I keep a mental dietary list which I review at the end of each day…”Let’s see, I had juice in the morning, salad at lunch, two vegetables at dinner and fruit for dessert. OK, now I’ve had my five or more fruits and vegetables and have done my nutritional duty to ward off cancer.” It turns out I am giving myself inadequately proven anti-cancer food advice.

The largest prospective study to date, the European Prospective Investigation into Cancer and Nutrition study (wisely acronymed the EPIC study), followed 478,478 individuals aged 25 to 70 years in 10 European countries for a median of 8.7 years. (How they got to a number that has those matching numerals is a mystery.) Unlike many large studies, women comprised the predominant gender (335,873 women vs. 142,605 men). The overall cancer incidence rates were 7.9 per 1000 person –years for men and 7.1 per thousand-person years for women. When the researchers analyzed the impact of daily veggies, they found that an increase of 100 grams (the equivalent of a serving of broccoli) reduced cancer risk by only 2% while a comparable intake of fruit (less than an apple) reduced cancer risk by just 1%. These were very low percentages…and were restricted to women; they didn’t even apply to men who gained no cancer protection.

I would like to remind you of a previous website article in which I cited articles that discourage women from drinking more than 10 grams (one drink) at any time. Well, the researchers that reviewed the EPIC data found that intake of fruit and vegetables did decrease cancer risk by 10% in heavy drinkers (more than 30 g daily for women and 60 grams for men). But considering all the damage that excessive alcohol consumption does to our health, proclaiming that the right foods will prevent certain cancers is not appropriate medical advice.

The American Cancer Society (ACS) still advises that we consume 5 servings of a variety of fruits and vegetables on a daily basis to help reduce cancer risk both directly as well as indirectly by helping maintain a healthy weight. In 2005, ACS made “the 5 rule” the third priority after healthy weight maintenance throughout life and adoption of a physically active lifestyle. The ACS meets to update its recommendations later this summer and will probably change them based on the EPIC study.

But before I encourage you to stop that “5-a-day” nutritional count let’s remember that cardiovascular disease is the number one cause of mortality in women (not cancer). There are many prospective studies that have shown that 5 servings of fruit and vegetables a day reduce cardiovascular risk by as much as 12%.  These foods contain nutrients and vitamins that are essential for all of our bodies’ functions. They most certainly help us maintain a healthy weight and a lower weight  (or more precisely, lack of obesity) will diminish our risk of diabetes, heart disease and many cancers. We have to eat something, and substitutions for fruits and/or veggies usually carry excess calories, sugar, salt and bad fats. (Think processed or junk food.)

I may stop computing those servings in the hope that I will reduce my risk of cancer, but I’ll keep up the count to maintain my heart, weight and future health and well being.

I routinely ask my new patients: “How much, on average, do you drink each week?” In order to make this question slightly less accusatory, I also add “do you usually have wine with dinner or a cocktail before?” If the answer is “yes, one or two glasses”, I then feel obligated to discuss the pros and cons of women’s alcohol consumption. I was therefore delighted to find an article under the heading of “Clinical  Crossroads” in last week’s JAMA which dealt with the question of whether a person (in this case, a 42 year old man) should drink for his health. The authors were kind enough to also consider the health implications of drinking for women. Here are some of the facts that they presented:

The estimated ethanol (alcohol) content per serving of various alcoholic beverages is similar, although their caloric content may vary. Twelve ounces of beer have 14 grams of ethanol and 150 calories, light beer contains 11 grams of ethanol but about 50 calories less; 5 ounces of wine contain 15 grams of ethanol and 120 -125 calories and finally 1.5 ounces of “hard alcohol” or spirits have 14 to 15 grams of ethanol and 100 calories.

Because women have a smaller volume of distribution in which to dilute the alcohol, overall smaller body size, and a different first –pass metabolism (alcohol is not as quickly metabolized by the liver), we experience the toxic effects of alcohol at approximately half the daily dose of alcohol as do men. One glass of  wine, serving of beer or “a drink” for a woman is like two for a man….so ( and I don’t meant to insult your intelligence, but  want to write this for emphasis)….two drinks at dinner would be the equivalent of four for a man. And that’s a number that would cause concern to most of their female companions.

