| Critics Say Gates’s Anti-Polio Push Is Misdirected Posted: 31 Jan 2011 12:18 PM PST On Monday, in a Manhattan town house that once belonged to polio’s most famous victim, Franklin D. Roosevelt, Bill Gates made an appeal for one more big push to wipe out world polio. Aijaz Rahi/Associated Press THOSE IN NEED A child braced herself as a health worker prepared to administer a vaccine during a polio eradication campaign in Bangalore, India. European Pressphoto Agency ON THE GROUND Bill Gates visited an Indian village to see the government’s efforts against polio. He has donated $1.3 billion toward the goal. Although that battle began in 1985 and Mr. Gates started making regular donations to it only in 2005, he has emerged in the last two years both as one of the biggest donors — he has now given $1.3 billion, more than the amount raised over 25 years by Rotary International — and as the loudest voice for eradication. As new outbreaks create new setbacks each year, he has given ever more money, not only for research but for the grinding work on the ground: paying millions of vaccinators $2 or $3 stipends to get pink polio drops into the mouths of children in villages, slums, markets and train stations. He also journeys to remote Indian and Nigerian villages to be photographed giving the drops himself. Though he lacks Angelina Jolie’s pneumatic allure, his lingering “world’s richest man” cologne is just as aphrodisiacal to TV cameras. He also uses that celebrity to press political leaders. Rich Gulf nations have been criticized for giving little for a disease that now chiefly affects Muslim children; last week in Abu Dhabi, United Arab Emirates, Mr. Gates and Crown Prince Sheik Mohammed bin Zayed al-Nahyan jointly donated $50 million each to vaccinate children in Pakistan and Afghanistan. In Davos, Switzerland, Mr. Gates and the British prime minister, David Cameron, announced that Britain would double its $30 million donation. Last month, when the Pakistani president, Asif Ali Zardari, went to Washington for the diplomat Richard C. Holbrooke’s funeral, Mr. Gates offered him $65 million to initiate a new polio drive. Twelve days later, publicly thanking him, Mr. Zardari did so. However, even as he presses forward, Mr. Gates faces a hard question from some eradication experts and bioethicists: Is it right to keep trying? Although caseloads are down more than 99 percent since the campaign began in 1985, getting rid of the last 1 percent has been like trying to squeeze Jell-O to death. As the vaccination fist closes in one country, the virus bursts out in another. In 1985, Rotary raised $120 million to do the job as its year 2000 “gift to the world.” The effort has now cost $9 billion, and each year consumes another $1 billion. By contrast, the 14-year drive to wipe out smallpox, according to Dr. Donald A. Henderson, the former World Health Organization officer who began it, cost only $500 million in today’s dollars. Dr. Henderson has argued so outspokenly that polio cannot be eradicated that he said in an interview last week: “I’m one of certain people that the W.H.O. doesn’t invite to its experts’ meetings anymore.” Recently, Richard Horton, editor of The Lancet, the influential British medical journal, said via Twitter that “Bill Gates’s obsession with polio is distorting priorities in other critical BMGF areas. Global health does not depend on polio eradication.” (The initials are for the Bill & Melinda Gates Foundation.) And Arthur L. Caplan, director of the University of Pennsylvania’s bioethics center, who himself spent nine months in a hospital with polio as a child, said in an interview, “We ought to admit that the best we can achieve is control.” Those arguments infuriate Mr. Gates. “These cynics should do a real paper that says how many kids they’re really talking about,” he said in an interview. “If you don’t keep up the pressure on polio, you’re accepting 100,000 to 200,000 crippled or dead children a year.” Right now, there are fewer than 2,000. The skeptics acknowledge that they are arguing for accepting more paralysis and death as the price of shifting that $1 billion to vaccines and other measures that prevent millions of deaths from pneumonia, diarrhea, measles, meningitis and malaria. “And think of all the money that would be saved,” Mr. Gates went on, turning sarcastic. “It’d be like 5 percent of the dog food market in the United States.” (Americans spend about $18 billion a year on pet food, according to the American Pet Products Association.) Both he and the skeptics agree that polio is far harder to beat than smallpox was. One injection stops smallpox, but in countries with open sewers, children need polio drops up to 10 times. Only one victim in every 200 shows symptoms, so when there are 500 paralysis cases, as in the recent Congo Republic outbreak, there are 100,000 more silent carriers. Other causes of paralysis, from food poisoning to Epstein-Barr virus, complicate surveillance. Also, in roughly one of every two million vaccinations, the live vaccine strain can mutate and paralyze the child getting it. And many poor families whose children are dying of other diseases are fed up with polio drives. “Fighting polio has always had an emotional factor — the children in braces, the March of Dimes posters,” Dr. Henderson said. “But it doesn’t kill as many as measles. It’s not in the top 20.” Also, the effort is hurt by persistent rumors that it is a Western plot to sterilize Muslim girls. The Afghan Taliban, under orders from their chief, Mullah Muhammad Omar, tolerate vaccination teams, but the Pakistani Taliban have killed some vaccinators. Victory may have been closest in 2006, when only four countries that had never beaten polio were left: Nigeria, India, Pakistan and Afghanistan. Those four have still not conquered it, although India and Nigeria are doing much better. Now four more — Angola, Chad, the Democratic Republic of Congo and Sudan — have had yearlong outbreaks, and another 13 have had recent ones: eight in Africa, along with Nepal, Kazakhstan, Tajikistan, Turkmenistan and Russia. And polio migrates. In 2005, it briefly hit both an Amish community in Minnesota and Indonesia, the world’s fourth most populous country. Both outbreaks were stopped by vaccination. Proponents of eradication argue that it would be terrible to waste the $9 billion already spent, and a new analysis, paid for by the Gates foundation, concluded that eradication, if successful, would save up to $50 billion by 2035. The United States is still committed. “If we fail, we’ll be consigned to continuing expensive control measures for the indefinite future,” said Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, which leads the country’s effort. Dr. Ezekiel J. Emanuel, chief bioethicist for the National Institutes of Health, who is seen as a powerful influence within the Obama administration, said he had “not seen enough data to have a definitive opinion.” “But my intuition is that eradication is probably worth it,” he added. “As with smallpox, the last mile is tough, but we’ve gotten huge benefits from it. But without the data, I defer to people who’ve really studied the issue, like Bill Gates.” The W.H.O. recently created a panel of nine scientists meant to be independent of all sides in the debate to monitor progress through 2012 and make recommendations. Dr. David L. Heymann, a former W.H.O. chief of polio eradication, said he was still “very optimistic” that eradication could be achieved. But if there is another big setback, he said — if, for example, cases surge again in India’s hot season — he might favor moving back the eradication goal again to spend more on fixing health systems until vaccination of infants for all diseases is better. “When routine coverage is good, it’s no problem to get rid of polio,” he said. Asked about that, Mr. Gates said, “We’re already doing that.” This posting includes an audio/video/photo media file: Download Now |
