Archive for February, 2012

Arsenic: it’s in juices too, along with lead

Tuesday, February 28th, 2012

Any arsenic or lead here?

In September of 2011 Dr. Oz, the Columbia University cardiothoracic surgeon turned TV personality, reported on a problem with apple juice. His show is often on one of the six screens in front of our health club’s exercise bikes. I didn’t know much about him and routinely read a book on the recumbent bike I ride for an hour, so I paid little attention…then.

His comments applied only to apple juice. He had commissioned an independent lab to check the arsenic level in five brands of  juice. They  found 10 of the 36 samples had arsenic levels higher than the EPA’s drinking water standard of 10 parts per billion (ppb).

The FDA called his publicizing the results of his study “irresponsible and misleading,” saying drinking all brands of apple juice is safe. What he hadn’t asked the lab to do was to determine if that toxin was in its inorganic form, felt to be dangerous, or in the less dangerous organic form. The FDA said they retested the same batches of juice and found the levels of the more toxic form to be well within safe limits, “almost zero.”

Their standard for combined organic and inorganic arsenic is 23 ppb; foods or beverages measuring above that level get retested to determine how much inorganic arsenic is present.

Let’s think about that cutoff level; drinking water, to be “safe” used to have less than 50 ppb, more recently 10 ppb has been set as the upper limit. As I’ve mentioned before, the state of New Jersey now has a standard of 5 ppb.

But in at the end of November, 2011, the website, MedPage Today briefly noted the results of a confirmatory study. Consumer Reports decided to measure both arsenic and lead in apple juice and grape juice. Nine of the 88 samples they had checked exceeded the “safe” limit.

This is supposed to be safe

Then in January, 2012, Consumer Reports.org published their full report online. That article mentioned that 25% of their samples had lead levels over the FDA’s bottled-water limit of 5 ppb. And of the 10% of the samples with elevated arsenic amounts, most was the highly toxic inorganic variety.

That report is well worth reading. The Consumers Union group, an advocacy offshoot of Consumer Reports urged that new limits be set for these toxins in juice: 5 ppb for lead and 3 ppb for arsenic. Groundwater contamination with those toxins was implicated in the elevated amounts found in fruit juices. Human activities release three times as much arsenic into our environment as do natural sources

Then in early February two senior members of Congress, one from New Jersey and one from Connecticut, introduced the “Arsenic Prevention and Protection from Lead Exposure in Juice Act of 2012,” AKA the “APPLE Juice Act of 2012.” If it passes, the FDA would be required to establish standards for arsenic and lead in fruit juices in two years time.

The other issue, of course, is how much juice kids actually drink. The American Academy of Pediatrics recommends no juice until age 6 months, and no more than 6 ounces a day until age six. The reality is over a third of a sample of 555 children, 25% of those age two and under and 45% of kids aged from 3 to 5, exceeded those limits.

We’ve got a long ways to go, but at least we’re hearing about these threats to the health of our kids and grandkids.

 

 

 

Arsenic toxicity: Part Two: What is in your baby’s food?

Friday, February 24th, 2012

Better check how it's sweetened

As I mentioned in my previous post, I read the American Medical Association’s recent email piece titled “Study finds high levels of arsenic in some baby formulas, cereal bars” and got interested in the topic. The issue is the use of organic brown rice syrup which is used instead of high fructose corn syrup to sweeten some organic food products, baby food especially.

I found an article in Environmental Health Perspectives titled “Food Safety: U.S. Rice Serves Up Arsenic.” The background was that of arsenic-based pesticides being used for years to kill off boll weevils in the southern cotton fields. That has ceased, but apparently arsenic stays around a long time and those same fields are now being used to raise rice. An extensive study by researchers from Scotland on the results was reported in 2007 in Environmental Science & Technology.

