Archive for the ‘Obesity’ Category

Should the kids be in the middle? It may depend on the kid’s middle

Tuesday, November 1st, 2011

This is not the example you should set

Wall Street Journal headline caught my eye, “Obesity Fuels Custody Fights.” It noted that childhood obesity is frequently being used by one parent or the other as grounds for custody changes with accusations concerning poor diets and lack of exercise flying back and forth.

That led me to a July 13, 201 article in The Journal of the American Medical Association (henceforth JAMA), “State Intervention in Life-Threatening Childhood Obesity.”

We’re not talking about mildly overweight kids here; in 2009 a 555-pound fourteen-yer-old boy, living in one of the southeastern states, was taken  by court order from his mother and placed into foster care. She in turn was charged with criminal neglect as the Department of Social Services for that state felt they must intervene or the boy would be at considerable risk for major obesity-related problems, especially diabetes type 2. I found a photo online of the boy and my jaw dropped.

The JAMA article notes “even relatively mild parenting deficiencies” can contribute to a child’s weight problems: having junk food in the home, frequently taking the kids to fast food restaurants, failing to model an active lifestyle.The CDC estimates `17% of America’s kids and teens are obese (we’re not just talking mildly overweight); that’s 12.5 million kids at risk. The two Boston authors who wrote in JAMA quote a study showing 2 million of those obese kids are grossly obese with a BMI at or beyond the 99th percentile for their age (a very small percentage of those grossly obese kids, it turns out, may have a genetic abnormality; in those rare cases, the parents aren’t to blame).

What can we do about this horrendous problem? Well, there are a variety of “bariatric” operations available in pediatric surgery programs; in dire cases state legal action may be

this makes more sense

necessary. But I liked what I saw the other day walking Yoda, our nine-year-old Tibetan terrier, on his morning constitutional (he gets an evening walk as well, which means either my wife or I or both get some extra exercise).

We came near the elementary school near us and there was a long line of kids, punctuated by an occasional teacher, running past. We stopped to watch, realized these were kindergarden and/or first grade kids, and finally had an opportunity to ask one of the teachers what was going on.

“It’s a new program we’ve started in the Poudre School District,” she said. “We keep the kids moving for thirty minutes. They can run and most do, or twirl around and walk the field next to the school, but they’ve got to keep moving.”

The conclusion in the JAMA article was stark, but offered a road to resolution. The authors noted, “An increasing proportion of US children are so severely obese as to be at immediate risk for life-threatening complication including type 2 diabetes.” They mentioned the pediatric weight loss surgical programs and state protective services, but finished with our need to decrease the need for those options through beefing up the social infrastructure and policies to improve both kids’ diets and guide them toward more physical activity.

Those solutions may work.

Getting it off versus keeping it off

Saturday, October 29th, 2011

What should you do when your scale calls for help?

I saw an interesting New York Times article on the 26th and kept it on my Kindle. It mentioned an article which just was published in The New England Journal of Medicine on why people who succeed in losing weight often find it difficult to not regain the pounds they’ve lost. Prior studies have speculated that a dieter’s metabolism changes with altered hormone levels bringing about increases in appetite.

I just looked at the short form of the NEJM article online; I don’t subscribe to that publication anymore and will have to get the whole article at the local hospital’s medical library. It’s a small but significant study, done by researchers in Melbourne, Australia utilizing fifty overweight or obese patients on an extreme ten-week diet, measuring levels of a number of hormones involved in appetite both at the end of the diet period and one year later.

The goal was to have the subjects lose ten percent of their body weight. Then they were to go on a maintenance diet to keep the weight off. Only thirty-four finished the diet period with the goal weight loss, some quit the study and others lost less than 10%.

So it’s really a very small group, thirty-four successful dieters, who were followed for an additional year. They started at an average of 209 pounds, ate only 500 to 550 calories a day for the initial ten-week study period and lost an average of 29 pounds (14%) of their initial weight. A year later the average patient had gained back half what they had lost and the hormone measurements, especially of leptin, ghrelin and peptide YY, all involved in appetite one way or the other, were still not totally back to normal.

Maybe that’s the reason so many people gain weight back after dieting. This may not have  been a large-scale study, but it speaks volumes.