Alcoholism has been ranked the third most important preventable cause of death in the United States. The National Institute on Alcohol Abuse and Alcoholism has issued the following guidelines for safe drinking:

* Up to 2 drinks for men younger than 65
* Up to one drink per drinking day (I’m not sure what constitutes a drinking day, but it’s their wording) for non-pregnant women and older adults

No alcohol for

* Women who are pregnant or trying to become pregnant
* Persons with medical conditions that could be made worse by drinking
* Persons who plan to engage in activities that require alertness and skill (such as driving a car)
* Persons taking certain over-the-counter or prescription medications (think sleeping medications, ant anxiety meds, antihistamines or anything that effects brazen chemistry)
* Persons recovering from alcoholism
*  Persons younger than 21

In order not to sound like an abolitionist, let me also proffer the data that was cited on the “biochemical effects of light to moderate alcohol consumption in short term feeding studies”. (Actually they were drinking studies). Researchers looked at certain biomarkers for cardiac disease and the effect of ethanol on these markers. HDL or high density lipoprotein (the good cholesterol) was minimally increased, but a lot of alcohol was needed to do this (60 grams per day in men and 35 grams in women). Alcohol seemed to work best on HDL if the levels were low to begin with. (Before menopause most women have fairly high HDL levels, perhaps due to their production of estrogen.) Triglycerides were increased in men who drank moderately but may have decreased in women (although beer with more carbohydrates seems to erase this phenomenon). Fibrinogen which is involved in clot production was lowered. Adiponectin which increases insulin sensitivity (a good thing) did minimally increase and as such may have lowered the risk of diabetes.

Now here is the concern for women: Light to moderate drinking increases the bodies own sex steroid hormones by 5% to 20% and can increase risk of breast cancer! This translates to an approximate 1% increase in the relative risk for each one gram a day of alcohol.   It also has an adverse effect on other cancers in men and women. Malignancies of the mouth, larynx and esophagus are increased in all moderate drinkers. The relative risk of developing these cancers (compared to nondrinkers) is approximately 1.4 to 1.7 with “just” 2 drinks a day.

So should we drink for our hearts or abstain for our breasts? Studies dating back at least 25 years have shown that 10 grams of ethanol per day among women (and 25 grams for men) lowered risk of coronary heart disease by 20 to 30%. The authors calculated that this conferred a 1% lower absolute 10 year risk for a 50 year old man who was deemed “average”, but remember our 10 year average risk at 50 is usually less than that of men.

It sounds like that one drink is a draw…but the authors go on to state that the typically high HDL levels in premenopausal women would appear to make any clinical benefit for alcohol limited at best, “and since the risk of breast cancer is increased, it is unlikely that premenopausal women would profit from drinking”.

There is so much more that we can do to prevent heart disease…not smoking, exercising, maintaining a reasonable body weight and if necessary treating elevated lipids (LDL cholesterol and triglyceride).

Alcohol is not a medicine. If you love it and want to drink a glass of wine with dinner or have that drink before….limit it to one.  Your choice to imbibe is similar to your desire for desert, but without the “nose”….it tastes good, you enjoy it and it adds to your meal. The toast “l’haim” (to life) that accompanies that drink is a wish, not a medical certainty.

Let me start with the scary and necessary-to-know statistics: Osteoporosis affects 10 to 12 million people in the US and forty million have low bone density (osteopenia). In 2005, over 2 million fractures were diagnosed. One in three Caucasian women over 50 will experience an osteoporotic fracture in her lifetime. (Whites and Asian women tend to have a lower bone mass than women of other ethnicities.) We also “out fracture” men (who have thicker bones) by a factor of 1.6.  And if a woman fractures her hip, she has a 20% chance of dying within a year. Osteoporosis is a very disabling, costly, and yes, mortal disease.

There has been a welcomed increase (both medically and financially) in pharmaceutical therapies that help avoid and/or treat osteoporosis. By now, you have all seen the ads and articles for the various bisphosphonates including oral alendronate (Fosomax), risedronate (Actonel) and ibandronate (Boniva) which can be used daily, weekly or monthly. There are also intravenous bisphosphonates that can be administered every 3 months or just once a year.

Then came the media outcry about potential side effects that these medications could cause….jaw necrosis, perhaps atrial fibrillation and more recently “atypical” fracture of the femoral shaft (long, upper leg bone), especially after long term use. I want to address the latter concern in this article.