They bought rice samples at supermarkets and ran detailed chemical tests on them, looking at arsenic levels and those of other elements found in tiny amounts (these are called “trace elements”). In all they purchased 134 samples with 80% of those from the South Central states and 20% from California. That’s about the percentages of where rice is grown in this country; almost 50% is from Arkansas. They bought many varieties of rice

The reason they tested for those other elements was to be relatively sure of where the rice was actually being grown. We sometimes purchase basmati rice from India at an Asian market nearby and can get rice from other countries at any of our supermarkets, but the researchers wanted to know if the rice they bought in Californai came from there and ditto for those samples they got at food stores in Arkansas. The background composition of the soil in different places varies, as you’d expect, so checking for the other elements could solve the issue of where the rice came from.

And where does this rice come from?

The findings were striking. Rice grown in the South Central states, on average, had more arsenic, a lot more. The standard for drinking water in the US is now 10 parts per billion. That’s tiny but for other cancer-causing materials the EPA assumes there’s no safe level at all and sets  limits that could result in anywhere from one in 10,000 to 1 in a million people exposed getting a cancer.

The current water standard for arsenic, at least according to Consumer Reports, gives an excess cancer risk of one in 500. That’s calculated on drinking a liter a day. The state of New Jersey set their water standard at 5 parts per billion. But there is no EPA standard for rice or other foods, at least not for arsenic.

And the average for rice grown in the south central areas was close to 30 parts per billion, while California rice ran around 16.

And who eats more rice?

Hispanics, Asian-Americans, many who are gluten sensitive and, most worrisomely, our babies and toddlers in the form of brown rice syrup.

 

Arsenic Toxicity: Part One, history & worldwide impact

Tuesday, February 21st, 2012

It looks harmless here

I started to write a post on arsenic in baby food since there’s been a spate of recent articles on this issue appearing both in newspapers and online (the AMA Morning Rounds email I receive started me thinking of the subject). But, as usual, when I began to pursue a topic, I found there was both a long history I needed to cover and, in this case, a worldwide problem that should be discussed.

Human industrial use of arsenic dates back 5,000 years. I found the Harvard Arsenic Project has a thorough coverage of varying aspects of our utilization of this element, both beneficial and detrimental. It has been used as a poison for many centuries since it has little if any odor or taste, especially when mixed with food or wine. A Roman leader named Sulla outlawed arsenic poisoning in 82 B.C., to no avail. In Italy in the 15th and 16th centuries, the Borgias, especially Pope Alexander VI and his son, Cesare were said to have killed scores of bishops and cardinals by liberally lacing their wine with arsenic; then, by Church laws, they owned the property of their victims.

Roger Smith, a Dartmouth Medical School Emeritus Professor of Pharmacology and Toxicology has published an online discussion of the uses of the element with the gripping title, “Arsenic: A Murderous History.”

Scientifically it is classed as a “heavy metal.” Nowadays we think of that term as referring to a form of music. But from the chemistry pound of view it actually is one of a group of elements that, volume for volume, are at least five times as heavy as water. Iron, lead and mercury are in that group, but so is arsenic.

If you were to ingest arsenic, diluted in wine or water, at an incredibly small level, 60 parts per million, you would develop belly pain, nausea, diarrhea and then die. Until a few years ago the US drinking water limit was 50 parts per billion. Then in 2000 the EPA proposed all 54,000 community water systems in this country should cut their arsenic levels to no more than 10 parts per billion.

but it's a a plague here

Our local water lab just told me our Fort Collins levels are less than 1 part per billion. That’s clearly not true elsewhere in the world. Over 137 million people in 70 countries are exposed to toxic levels in their drinking water. Bangladesh has the most well-known problem. When more than eight million deeper wells were dug in the 1970s and beyond, as an attempt to lower the infant death rate from ineffective water purification, arsenic  replaced infectious diseases as a major threat. The drinking water for more than 30 million people had levels over 50 parts per billion.

So they potentially could develop chronic arsenic effects include skin, lung, kidney, liver or bladder cancers and perhaps a variety of cardiovascular and respiratory diseases.

We’ve a long, long ways to go before we solve the issues raised by arsenic.