Eat a healthy diet, not a 500-calorie/day plunge

The Los Angles Times commended on the article and on dieting in general. They noted that four out of five initially successful dieters regain their weight, sometimes more than they lost by dieting. Of course most of them hadn’t gone on such a stringent diet. It makes much more sense to me to lose weight gradually, a pound or so a week is a reasonable goal.

I did that back in early 2009, losing ~30 pounds, and this morning I was still 27 pounds down. I also decided to make exercise a must in my busy schedule and go to the gym six days a week on the average. I can burn ~550 calories on the recumbent bike before I do stretches and work on a few machines. I also walk our new dog twice a day for 20-30 minutes.

Many people say they can’t find that much time in their day and yet they find time for TV or movies or their email.

I think it’s time to change priorities; take some of the time you spend sitting and walk or exercise instead. Gradual weight loss combined with an increase in calories burned makes much more sense than going on 500-calorie diets. I’d like to see measurements of those same hormones in a group who try this approach.

Otherwise you’re just paraphrasing Admiral David Farragut at the 1864 Battle of Mobile Bay, “Damn those hormone levels; full speed ahead.”

 

 

More on the heatwave and its consequences.

Thursday, September 1st, 2011

Here's one way to cool off

This morning I read in the New York Times Breaking News that comes to my Kindle that NYC has recently seen an unprecedented number of heat-related deaths. The age range of the victims varied considerably; youngsters, a 45-year-old  woman and some elderly folk all were struck down. Today I’d like to concentrate on older adults.

You may or may not believe in global warming (I certainly do) and, if you do, whether humans are making a significant contribution to it. But in the meantime we seem to be experiencing a hot patch and we have to cope with that.

I got up fairly early, took Yoda, my Tibetan terrier, to Whole Foods to buy a sack of his dog food and then took him for a walk. All in 72 to 75 degrees on a day that will later see a 95+ degree peak temperature. And this is in Colorado at 5,200 feet elevation. I checked out temp predictions for Denver and for the mountains; the former will be just under 100 degrees later on today whereas those areas at considerably higher elevation will stay in the 70s.

But agewise, I’m also in my 70s, as of April, and therefore read with interest the National Institute on Aging’s paper titled “NIH tips for older adults to combat heat-related illnesses.” The basic concepts are threefold: we lose some of our ability to adapt to heat as we get older; we are in a group that frequently has underlying diseases/conditions that fare poorly in hot weather; the meds our physicians use to treat those diseases sometimes limit our ability cope with the  heat.

I’ll add a link to the article below, but will paraphrase some of their points and add my own spin.

Firstly some of the physiologic changes we experience as we age limit our ability to respond to elevated temperatures. Those include our cooling via sweating or , in some cases, our limited mobility and, in other cases, our mental responses or lack thereof. Additionally, our ability to vasodilate small blood vessels may be compromised.

Then we’re experiencing, as a nation, an epidemic of obesity and concurrently those who exceed their weight goal by a large amount experience more heat-connected problems. I searched medical websites for the rationale and, if I were a teenager, would have said, “Duh!” The layer of adipose tissue the obese accumulate is the equivalent of wearing an insulted suit, something you wouldn’t want to do in the heat of a summer day.

And then there are all those medications we take as we age. One article I found said older people take 2 to 6 prescribed drugs while also taking a number of OTC medications. Those drugs can directly alter our response to heat while potentially causing increased body temperature in a number of other ways, e.g., hypersensitivity reactions or the pharmacological action of the drug itself.

That helps

So if you’re an older adult, avoid the heat of the day, get enough fluids and, if necessary, contact the Low Income Home Energy Assistance Program (through HHS) for help with home cooling.

http://www.nia.nih.gov/NewsAndEvents/PressReleases/PR20110718hyperthermia.htm

Will this work and is it safe?

Tuesday, July 5th, 2011

The ultrasound said 9 pounds

I’m still digesting Taubes’s work with mixed feelings, but his concept that insulin is central in the obesity epidemic took on a new meaning today. I was reading the “Health & Wellness” section of The Wall Street Journal and came across an article titled “Programming a Fetus for a Healthier Life.” I was intrigued and read further, finding the U.K. government is backing a research effort in the realm of “fetal programming,” changing the uterine environment during pregnancy in an attempt to better a child’s health for the better in later years.

This is new turf for me and normally not an area I would have written about; in this case, however, the experiment, thus far only in its early stages, hopes to prevent obesity.

