This last weekend my husband and I ate out twice; the first night we went to an excellent Italian restaurant and had delicious pasta (mine in mushroom sauce, his with lobster and tomato sauce). The next night (obviously I didn’t cook) we had sushi and edamame – the former dipped in soy sauce and the latter sprinkled and boiled with salt. In retrospect, we ate way more sodium then we should have; as do 90 % of Americans.

I’ve previously written articles about the dangers of our overabundant salt consumption. But just to remind you about the sodium stats:  The Dietary Guidelines for Americans, 2005 state that persons with hypertension, all middle-aged and older adults and all blacks should limit their intake of sodium to 1,500 mg/day. These specific groups include nearly 70% of the US adult population!  The rest should be content with levels that are no higher than 2,300 mg/day.

(If we underwent a population-wide reduction in sodium to 1,500 mg a day, we could reduce the number of new cases of coronary heart disease by 60,00 to 120, 000 cases and stroke by 32,000 to 66,000!)

To estimate the proportion of adults whose sodium was within recommended limits, the CDC analyzed data from the National Health and Nutrition Examination Survey (NHAMES) for 2005-2006, the most recent data available. They found that only 5.5% of those who should be limited salt eaters followed the 1,500 mg/day guideline and when it came to those allowed more sodium,  only 18.8% were less-than- 2,300g/day-compliant. I and my husband certainly didn’t meet any of these guidelines this past weekend!

Aside from the obvious (soy sauce and salted edamame), where does all that sodium intake come from? Well, here are some salty tidbits from an editorial note on the CDC report in this week’s Journal of the American Medical Association: In the United States, an estimated 77% of dietary sodium intake comes from processed and restaurant foods and only 10% comes from table salt (1/2 a teaspoon contains 1200 mg of sodium) and cooking. The foods with much of the excessive sodium that we consume also have the most calories, even though they may not taste salty. The authors state that “Grains contribute the largest amount of sodium and calories followed by meats.” This sodium laden grain category includes frozen meals, soups and breads. The meats with the most sodium consist of lunch meats, sausages and hot dogs. Even when the vegetable category was analyzed, it too was found to contain way too much sodium, probably because it included vegetable based soups, sauces, white potatoes (those salty French fries and potato chips), salads with dressing as well as canned vegetables. In the NHAMES study, a more detailed look at the sodium containing culprits found that yeast breads, chicken, mixed chicken dinners, pizza, pasta dishes and cold cuts topped the list.

Because the NHAMES data was obtained though self-reported intake, many scientists feel that the population’s sodium consumption was actually higher. (We tend to make our previous meals sound smaller and healthier than they were; I know that when I wrote about my food intake I omitted the chocolate and tapioca pudding that I ate). And the sodium from salt added at the table was not calculated in the NHAMES questionnaire…. and we all know people who salt everything, even before they have tasted it.

It’s apparent that we have to become better sodium consumers if we want to confront our number one cause of death.  Since sodium intake largely comes from processed and restaurant foods, we have to start “deprocessing” and, if possible, (now I know I am entering dangerous culinary territory) cook for ourselves or at least know how our food is prepared and cooked. (I made this latter statement for all of you out there who rely on others to prepare the food you eat at home). Become a restaurant pest and ask what each dish is made from and how it’s prepared. Get your salad with dressing on the side and use very little. Sauces can also go on the side or be eliminated. Bread, french fries and pickles should not be an eating-out staple. Those quick take-out sandwiches with cold cuts (and/or the hotdogs) are not a terrific way to get your nutrients.

Oi …. so what’s left to eat? Well fruits are always fine, raw veggies are great and then “unsauced” and uncured fish, chicken (not plumped in salt water), meat, eggs (properly cooked and from non salmonella contaminated chickens) as well as dairy should all contain no or at least less sodium. Remember, whatever is pre-prepared and packaged to last long and taste sweet or salty, probably contains a lot of sodium. Read the label, it will tell you how many milligrams of sodium a portion contains. You might be surprised. Meanwhile, I’ll go take my blood pressure!

I was browsing through my weekly New England Medical Journal when I came upon a review article about nicotine addiction. There were a few startling facts that we all sort of know but I thought it might be appropriate to reaffirm them in my newsletter.