| Mind: A Home Treatment Kit for Super Bowl Suffering Posted: 31 Jan 2011 12:58 PM PST Every year scientists report that watching the Super Bowl is somehow unhealthy, even dangerous. Large bowls of snacks encourage overeating. Traffic accidents may increase after the game, too. This year, a study in the journal Clinical Cardiology released on Monday warns that a loss by the hometown team in the big game leads to “increased deaths in both men and women, and especially older patients.” One of the authors said in a press release that “stress reduction programs or certain medications might be appropriate in individual cases.” Therapists in Wisconsin and Pennsylvania are prepared. Most have seen plenty of people who suffer from what could be called Football Attention Neurosis (F.A.N.), in their practices, in their living rooms, and sometimes in the mirror. “The belief that these patients have is that the world will end if the Steelers — uh, I mean, their team loses,” said Mark Hogue, a psychologist at Northshore Psychological Associates in Erie, Pa., who owns a trunkload of Pittsburgh Steelers paraphernalia, including a Snuggie. “As a therapist, you need to take that fear seriously.” “Many patients, it needs to be said, will be self-medicating,” said Ursula Bertrand, a psychologist in private practice in Green Bay, Wis. “This can be helpful, but in excess it can also make anxiety attacks more likely.” The causes of those attacks are very specific to the fan’s team, experts said. A patient with an attachment to, for instance, the Green Bay Packers may be especially symptomatic if he or she sees the team’s quarterback running unprotected with the ball, especially if that quarterback has suffered previous concussions. The same patient might also suffer heart palpitations “whenever the Packers go out to receive a punt,” said Bradley C. Riemann, director of the Obsessive-Compulsive Disorder Center and cognitive-behavioral therapy services at Rogers Hospital in Oconomowoc, Wis., who has tickets to the Super Bowl and often travels to follow the Packers. In contrast, a patient with an attachment to, for example, the Steelers might experience stabs of panic whenever he or she sees the team’s offensive line try to protect its quarterback from a surging defense. “They’ve had so many injuries on the line that it can be very hard to watch” for the patient, said Sam Knapp, a psychologist in Harrisburg, Pa., who records every Steelers game and watches only the victories. Clearly, there’s a need for guidelines to deal with such patients. The following are derived from years of observations in the field and conversations with hundreds of sufferers of F.A.N. No licensed professional had, or would have, anything to do with them. They are the therapy version of fantasy football. However, unlike many medical interventions, you can try these at home. Treatment Guidelines Football Attention Neurosis I. Establishing a Therapeutic Alliance (Pregame) Patients often arrive on the couch well before kickoff, agitated and highly resistant to treatment. Proceed with care. Attempts at small talk or queries about their mental well-being may at first be met with an irritated stare, a gesture toward the flat screen and insensitive remarks like “Do you mind?” or “The game’s about to start, O.K.?” This is the disorder talking, not the person. It also provides an opportunity to establish trust, by sitting with the sufferer and his or her feelings. A strong alliance is essential going forward, because it is often the case that treatment will involve asking the patient to do things that may be frightening or profoundly uncomfortable, like sitting quietly with eyes open as an erratic kicker attempts a late field goal. II. Evaluating the Severity of Impairment (First Half) The severity of the disorder will usually reveal itself early in the first half of the football contest. Some patients will exhibit physical symptoms, including flushing, heart palpitations, chest pain, even a choking sensation, when their team chokes. Others may show psychological signs, like disorientation, a numbed trancelike state, or disordered vocalizations like “What the...,” “How in the name of...,” “Oh, lord, no.” “Tell me that didn’t just happen!” is another characteristic rhetorical reaction to an undesired play in the contest, almost always followed by this remark: “I can’t watch this anymore.” Caution: Do not approach patients in these moments. They are fragile and prone to hurling nearby objects, including mini-bagels, plastic cups, pigs in a blanket — even themselves, in extreme cases, to the floor. The time to complete the assessment is during commercial breaks, which are frequent and lengthy. Be sure to determine the family history (sample question: “Was your mother buried in a Reggie White jersey?”) and to make a careful review of medications, including nutritional supplements, prescriptions and a rough count of the 40-ounce malt liquor cans arranged like a mini-Stonehenge around the couch. III. Formulating a Treatment Plan (Halftime) Patients ritually leap to their feet and disappear at halftime. This break allows the therapist time to develop an intervention for the second half, when symptoms are most severe and disabling. The goals of treatment are the same for all patients: to reduce anxiety, to eliminate avoidance behaviors, to soothe physical symptoms like sleep loss, chronic groaning and cursing at the TV and the pets. Yet each individual suffers at different times and for different reasons, and the treatment plan must be tailored accordingly. IV. Administering Therapy (Second Half) The first commercial break after the second-half kickoff is the time to explain to the patient that his or her suffering is rooted in cognitive misconstruals, automatic assumptions that do not stand up to scrutiny. For example, beliefs like a player “always fumbles” or “never makes late kicks” or “couldn’t cover my grandmother” represents an overestimate of risk. Each player is competent; each has succeeded in the past; all could cover Grandma, even on a slippery field. Likewise, the notion that world will end if the patient’s team loses — catastrophizing, as this sort of thinking is known — does not stand up to the evidence. Remind the patient: Life resumed after each previous loss that the team suffered. And, in time, taste returned to food, colors became visible, feeling returned to extremities. Breathing exercises are highly recommended and become increasingly important as the football contest nears the fourth quarter, when events on the field are likely to prompt strong physiological reactions, like a pounding heart, hyperventilation, even dizziness. These internal cues, as they’re called, can escalate the feeling of panic, a self-reinforcing cycle resulting in groans and cries that can be frightening to small children, pets and sometimes neighbors. In the final minutes of the game, be forewarned: Many patients will move beyond the reach of therapy. Their faces may change, their breathing appear to stop. Researchers have not determined whether this state is closer to Buddhist meditation or to the experience of freefall from an airplane. All that is known is that, once in it, patients will fall back on primal coping methods, behaviors learned in childhood within the cultural context of their family. Like emitting screams. Or leaping in an animated way, as if the floor were on fire. Or falling on their back and moving their arms and legs like an overturned beetle, in celebratory fashion. Important note to therapist: At this point, if you are rooting for the same team as the patient, it will not violate ethical standards to join in. |
