Yes, Diet Affects Attention. Really.

This past week CNN's health blog ran a post by Sonjay Gupta, MD called "Does ADHD Come From Food?" While it's great that CNN and its well-known doctor have given this important issue such a visible platform, it is more than a little disconcerting that the link between diet and attention is presented as a new and unproven concept. The link is fairly well documented in the scientific literature, including this landmark study in The Lancet that was the basis for the strict EU food labelling laws that I've written about previously. All in all, there is a lot of evidence that while not all attention issues are due to foods, some probably are. 

The Feingold Association, which has been around for decades, was one of the first groups to organize around this issue. I encourage you to poke around that organization's web site, look at the evidence and read the "real life" stories. I especially like the story called Taylor's Fuzzy Brained Mice, in which a kid trained four mice to run a maze, then gave two of the mice small amounts of yellow food dye in their water. The results are pretty astonishing - the rats with the dye in their water took longer to run the same maze that they previously completed with times similar to the mice who drank regular water. Further, this confusion was reversed once the colored water was switched back to normal.

Of course, individual stories (called anecdotal evidence in scientific parlance) do not true evidence make. Therefore, the Feignold site also lists many well-conducted scientific studies evaluating the effects of the Western diet on ADHD and other health concerns. It's pretty damning.

And it's not just artificial colorings, flavorings, and preservatives that are suspicious. Nutritionists and dietitians also speculate that the hydrogenated oils found in many processed foods compete with the good fats, like those found in fish and nuts, for valuable real estate in the body. In what is probably an oversimplification of complex brain chemistry, here is one possible scenario: the neurons in your brain are sheathed in fat, which allows electrical impulses to efficiently travel from one neuron to another, resulting in smoothly functioning nervous system. The substitution of hydrogenated oils for the good fatty acids creates a different type of coating of fats around those neurons - replacing the supple, conducive covering provided by good fats - thus interfering with clear thinking and focused attention. Nutritionist Kelly Dorfman explains it all here.

Unfortunately, what is emerging is that eating optimally is not as simple as choosing fruits and vegetables. An article published last year in the journal Pediatrics (the journal of the American Pediatric Association), showed that even moderate exposure to certain pesticides was associated with ADHD. Time magazine wrote about the article here. The authors of the article hastened to point out that eating conventionally grown fruits and vegetables is still preferable to eating junk food. But it does raise the issue of health equity: if organic produce is truly superior, a healthy diet is out of reach for many people for financial reasons. This pushes the issue from one of choice to one of social justice.

In the past few years there have been a slew of reliable studies on the effects of diet on behavior, learning, and attention. The only thing that's remarkable here is the slowness of the medical profession to get on board with this concept.  It's time to move past the endless debate of cause and effect (which is kept alive by the deep pockets of the food industry, its lobbying leverage, and consumers' appetites for poor-quality food) to actually doing something about it. There are many important avenues to explore: why some people are more susceptible to food impurities than others and how those individuals can be screened; what alternatives exist to current colorings, flavorings, stabilizers, etc; and of course, restricting the presence of those impurities in our foods. That's what the Center for Science in the Public Interest is trying to do by lobbying the US Congress to ban certain artificial colorings used in foods. But until then, consumers can do something on their own: make wise food choices. Voting with your checkbook is a time-tested way to bring about change.

###

Ruining it for the Rest of Us

In case you missed Dr. Paul Offit's interview on NPR regarding problems caused by those who don't vaccinate their kids.

I've written about herd immunity and the worries that we are losing it before:

The concerns are growing.

###

Beautiful AND Smart

Standard prescription bottle

As someone who makes a living with words it pains me to say this, but here goes: one picture really is worth a thousand words. This is especially true in my line of work, medical and scientific communications, where pictures and graphics are necessary to reach audiences with low literacy, low vision, or impaired thinking due to age, strokes, or even getting up in the middle of the night to tend to a sick child.

I am so impressed with all the good design being applied to medical issues these days. For example, Wired magazine recently ran a competition to re-design some of the most common laboratory test results. The amazing team at Information is Beautiful was the winner for its remarkably useful re-dos of some of the most common lab reports into graphics that not only clearly explain the lab findings, but tell you what they mean and what you can do about them, if say, your triglycerides are higher than they should be.