The underlying concept is the work of Dr. David J. P. Barker, who published a theory in 1997 termed the “thrifty phenotype,” saying that in poor nutritional conditions, a pregnant woman can modify the development of her unborn child such that it will be prepared to survive in a resource-limited environment. The extension of this says reduced fetal growth is associated with a number of later-life chronic conditions.

Barker is now both Professor of Epidemiology at an English university and Professor in the Department of Cardiovascular Medicine at the Oregon Health and Science University. In 1995 his theory was renamed as the Barker hypothesis by the British Medical Journal. Now it’s being applied in a very different setting.

a model of human insulin

The study is attempting to enroll obese pregnant women, 400 of them, in a trial of an oral agent called Metformin, normally utilized to treat type-2 diabetes, to lower their blood sugars, which tend to run higher than normal. The thought is that glucose is passed on to babies in utero and they then end up larger than normal birth weights and elevated insulin levels, setting the stage for lifelong obesity.

Dr. Jane Norman, a maternal-fetal health specialist at the University of Edinburgh is a lead investigator. A prominent US specialist, on the board of the 2,000-member Maternal-Fetal Medicine Society and not involved in the study, says he’d have no qualms about his patients joining the Metformin-taking moms-to-be.

I searched the literature and found the following

“Does metformin cause birth defects? Is it safe to take it during the first trimester?

Most studies suggest that metformin is not associated with an increased risk of birth defects. Some early trials suggested that the use of metformin during the first trimester was associated with an increased risk of birth defects. However, it is not clear whether these were caused by metformin or poor control of the mothers’ diabetes. More recent trials studying the safety of metformin during pregnancy, mostly when used to treat insulin resistance in women with PCOS (polycystic ovary syndrome), did not show an increased rate of birth defects or complications at birth.”

So the concept appears to be a reasonable test of whether the uterine environment can be safely altered with a drug to prevent obesity.

Wow!

So what should I eat?

Friday, June 24th, 2011

Medical research comes through for us

I was reading my morning papers yesterday, The Wall Street Journal (hard-copy edition) and the New York Times breaking news (on my Kindle). I came across a June 23, 2011, WSJ article titled “You Say Potato, Scale Says Uh-Oh.” It detailed a recent research study online in a prominent medical journal. The premise was what you choose to eat will determine what happens to your weight over a four-year period.

The overall conclusion, once again, is picking healthier items for your diet leads to less weight gain. Most American adults gain a pound a year, but if they add a serving of French Fries on a daily basis, they’ll gain more (3.35 pounds). The NEJM said the participants in three huge studies (a total of 120,877 U.S. men and women who were free of chronic diseases and non-obese at the start of the studies), gained most if the extra item was potato chips, and lost weight if it was yogurt. The list, after chips, in deceasing correlation to weight gain included potatoes, sugar-sweetened beverages and unprocessed red meat or processed meat.

Negative numbers were noted for the addition of vegetables, whole grains, fruits, nuts and then yogurt. Other lifestyle influences were examined. If one of the subjects exercised regularly, they lost weight; if they watched much TV, they gained pounds.

So what’s new here? Huge studies over lengthy time periods + a few different conclusions.

The study’s co-author, Dr. Walter Willet, the chairman of Epidemiology and Nutrition at Harvard’s School of Public Health was interviewed on NPR New’s program “All Things Considered.” He commented that highly refined foods-sugar-added beverages and potatoes, white rice and white bread-were related to greater weight gain. The presumption is these foods are rapidly broken down into sugar, absorbed and then quickly removed by the action of insulin. So if you eat these things, in a short while you’re hungry again.

high-protein Greek-style yogurt

Nuts have fat, but keep us satiated for a prolonged time. Yogurt was a surprise to the research group (we’re talking about natural yogurt without added sugar) and the mechanism for its influence on weight is unclear, but may relate to the healthy bacteria included.

The bottom line may be just because some foods contain fat, doesn’t necessarily mean they’ll be fattening. On the other hand, foods that keep us satisfied for a longer time may help us control our overall calorie intake over the long haul.

 

 

 

Hypertension: some good news

Tuesday, May 31st, 2011

Let's check your BP

I was reading a blog post from May 2010 written by an unidentified cardiologist. Some of the underlying issues were worth following to better sources. The blog stated that high blood pressure is our most common chronic disease. It went on to mention the connection between BP and weight, saying, as a nation, America is one million tons overweight. It claimed that ten pounds of weight loss could normalize the BP of many Americans.