Remember, these medications work by binding to the bone, preventing cells called osteoclasts from drilling minute cavities that make the bone porous. Cells called osteoblasts then do “their thing” and fill the cavities up. When stable, the drilling and filling are equal and thus maintain bone structure and strength. However if the drilling outpaces the filling, there is bone loss. This occurs with age (unfortunately after 30), and is accelerated by lack of estrogen (menopause) certain medications, especially steroids, diseases and the “wrong” genes. It is also aided and abetted by lack of proper nutrition.

Just to reiterate, bisphosphonates help stop the drilling and with time those minute cavities that made the bone porous get filled, diminishing the risk of fracture. We now know that these bisphosphonates attach and remain in the bone performing this job for years after being discontinued.

Recent cases have appeared in medical journals in which the femoral bone fractured in a horizontal fashion without prior significant trauma. In most instances, the patients were taking long term bisphosphonates.  How concerned should we be about this newly media reported “atypical” femur fracture?

An article in the May issue of The New England Medical Journal may help allay physician and patient concerns. It concludes that this type of fracture is truly rare. The authors used data from 3 randomized and placebo-controlled, prospective studies involving 14,195 women and 55,000 person years of observation. The risedronate data that they reviewed provided up to 10 years of study. All together, they found a total of 12 fractures in 10 patients that were classified as possible “atypical” femur fractures. (To be accurate, they were called subtrochanteric or diaphyseal fractures). The incidence came out to just 2.3 per 10,000 patient years. The authors also calculated that treating 1,000 women who had osteoporosis for 3 years would prevent about 100 fractures (including 11 hip fractures), a benefit that way exceeded the risk of “atypical” fracture, if indeed it was caused by the bisphosphonates.

So what does this mean? Well according to an editorial that followed the article, “physicians should not rush to judgment and stop prescribing bisphosphonates because of concern about atypical femoral fractures.” They should, however, reevaluate patients who have received long term therapy in the context of contemporary guidelines. (And for these please see my previous website article that discusses the use of FRAX to determine for whom and when to start therapy.)
I now review the FRAX indications for each patient who is at risk for osteoporosis. If she is a candidate for medication I will prescribe it, but carefully follow her with tests to check for bone loss. If she is stable for a number of years (usually 5 years) I suggest stopping the medication or at least taking a drug holiday. The good of the bisphosphonates still outweighs a possible bad, at least for those who need it.

Now, although I usually end my weekly newsletter with just one article, I have to mention another that just came out in JAMA. It also dealt with bone fractures. As we now all know, Vitamin D has become the vitamin “De jour”. The amount of D found in up to 70% of American is inadequate; low levels have been associated with osteoporosis, heart disease and a number of cancers. I ask all my patients about their Vitamin D intake (and exposure, remember you can get it though sun rays) and repeatedly advise them to take at least 1,000 international units (IU’s) daily.  I often check Vitamin D levels with a blood test, especially if there is a history of low bone density. For those whose level is found to be extremely low, I prescribe 50,000 units of Vitamin D-2 a week or every other week for several months, and then recheck their levels. If they have achieved a D level that is sufficiently high, I have them continue with an OTC supplement of up to 2,000 units daily.

Researches in Melbourne, Australia tried to maximize Vit D administration by giving elderly women considered to be at high risk of fracture  a dose of 500,000 IU of Vitamin D orally once a year.  They carried out a double-blind, placebo-controlled trial in 2256 women aged 70 or older. Half were given this very high yearly dose for 3 to 5 years; the others were given a placebo. There was no difference between the 2 groups with regard to calcium intake (indeed it increased for both). But contrary to expectations the group that received the high dose Vitamin D experienced 15% more falls and 26% more fractures than the placebo group. And the increase in falls was most apparent in the 3 months after they were given high dose Vit D! Frankly, the authors couldn’t explain this but went on to suggest that dosing should be more frequent and at lower doses. So far I (and most of my colleagues) will probably stick to advising daily 1,000 units or more of D and if your levels are low that you increase the dose (with a prescription) on a weekly or biweekly schedule. But I doubt we will prescribe that single oral dose once a year. So please continue to use D and calcium on a regular basis for better bones. And if necessary, go ahead and take that bisphosphonate that I or another doctor may have prescribed. The bones you strengthen will be there to stand you in good stead!

We commonly use the adjective “sweet” to imply niceness….and of course the taste that has so domineered our palate. But the “added sugars” that help achieve the latter are anything but sweet to our hearts, brains or blood vessels. (I’ll refrain from using the word bittersweet.)  They are cloying together (my new term) to raise our bad cholesterol and enhance our demise from heart attack and stroke.