Redesigned tests results. Wired magazine

Target prescription bottles

This application of design know-how to practical health products is not only a visual treat, it is a potentially lifesaving tool. Deborah Adler, the designer behind Target's re-imagining of the prescription pill bottle,  was inspired to take on this task for a school project after her grandmother accidentally took her grandfather's medication. Target's nifty system of colored rings, one color for each family member, is designed to counter that problem, which is amazingly common - a poll conducted for Target found that 60% of prescription drug users have taken their medications incorrectly.

The Grocery Manufacturing Association is releasing new food labels that are much clearer in their declarations of saturated fat, sugar, calories, and so on. Unfortunately, these labels, while a great improvement over the current ones, fall short of what the FDA suggested. But still, in an area as crucial to health as food labeling, I'm willing to take some innovation and hope that future iterations will be even better.

Grocery Manufacturing Association's new food labels

Expanding out from graphics to interactive applications, web sites are getting better at incorporating plain language and snappy illustrations to allow low-literacy users access to the information, and the use of video and audio podcasts enable concepts to be demonstrated or spoken, which is useful for visually impaired or non-literate individuals. The US government has an ongoing plain language initiative, which should result in its websites, forms, and information being delivered in a more accessible way.

So hats off to the communicators of the world who are applying their technical skills to some tricky problems. Medical knowledge is no good if the patient does not understand it, is confused by complicated protocols, or can't read the name on a prescription bottle.

### 

Erector Sets for All!

The Global Village Construction Set can be used to make 50 different machines. DIY. Open Source.
Image source.

My sister (hi, Anna!) sent me a link to Open Source Ecology. As it is described on their Wiki, OSE is "a movement dedicated to the collaborative development of tools for replicable, open source, modern off-grid resilient communities."

Yeah, I didn't really know what that meant, either. But it looked interesting, so I dug further. Basically what these enterprising folks are doing is creating a set of basic machine parts, such as wheels, hinges, hoses, motors, and so on from which you could build the 40 most essential tools - including an endloader, a tiller, and a brick maker - that are needed to construct and run an entire village. Even a tractor. Or a single, walk-behind tractor for small plots of land or uneven terrain.

For anyone who has ever played with an erector set or Legos (not the kits! just a box of different pieces),  you can envision the possibilities that can be made from interchangeable parts.

OSE is  group of designers, farmers, engineers, and construction people. Their information, drawings, and videos are open sourced and available on the Internet to anyone. Yay!

This project speaks to me because one of my degrees, design science, focused on just this type of engineering - creating, on a tight budget, something that fills a specific need. I love seeing how people are putting their basic engineering and construction skills to work to create a benefit that many can enjoy. This project brings to mind the wonderful Design for the Other 90% and the Rural Studio project at Auburn University, other examples where individuals have put their collective brainpower and skills to use in creating useful dwellings and machines inexpensively for the common good.

What does this have to do with health? Plenty! Sometimes the limitations to health are mechanical. After all, digging wells, making bricks for homes or latrines, and tilling ground for a garden are quite labor intensive without machines. If a community could invest in and share one tool kit, there could be lots of projects that would benefit many. From OSE

"...most of the technologies needed for a sustainable and pleasant standard of living could be reduced to the cost of scrap metal + labor."

Scrap metal plus labor? Sounds like a good deal. It also sounds like something larger funders could get behind. There is a way for small donors (read: you and me) to support this interesting work on the website, but it would be great to see a McArthur Prize or a sizeable grant push this work further.

Here's a video from OSE's site:


Global Village Construction Set in 2 Minutes from Open Source Ecology on Vimeo.


After reading a bit more about this group, I realize I'm somewhat late to the party. The founder has been a TED speaker and they've been widely written about. Let's hope an infusion of new interest will accelerate their already admirable progress.

###

Correction: 16 January 2001: I was contacted by OSE and learned, among other things, that one of the founders, Marcin Jakubowski, will be speaking in late February at the TED conference.

Every 43 seconds...

...someone dies from gun violence.

What an eye-catching public health campaign.

To bad it's not in the United States.

Things Can Change, Perhaps

Tobacco drying. Image courtesy of CDC.

Recently, our family took a step into the modern age by opening a subscription to an online movie outlet so that we can stream movies over the Internet to our television. All this means is that we have spent way too much time over winter break watching movies that we missed when they were released or that we've seen before and of which we are especially fond. Such is the case of the The Insider, Michael Mann's recounting of the beginning of the sea change in opinion against the big tobacco companies.