 

 

Exercise counts most for kids

Saturday, February 18th, 2012

thumbs up on this activity

In a previous post I mentioned former neighbors whose two boys had to run around outside for an hour a day (and they did spend most of that hour literally running), before they got any “screen time.” I thought that was admirable and noted both kids were slender.

Now I found an article in the February 15, 2102 issue of JAMA that confirms the wisdom of the approach my friends took toward this issue. A sextet of authors from the UK, Norway, Sweden and Canada published results for the International Children’s Accelerometry Database Collaborators (ICAD).

First I had to make sure what accelerometry meant in this context. The dictionary definition was only somewhat useful. It obviously refers to a gadget for measuring acceleration, but when I returned to a prior study  of 1,862 British children aged 9 or 10 published in 2009 in the American Journal of Clinical Nutrition, I learned it’s a very expensive and sophisticated gadget. My wife has a step counter that our local hospital seniors’ organization, the Aspen Club, gave her free. The device used in the large-scale research project, sold by a Florida firm, does lots more than just count steps. Among other thing it also monitors how much energy you expend and what your activity intensity has been. Of course the current model I found online costs $1,249, but there is a volume discount.

That earlier study concluded we need to get our youngsters really moving in order to “curb the growing obesity epidemic.”

The current paper offers a more nuanced viewpoint. It has a daunting title: “Moderate to Vigorous Physical Activity and Sedentary Time and Cardiometabolic Risk Factors in Children and Adolescents.”  The study looked at exercise levels and screen time in over 20,000 kids ages 4 to 18. Overall those who got more exercise improved all the risk factors measured: waist size, blood pressure, insulin levels, triglycerides and HDL cholesterol.

thumbs down on this one

Once levels of physical activity were factored in, sedentary time seemed relatively unimportant. But a smaller group, 6413 kids, was followed  for a little over two years and neither screen time nor exercise seemed important in changes in waist size, while kids who, at the start of the various studies, had bigger bellies, also had them later. I’d bet most of those were quite TV-addicted, since the paper warns that activity (or lack of activity actually) is often a clue to snacking and soft drinks.

I may show the short form of this paper to the principal of the nearby grade school I’ve mentioned previously. All those kids, starting in kindergarden, have a one-hour exercise period mostly spent running. I think it’s a school-district-wide program and just confirms what to me is common sense.

Lots of our youngsters are spending their days sitting in front of a screen of some sort instead of playing active games outdoors. Even in the age group followed in the recent article, a quarter of the kids were at least overweight; 7% were already obese. The average time for active play was a half an hour a day and the average for screen time was close to six hours a day.

I doubt we can totally reverse those numbers, but it’s a good idea.

End of Life Care

Wednesday, February 15th, 2012

Hospice care nurses can make you smile

We’ve had a relative and a friend who each had Hospice care, one in another state and one locally. Both their spouses thought that Hospice was wonderful and wondered why they had to wait so long before their loved one was eligible for it. So when the Annals of Internal Medicine for February arrived, I decided to read an article titled “End-of-Life Care Discussions Among Patients with Advanced Cancer” and the section called “In the Clinic” which this month was on Palliative Care.

I knew that Hospice is for patents in their last six months of life. More than three quarters of them have at least one of four diagnoses: congestive heart failure, kidney failure, dementia or chronic obstructive pulmonary disease (emphysema). They have no life-saving avenues left and are normally not in a hospital setting. Some prefer to die at home and some are in long-term care facilities. We have a local organization, Pathways Hospice which supplies care for patents in several Northern Colorado communities; they offer on-call nursing care 24/7, spiritual care, appropriate medical equipment and counseling services. Their care is overseen by physicians trained in Palliative Medicine.

I thought the two overlapped, but didn’t know as much as I wanted to much about Palliative Care itself. It’s now a subspecialty recognized by the American Board of Medical Specialties and its physicians usually work with a team that may include social workers, chaplains, physical therapists and pharmacists. The patents they care for have severe illness and are usually in a hospital setting, although some may be seen in outpatient clinics.