Our palate preferences have been fostered and exploited by the food industry. They know their market and have been happy to cater to our preferred taste for sweet by adding sugars in the form of refined beet or cane sugars and high-fructose corn syrup in processed or prepared food.

According to an article published in a recent Journal of the American Medical Association (JAMA), we ingest an average of 89.8 grams (21.4 teaspoons) or 359 calories of added sugar daily. This represents 15.8% of our total daily caloric intake and 31.7% of our total carbohydrate intake (as compared to just 10.6% in the late 70’s). These numbers were based on a study of adults who participated in the National Health and Nutrition Examination or NAHMES. (No, it wasn’t a pass-fail test and the subjects were not college students; as a matter of fact, they consisted of a “US civilian, noninstituitionalized population designed to obtain nationally representative estimates on diet and health indicators”). Individuals who were taking cholesterol- lowering medications and those with a diagnosis of diabetes were excluded. More than 6,000 adults were followed between 1999 and 2006; over half were women. (So we had due representation.) The participants were interviewed and gave a detailed 24 hour dietary recall. The nutrient content of the food they stated that they had consumed was determined by NAHMES from the US Department of Agriculture Nutritional Database as well as the MyPyramid Equivalents Database. (I guess a single source might have been questioned by the food industry.) The NAHMES investigators also collected fasting blood samples which they then tested for 3 lipid abnormalities: elevated triglyceride levels, elevated levels of small LDL-C particles and reduced HDL-C levels …all of which contribute to “dyslipidemia” (bad lipid levels that lead to coronary heart disease). So here is what they found:

• A mean weight gain in one year of 2.8 pounds among those “extra sugar eaters” who consumed 25% or greater total energy from added sugar compared to a mean loss of 0.3 pounds among those who consumed less than 5% total energy from sugar.
• In women who consumed more than 10% of their calories as added sugar, the odds that their good cholesterol or HDL-C  was low (think the stuff that acts as  a roto-rooter in your arteries) was 50 % to 300% greater than women who consumed less than 5% added sugar in their diets.
• A higher level of triglycerides and a higher ratio of triglycerides to HDL-C in those who consumed more than that 10% of calories though sugar.

I know I am giving a lot of “higher” and “lower” numbers, but alas, that is what statistics are all about. Put simply, the higher your intake of “added sugar” the more likely you will gain weight and ruin your good and bad lipid levels. It’s not enough to just eat low fat or abstain from the wrong fats in order to maintain an internal cholesterol and fat ratio that will protect your blood vessels, heart and brain. You have to abstain from ubiquitous “added sugars”. Check the labels on those sodas, coffee drinks, canned food, cookies, soups, cereals, breads or anything that is processed. (And the term “naturally sweetened” doesn’t mean that the sugar is exempt from the above.). Your overall “added sugar” should not be higher than 100 calories a day or 5% of your caloric intake. There is nothing sweet about the wrong fats that clog vessels and result in heart attack and stroke.

As a fellow of ACOG (The American College of Obstetricians and Gynecologist, the term “fellow” has no gender significance)….I recently received a survey to complete with questions about my age, number of hours I teach, see patients, percent of patients who are on Medicare, languages I speak, etc….the usual questions that one would expect them to ask in order to keep their census up to date. But this time they included a second page of questions that asked about my knowledge of a specific infection. When I realized my knowledge was minimal (actually I didn’t know anything about it), I quickly looked it up so that I could mark their queries in other than the column “I don’t know”. (The survey was multiple choice).

I’d like to share the information I learned with you….not because you too will be “tested” but because general knowledge about this water borne infection in not well known (even by doctors) and there are warnings that should be issued to help protect many of us.

The infection is due to a parasite called Cryptosporidium. It causes (you guessed it) cryptosporidiosis (nick name Crypto) …which usually manifests itself as diarrhea. It’s a fascinating organism. It thrives in cattle, sheep and pigs as well as wild animals such as deer, elk and moose, especially their young offspring (calves and lamb) and, unfortunately, in humans. Once a parasite gets to the small intestine (the gut) though ingestion, it can multiply and recycle indefinitely. In a fascinating process, once in the gut, this microscopic parasite actually undergoes a sort of fertilization to form a zygote, and this ends up having 4 offspring called sporozoites. (Sorry if I am getting too detailed, but it’s the biologist in me.) Some sporozoites remain in the gut and infect new cells. Others that get surrounded by a cyst wall become oocysts, and these are passed in the feces and into the environment. All this happens astoundingly quickly…each generation can develop and mature in 12 to 14 hours. During the last 2 decades, “Crypto” has become one of the most common causes of waterborne disease in humans in the US and through out the world!