I initially got into today’s data search because of a Wall Street Journal article (Personal Journal; May 31, 2010; pp.D1-2) titled “A Long-Awaited Advance in the War on Blood Pressure.” I Googled the author, Ron Winslow and he is the deputy editor for health and science and a senior medical and health care writer for WSJ with over a thousand articles written.

He reported that the American Society for Hypertension (ASH) met in New York last week (May 21-24,2011) and Dr. Brent Eagan, the vice president of ASH, and Professor of Medicine at the University of South Carolina reported some real progress on the multi-state Hypertension Initiative he heads. It’s working with ~500 primary care practitioners and over 110,000 hypertensive patients in the Southeast. Nearly 70% of their patient have controlled BPs now (vs. 40% a decade ago).

About as far away as you can get in the U.S., Kaiser Permanente’s northern California branch follows >600,000 patients with hypertension and reported at the same ASH meeting that 80% of that group have controlled BP readings compared to 44% ten years back.

One of the Kaiser patients had a regular checkup in 2007 and had mildly elevated BPs then (145/74). Her own comment was, “Here in northern California, we believe in exercise and good nutrition and we’re not into pills.”

Yet her doctors started her on two medications for hypertension and early this year her BP was 117/74. She’s walking three miles three times a week, eating fruits and vegetables and going to a strength-training class at a gym. I don’t know if she lost weight also, but I wouldn’t be surprised. I mentioned in an earlier post, that my own BP fell markedly after I lost ~25 pounds, and the dosage of the anti-hypertensive drug I’ve been on for years had to be cut in half.

Guess who's at higher risk for CV disease

So why am I writing about this in a blog devoted mostly to weight/diet/exercise?  First, there’s an increased awareness of the association between excess weight, high BP and cardiovascular risk at all ages. An article in the Feb 3, 2009 edition of Circulation looked at the issue in children and adolescents. Concentrating on the Metabolic Syndrome (obesity, diabetes, hypertension, abnormal blood lipids), there was, even in these young people, a definite correlation between the degree of obesity and cardiovascular risk. They stated that strong evidence places obesity as the most significant risk factor

Can I tie all this together? Well I’d say bluntly that obesity is our major enemy, it’s a major causal factor in hypertension which is being treated pharmacologically at earlier stages and that diet and exercise are extremely useful ways to combat both entities.


Brian Wansink’s “Mindless Eating” concept

Tuesday, May 24th, 2011

Don't fill your plate this way

I just read Brian Wansink’s book, Mindless Eating: Why We Eat More Than We Think. Wansink got a PhD in Consumer Behavior from Stanford and from 2007 to 2009 was the USDA’s Executive Director for Nutrition Policy and Promotion. He’s currently in an Endowed Chair at Cornell and won the humorous Ig Nobel Prize in 2007.

If you’ve never heard of the Ig Nobel Prizes, Google the term. They started in 1991 and were originally given for discoveries “that cannot, or should not be, reproduced.” They are presented by Nobel laureates in a ceremony  sponsored by three Harvard groups, broadcast on NPR, on the Internet and on Science Friday the day after Thanksgiving. Some are thinly veiled criticism (BP was a co-winner in 2010 for disproving the old belief that oil and water don’t mix). Most are for serious work that has a humorous slant (malaria-carrying mosquitoes are equally attracted to the smell of Camembert cheese and human feet; this led to insect traps in Africa being baited with that cheese).

In Wansink’s case, his award was given in the Nutrition category for studying people’s appetite for mindless eating by secretly feeding them a self-refilling bowl of soup.

His work has focused on how our environment influences our eating habits. Wansink says we all make well over 200 food choices a day (what to eat, what to drink, how much of each) and we rarely know why we make those decisions or if they are helpful/healthy choices.

For instance, one of his experiments showed using smaller plates can help you serve and eat less. Another concerned fat-free foods, which may have nearly as many calories (and sometimes more) than the standard version of the same food item. In one of his studies, normal-weight subjects given low-fat foods actually consumer one-sixth more calories and overweight subjects took in nearly 50% more calories.

