Price felt that to ensure the proper development of their children, mothers should eat a diet rich in fat-soluble vitamins both before and during pregnancy. This makes sense in light of what we now know. There is a pool of vitamin K2 MK-4 in the organs that turns over very slowly, in addition to a pool in the blood that turns over rapidly. Entering pregnancy with a full store means a greater chance of having enough of the vitamin for the growing fetus. Healthy traditional cultures often fed special foods rich in fat-soluble vitamins to women of childbearing age and expectant mothers, thus ensuring beautiful and robust progeny.