| Essay: Out of Camelot, Knights in White Coats Lose Way Posted: 31 Jan 2011 12:40 PM PST When I look at my career at midlife, I realize that in many ways I’ve become the kind of doctor I never thought I’d be: often impatient, at times indifferent or paternalistic. Of course, the loss of one’s ideals is a crucial component of the midlife phase, often leading to depression, nostalgia and regret: the proverbial midlife crisis. And it occurs to me that my profession is in a sort of midlife crisis of its own. The modern era of medicine began a little less than 40 years ago, with the Health Maintenance Organization Act of 1973, which ushered in the age of managed care. Managed care was supposed to save American medicine by stemming the rise in spending initiated by Medicare. It failed to do that. Instead, it did away with the kind of medicine that made people want to be doctors in the first place. In the last four decades, doctors have lost the special status they used to enjoy. Physicians used to be the pillars of any community. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler you could aspire to become. Doctors possessed special knowledge. They were caring and smart, the best kind of people you could know. Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. But while doctors often blame managed care for their situation, managed care didn’t create this crisis. It originated from the abandonment of ideals that made managed care necessary in the first place. In a recent essay in The Journal of the American Medical Association, Dr. Sachin H. Jain and Dr. Christine K. Cassel discuss the conception of physicians as “knights” or “knaves” (an idea developed by the economist Julian Le Grand in his study of British civil servants). Knights, they wrote, practice medicine to save and improve lives. The best thing government can do is to get out of their way and let them do their jobs. Knaves, on the other hand, put their financial well-being before their patients, often ordering tests and studies for personal gain. Government needs to guard against their malfeasance. The history of American medicine over the past half-century can be interpreted through this framework of changing perceptions. In the mid-20th century, physicians were among the most highly admired professionals, comparable with Supreme Court justices. It was a period when life expectancy increased sharply (to 71 years in 1970 from 65 in 1940), aided by such triumphs of medical science as polio vaccination, penicillin and heart-lung bypass. Depictions of physicians on television were overwhelmingly positive. Doctors were able to trade on this cultural perception for an unusual degree of privilege and influence. Organized medicine used this influence to try to defeat nationalized health insurance plans like Medicare, seeing them as an attempt to undermine income and autonomy. Doctors were content with the status quo. They could regulate fees based on a patient’s ability to pay and look like benefactors. They viewed Medicare as the end to medicine as they knew it. It turned out that they were right, but not in the way they imagined. After Medicare was created in 1965, doctors’ salaries actually increased, as demand for physicians’ services skyrocketed. In 1940, in inflation-adjusted 2010 dollars, the mean income for American physicians was about $50,000. By 1970, it was nearly $250,000, nearly nine times the per-capita gross national product. (It has dropped since then, to about six times per-capita G.N.P.) But as doctors profited, they were increasingly perceived as knaves, bilking the system. “It was a free-for-all,” a senior physician at my hospital who worked through that era told me recently. Doctors, he said, were helping each other game the system; the operative phrase was “I’ll scratch your back if you scratch mine.” “Before Medicare,” he went on, “doctors were not so focused on making money. Professional attainment still meant something. But if you call attention to this you are considered a ... .” He struggled for the right word. “Troublemaker?” I offered. “Yes, a bad apple. There are so many unnecessary procedures. But all these doctors are board-certified. Who am I to tell them what to do?” The transition from knighthood to knavery had major consequences. In 1973, fewer than 15 percent of several thousand practicing physicians reported any doubts that they had made the right career choice. In 1981, 48 percent of office-based doctors said they would not recommend the practice of medicine as highly as they would have 10 years earlier. In 2001, 58 percent of about 2,600 physicians questioned said their enthusiasm for medicine had gone down in the previous five years, and 87 percent said the overall morale of physicians had declined during that time. And nearly half of 12,000 physicians questioned recently said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. Three-quarters said medicine is either no longer rewarding or less rewarding. This growing discontent has serious consequences. One is a looming shortage of doctors, especially in primary care. Try getting a timely appointment with your family doctor. In some parts of the country, it is next to impossible. A report published in November 2009 by the Association of American Medical Colleges projected a shortage of as many as 150,000 physicians by 2025. But perhaps the most serious downside is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. There has always been a divide between patients and doctors, given the disparities inherent in the relationship, but this chasm is widening because of time constraints, malpractice fears, decreasing income and other stresses that have sapped the motivation of doctors to connect with their patients. Of course, doctors are not the only professionals who are unhappy today. But as the sociologist Paul Starr writes, for most of the 20th century medicine was “the heroic exception that sustained the waning tradition of independent professionalism.” It is an exception whose time has expired. Abandoning core professional ideals, and the resultant change in perception and policy, has taken a bigger toll on the profession than doctors could have imagined in that midcentury golden age. Sadly, those once heroic knights have only themselves to blame. Dr. Sandeep Jauhar is a cardiologist and the author of “Intern: A Doctor’s Initiation.†|
