We like our sweets…If I really wanted to impress you with scientific taste I would phrase that differently and point out that the taste receptor for sweetness, T1R2/RIR3 detects sugar at a concentration of 1 part to 200 and “notifies” the brain about this pleasurable sense. But as great as our fondness for sweet tasting foods, we are much more aware of and put off by bitter substances, which can be detected in the range of a few parts per million! (I will spare you the receptor details.)

When refined and concentrated sugar (usually sucrose and high fructose corn syrup) is consumed in large amounts, it immediately causes a rise in blood glucose. In order to stabilize elevated blood glucose levels the pancreas will, if functioning, produce insulin. Elevated insulin then causes an increase in triglycerides, fat deposition (in unwanted parts of our body), inflammatory factors, and oxidative radicals….all of which are associated with coronary heart disease, diabetes and obesity.

In an effort to please our taste buds without suffering the consequences of too much refined sugar many of us use artificial sweeteners, especially in our drinks. According to an article in the American Journal of Clinical Nutrition, our per capita diet drink intake has increased from less than 1 ounce per day in the 1960′s to about 4 ounces per day in this decade. Moreover, among regular consumers of diet drinks, intake is now greater then three 8-oz servings per day.

I switched from diet colas to water about 2 years ago, but admit I still indulge in ice tea and (when my reflux lets me) coffee, both sweetened with artificial sweetener. After all, there are currently 5 types of synthetic “no-calorie” sweeteners as well as Stevia (a natural extract) that have received FDA approval. They all are more potent than sucrose and elicit a sense of sweetness in very small concentrations. It’s so easy to just tip a pink, yellow or blue packet into a drink. (And the manufacturers of all those diet sodas do it for us.)

A recent commentary in The Journal of the American Medical Association pointed out some disturbing concerns that I thought we should all consider. The author (who is an MD and PhD in the Department of Medicine at Children’s Hospital in Boston) pointed out that calories displaced by artificial sweeteners may be replaced over time with other fattening sources. (I immediately thought of my dinners with friends…we put sweetener in our coffee and then smugly order a calorie intense dessert.) He also stated that “frequent consumption of hyper-intense-sweeteners may cause taste preferences to remain in or revert to, an infantile state”. This can cause individuals to pass up less intensely sweet foods such as fruit and indeed avoid foods that are unsweet. (There go the vegetables and legumes!). An overly stimulated sweet tooth may end up sabotaging the type of healthy diet that prevents weight gain.

The author then went after diet drinks which, as we know, have no calories and no nutrients. If they are consumed instead of other foods, they can produce a disassociation between sweet taste and caloric intake and hence “disrupt the hormonal and neurobehavioral pathways regulating hunger and satiety”. He cited an experiment in which rodents fed saccharine compared with those fed glucose, increased their overall caloric intake and gained weight. Another study compared rodents’ preference to cocaine versus saccharine…and surprisingly, they preferred the latter! This would seem to show that the taste and desire for sweetness (at least among rats) was more addictive than the desire for abused drugs.

Although he admits that there are no long-term prospective studies of diet drink consumption and body weight in humans, he does cite an observational study: The San Antonio Heart Study found a relationship between diet drinks and measures of adiposity over a 7 year period among 5158 adults. Those that consumed more than 21 servings of diet drinks per week (if you haven’t done the math, it’s 3 a day or what the average diet drink consumer now imbibes), had a 2-fold increased risk of becoming overweight or obese. And in another study of 6814 individuals (The Multi-Ethnic Study of Atherosclerosis), daily consumption of diet drinks was associated with a 36% increase risk for metabolic syndrome (high blood pressure, high triglycerides, high blood sugar, excess weight around the waist and ultimately high risk for coronary heart disease) as well as a 67% greater risk for type 2 diabetes when compared to non diet drinkers.

So what are we to take away from all this? I don’t think the current data constitute a mandate against any diet drink consumption. We certainly don’t want our children (or ourselves) ingesting a major portion of their calories from refined sugars and corn syrup. However, if artificially sweetened drinks replace unsweetened drinks or less sweet food, the result may be weight gain as well as the absence of the nutrition needed to maintain good health. So when you reach for that diet drink or sweetener, why not reconsider and try quenching your thirst with water (flat or carbonated), non fat milk or even tea or coffee sweetened with just 2 teaspoons of sugar. Or, if like me you can’t reach for that sugar, use that yellow, pink or blue packet, but as rarely as possible.