There are no treatment limitations for this group of patients, but for some the article said, “You would not be surprised if the patent died within 12 months.” Other have had recurrent hospital admissions or complex care needs. They may have limited family support or chronic mental illness.

Management of their symptoms: pain, shortness of breath, nausea, agitation and distress, delirium and “failure to thrive” are crucial avenues for the Palliative Care team to address. Those teams have quadrupled in the last ten years.

The link I supplied led me to a directory of hospitals which offer Palliative Care teams. Physicians trained in Palliative Medicine supervise both those teams and Hospice activities.

But it's best to have that talk while you're still able to.

The problem I noted reading the Annals articles was that many patents don’t ask their docs about EOL care and, somewhat surprisingly, many physicians don’t have any discussion with their patients about this crucial area until the very last moment, if that. Frequently people in the final month of their lives finally have that EOL talk; often they’re an inpatient by then and being cared for by someone other than their long-term physician.

My wife and I have discussed what we do and don’t want, but I think it’s time for me to let my primary care physician know what I’ve decided. At present I’m basically healthy, but I’m also about to turn seventy-one and you never know.

 

 

Adults, obese and otherwise

Sunday, February 12th, 2012

PIck well and cut back your waste/waist

In my last post I explained the concept and the math behind the body mass index (BMI) approach to evaluating if your weight was normal or not (your BMI is very  well in synch with the most scientific methods of determining body fat percentages). Now I want to expand on that a bit  with some recent statistics and some thoughts on how we can lose weight if we need to. Unfortunately, some of us have lots of extra pounds we should shed if we want to have our best shot at leading long, healthy lives.

The Feb 1, 2012 issue of JAMA had a number of interesting articles on obesity. I’ve previously mentioned several on childhood and adolescent obesity; today I’d like to zero in on two whose focus is American adults.

Four CDC staffers, led by Katherine Flegal, PhD, published the most recent statistics from a recurring national survey with the daunting acronym NHANES. This national health and nutrition survey (the E stands for examination) started in 1971, but from 1999 on has been released results in two-year cycles. The current article from the National Center for Health Statistics, looking at the 2009-2010 NHANES data had a little good news and lots of bad news.

After 1980, until the turn of the 21st century, the prevalence (scientific term for percentage) of obesity in our population kept zooming up. Now it appears to have leveled off. I guess that’s something we should be happy about, except now over 35% of adults in this country are obese. Men and women have about equally high rates of obesity and men have caught up to women in this regard over the last twelve years. Some subsets, by sex and racial groups, are even more likely to be obese or very obese.

The worst news from this article was that no group–men, women, non-Hispanic whites, Hispanics or non-Hispanic blacks–had a decrease in the prevalence of obesity in this most recent data set.

So which exercise and diet should we try?

getting enough exercise is difficult when your joints hurt

Many adults report “No Leisure-Time Physical activity.” Overall, more of us are exercising, but the data vary from state to state. Those who have arthritis, fifty million in the US, need special attention or are even more likely to get no exercise. The CDC has worked with the Arthritis Foundation to develop ideas for this huge group. Going back to my review of articles on youngsters, I think for the rest of us, we could begin with simple steps, parking at the far end of the parking lot and substituting some walking for part of our screen time as two examples.

Harvard Medical School’s free online HEALTHbeat publication had a review of pros and cons of various diets in its Feb 7, 2012 edition. The bottom line still is if you want to lose weight, you must cut down on your calories. The Mediterranean-style emphasis on fruits and vegetables, unrefined carbohydrates, nuts, seeds and fish may be the most effective in reducing cardiovascular and diabetic risks.

My New Year’s Resolution is to keep my weight under 150 pounds. I have to work at it as I like to eat, but most of the time I’ve stayed away from splurges.

How about you?

 

JAMA

 

 

Adulthood: when your BMI is more important than your IBM (stock)

Thursday, February 9th, 2012

I do this at home, without clothes

In my last post I wrote about our upcoming generations and their obesity issues. Unfortunately, as you might have easily been able to predict, that carries over into adulthood. The same issue  (Feb 1, 2012)  of the Journal of the American Medical Association (usually called JAMA) had several articles on adults also. To begin with the National Health and Nutrition Survey (NHANES) looked at the body mass index (BMI) of men and women from 1999 through 2010.