For those of you who haven't seen it, The Insider takes place in the mid-to-late 1990s. The story revolves around a high-level Brown and Williamson research scientist, Jeffrey Wigand, who told the truth about his employer and the tobacco industry first in a deposition in Mississippi (where the Attorney General was suing tobacco companies to get them to pony up for Medicaid expenses for illnesses related to tobacco use) and then during a Mike Wallace interview on 60 Minutes. The plot becomes more complicated when 60 Minutes aired a heavily edited version of the original interview because its parent organization, CBS/Westinghouse, was concerned about potential lawsuits from the tobacco company. The original interview, which strongly indicted big tobacco as being fully aware of (and working to enhance) the addictive properties of its products and gave evidence that the CEOs of the big seven tobacco companies perjured themselves in a congressional hearing, was aired a few months later. However, it was only aired after other news outlets discredited the smear campaign against Dr. Wigand that was orchestrated by his former employer and outed 60 Minutes as caving to corporate interests.

It was a public health story, corporate whistle-blower story, and a journalism ethics story all rolled into one big messy ball of a movie. And, for the most part, it was true.

What is iconic of that time is the image of the seven tobacco CEOs (referred to as the Seven Dwarfs) standing in the Hon. Henry Waxman's hearing and perjuring themselves by declaring, under oath, that nicotine is not addictive. Below is a Youtube video of this historic moment that exposed these corporations for what they are - makers of nicotine delivery devices.

I was working at the American Cancer Society when these events began unfolding, but honestly, I didn't appreciate the magnitude of them at the time. Sure, everyone knew that tobacco use was the number one cause of cancer and that nicotine was addictive and that tobacco companies wanted to addict people - especially young people - in order to replace customers that would inevitably die. But the power and influence of the tobacco companies were formidable and those of us in public health held slim hope that a right-leaning Congress would support public health over big tobacco.  Fortunately, there were some visionaries who could see the far-reaching effects of the rulings, visionaries who never gave up the fight despite personal and professional hardships.

Because what emerged from all this was a deal of historic proportions: in 1998, the attorney generals of 46 states and the big tobacco companies signed the Tobacco Master Settlement Agreement, (MSA) in which the tobacco companies agreed to pay $246 billion over 25 years to the states, desist from marketing to youth, end all outdoor advertising (remember cigarette billboards?) and other sanctions. Four other states had individual agreements that predated the 1998 MSA. The money has been used to  bolster Medicaid, fund campaigns against smoking and smoking cessation programs, and other health-related items.

So that's the good news.

There is some bad news, too. In fact, there is a lot of bad news. In recent years, criticism has grown against financially strapped states because they are diverting the MSA money away from its intended uses. In fact, they are diverting MOST of it from its intended use. This from the Campaign for Tobacco-Free Kids, which publishes an annual report on how the money from the MSA has been used:

"Our latest report, issued November 17, 2010, finds that the states have cut funding for tobacco prevention and cessation programs to the lowest level since 1999, when they first received tobacco settlement funds.

"The states this year (Fiscal Year 2011) will collect $25.3 billion in revenue from the tobacco settlement and tobacco taxes, but are spending only two percent of it — $517.9 million — on programs to prevent kids from smoking and help smokers quit."

Of course, the tobacco companies love this. Fewer education and smoking cessation programs mean more cigarette consumers. And that is exactly what has happened. Any progress made in reducing smoking has slowed or even stalled. From Campaign for Tobacco-Free Kids' most recent report:

"The CDC recently reported that the adult smoking rate in 2009 was 20.6 percent – essentially unchanged since 2004 when 20.9 percent smoked.   This is a troubling development after decades of progress in reducing adult smoking rates.  While smoking among high school students has declined by 46 percent from a high of 36.4 percent in 1997, 19.5 percent of high school students still smoke and declines have slowed in recent years, according to the CDC. "

So looking at the movie again, during a different phase of my life, is an interesting experience. On one hand, it is an affirming experience because the daily minutiae of working in public health for governments or non-profits can be slow and frustrating. There can be a lot of waste, bureaucracies to wade through, and we all lose sight of our goals from time to time. Therefore, The Insider reminded me that things can change, albeit with great difficulty and usually not very quickly, but every now and then we can hit it out of the park and score big for public health.

On the other hand, watching the movie was incredibly frustrating because by all accounts, politics as usual have minimized the effects of this landmark settlement.