So here are some of the data that make you want to stop and take a deep breath of clean air.
•    Smoking causes 1 in 5 deaths in the United States.
•    435,000 people in the US die prematurely from smoking related diseases.
•    The chance that a lifelong smoker will die prematurely from a complication of smoking is approximately 50%.
•    Currently 45 million Americans smoke tobacco.
•    70% of smokers would like to quit and every year, 40% do….at least for 1 day.
•    More than 80% who attempt to quit on their own return to smoking in 1 month.
•    Each year only 3% of smokers quit successfully. (This blew me away!)

Let’s start with how smoking affects the brain. Inhalation of smoke from cigarettes gets nicotine to the brain in just seconds. (It’s a fabulously efficient route of drug administration!) Once in the brain it stimulates receptors (to be exact, they are called cholinergic receptors) causing them to release a variety of neurotransmitters. One of them, dopamine, signals a pleasurable experience. Other substances in cigarette smoke cause enzymes to activate neurotransmitters that feed our sense of well-being and emotions…dopamine, norepinephrine and serotonin. In addition, bi-products of acetaldehyde in cigarette smoke inhibit an enzyme called monamine oxidase and enhance the addictiveness of smoking by reducing the breakdown of dopamine.

And just to continue in this neurochemical explanation…. tolerance or “neuroadaptation” occurs with repeated exposure to nicotine though “self- multiplication”  of the number of binding sites on the nicotine receptors in the brain  . Unless these increasing number of receptors are bound by nicotine, they create craving and withdrawal symptoms of anxiety and stress. In order to sustain sufficient levels of nicotine to satisfy these receptors, the owner of the “nicotined” brain has to keep smoking!

Clinically, the authors of the article point out that “nicotine induces pleasure and reduces stress and anxiety” and that smokers use it to modulate levels of arousal and to control mood.  Most addicted smokers feel that inhalation of tobacco is necessary to improve their concentration, reaction time, and performance of certain tasks. They smoke to get relief from withdrawal symptoms (irritability, depressed mood, restlessness and anxiety) and this is probably what makes them feel better and able to perform.  Apparently, the intensity of the mood disturbances that occur from withdrawal from smoking is similar to that found in psychiatric outpatients.

So what about all those nicotine products that are supposed to aid smoking cessation? Although they supply nicotine to the body (and brain) they do so much more slowly than inhaled nicotine. And they don’t contain the other additives in cigarettes that have been designed to enhance their addictiveness. They help but, unfortunately, are not totally effective substitutes.

It’s felt that light smokers and occasional smokers smoke for the positive reinforcement and have minimal or no withdrawal symptoms. (And they are the ones that can most easily quit!)

Studies on twins have demonstrated that there is also a genetic propensity to cigarette dependence. Researchers have even found specific genes and gene regions that are associated with nicotine dependence. (This is interesting, but I would not suggest that a genetic study be done to see if a person has the dependence gene and if it’s not present, go ahead and smoke!)

So who is vulnerable? The answer is the young. Eighty percent of smokers begin smoking by the age of 18. Risk factors include peer and parental influences, behavioral problems (lack of scholastic and social success), personality characteristics such as rebelliousness, risk taking, depression and anxiety as well as genetics. Exposure to nicotine can then cause the brain changes that lead to addiction.

Women seem to be at a greater risk for smoking addiction than men. They are more strongly influenced by conditioned cues (eating, socializing and de-stressing), not to mention their desire to be thin, and have worse symptoms of withdrawal when they try to stop. Women also metabolize nicotine more quickly than men and this impacts their receptors more profoundly. Moreover as “rapid metabolizers” they need to take in more cigarette smoke per day than those who metabolize nicotine slowly. Rapid metabolism of nicotine is also associated with more severe withdrawal symptoms.