| Global Update: H.I.V.: Drugs Often Reserved for the Very Sick May Stem Mother-to-Baby Infections Posted: 31 Jan 2011 12:49 PM PST Breast-feeding mothers infected with the virus that causes AIDS can pass it along to their babies. But this is much less likely if the women receive antiretroviral triple therapy, according to a new study — even when they are not yet sick enough to qualify for it. In the study, published by The Lancet this month, researchers followed 805 mothers and newborns in three African countries from midpregnancy to the end of breast-feeding. (It is common for babies in Africa to be breast-fed for many months, and water and other foods may irritate the gut and increase the risk of infection.) All the women were infected with H.I.V., but none were close to full-blown AIDS, so they would not normally qualify for triple therapy in poor countries where health ministries are forced to choose who gets the drugs and who doesn’t. For the study, half were given triple therapy until breast-feeding ended, and half got the standard, cheaper treatment: daily doses of AZT for a few weeks before labor, a single dose of nevirapine at birth for both mother and baby, plus two drugs for a week after the birth. After a year, the mothers getting triple therapy were 43 percent less likely to have infected their babies. Even before publication, the study led the World Health Organization to revise its guidelines to encourage triple therapy for pregnant women. But with donor money shrinking, not all poor countries can offer it. |
| Cases: A Mantra: No Crying in the CAT Scanner Posted: 31 Jan 2011 12:40 PM PST I have not cried. Not once. O.K., I’ve come close. I teared up when my gynecologist said she was sending me to a breast surgeon. And again after learning I had cancer, when I told my surgeon I had a 10-year-old daughter and lots of graduations and performances still to attend. And once more, the morning after my lumpectomy, when, exhausted and anesthesia-addled, I somehow convinced myself the cancer was my fault. (I was not religious about breast exams; I didn’t follow up after that episode of mastitis.) But tears don’t count unless they come out and flow down your face. Today, though, if I let them, I know that is exactly what they will do. I am lying in the CT scanner, whose huge metal doughnut blocks most of my view. I see shirts, waistbands and the hands of those working on me — a radiation oncologist, a physicist, a technician. But no faces. The table is cold and hard. I have lost track of time (the clock is another thing I cannot see), but I think I’ve been here almost two hours. Clasped above my head, my hands have fallen asleep. “Lower!” the oncologist barks at the technician, whose marker is poised to draw on my skin. “Here?” She repositions. “No, the other side.” Her hand leaves my skin, then alights, like a wary butterfly. They are working on the hardware that my surgeon implanted in me yesterday. She tunneled it into the empty tumor cavity, then expanded it, ship-in-a-bottle style, to fill the hole. The catheter resembles a small kitchen whisk with hollow tines. Radioactive pellets will travel through the tines like tiny subway cars, delivering just the right amount of radiation to every inch of my breast tissue. The whisk’s “handle” protrudes through my skin. During my radiation sessions, at the treatment facility down the road, the handle will be connected to the lead-lined contraption that houses the pellets. Physicists will use today’s scans to calculate where and how long each pellet stops on its journey through me. I am fortunate to qualify for this treatment (my tumor just squeaked in under the size cutoff), which substitutes one intense week of radiation twice a day for the traditional six weeks of once-a-day visits. The oncologist introduces me to another physicist, the third one today. All I see of him is the glint of his belt buckle. My hello is lost in their chatter. I recall yesterday’s procedure in my surgeon’s office. In contrast to today’s, it was uncomfortable. (To achieve a snug fit, the catheter — the width of a chubby crayon — is squeezed through an incision that could accommodate a svelte Crayola.) That room was also filled with strangers (nurses, medical students, whisk-manufacturer representatives). But except for occasional asides to an assistant, my surgeon spoke only with me. The others were spectators. This morning I am the spectator, and I have the worst seat in the house, my view almost totally obstructed. I am also the table. My jeans-clad lower half is a repository for markers, papers and whisk-related detritus. I am startled by fingers brushing roughly across my crotch, the physicist scooping up markers. They are cleaning up; I will soon be released, right after the final scans. Although there will be more X-rays and measurements at the radiation treatment center, I will at least be off this table and one step closer to going home. Instead of relief, though, I feel a faucet turn on behind my eyes. I panic. The last thing I want to do is cry. To have these well-meaning strangers pat my shoulder and bring me a cup of water, delaying my liberation from this chamber. There’s no reason to cry. I’m not in pain. The worst thing anyone has done is use me as a table. “Breathe in, hold your breath, breathe normally,” the automated voice chants as I advance through the scanner. I clamp my eyes shut and compose a mantra to hold me together and avoid any delay: “There’s no crying in the CAT scanner. There’s no crying in the CAT scanner.” The floodgates hold. They keep holding while I get off the table, get dressed and walk through the hospital, still reciting the mantra. Outside, though, the floodgates begin to crack. Maybe it’s the sunshine; maybe the sight of my car, which, instead of taking me home, will take me to more cold tables and marker-wielding strangers. I change mantras — “There’s no crying in the parking lot ...” — and hurry to my car. Fortunately, crying is allowed in the car. So I cry, letting the tears fall onto the steering wheel and into my lap. Then I mop up, turn on the ignition and drive to the next appointment. Dr. Ellen D. Feld is an internist who teaches at Drexel University. |
| Q & A: The Way You Wear Your Fat Posted: 31 Jan 2011 12:29 PM PST Q. Does the body put on fat in actual layers, or does fat I accumulate now mix with body fat I’ve had for years? A. “Fat is deposited diffusely and not in layers,” said Louis J. Aronne, director of the comprehensive weight control center at NewYork-Presbyterian/Weill Cornell Medical Center. “It is added to fat cells that already contain fat and expands them." If weight is gained rapidly, Dr. Aronne said, new fat cells may be made, but they do not accumulate in layers. “If subcutaneous fat stores cannot accept all the fat for genetic, medical or other reasons,” he said, “more of it winds up inside the abdomen, where it presents a greater metabolic risk because it is in the circulation of the liver.” A 2008 study in the journal Nature found that the number of fat cells in the body is set in childhood and early adolescence and stays constant even after significant weight loss, for both lean and obese people. “This explains why it’s so difficult to lose weight,” Dr. Aronne said. “When fat cells shrink, levels of a fat-cell hormone, leptin, drop faster than fat mass is reduced. This tricks the brain into thinking you’ve lost more weight than you actually have. It’s also interesting that fat cells don’t live forever, but the number somehow remains constant.”