The usual source of infection is water that has been contaminated by the feces of animals or infected humans. If a person drinks the water or involuntarily swallows it while swimming, they then “catch” cryptosporidiosis. Crypto has been found in swimming pools, hot tubs, Jacuzzis, fountains, lakes, springs, rivers, and ponds which can be contaminated with sewage or feces from humans or animals. It can be spread by eating uncooked food that is contaminated, by touching your mouth with contaminated hands…which could have “picked up” the parasite from touching surfaces (and this includes diapers) that have been contaminated by stool from an infected person or handling an infected cow or calf. (We do the latter infrequently in LA.)

Symptoms of the infection usually appear within 2 to 10 days of exposure and include diarrhea, abdominal cramping, nausea, vomiting, low grade fever and weight loss. In persons who are immunocompromised (due to diseases such as AIDS or cancer), the infection may become life threatening. The good news is that the immune system in healthy individuals is able to stop the infection, although symptoms may last for one to two weeks. But even after symptoms subside, sporozoites can be excreted in the feces and if that person swims, he or she can pass them into the water from spores that are present in the outer part of the anus or even on the thighs (ugh!). Here is where physician advice should include sanitary precautions to wash hands, use separate towels and not go swimming for 2 weeks after all the symptoms have resolved. The other rather concerning information that I discovered was that chlorine disinfection of the organism is ineffective; even one oocyst can withstand pure bleach for 24 hours and still cause infection .Most water filters today do remove small particles including cryptosporidium from our drinking water…but this may not occur in home wells (or swimming pools).

According to the CDC, the best way to protect yourself and others from this cause of diarrhea is to:

• Wash your hands after using the toilet and before handling food (especially for persons with diarrhea).
• Wash hands after every diaper change, especially if you work with diaper-aged children.
• Do not swim if you are experiencing diarrhea (essential for children in diapers) and stop for 2 weeks after diarrhea subsides
• Avoid water that might be contaminated.
• Do not swallow recreational water.
• Do not drink untreated water from shallow wells (or boil it first).
• Do not consume untreated ice or drinking water when traveling in countries where the water supply may not be safe.
• Use safe uncontaminated water to wash all food that is to be eaten raw (and if there is a chance that the food might be contaminated, peel it).
• Avoid eating uncooked foods while traveling in countries with poor water treatment and food sanitation
• You’ll love this one….avoid fecal exposure during sexual activity.

The diagnosis can only be made if stool samples are tested for the parasite, and frankly the test is not always positive the first time so several samples may be necessary.

The only FDA approved treatment is through a prescription of a medication called nitazoxanide (brand name Alinia). Most people with healthy immune systems will recover without treatment. Diarrhea should be managed with fluids to prevent dehydration.

So now you know and could “pass” the survey put out by ACOG. If I include a bottom line, as I usually do in my newsletter, it would probably include the phrase “Don’t swallow” (at least while swimming), know your drinking water source and wash your hands!

Most of us plan our medical appointment based on symptoms and complaints, need for check up, schedule and of course, the availability of our physician or health care practitioner. There are only so many early morning openings, and these may be further diminished when doctors make hospital rounds and/or perform surgeries before arriving at the office. If you don’t want to leave home without breakfast in the morning or you have to make a late afternoon appointment, you may not be willing or able to fast for blood tests. (I encourage everyone to eat their breakfast…I won’t leave home without it. This may be the time to mention that individuals who don’t eat breakfast have a shorter life span….fasting from dinner until lunch will result in an overly aggressive i.e., high, insulin response to the delayed meal. Elevated insulin levels can cause fat to accumulate in unwanted places and increase the risk of cardiovascular disease.)

So there you are at the doctor’s office, you have not fasted and you are told that the blood test for diabetes (and perhaps heart disease) can’t be done…Thus is no longer inaccurate. An article just published in the March 4 issue of The New England Journal of Medicine reported that a non fasting blood test called glycated hemoglobin (also known as hemoglobin A1c) will diagnose risk of diabetes just as well or better than a fasting blood sugar (glucose) test and can also strongly indicate risk of cardiovascular disease and death from any cause!