“AARRGGHH” you say, “Why the hell should I care about whatever BMI is enough to try to understand it?”

Well, that’s a tough question, I admit. But BMI is the standard way of deciding if a person is too thin, normal, overweight or obese. So let’s give it a try.

Your BMI is a number calculated using your height and weight.  If you weight 250 pounds and you’re a seven-foot tall basketball professional center player, you’re unlikely to be obese. But if you’re five foot, six inches tall, and don’t exercise at all, like the adolescent I was reading about recently, you’re far too heavy. In the first case, the athlete has a lot of muscle, whereas the youngster is almost certain to be carrying around a lot of excess fat.

For a long time physicians just weighed their patients. That plus eyeballing their bodies in an exam room works for most people. Then along came the BMI as one way of getting a little more scientific. I looked online for the history of the use of body mass index as I suspected it was “invented” by a European (it was). It certainly seems to me to favor the metric system. There it’s easy to figure out your BMI; you divide your weight in kilos by your height in meters. It’s much more complicated using pounds and inches (BMI = weight in pounds divided by height in inches squared and that number is multiplied by 703) The CDC explanation of BMI is helpful and also supplies a “widget” you can download and a calculator if you just want to bookmark the website.

height counts, for adults too

So now you’ve (hopefully) figured out your own BMI; What does it mean and how reliable is it?

First the numbers: most people with a BMI under 18.5 are skinny, underweight. That probably excludes a whole passle of long-distance runners. Most people with a BMI over 18.5 and under 25 are in the “normal” weight category. I used the CDC calculator and my number is 20.5. Most whose magic number is 25+ and less than 30 are overweight and almost anyone whose BMI is over 30 is obese. The teenager I mentioned above has a BMI of 40.

Okay, you say. Now what do I need to do once I know what category I’m in.

I’d start with the eyeball test. Do you have a roll around the middle? In early 2009, weighing only three pounds more than I had for twenty years, I clearly did. I made up my mind to do something about that excess flab, knowing that fat in the belly also implies arteries that are narrowing down.

After losing thirty pounds and keeping it off, I bounced up after the Superbowl and went back on my diet, i.e., consuming fewer calories. I went to a meeting last evening; there were lots of goodies, but I ate only carrots and cucumbers. This morning I’m at 148.2 pounds, smack dab in the middle of the three-pound “ideal weight” range I decided on.

Harvard Medical School just published a piece titled “Choosing the diet that will work for you.” The central theme is cutting calories.

The very high-priced spread

Saturday, February 4th, 2012

This obese teenager could be headed for trouble

I’ve been concerned about our burgeoning problem of excessive weight, so when the Journal of the American Medical Association for February 1, 2012 arrived, I was intrigued by the variety of articles touching on the subject. Let me start with a disclaimer: I have no clear-cut special competence, no magic bullet for preventing or treating obesity in our children. I do think it’s a major threat to the upcoming generations here and elsewhere in the world. I am also very aware that its opposite numbers, hunger and even starvation, threaten whole populations around the globe.

But my own background, both as a physician and as someone who has successfully fought weight issues (I weighed 218 in 1969 and 148 this morning), has made me concentrate on the American epidemic of eating to excess as a major area of my interest.

The first article dealt with kids and adolescents. A group of CDC researchers reported an update on obesity in American kids, giving data from 199 to 2010. The newest statistics show nearly ten percent of our infants and toddlers are obese and close to 17% of our kids ages two to nineteen. As the kids got older, more boys than girls were obese in this survey with over 4,000 participants.