I know that all this information is pretty depressing and makes it sound as if women who smoke are destined to continue their addiction. By now, we all know that smoking leads to an unacceptably high risk for cancer, heart and pulmonary disease, osteoporosis, fertility problems, miscarriage, early menopause, wrinkles and a shortened life span. We need the type of call to action we have used in our fight to confront breast cancer. Our state and national public health departments are trying. Smoking has to become anathema to all. Supportive physicians, friends, family and medication can help those who smoke quit. This is not a “give up” situation. There are new medications; these and behavioral therapy, hypnosis and the right “instead of” nicotine products can be effective. We should be able to do a lot better than that 3% success rate.

The ultimate goal will be the prevention of smoking by teenage girls so that they do not become addicted. Now we just have to get to them with the right message before the tobacco company does…

By now most pediatricians and Moms know that the HPV vaccine that works against 4 types of human papiolloma virus (known as Gardasil) is recommended for females age 9 though 26. Gardasil is widely advertised as the vaccine that helps prevent cervical cancer. (Two of the HPV’s that are targeted in this immunization, 16 and 18, cause 70% of cervical cancers). These and other HPV’s are spread through sexual contact. There are at least 100 HPV types….all easily contracted through the touch of a penis (or other sexual part or instrument, depending on sexual preference and type of sexual activity). We now realize that certain high risk HPV’s (including but not limited to 16 and 18) can also cause other cancers including certain anal, penile as well as oropharyngeal and oral cavity cancers.

In the past, women were taught to look for “something” on the sexual member or their partner….i.e. a wart or an ulcer (a warning that herpes or syphilis was dwelling there). Unfortunately, the lack of a visible lesion does not mean that the Herpes virus or HPV is absent. Both types of viruses can be invisibly secreted and ready to jump right in (or on) any contacted skin or mucous membrane! And rarely is the examination at time of sexual activity performed with a microscope or special stains to detect microscopic lesions (Maybe this is where I mention the use of a vinegar solution which can help demonstrate small white areas that are often associated with certain HPV lesions. We call it acetic acid and it’s applied to the cervix (or penis) during a microscopic examination by the health practitioner when checking for HPV caused changes and/or dysplasia of the cervix or other genital tissue.)

This quadivalent (four type) human papillomavirus vaccine will not only protect from cervical cancer (and potentially cancers in other areas as stated above), but also genital warts. Let me emphasize….the warts we see (they feel granular and look like little pink or reddish growths and are often slightly uneven) are not from the types of HPV’s that cause cancer. They are due to HPV types 6 and 11. However since HPV’s may gather in groups, there is no reassurance that only one type is present.

Approximately 500, 000 cases of genital warts are estimated to occur each year in the Untied States. Hundreds of millions of dollars are spent treating them; they cause discomfort, embarrassment, as well as sexual and social isolation to those who are affected.

Clearly HPV infection has no gender preference….however cervical cancer has been a top priority for immunization and treatment. In the developing world (were PAP smears and screening are extremely limited or absent), cervical cancer is a major cause of death in women. When the Gardasil vaccine came out the FDA and the Advisory Committee on Immunization Practices (ACIP) recommended its use in young girls and women, preferably before they became sexually active and exposed to HPV infection.

But what about boys? I’m now happy to report that on October 16 2009 the FDA licensed Gardasil for males aged 9 to 26 for prevention of genital warts caused by HPV types 6 and 11. A week later the ACIP provided guidance stating that this vaccine may be given to males to reduce the likelihood of acquiring genital warts; however they don’t recommend its routine use among males. All this was recently reported in the section that contains reports from the Center for Disease Control in The Journal of the American Medical Association (JAMA).

So far the CDC feels that it’s most cost-effective to immunize girls because “the health burden is greater in females than males and numerous models have shown vaccination of adolescent girls to be a cost-effective use of public health resources; improving coverage of females aged 11 to 12 years could potentially be a more effective and cost-effective strategy than adding male vaccination”.

Having said this, the JAMA report adds that men who have sex with men (MSM is the medical term) are indeed particularly at risk for condition associated with HPV types 6,11,16 and 18; diseases that include anal cancers and genital warts, and that Gardasil could help prevent this. Now that’s a quandary for parents….how do you assess the future risks for your son at age 11? And even if you don’t feel he is at high risk….if his future sexual partners (be they female or male) are not immunized, then he will be, moreover once infected he can spread the HPV’s to others.