Until recently, the standard measure used for diagnosis of diabetes was a fasting blood sugar. Glycated hemoglobin is a test that reflects your previous 2 to 3 month exposure to glucose and will include spikes that occur after eating. It doesn’t vary from hour to hour or day to day and is not dependent on what you just ate. It is essentially the glucose “truth meter” for what you have consumed and your blood glucose response over the past few months. It has traditionally been used for the determination of glucose control among those who have already been diagnosed with diabetes and are on therapy. But this and other reports will eventually make glycated hemoglobin the test “of choice” for diagnosis and assessment of diabetic risk in everyone.

The Atherosclerosis Risk in Communities (ARIC) is a community -based prospective study of middle-aged adults from four U.S. centers. It was started in the late 80’s and continues to present time. During the study, the researchers measured the glycated hemoglobin in blood samples from 11,092 adults who did not have a history of diabetes or cardiovascular disease. More than 55% of those tested were women. Their ages ranged from the mid-forties to mid-sixties. For the individuals who were found to have glycated hemoglobin of 6.0 to 6.5%, the risk of diabetes (the technical term was multi-variable-adjusted hazard ratio) was 4.48. (Those who had values of 6% to 6.5% were 4.48 times more likely to develop diabetes then individuals used as a reference who had glycated hemoglobin of less than 5.5%). For those individuals who had a level greater than 6.5% the risk was 16.47. The researchers then checked to see who developed coronary disease and stroke. The hazard ratio for a value of 6 to 6.5% was 1.76 and over 6.5% was 1.95 (or a 95% increase over those with low glycated hemoglobin levels.) They also looked at death from any cause and found that the higher the glycated hemoglobin, the greater the risk of mortality. Moreover glycated hemoglobin levels were found to be more predictive of disease than fasting blood sugar levels.

Studies have show that among people in the United States who do not have a diagnosis of diabetes, over 2.4 million have a glycated hemoglobin higher than 6.5% and 7 million have a value higher than 6.0%. This is an ill inspiring number.

Bottom line: A non-fasting blood test for glycated hemoglobin can help determine whether you are at risk for development of diabetes, cardiovascular disease and even early death. Hopefully it will be less than 6.0%. Most of us now know our cholesterol and lipid levels; it may be just as important to know your glycated hemoglobin level. If it’s too high you and your doctor will need to discuss the necessary behavioral changes and therapies that will help you to maintain your health.

I, like most Americans, love salt. My ethnic culinary background has made salt a very traditional condiment. (Think chicken soup, koshered fowl, pickles, smoked white fish, hummus, pitas…then add on American potato chips, processed meats, breads, cookies, sauces and salad dressings). I was going to have a string cheese as a snack while I wrote this….but I looked at the wrapper and it contains 210 mg of sodium (remember sodium chloride is salt). And since a quarter of a teaspoon of simple salt is 1.5 gram or 590 mg of sodium, I guess I also won’t salt those carrot sticks.

An article appeared this February in The New England Journal of Medicine that was titled “Compelling Evidence for Public Health Action to Reduce Salt Intake”. Their projections were astonishing. The authors, from The University of California, San Francisco, used a computer program called the Coronary Heart Disease Policy Model to quantify the benefits of reducing dietary salt by 3 grams a day (or in sodium terms, and that’s what you find on food labels… 1200 mg of sodium per day). This reduction would have a tremendous effect, reducing the annual number of new cases of coronary heart disease (CHD) in the U.S. by 60,000 to 120,000, stroke by 32,000 to 60,000 and heart attack by 54,000 to 99,000 and reduce the annual number of deaths from any cause by 44,000 to 92,000. (And, for the mostly women readers of my website…please note that the projected reductions in stroke would be greater among women than men.) All this could save $10 billion to $24 billion in health care costs annually!

In short, salt reduction would be as beneficial as interventions that reduced smoking in the US by 50%, a 5% body mass reduction in all obese adults or the use of drug therapy for people with hypertension and hyper cholesterol levels. Moreover it is probably as important as reducing trans fats in all foods and increasing our consumption of fruits and vegetables. The authors of a commentary in the same issue also point out that salt reduction may reduce risk of gastric cancer, kidney disease, congestive heart failure and osteoporosis.