Exposes about food contamination have been the subject of socially and nutritionally minded authors for hundreds of years. In 1906 Upton Sinclair wrote the book “The Jungle” which detailed the horrible conditions in Chicago’s meat packing houses. (Remember he wrote about workers who fell into rendering tanks and were ground along with animal parts!) Although conditions for the workers (but not necessarily the cows) have vastly improved, contamination of meat products (usually from bacteria) as well as vegetables and fruit are still common, especially as food sources go global. (Do you know where your strawberries come from? What about your fish?) And when a particular pathogen enters the food chain and causes sickness or death to the consumer, it enters so many widely distributed products that identifying its final “resting place” (other than the GI system of the unfortunate person who ate it) requires extraordinary food surveillance. The CDC estimates that 5,000 Americans die from 76 million cases of food-borne illness in the United Stated every year. The most susceptible are the very young, the very old, the immunocompromised, pregnant women and their fetuses.

Pregnancy can diminish immune resistance and an unfettered infection can cause miscarriage as well as fetal malformations, disability, illness and death to the newborn. Hence food safety and safe food choices are especially important in pregnancy. Here are some of the food-borne pathogens and the foods that may contain them that merit special attention…

Listeria monocytogenes

This bacterium is usually killed by pasteurization and cooking. It can, however be airborne and contaminate treated foods. And to make matters worse it can grow inside a refrigerator!

Foods likely to be contaminated: Unpasteurized milk products, refrigerated and ready-to-eat- products (dairy, meats, poultry and seafood and deli products). The prevalence of Listeria in these foods is estimated to be nearly 2%. Food packaged in the store is less safe than that packaged by the original manufacturer.

Symptoms: Typically mild…low grade gastroenteritis, or flu like symptoms. More serious infection (called listeriosis) causes vomiting, abdominal pain, diarrhea with fever and in some cases meningitis and overwhelming infection (septicemia). Pregnant women are 20 times more likely to develop listeriosis than all other individuals, indeed one third of all cases occur during pregnancy. And even if the initial symptoms are mild, the bacteria may cross the placenta and infect the fetus.

The FDA and CDC have issued guidelines for safe eating in pregnancy in order to avoid listeria infection. These include:

* Avoid cross-contamination with fluid from hot dog packages.
* Keep raw meets separated from vegetables, cooked food and ready-to-eat foods.
* Eat perishable foods as soon as possible.
* Throw out expired food.
* Wipe spills immediately and clean the refrigerator regularly with hot water, liquid detergent and then rinse.
* Eat lower risk food and avoid unpasteurized milk or any foods from raw milk!
* Don’t eat hot dogs, luncheon meats or deli meats unless reheated or steamed. Don’t eat refrigerated pates or meat spreads. (OK if canned)
* Don’t eat refrigerated smoked seafood unless it’s in a cooked dish. These are often labeled “nova-style”, “smoked”, “kippered” or “jerky”. (So there goes that bagel, cream cheese and lox…I guess the bagel and cream cheese can stay as long as the latter is pasteurized!)

Toxoplasma gondii:

This is a parasite which can cross the placenta and cause surviving children to have long-term problems (specifically serious eye and brain damage). Most pregnant women have no symptoms when infected. The fetus is at risk if the mother is exposed just before or during her pregnancy, but is unlikely to become infected if the mother has had the infection in the past. (This can be checked with a special antibody test; however, the test is not routinely done in the US because there are no established effective treatments.)

Food Sources: Contaminated meat, especially wild game (if undercooked or raw), unpasteurized milk, unwashed fruits and vegetables, contaminated water.

Other Sources: Cats are hosts to this parasite and become infected if they are kept outdoors, hunt and/or eat raw meet. They excrete the toxoplasmosis as cysts or eggs in their feces. The chance of infection from a cat is low if it is kept indoors, doesn’t hunt or eat raw meat. (Cat food manufacturers know this.)

Here are the CDC guidelines to prevent Toxoplasmosis infection:

* Freeze meat for several days before cooking
* Cook meats to at least 160 degrees (or higher to kill other pathogens). Note meats that are smoked, cured in brine, or dried may still be infectious.
* Keep children’s sandboxes covered.
* Wear gloves when gardening or handling sand in sand boxes.
* Peel and thoroughly wash fruits and vegetables before eating.
* Keep your cat indoors; don’t feed it raw or undercooked meats or unpasteurized milk
* If possible have someone else change the litter box, if not, wash your hands and disinfect the litter box daily with near boiling water for 5 minutes.
* Don’t get a new cat while pregnant or handle stray cats, especially kittens.
* Don’t drink unpasteurized milk, including goat’s milk.
* Don’t drink water from the environment unless it’s boiled. (I guess they mean water from rivers and streams…. This seems like a good idea in general.)
* Control rodents (I won’t comment on this one).
* If you butcher wild game or venison, bury the organs so that feral cats can’t eat them and spread infection. (I guess this applies to very few of us, oh, but wait…there’s Sarah Palin!)