Readers are invited to submit questions by mail to Question, Science Times, The New York Times, 620 8th Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com. Questions of general interest will be answered in this column, but requests for medical advice cannot be honored and unpublished letters cannot be answered individually. This posting includes an audio/video/photo media file: Download Now |
| Reputation of a Berry Is Difficult to Confirm Posted: 31 Jan 2011 10:09 AM PST For decades cranberry juice has enjoyed a reputation as an effective way to prevent bladder infections. Scientists have doggedly tried to confirm this well-known folk truth with dozens of studies, some in test tubes and some in people. Share your thoughts on this column at the Well blog. Go to Well » The latest results are now in, and the answer is conclusive: This field is all bogged down. Some older studies found the juice worked. Some found it didn’t. All were too small to be definitive. In 1998 a substance presumed to be the active component in the cranberry was identified with some fanfare, and two years ago another study suggested that a cranberry extract containing this substance was almost as powerful as an antibiotic. Now a large, impeccably designed and executed study of cranberry juice has found that the presumed active compound apparently has no effect. And yet the newest study closed no doors. It may simply mean that the juice works, but by an unknown mechanism. How can one little berry be so difficult to pin down? For one thing, the cranberry contains more than 200 active substances in addition to vitamin C, citric acid and an array of other acids. The old theory that these acids sterilize the urine by acidifying it has been disproved: It turns out that even after a person chugs several liters of cranberry juice cocktail in one sitting, the urine does not become acidic enough to slow bacterial growth. But researchers have repeatedly shown that the juice does effectively prevent some species of bacteria from adhering to the cells that line the urinary tract. More to the point, urine from both mice and people who drank modest amounts of cranberry juice also prevented bacterial adherence. The substance responsible for this effect was identified in 1998 by a team of researchers in New Jersey as proanthocyanidin, a chemical related to tannin. Blueberry juice contains it, but other juices do not. The chemical apparently stops tiny hairs on the surface of bacteria from plugging into receptors on cells lining the urinary tract. In 2009 Scottish researchers reported they had assigned some women with frequent bladder infections to take a daily capsule filled with cranberry extract. It seemed to prevent recurrences almost as well as a daily antibiotic pill, raising hopes that the cranberry could help limit the use of antibiotics. But meanwhile, armed with a grant from the National Center for Alternative Medicine and cranberry juice cocktail from Ocean Spray, researchers in Michigan had set out in 2004 to do the definitive placebo-controlled study. They enrolled young, healthy women who had just recovered from a bladder infection. Statistics predicted that about 30 percent of them could be expected to get another infection within six months. Half the 319 subjects were assigned to drink 16 ounces of low-calorie cranberry juice cocktail daily. The others were given a placebo drink manufactured by Ocean Spray to look and taste the same, but with no cranberry content. The results were published this month in Clinical Infectious Diseases. After six months, the women in the placebo group had 23 new infections and those in the cranberry group had 31, a statistically insignificant difference. The juice apparently offered no protection. But the researchers were intrigued by the strikingly low overall recurrence rate of 17 percent, far less than the expected 30 percent. “It is possible,” they wrote, “that the placebo inadvertently contained the active ingredient(s) in cranberry juice.” In an interview, the senior author, Betsy Foxman, a professor of epidemiology at the University of Michigan School of Public Health, offered some ideas for what could be going on. Both the juice drink and the placebo contained vitamin C — could that have prevented recurrent infection? Could just drinking two extra cups of fluid per day have helped? Could it have something to do with the coloring used to tint the placebo — after all, antibiotics were first identified by the German dye industry. “It is still a big question mark,” Dr. Foxman said. Her research into the cranberry is continuing. |
| Recipes for Health: Vegetable Casseroles for Frigid Nights Posted: 31 Jan 2011 12:33 PM PST Cold weather and winter vegetables both lend themselves to comforting, bubbly baked dishes — and I don’t mean the casseroles conjured up from creamed soups tossed with overcooked meats and canned vegetables. Some of my favorite winter casseroles are gratins, which are baked until the edges and top brown. (The browned part, including the bits you like to scrape off the sides of the dish, are the gratinée. Grater mean "to scrape" in French.) Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. Some of this week’s gratins are made with a couple of pounds of a cooked vegetable, seasoned and bound with eggs, milk and a small amount of cheese. (In Provence, rice is also used to help bind the mixture.) Gratins are a great way to use both fresh or leftover cooked vegetables. I also like casseroles that combine cooked grains and vegetables. I season the grains, sometimes with Middle Eastern spices like allspice and cinnamon, place them in a baking dish in an even layer, and then top them with cooked vegetables (beets, for instance, in one of this week’s recipes). You can top the vegetables with cheese or a béchamel, or just drizzle olive oil over them and top it all with drained yogurt mixed with pungent, pureed garlic, as they do in the Middle East. Casseroles need not contain eggs or dairy products. And baked beans, exceptionally creamy after their long simmer in the oven, can be made into perfect vegan fare. Add vegetables of your choice and you’ll have a perfect one-dish meal. Mushroom and Greens Gratin This savory gratin is a regular item in my winter repertoire. Those 1-pound bags of sturdy greens, sold in my market as “Southern Greens Mix,” are a winter godsend. All the time-consuming work has been done, and the rest can be accomplished while the blanching water comes to a boil. 1 1/2 pounds greens, such as chard, stemmed and washed (2 bunches); or a 1-pound bag Southern greens mix, stemmed and washed 2 tablespoons extra virgin olive oil 1 or 2 shallots or 1 small onion, finely chopped 1/2 pound mushrooms, sliced Salt and freshly ground pepper 1 teaspoon finely chopped fresh rosemary 2 large garlic cloves, minced 2 ounces Gruyère cheese, grated (1/2 cup) 1 ounce Parmesan, grated (1/4 cup) 3 eggs 1/2 cup milk 1. Preheat the oven to 375 degrees. Oil a 2-quart baking dish or gratin. 2. Bring a large pot of water to a boil, salt abundantly and add the greens. Cook for one to four minutes, depending on the type of green (sturdy greens take longer), until just tender. Transfer to a bowl of ice water, then drain and squeeze out water. Chop coarsely. 3. Heat the olive oil over medium heat in a large nonstick skillet, and add the shallots or onion. Cook, stirring, until tender, three to five minutes. Add the mushrooms, and cook, stirring often, until tender, about eight minutes. Add salt and pepper to taste, and the rosemary and garlic. Cook for another minute. Add the greens, and stir together for another minute. Adjust seasonings. 4. Whisk together the eggs and milk. Add salt and pepper, and stir in the cheeses and mushroom/greens mixture. Scrape into the baking dish. Bake 35 to 40 minutes until browned and sizzling. Serve hot, warm or room temperature. Yield: Serves four to six. Advance preparation: The mushrooms and greens can be prepared up to three days before assembling and baking the gratin. Nutritional information per serving (four servings): 262 calories; 18 grams fat (6 grams saturated fat); 182 milligrams cholesterol; 10 grams carbohydrates; 4 grams dietary fiber; 269 milligrams sodium (does not include salt to taste); 17 grams protein Nutritional information per serving (six servings): 174 calories; 12 grams fat (4 grams saturated fat); 121 milligrams cholesterol; 7 grams carbohydrates; 3 grams dietary fiber; 179 milligrams sodium (does not include salt to taste); 12 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health." |