Wansink says low-fat foods have a “health halo;” we think they’re better for us and therefore, in a sense, give ourselves permission to eat more of them.

Container size is another of his “food trap” areas. When presented with a larger package, a larger bottle of a soda or a short, fat glass to pour a drink into, we end up eating or drinking more.

He suggests a series of food trade-offs and food policies (if I want that doughnut, I need to spend an hour walking; I’ll only eat snacks when I’m sitting at the table).

Try eating with these instead of a knife and fork

I liked Wansink’s books, already had been using many of his strategies, but found others I can adopt. I think his studies and concepts are valid and his ~300-page publication well worth reading.If you do so, you may find yourself using chopsticks the next time you eat Chinese food. You’ll likely eat less per bite and eat slower.

I may try them for American food.

 

Katz Redux

Tuesday, May 10th, 2011

I went back to Dr. David Katz’s classic article published in the Harvard  Health Policy Review in 2006. His example of the Pima Indian tribe had caught my eye the first time through the piece and serves as a cautionary note for the rest of us. I decided to explore the subject further.

mesquite tree

The Pimas, who live not far from us, in the four corners region where Arizona, Colorado, New Mexico and Utah meet, used to be outdoors men and women, taking long-distance walks on a regular basis and eating a diet that fits all the modern parameters for healthy eating. it included two unusual items one of which was mesquite,  which I think of as a tree. I’ve now found that mesquite has bean pods that can be dried and ground into a sweet,nutty flour high in calcium, magnesium, potassium, iron and zinc, and rich in the amino acid lysine.

The other native foodstuff was a drought-resistant bean, tepary, which has recently been introduced into African agriculture . All in all they exercised much more than many of us and ate a high-fiber, low-fat low-sugar diet without an abundance of calories.

Then civilization happened to the Pimas. Now they own casinos and don’t walk anywhere as far as their forebears (their per capita income is still on the low side). They also eat a less healthy “American diet” similar to the rest of us.

The consequences were those you’d expect. obesity and diabetes. Fifty percent of the adult Pimas are obese and of those 95% have diabetes. The tribe is now part of a major NIH research project (the website is at http://diabetes.niddk.nih.gov/dm/pubs/pima and then add /pathfind/pthfind.htm or /obesity/obesity.htm), which over the past 30 years has shown that before gaining weight, overweight people have a slower metabolic rate.

This so-called “thrifty gene” theory originally suggested in 1962, looked at populations, like the Pimas, who over thousands of years would have alternating period of famine and feast. When there was little to eat, they stored fat. Now that they don’t need to do this in the same fashion, the gene has led them toward the diseases associated with obesity, especially diabetes.

less healthy than mesquite flour

An update from the Harvard School of Public Health mentioned the mayor of Boston having banned sale and advertising of “sugar-loaded drinks” from city-owned buildings and city-sponsored events. The chair of HSPH’s Department of Nutrition was quoted as saying, “There is abundant evidence that the huge increase in soda consumption in the past 40 years is the most important single factor behind America’s obesity epidemic.”

So not all of us have thrifty genes to blame for weight gain. But we can start by abandoning those sodas and other sugar-laden drinks.  And perhaps, to whatever extent we can, returning to a diet similar to our own ancestors, with more locally grown fruits and veggies leading the way to better health.

 

 

Today’s trail led back nearly five years

Tuesday, May 3rd, 2011

It's time to eat less and do more

There was an interesting article in the Wall Street Journal this morning titled “The Bigger the Belly, the Bigger the Risk.” It cited an article published online yesterday in the Journal of the American College of Cardiology with the lead author being a Mayo Clinic (Rochester branch) physician named Francisco Lopez-Jimenez.

I followed the paper trail (that’s not exactly correct since it’s an online publication) and read the abstract, then another of Dr. Lopez-Jimenez’s articles, then a commentary and followed those concepts back to a long article written in 2006 by a Yale staffer, Dr. David L. Katz.

Dr. Katz’s article in the Harvard Health Policy Review (Vol. 7, No. 2, Fall 2006, pp.135-151) is one of the best I’ve ever read and I’ll concentrate on it today and then move up to 2011.

Katz gives statistics (remember these are almost five years old) showing at least 15% of kids ages 6 to 19 are overweight with higher percentages for Hispanic and Black children. Then he notes that more than two thirds of kids over 10 who are obese will turn out to be obese as adults. They will then be subject to the big three obesity-relayed diseases, diabetes, heart disease and cancer. And while they are children, their quality of life is less, for many reasons.