Raw Fish:

This is where raw sushi and sashimi get boycotted by pregnant women. Raw fish can harbor parasites such as roundworms, tapeworms and flatworms as well as bacteria and viruses. And don’t forget, ceviche (fish prepared in acid and not really cooked) is included in the raw category. If you do dine in a Japanese restaurant during pregnancy order the vegetable or cooked sushi, although some purists might worry that these are prepared with the same utensils as the raw stuff. Maybe you should just get the teriyaki or the noodle soup…

Sprouts:

Just when you thought that you could and should consume healthy vegetables such as sprouts (alfalfa, clover and radishes), I have disappointing news. It turns out that sprouts have been found to contain E.coli and Salmonella. (A 2007 survey of retail foods in the US found a bad strain of E.coli in 1.5% of alfalfa sprouts compared to 0.17% of ground beef that they sampled!). Sprouts are produced under warm, moist conditions which encourage the growth of bacteria. They become internalized in the seed during sprouting. So washing doesn’t remove the bacteria! The only safe way to eat sprouts during pregnancy is to cook them.

Eggs:

So many chickens live in crowded squalor, infecting one another and their eggs with salmonella. The current estimates are that 1/20,000 eggs contain this bacteria. We are not talking abstention here….just cook the egg until the whites and yolks are firm. If you are making Cesar salad or a food that requires raw egg, use pasteurized egg. And always wash you hands after handling eggs.

Peanuts:

Strictly speaking, this legume should not be part of a discussion of contaminated foods. But peanut allergy is such a concern, I have included it in this article.

Should a pregnant woman avoid eating peanuts in order to diminish the risk of peanut allergy in her child? We used to tell pregnant women that this was a forbidden nut. But statistics subsequent to this admonition have shown that it doesn’t seem to make a difference and peanut allergy in children has increased. Indeed a 2008 study showed that sensitization does not appear to occur from intra uterine exposure. According to the American Academy of Pediatrics there is a lack of evidence that maternal dietary restrictions during pregnancy play a significant role in the prevention of peanut (and other) allergies in infants. So if you have some peanut butter, don’t feel guilty.

Water:

Municipal water is generally very safe in the US. (Although I probably should modify this statement… there was a recent article in the New York Times that exposed water contamination that was not reported nor efficiently dealt with by the EPA….mostly in smaller communities.). Most bottled water does not contain fluoride which will benefit the future teeth of the developing fetus. And if water is sold in certain types of plastic containers it can become contaminated with potentially harmful chemicals.

I have not dealt with “the fish or no fish” debate (other than the raw kind) nor have I begun to discuss organic versus non organic, processed food, fats or caloric intake. I’ll leave all that for another article (or more). But I hope that the above gives you (if you are pregnant) or someone you care about (i.e. daughters, relatives and friends) a sense of which foods and food preparations are potentially harmful to a pregnant women and her baby. When it comes to contamination and infection, she is eating for two.

By now most of you have probably heard that ACOG (The American College of Obstetricians and Gynecologists) has made new recommendations as to how often and when to start doing Pap smears. Despite the timing, I don’t feel these are either economically or politically inspired by the currently debate on health care reform. The reasons behind these new recommendations are scientifically sound. I would like to share some of them with you…

It’s extremely difficult for women to reconsider their Pap priorities; after all we have been told for decades that we must have a yearly Pap smear. Indeed we were lead to believe that the Pap was the foremost reason to visit our gynecologist. (When I went to work in Israel after finishing my residency in the US, I tried to explain the importance of Pap smears. My colleagues and residents were puzzled…they had seen very few cases of cervical cancer and thought it only occurred in women with uncircumcised partners…. I’m not sure why it was uncommon, perhaps at the time the population was more monogamous. But a sexually active circumcised penis can spread the viruses that lead to cervical cancer as well as one that is “uncut”. Today Israeli gynecologists routinely do Pap smears. If you continue to read below however, you will see that “routine” has changed for everyone.) But I digress…

Many women believe that the Pap smear can, in its mythological and histological wonder, pick up every type of cancer “down there” including endometrial and ovarian cancer. Unfortunately, it usually won’t. The Pap can detect cells that herald the presence of cervical precancer and cancer caused by sexually transmitted HPV (human papilloma) viruses. There are more than 100 types of these ubiquitous HPV’s. They are all very contagious and easily transmitted during sexual intercourse. At least eighteen of them are deemed high risk. The high risk HPV’s are oncogenic agents which, if not cleared by the immune system, can enter the DNA and cause mutations in the cells of the cervix. These mutations can lead to the development of a precancerous lesion termed high grade squamous intraepithelial lesion or HSL and in turn this can go on to become invasive cancer.

Although an astounding proportion of young women (50 to 70%) are found to have HPV present in their cervix within 2 to 3 years of onset of intercourse, the majority have an immune response that is strong enough to clear the viruses within 8 to 24 months. Before they do, however, they may develop minor or low grade squamous intraepithelial lesions (LSL) that can then appear as an abnormality in a Pap smear. But as the virus is cleared, so usually is the low grade lesion. Patience is all that is needed to “cure” most of the early changes (termed dysplasia) caused by HPV in these young women.