| 12 Years On, Tobacco Suit Due in Court Posted: 31 Jan 2011 09:02 AM PST A big tobacco case is set to start on Monday in St. Louis involving dozens of local hospitals, the nation’s biggest tobacco companies and 12 years’ worth of filings that fill 43 boxes in the city’s towering limestone courthouse. But it has attracted little of the intense interest that once surrounded lawsuits against major cigarette producers — a sign, specialists say, that a tumultuous period of tobacco litigation is winding down after more than a decade with little financial damage to the industry. The St. Louis lawsuit, which is seeking to recover costs for the treatment of smoking-related diseases, was filed by the hospitals in 1998. That year also was the high point of tobacco litigation, as state attorneys general struck a $206 billion deal with cigarette makers to settle lawsuits they had filed to recover costs related to smoking. That settlement, legal specialists said, helped reshape how tobacco companies did business, like leading to an end to cigarette advertising in the United States. But more broadly, they said, the tidal wave of tobacco cases brought by smokers and others has failed to significantly weaken the industry, which continues to generate large revenues, remains a potent political force and has shifted its aggressive promotional activities overseas. “In the large scheme of things, the impact of tobacco litigation has been minimal,” said Robert L. Rabin, a professor of law at Stanford. Nationwide, thousands of actions brought by smokers are pending, and it will be years or decades before the last one is tried and appealed. But the St. Louis trial belongs to a genre of lawsuits — like the state attorneys generals’ case — that smoking opponents once hoped would deliver a body blow to the tobacco industry, by requiring producers to pay third parties for the toll their products had taken. Over time, dozens of such lawsuits were filed on behalf of unions, pension funds and even foreign governments. However, only two of those cases made it to trial, specialists said. In one of those cases, cigarette makers triumphed; in the other, a verdict against them was overturned on appeal. The St. Louis case may be the last of its kind to go to trial, said Edward J. Sweda Jr., a lawyer with the Tobacco Industry Liability Project at the Northeastern University School of Law in Boston. Stephen D. Sugarman, a professor of law at the University of California, Berkeley, said he did not expect the St. Louis suit to be any more successful than those that had preceded it. He said that the difficulty for third-party claimants like hospitals was that they were trying to stand in the shoes of the smokers themselves. Despite those odds, the St. Louis case is proceeding like a make-or-break trial. It is expected to last six months and, in preparation for it, court officials sent questionnaires last year to 6,000 prospective jurors. Cartons of motions and other pretrial proceedings are stacked pell-mell in the dusty, warrenlike records department at the courthouse. Lawyers and companies involved in the case — including the Altria Group, the producer of Marlboro and other popular brands — were asked not to comment on it by the presiding Circuit Court judge, Michael P. David. But last Wednesday, lawyers representing the hospitals and cigarette makers continued to argue before Judge David over which documents could be used at the trial. During a break, Judge David offered a reporter an observation about the gaggle of high-priced legal talent. “At one point, I thought I could figure out who the lead attorney is, but now I’m not going to hazard a guess,” he said. “I wish they had jersey numbers.” While tobacco producers have averted major financial damage, there are certainly no guarantees that the industry’s legal fortunes will not turn. As of late last year, Altria, for example, faced more than 10,000 cases related to smoking, including 7,000 brought on behalf of Florida smokers, according to a company filing with the Securities and Exchange Commission. Altria and other producers also face class actions charging that they falsely claimed that “light” or “ultra-light” cigarettes lowered the health risks of smoking. Typically, cigarette companies have defended themselves by asserting that smokers were aware of the risks of smoking but still chose to do so. Looking back on the long tobacco battles, Matthew L. Myers, the president of the Campaign for Tobacco-Free Kids, an advocacy group in Washington, D.C., said he believed the cases brought by the state attorneys general had the most enduring impact. But he said even the intention of that deal had been watered-down because settlement-related money intended for antismoking activities was quickly diverted by financially hard-pressed states into unrelated programs like road building. Dr. David A. Kessler, who sought to regulate cigarettes while he led the Food and Drug Administration in the 1990s, said that litigation did play a role, with scientific and public health initiatives, in changing public perceptions about smoking. One contribution, he added, involved the release of internal company documents showing that industry executives knew of the health risks of smoking even while publicly denying them. A lingering image from the tobacco wars was the 1994 photograph of top cigarette company executives testifying before Congress that they did not believe cigarettes were addictive. As the St. Louis case unfolds, at least one result of the last two decades of litigation against cigarette makers will continue — the mea culpa phase. Cigarette makers will soon have to sponsor “corrective” statements on television and in newspapers to rectify previously misleading claims about the risks of smoking and second-hand smoke. The action stems from a 2006 court ruling in a lawsuit filed in 1999 by the federal government against tobacco producers, contending that producers lied for decades about smoking risks. In that case, Federal District Judge Gladys Kessler ruled in favor of the government, holding that cigarette makers had violated civil racketeering laws. In addition to requiring cigarette companies to run factual statements, she made other rulings, including prohibiting the industry from using terms like “low-tar”, “mild” and “natural” in packaging or advertising. A spokesman for Altria, Steven Callahan, said that the Justice Department was expected to propose a series of corrective statements in the next few weeks, and that producers like Altria would respond in March. Mr. Callahan said no timetable had been set for those statements to appear. Malcolm Gay contributed reporting. |
| Well: Rethinking the Big Breakfast Posted: 31 Jan 2011 12:38 PM PST |
| Well: Studying Cranberry Juice for Infections Posted: 31 Jan 2011 10:07 AM PST |