Then there was an article titled “Weight Loss Stratagies for Adolescents,” based on a Boston Children’s Hospital Conference roughly a year ago. The MD, PhD Harvard Professor of pediatrics who discussed the issue began with the case history of a particular obese girl, a fourteen-year-old who was five foot six and weighed nearly 250 pounds (giving her a body mass index,BMI, of 40). Her adoptive parents were overweight themselves, but had to learn to “back off” in their attempts to control her diet. There is some early data that suggests that parents can help by providing health food choices in the home and facilitating enjoyable physical activity throughout the day (versus a fixed “exercise time).

I had seen an example of that with some former neighbors whose boys, in order to have their one hour of “screen time,” had to be outside playing for several hours at a time. Both youngsters were lean.

One critical point to be made is avoiding focusing on obese kids only. A large Danish study, published in the New England Journal of Medicine in December, 2007,  followed over a quarter million children born in the 1930 to 1976 time period. Denmark established a national civil register of “vital statistics” in 1968 and enrolled everyone in the country, giving them a unique number, ironically termed their CPR number. Although that had nothing to do, I gather, with cardiopulmonary resuscitation, which is what I think CPR means, the study did look at risk factors for coronary heart disease.

When your heart's on fire, it may not be from love

The results are impressive and threatening: every one point increase in BMI across the spectrum was associated with an increased risk of coronary artery disease. A child didn’t have to be fat to be at risk later on. One calculation estimated that a 13-year-old boy weighing 25 pounds more than the average had a one-third increase in the likelihood of having a heart attack before the age of sixty.

It’s time to start helping our kids live leaner and longer, healthier lives.

 

What sweetener do you use: Part 6; the fake sugars

Wednesday, February 1st, 2012

Nearly a month ago I started to write a post on the “Fake sugars,” I had read an article on them in the Personal Journal section of The Wall Street Journal, but got distracted when I realized I needed to think about (and write about) table sugar and high fructose corn syrup.

they're all sweeter than sugar

So now I’m finally going to start on the artificial sweeteners. There are four major ones that WSJ reviewed (they even had a panel of tasters): Sweet’N Low, Equal, Splenda and Truvia. They came on the market, respectively, in the 1970s, 1980s, 2000 and 2008. All have zero calories per packet, whereas table sugar has 15 or 16, depending on who you read, per teaspoon. They cost much more than sugar and are considerably sweeter. A Mayo Clinic article online reviews the general subject and terms these chemicals as intense sweeteners.

The National Cancer Institute mentions that they are regulated by the FDA and, in an August 2009 online paper, states there is “no clear evidence that the artificial sweeteners available commercially in the United States are associated with cancer risk in humans.”

The most recent addition to this mix, called Truvia when it’s made by Coca-Cola and Cargill, or PureVia when it’s parents are PepsiCo and Merisant, comes from a plant called Stevia, found in South America. Stevia has a curious history in the United States; it was added to teas by Hain Celestial until the FDA got an anonymous letter questioning its safety in late 2007. At  that point the FDA banned its use in foods, but in 2009, faced with major industry interest, Stevia by-products were approved as food additives (but not Stevia itself).

Stevia, saccharin and the real sugar

Now Truvia and PureVia are being used in a wide range of processed food and beverages. A cousin to the chemical they contain has been extensively used in Japan for over twenty years without major side effects being noted and Stevia, the parent plant, has not only been used for centuries in South America, but also touted for its supposed health benefits.

So why do I have some lingering doubts, in fact some major concerns about all of these chemical food additives, not excluding Truvia and PureVia?

As best I can tell the vast majority of the research on them has been sponsored by the same companies that profit from them. I fail to see independent, carefully performed, double-blind controlled studies especially on the “new two.” Some research has been done on their chemical components, including one four-month study on type 2 diabetics that did not show either high blood pressure or high blood sugar as a result of consuming the active agent in Truvia.

But it’s not just diabetics who are being exposed to the chemicals in these sweeteners. Most of us are, if we consume a diet drink or anything labeled “light.” And medical history informs us that untoward effects may show up in relatively small number (or perhaps even large numbers), years later.

So I’m going to avoid “fake sugars” whenever I can. And perhaps, just perhaps, someday I’ll find out I was being smart in doing so.