It turns out that we are a population of salt eaters ….consuming more than in many other developed countries. Although the current guideline for salt consumption by The Departments of Agriculture and Health and Human Services is less than 5.8 g of salt (2300 mg of sodium) with a lower target of 3.7 g of salt per day for persons over 40, blacks and persons with hypertension; the average man in the U.S. consumes 10.6 g of salt per day and the average woman 7.3g per day. And statistics have shown that the amount of salt we consume is on the rise.

So what can we do? Certainly look at labels.  Seventy-five percent to 80% of the salt in the U.S. diet comes from processed foods. Our government (doesn’t it always seem to come back to them) should probably begin a program of regulations on the salt content of processed food, make labeling clearer and work with the food industry to reduce salt….it worked for trans fats. And it behooves us, the consumers, to look at those labels, choose less salty alternatives (begin with cans of soup and breads and hey potato chips and pickles may have to go) and of course start using foods that are not processed. (Well at least try in some areas of food preparation….it may be difficult for most of us to bake all our breads or raise our own fowl and meat.)  And let’s not forget to diminish the salt intake of children. Between their processed snacks, cereals and the children meals at takeout and eat –in restaurants they are being inundated with salt.  Hypertension and plaque build up starts at a very young age as does the preference for salt.

Studies have shown that as salt intake is reduced, children and adults prefer food with less salt. Our taste receptors change over the course of just weeks or a few months. Taste is an acquired sense that can be changed. I for one will try to continue to enjoy what I eat sans excessive salt. (There goes the salt rim on the Margarita glass, oh well….)

One last encouraging note; the article pointed out that even if there was a more modest reduction in our salt intake by as little as 1 g a day there would be a significant projected decline in the annual rates of cardiovascular events and deaths. So if you can’t go salt free try for salt “freer”

We have all heard the weight gain formula: 3500 calories that are not burned off will add 1 pound of fat tissue. So if that’s the case 1 extra cookie that has 60 calories, when consumed daily, will add 0.5 pounds monthly or 6 lbs a year. Now let’s say you eat that cookie daily for a decade….does that mean you will gain 26 lbs, or if you eat it for 4 decades, you will gain more than a hundred pounds? Add to this the distressing fact that our basal body metabolism decreases by about 5% each decade…By now that cookie could make us look like sumo wrestlers before we get to take advantage of Medicare! (The last phrase is not meant to be an ad for Medicare Advantage.)

Well according to a very relevant commentary recently published in JAMA, this is not the cookie’s (nor you body’s) destiny. Weight gain does occur when your caloric intake increases above your energy expenditure, but it doesn’t continue indefinitely. The increased initial weight from that cookie requires more calories for maintenance. (It’s physics again, a heavier body needs more sustenance to stay heavy.) Eventually your weight will stabilize after several years of extra cookie consumption at approximately 6 lbs. But once you are in a steady weight state and you up your cookie consumption to 2 extra cookies, the process will begin over again.

The author of the JAMA commentary brought up some additional weighty information. If a young adult woman adds 1 oz of a sugar sweetened beverage and walks 1 minute less a day, she will have a temporary caloric excess of about 13 calories, leading to a weight gain of 1.4 lbs in one year. If she repeats nutritional and exercise changes of this nature on an annual basis for 28 years she will have a 370 calorie energy gap and a 35 lb weight gain. And she will not be alone in her caloric overage. The estimate is that the average per capita energy intake in the U.S.A since the 1970’s has increased by up to 500 calories. Our readily available food supply and mass encouragement to eat more and sweeter (for less money) has worked and contributed to our ever increasing girth. Obesity will overtake cancer as a cause of premature death! Future health care will have to start with food care, but now I digress.

Here come the “I am going on a diet or at least not eating that cookie” facts. As you loose some of that fat from your body, you also need less fuel to maintain that loss. Your weight recalibrates at a new steady state. Your body also “misses” some of that weight and strives to conserve whatever calories you do consume. So to continue to loose weight you have to further restrict your diet (much more than that cookie) and/ or really increase your energy output (i.e. exercise). Walking one mile a day expends just an additional 60 calories when compared to resting; the minimum to make up for that cookie. But to lose more you have to do more, and consume less. Unfortunately you can’t just rest on early weight loss laurels and resume your old diet and restricted physical routine. If you do the weight you lost will just come back. That New Year resolution has to be one that goes on and on and on…

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.