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| Personal Health: Scientists See Dangers in Energy Drinks Posted: 31 Jan 2011 11:11 AM PST With widespread alarm about deaths linked to alcohol-and-caffeine-laced commercial drinks like the fruity malt beverage Four Loko, it’s easy to overlook problems that may be linked to the so-called energy drinks that spawned them. But a number of scientists are worried about highly caffeinated beverages like Red Bull, Rockstar, Monster and Full Throttle, which are popular among teenagers and young adults. The often bizarre combination of ingredients in these drinks prompted three researchers from the University of Texas Health Science Center at Houston and the University of Queensland in Australia to examine what is known — and not known — about the contents of these beverages, which are sold alongside sodas and sport drinks in supermarkets, drugstores and highway rest stops. Their review of all the studies in English in the scientific literature, published in November in The Mayo Clinic Proceedings, led them to question both the effectiveness and safety of energy drinks. Long-Term Effects Unclear The researchers noted that the drinks contain high levels of caffeine and warned that certain susceptible people risk dangerous, even life-threatening, effects on blood pressure, heart rate and brain function. The authors noted that “four documented cases of caffeine-associated death have been reported, as well as five separate cases of seizures associated with consumption of energy/power drinks.” Additional reports include an otherwise healthy 28-year-old man who suffered a cardiac arrest after a day of motocross racing; a healthy 18-year-old man who died playing basketball after drinking two cans of Red Bull; and four cases of mania experienced by individuals known to have bipolar disorder. Using an abbreviation for energy beverages, Dr. John P. Higgins and co-authors wrote in the Mayo journal that because “teens and young adults, both athletes and nonathletes, are consuming E.B.’s at an alarming rate, we need to determine whether long-term use of E.B.’s by this population will translate into deleterious effects later.” His co-author Troy D. Tuttle, an exercise physiologist at the Houston university, said in an interview: “Almost all the studies done on energy drinks have involved small sample sizes of young, healthy individuals in whom you’re unlikely to see short-term ill effects. “But what about the long term? What about liver and cardiovascular disease, insulin resistance and diabetes? We could speculate about a lot of possible problems, but we just don’t know.” He urged the Food and Drug Administration to “step in and regulate this market,” which currently has few restrictions on the kinds and amounts of ingredients and the claims that are made about them. Manufacturers have labeled the beverages “dietary supplements,” which absolves them of the federal regulations that govern sodas and juices and allows producers to make “structure and function” claims, like “Enhances athletic performance” and “Increases caloric burn and mental sharpness.” As Mr. Tuttle described the marketing strategy for energy drinks, “the companies have taken a cup of coffee — or two or more cups of coffee, added a lot of hip-sounding stuff and marketed it with a hot, modern, trendy push for young people who want to look cool walking around with a can of Red Bull. “Anyone can buy these drinks, even 11- and 12-year-old kids.” In an e-mailed statement, the American Beverage Association said, “Most mainstream energy drink brands voluntarily put statements on their containers, including advisories about use by people sensitive to caffeine.” Also, the organization said many of its members voluntarily list the amount of caffeine on their product labels or have provided caffeine content information through their Web sites and consumer hot lines. Kevin A. Clauson, a doctor of pharmacy at Nova Southeastern University in West Palm Beach, Fla., who had previously reviewed safety issues surrounding energy drinks said that his main concerns were “the amount of caffeine, which can be injurious particularly to people with a pre-existing cardiovascular abnormality” and “the effects of these drinks when they are combined with alcohol, which can have disastrous consequences.” After several states made moves to ban Four Loko, it was reformulated to remove the caffeine and two other ingredients, guarana and taurine, but Dr. Clauson said that was “unlikely to have a substantial impact” on young people, who will continue to combine alcohol with energy drinks. The caffeine and caffeinelike ingredients in these drinks can mask the perception of inebriation — and that can increase the risk of drunken driving or other dangerous behaviors. Mr. Tuttle, who works with sports teams, is concerned about the effects of energy drinks on athletic performance. “A lot of kids are reaching for energy beverages instead of sport drinks, which unlike the energy drinks are mostly water with a nominal amount of sugar and electrolytes,” he said. “The energy drinks contain a slew of ingredients, most of which are unresearched, especially in combination with one another.” A Potent Brew For an athlete engaged in intense exercise, the high doses of sugar in energy drinks can impair absorption of fluids and result in dehydration. A 16-ounce can of an energy drink may contain 13 teaspoons of sugar and the amount of caffeine found in four or more colas. Mr. Tuttle noted that caffeine, which is known to improve muscle action and performance, especially in endurance activities, is banned in many sports competitions. Thus, consuming an energy drink close to an event could disqualify an athlete. Other ingredients often found in energy drinks include taurine, glucuronolactone, B vitamins, ginseng, guarana, ginkgo biloba and milk thistle. Mr. Tuttle calls guarana particularly worrisome because it acts as a stimulant, like caffeine. “The B vitamins, which are important enzymes for energy utilization, are added to legitimize the high levels of sugar,” he said. “But the American diet, which is very high in protein, already has plenty of B vitamins. These drinks are a kind of sensory overload for the body, with too much stuff coming in at the same time.” Adding alcohol to the mix, as some consumers were doing even before drinks like Four Loko came along, can be a recipe for disaster. Under the stimulation of energy drinks, people may think they are sober when they are not. Such was the fate of Donte’ Stallworth, a wide receiver for the Cleveland Browns who killed a pedestrian with his car in March 2009 after drinking multiple shots of tequila and a Red Bull. Mr. Stallworth said he did not feel intoxicated at the time of the accident. “Caffeine is being treated as a flavoring agent, not a drug,” Dr. Clauson said. “The average healthy person who consumes one serving of an energy drink is unlikely to encounter difficulty.” Those most likely to get into trouble, he said, are “toxic jocks” who overindulge and those with an underlying heart condition. This posting includes an audio/video/photo media file: Download Now |
| Really?: The Claim: Contraceptives Can Make You Gain Weight Posted: 31 Jan 2011 09:51 AM PST THE FACTS Share your thoughts on this column at the Well blog. Go to Well » Weight gain may be the most feared side effect of birth control. Concerns about pills’ and patches’ producing extra pounds have been known to keep some women away from them. But most studies have found that those concerns are unwarranted. And women who do end up gaining weight, experts say, may simply be misperceiving normal weight gain over time as an unwanted side effect of contraceptives. In a broad analysis published in the Cochrane Database of Systematic Reviews, researchers combed through data from several randomized trials that compared hormonal contraceptives and placebos. (It was not clear what kind of birth control was used by the subjects who took placebos.) There was no evidence from any of the studies that women using the contraceptives gained any more weight than those given a placebo. The researchers then looked at studies comparing different doses or regimens of various hormonal contraceptives, which “showed no substantial differences in weight,” they reported. Another study in 2008 at the University of Massachusetts Medical School followed 150 female athletes ages 18 to 26, some of whom were randomly assigned to a group that took oral contraceptives. Others served as controls. After two years, the scientists concluded that the contraceptives did not cause any gain in either weight or body fat. THE BOTTOM LINE Hormonal birth control does not appear to lead to weight gain. ANAHAD O’CONNOR scitimes@nytimes.com |