Social and sexual equality would suggest that we should immunize all of our children. That recommendation is still not public policy. But at least the availability of the vaccine for girls AND boys is now accepted. Discuss this amongst yourselves and your pediatrician. The series of 3 shots needed to giver immunity take 6 months….and may not be covered by insurance, especially when used in males.  This is yet another decision that now has to be considered as we raise our progeny.

Our phones have been busy with questions about calcium supplements ever since the article in the LA Times health section appeared on August 2. It was titled “Calcium Supplements Linked to Heart Attacks” and quoted from an online report in the British Medical Journal (BMJ). To the newspaper’s credit, after using a heart-stopping (if not a supplement- stopping) headline, they gave the actual website on which the article was based. It was titled “Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis”. (Not as attention grabbing, but more accurate.)

First, let me address the fact that this was a “meta-analysis”. That means that they took a number of articles and studies, lumped them together and drew their own conclusions. So even if a study was poorly done, this type of analysis won’t question the results but simply adds them to the overall assessment. Small, short-term studies are counted together with larger and/or longer studies.

The research fellows (their title, not their gender) from the Department of Medicine at The University of Auckland who wrote the paper, searched several data bases and reference lists to find “randomized, placebo controlled trials with calcium supplements of at least 500 mg a day that included 100 or more participants of mean age more than 40”. None of the studies were conducted for the primary assessment of heart outcomes. What they found on their pooled analysis of around 12000 participants (from 11 studies) was that calcium supplements WITHOUT VITAMIN D were associated with a 30% increase in the incidence of heart attack. They excluded studies that compared calcium supplements with D or the co-administration of Vitamin D to subjects who received neither. Milk products that contain calcium were not included in their analysis.

Whenever a study is published in a peer reviewed journal, there has to be a discussion of previous data. (Unfortunately this was not done in the LA Times article). The authors of the BMJ article did point out that in two prospective, observational studies of women in the US (they were followed to see how they fared with various levels of calcium intake), those with the highest fourth of calcium intake had a 30- 40% lower cardiovascular mortality than those in the lowest fourth, and those in the highest fifth (i.e. the most calcium selective) had a 30-40% lower risk of ischemic (non-hemorrhagic) stroke than those in the lower fifth. The well known Women’s Health Initiative (WHI) reported that calcium and Vitamin D had no effect on the risk of coronary heart disease or stroke. However, the WHI was conducted with relatively low doses of Vitamin D (400IU) and this might not have been enough to make a difference.

Vitamin D deficiency has been associated with cardiovascular disease. Moreover (in my ode to D), in order to get ingested calcium (either in food or supplements) into our bones in an appropriate fashion so that it can help prevent fractures, we need vitamin D. And since a majority of Americans have now been found to be Vitamin D deficient…I think what we can take one bit of important information away from that scary headline and that is: Calcium supplements in the absence of appropriate D may not sufficiently help our bones, moreover, much more research is needed to establish whether it can cause harm to our cardiovascular system.

I’ll finish with the current recommendations that have been issued by the National Osteoporosis Foundation: 1,200 mg of calcium a day AND Vitamin D 800 to 1,000 units should be the daily nutritional goal for women over the age of 50.

And, women under the age of 50 should get 1,000 mg of calcium every day (together with that all important Vitamin D).

Count the amount of calcium you consume in your food (especially milk products) then supplement what is missing. Read the labels on containers….they state the percent of calcium per serving based on a total daily requirement of 1,000 mg a day….so if the label states that a portion contains 30% of daily calcium, it contains 300 mg. The average diet without any milk products contains 250 mg of calcium. You can then figure out how much you should supplement….but remember the need for D Many physicians feel that higher than currently suggested amounts of Vitamin D are necessary for bone, heart, colon, breast and other organ health in adults. It’s hard to overdose on D, but don’t try to take daily doses of over 2,000 units on your own. If you are unsure how much you are absorbing from the sun, or getting with your food or supplements, your Vitamin D level can be measured with a blood test.

A calcium a day (or probably more depending on your food and the type of calcium you take) with that all important D helps keep the doctor away, or at least should help make your doctor less, not more worried about your health!