Until recently doctors responded to mild and moderate Pap abnormalities in a sexually active adolescent or young woman with immediate reaction and action….we notified her that there was something “off” in the Pap smear and further testing was needed. (And she then called her Mom who invariably became hysterical.) We did colposcopy (an exam of the cervix with a microscope) and often followed this with biopsies. Then if the latter confirmed even mild changes we were taught to “catch and treat” immediately. We froze the offending cervix with cryotherapy to destroy the superficial “bad” cells or tried to destroy them with laser. (None of this killed the offending virus….we were treating the result not the cause.) And if the cells showed a more worrisome lesion we removed a part of the cervix with a procedure termed a LEEP or did a cone excision.

Well it turns out that early treatment in very young women was, in many cases, unnecessarily aggressive and harmful. The treatment could scar the cervix and lead to problems getting pregnant, maintaining a pregnancy to term (i.e. cause premature labor) and finally increase the risk of cesarean section.

Research on sexually active young women to see “what would happen if we left these early lesions alone” has shown that invariably the lesions do clear. Hence ACOG now recommends that gynecologists begin performing Pap smears in all women at the age of 21. The risk of missing a serious lesion in sexually active young women and adolescents is estimated to be 1-2 cases in a million. If Pap smears were done earlier, tens of thousands of minimally abnormal changes would be found and result in unnecessary procedures that could harm the future fertility and pregnancy in these young women.

ACOG also addressed the frequency of Pap smears in women who are older… No one wants to ignore the harm that high risk and non-cleared HPV’s can do over time. Hence the organization recommends Pap smears be performed every 2 years in women ages 21 to 29. And for women over 30, they feel it is probably sufficient to do the Pap smear every 3 years. (These women should already have a Pap history and are more likely to be in a mutually monogamous relationship.) To qualify for the 3 year rule a woman over 30 should have had 3 negative Pap’s. And negative Pap smears are most reassuring if HPV testing is also negative. (Note, I routinely order HPV testing in my patients when I do their Pap.)

Exceptions are made and Pap testing should be done more frequently for women over the age of 21 if they are immunocompromised, have been HIV infected, were treated for CIN2 or CIN 3 (high grade lesions) in the past or are DES exposed (their mother took DES while pregnant).

Remember if you are not in this risk group, if your Pap smears have been normal for many years, you do not have HPV and you are in a mutually monogamous relationship, nor have you had HPV in the past….you are not going to get cervical cancer unless you have a new “source” of HPV!

When it comes to stopping Pap smear testing….it’s a bit more complicated. Women aged 65 and older represent 14.3 % of the US population and have 19.5% of new cases of cervical cancer. In white women in the US the rates of new-onset of cervical cancer peaks in the 5th decade of life then decreases, in Hispanic women it is in the early 70’s and in Asian and Pacific Island ethnicity the incidence peaks in the late 70’s. The American Cancer Society recommends discontinuing Pap smears at 70; the US Preventive task Force has set the age at 65. ACOG suggests that if a woman over 65 is sexually active, and has more than one partner that she is still at risk and should get Pap smears. (Albeit she is less at risk than a younger woman because her cervical cells have undergone changes that make them less accessible to HPV caused mutations.) And women with a past history of abnormal Pap’s should continue screening until results are negative for 10 years.

Finally what about the women who have had a hysterectomy? If the cervix was not removed (a subtotal hysterectomy) you still need Pap smears with the same frequency as a woman who had not had this surgery. If however, the cervix was removed during the procedure (a total hysterectomy), then the only reason to continue having Pap smears is if the hysterectomy was done for a cervical high grade lesion or cancer. In this case the Pap can check for recurrence of the lesion in the vaginal cuff.

I know this all seems complicated. What I want to emphasize is that less frequent Pap smears does not mean less frequent pelvic, breast, or general exams. You will still receive annual reminders to come to see me (or whomever you go to for your gynecologic care). At that time we can discuss how often your Pap smear should be done. The rest of your exam can ascertain possible pathology in your breasts, uterus, endometrium, ovaries and hormones as well as any issues related to your general health (weight gain, diabetes, coronary vascular risk, hypertension, and bladder problems to name a few).
Women younger than 21 still need to discuss contraception, and if sexually active should be checked for STD’s, and taught how to prevent them. And if any woman has menstrual problems she should seek diagnosis and treatment. Women who plan to conceive should be seen and given appropriate preconception tests and advice.

The era of reproductive health sets the status for our entire lives. Once we enter menopause there are many more health and well-being issues we have to deal with. (Please note I haven’t even begun to talk about hormonal issues.) The cervix is just one part of our reproductive system. Pap smears save lives….but we are more than a cervix and need to maintain the health of the rest of our body.

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