| The New Old Age: Readers' Questions: The Shingles Vaccine Posted: 31 Jan 2011 10:14 AM PST |
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| Letters: Keeping Up With Medicine (1 Letter) Posted: 31 Jan 2011 12:08 PM PST To the Editor: “As Doctors Age, Worries About Their Ability Grow” (Jan. 25) raises important questions about our nation’s system for ensuring lifelong learning and performance improvement among physicians. While Continuing Medical Education has served our medical community well, new, more comprehensive approaches are being considered. The Federation of State Medical Boards has proposed a system in which physicians would be expected to demonstrate their continued professional development every few years to qualify for license renewal. We believe this new approach will help address many of the issues raised in your story. Humayun J. Chaudhry, D.O. Euless, Tex. The writer is president and chief executive of the Federation of State Medical Boards. |
| Letters: Guardians of a Ritual (1 Letter) Posted: 31 Jan 2011 12:10 PM PST To the Editor: Re “A Young Life Passes, and a Ritual of Birth Begins” (Cases, Jan. 25): Dr. Mark S. Litwin describes “the anxiety associated with an old fashioned bris on a kitchen counter.” A mohel, who is a trained ritual circumciser, is a religious practitioner who uses sterile technique and the most modern methods. He performs the bris with an efficiency, tradition and warmth that elevate the moment and put parents at ease. As a full-time mohel on staff at both Long Island Jewish and North Shore University Hospitals, I can assure you that a traditional bris is done with compassion and dignity. A certified full-time mohel is usually far more experienced than a doctor who does ritual circumcisions as a sideline or hobby. Rabbi Paysach J. Krohn Kew Gardens, N.Y. This posting includes an audio/video/photo media file: Download Now |
| New Dietary Advice From Government: Just Eat Less Posted: 31 Jan 2011 01:02 PM PST The latest nutrition guidelines released Monday by the federal government reiterate much of the advice from previous years: eat less salt and saturated fats, eat more fruits and vegetables and whole grains. But there is a startling difference. This time, the government suggests that Americans also just eat less. More specifically, the guidelines urge Americans to drink water instead of sugary drinks like soda, and it suggests that they avoid fatty foods like pizza, desserts and cheese (albeit deep in the report). While all of that may seem obvious, given the nation’s obesity problem, it is nonetheless considered major progress for federal regulators who have long skirted the issue, wary of the powerful food lobby. “They are blunter here than they’ve ever been before, and they deserve credit for that,” said Marion Nestle, professor of nutrition at New York University and a critic of government nutrition guidance. “They said, ‘Eat less!’ I think that’s great, and to avoid oversized portions. That’s the two best things you should do.” Margo Wootan, the director of nutrition policy at the Center for Science in the Public Interest, said previous guidelines — which are revised every five years — offered “big vague messages” about reducing cholesterol, salt and sugar. The guidelines released Monday, she said, were “much more understandable and actionable.” As an example, she noted that the guidelines suggested that half of a plate should be covered in fruits and vegetables. “Before, the dietary guidelines said eat more fruits and vegetables but that could mean add a slice of tomato to your hamburger,” she said. Among the recommendations: anyone 51 or older, all African-Americans, children, and adults with hypertension, diabetes and chronic kidney disease should cut their salt consumption to 1,500 milligrams a day; the recommendation for everyone else is 2,300 milligrams, which equates to a teaspoon. In addition, the guidelines recommend consuming less than 10 percent of calories from saturated fatty acids, replacing them with so-called good fats like monounsaturated and polyunsaturated fatty acids. The guidelines suggest making fruits and vegetables half of a plate, choosing fat-free and low-fat dairy products, and eating more whole grains and seafood. While the guidelines are ostensibly for consumers and federal nutrition programs, they are just as much directed at the food industry, which will now have to consider reformulating its products. The sodium recommendation in particular may prove challenging, since Americans consume most of their salt by eating processed foods, and manufacturers have struggled to significantly cut salt. Similarly, restaurants continue to serve oversized portions, even though nutrition experts have railed for years about them being too large and contributing to the obesity crisis. “If companies don’t change their practices and reformulate their products, people don’t have a chance of following the dietary guidelines,” Ms. Wootan said. The Department of Agriculture revises the Dietary Guidelines for Americans, a thick booklet that lays out an ideal diet to maintain health, every five years. The panel produces a draft that is then reviewed and tweaked by regulators and eventually made public. In 2005, the last time the guidelines were revised, the government urged Americans to eat more whole grains and less sugar. It was the first time the guidelines recommended replacing refined grains with whole grains, and it prompted major changes in the ingredients used by food manufacturers. General Mills, for instance, replaced refined grains with whole grains in its breakfast cereals, and many bread makers did the same. The 2005 guidelines were used to revise the government’s popular Food Pyramid. But nutrition experts have previously complained that the process has been skewed by politics, particularly the influence of the powerful meat and dairy lobby. In addition, they complain that the guidelines never go far enough, telling Americans what they should eat but rarely being specific about what they should not. And given the level of obesity in America, some question if anyone is paying attention. “I must admit personally that I never read the dietary guidelines until I got this job,” said Agriculture Secretary Tom Vilsack at a Monday morning news conference. But he said he carefully read the guidelines and changed his eating habits after he realized how far apart his diet was from the guidelines. “Personally my life has changed,” he said. Though praised by nutrition experts, they nonetheless had their quibbles. Ms. Nestle said government regulators could be even more blunt. She said they continue to cite specific foods when telling people what to eat more, while they tend to use nutrients when telling people what to eat less. For example, the guidelines say, “Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars and sodium.” “It means eat less junk food,” she said. And Ms. Wootan said she wished regulators were more explicit in their advice “to reduce the intake of calories from solid fats and added sugars,” which she described as worthless. Instead, she suggested, “Cut back on cheese, hamburgers, pizza, cookies and pastries.” {cq} This posting includes an audio/video/photo media file: Download Now |
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