What I didn’t realize was even those who lose weight as adults, but were obese as kids, are at increased risk.

Not the right choice for weight loss

He goes on to explain that as a species, we ate, historically, when we could, stored fat for times when food was scarce, and exercised a lot. All that has changed, but we still tend to eat more than we should, given the fact that for many of us food is abundant. And our modern labor-saving devices mean we usually exercise far less than we should. We also eat the wrong things. The end result is weight gain, to the point of frank obesity for many.

Today’s article said where you carry excess weight is more important than the sheer fact of being overweight. I read several of Dr. Lopez-Jimenez’ publications, and their main thrust is that central obesity, i.e., having a large roll around your waistline, is much more detrimental than simply having a higher than usual weight or BMI.

Lopez-Jimenez and his co-authors looked at studies following patients with heart disease, but other papers support their basic theme. The NIH’s director of cardiovascular sciences, Dr. Michael Laurer, who wasn’t involved in the Lopez-Jimenez study, is quoted as saying, “Fat is not created equal and where fat is located makes a difference.”

The other comment that was somewhat new also came from Dr. Laurer who said, “Fat isn’t an inert substance.” Apparently scientists have found a number of toxic chemicals can be released from fat.

I’m heading to the gym next where I’ll see a number of men in the locker room who have built up their upper body muscles, but have a considerable roll around their mid-section. They need to adopt a new exercise, pushing away from the dinner table.

 

Obese kids, a growing problem

Tuesday, April 26th, 2011

eating too much of the wrong things

There is a very interesting article in the Wall Street Journal today about how Portland, Maine, concerning about the growing number of obese kids in the community, developed a city-wide plan to combat the issue. Their concept has now spread elsewhere in the state.

Well that caught my attention and I started looking for background medical and non-medical data. Many of the websites I visited initially were poorly written, causing me to move on, but I found one for the 6th Biennial Childhood Obesity Conference to be held in San Diego starting 0n June 27th (www.childhood-obesity.net). The underlying dire fact is the percentage of kids in the US who are overweight or frankly obese has nearly tripled in the last thirty years.

The conference offers youth scholarships for travel, hotel accommodations, meals (presumably healthy ones) and registration/materials fees. This way kids ages 14 to 18 can meet with medical experts, teachers, policy makers and other kids to hear the evidence-based best approaches to combating obesity.

some start off the wrong way

Former President Bill Clinton’s foundation’s web page said we’ve got ~25 million kids in the overweight and obese danger zones and the medical therapy for obese kids costs us three times that of normal weight kids. Twenty-five percent of our children don’t engage in any kind of free-time physical activity.

So is it genetics or food or activity that’s causing the problem. I think the answer is “yes,” but I’d certainly put more emphasis on the latter two factors. Less than 25% of our high school kids take PE on a daily basis; instead they spend an average of four to five hours a day doing non-exertional “techy” activities including video games, computer use and even plain old television watching.

So back to Portland’s plan. They developed a 5-2-1-0 concept: five servings of fruits and veggies, 2 hours or less of “screen time,” at least one hour of exercise a day and zero sugar-filled drinks. They’ve already reversed the upward trend in obesity, but at considerable cost ($3.7 million) and with some difficulty in measuring the results. Now the CDC has recently given over a quarter of a billion dollars to 39 US communities in an effort to both start programs and follow their outcome.

I Googled the name of Dr. Victoria Rogers, a pediatrician mentioned in the article. She works as Director of the Kids Co-op at the Barbara Bush Children’s Hospital at Maine Medical Center and is involved in the 5-2-1-0 Goes to School program, another  Portland-based program called “Let’s Go!,” and the state-wide Maine Youth Overweight Collaborative.

In Maine alone, Let’s GO is now active in nearly 350 schools and the local business men and women who funded the original project are able to see some preliminary results already. One phone survey found increasing (but still relatively low) percentages of kids adopting healthier eating and exercise habits. Dr. Rogers and her cohorts want to follow 1,500 kids who are in the Let’s Go! study long term to see if they change their eating and exercise habits for a lifetime.

So what’s happening in your town or city and your state. It’s our kids; we have to make a difference in their lives and this is a great way to do so.