Ultimately, though, if you're looking for an influx of optimism that sometimes good does prevail, or just an interesting way to spend a few hours with a real-life dramatic story, I recommend revisiting The Insider. It is dated a bit - the cell phones look like shoeboxes, the fax machines spit out curly paper, and everyone's eye glasses are so outdated that they're coming back in style again. But the outcome of this David and Goliath story has changed how the world views Big Tobacco and saved many, many lives in the process. Not as many as could have been saved, but it's been at least a baby step in the right direction.

###

Tangent: During the research process for this post, I was reminded what a staunch advocate for health we have in California Representative Henry Waxman. He has been in the trenches for years, holding hearings and crafting legislation in order to protect our health and welfare.  He has been a good public servant and we could use more like him.

Orange Things

I just have to say this: I love Nicholas D. Kristoff. I really do. His efforts to raise awareness of crimes against women and girls worldwide have been heroic. And his overall work to shine a light on areas of inequity and poverty are enough to qualify him for, if not a full saint, then at least someone working his way up the rungs of the sainthood ladder. But his Thanksgiving day column that encouraged the development and use of biofortification of certain crops in developing nations gave me pause.

At first glance, one might wonder what's wrong with breeding crops to incorporate iron, zinc, Vitamin A or other important vitamins and minerals into their edible parts. After all, these substances can save vision and lives. As he noted,

"It may turn out that one of the best ways to save children's lives, or to save women in childbirth, doesn't involved doctors, but rather, high-tech seeds." 

Sounds simple, cheap, and easy, right? At the risk of being all wet-blanket-y about it, I think it sounds neither simple nor cheap and also as if it has great potential for unintended consequences.

There are two avenues of research here - conventionally bred crops produced in the public domain, and genetically modified ones developed and owned by corporations. Developing nutrient-dense crops available to anyone is a noble idea and enabling families in Africa to grow vitamin-packed orange sweet potatoes instead of the typical white sweet potatoes that they always have grown is a great idea. However, once it gets more complicated than that scenario, I have concerns.

For one thing, I have long been uncomfortable in rushing science in the name of helping impoverished countries. After all, the United States and Europe are still grappling with the role genetically-modified crops - of which many biofortified crops would be - can play in feeding their citizens, especially in light of the facts that pests are growing resistant to some of those expensive, herbicide-intensive crops and the long-term implications of ingesting those crops are not fully understood even by those who embrace them.  It also seems like bringing back the buggy whip when you consider that some of the crops that are proposed will require pesticides and herbicides, chemicals whose use citizens in the developed world are trying to minimize, due to the mounting evidence of their health and environmental hazards. So why do we think making ever-more complicated plants and encouraging their use in impoverished areas are good ideas - especially when individuals in developed countries are clamoring for simpler, organic, back-to-basics clean food? Is cast-off technology from the developed world the best we can offer to developing countries?

Some may argue that that imperfect solutions are better than nothing when the stakes are as black and white as survival versus death . There is a grain of truth to that argument, which basically falls under the heading of "don't just sit there, do something." However, we already have a perfect solution - vitamins exist in pill and powder forms and some designer waters are already enhanced with some of those vitamins. The problem is that vitamins are too expensive for many developing countries, and the logistics of getting them to every person on a regular basis can be daunting. However.

For-profit companies do just that.

Let's repeat that sentence.

For-profit companies do just that.

They just don't do it with vitamins.

But they do it with cigarettes. And they do it with soft drinks. It no longer surprises me when I see the cheery red and white of Coca-Cola products in the Amazon basin in Brazil or a kid puffing on a Marlboro in Thailand. It seems when the bottom line is at stake, human ingenuity finds ways to source components of products, assemble those products, and then figure out how to market, deliver, and sell them regardless of the challenges presented by the location. For example, by harnessing local ingenuity and providing a profit incentive, Coca Cola has mastered the logistics of getting its, shall I say,  product-of-questionable-nutritive-value into the most remote reaches of Africa. And I believe one of Coke's products is vitamin-enhanced water.

Therefore, for this particular problem, it may be better to practice what Buddhists know: "Don't just do something, sit there." Just sit there and think. Look around. Take a page from Melinda Gates' play book and learn what we can from what Coca-Cola already does.

One of the reasons I would encourage the public health world to look for a simpler solution is firsthand knowledge of how long it can take to create these complicated plants and then figuring out how much of them individuals would have to ingest in order to attain certain levels of the vitamin. Years ago, I used to manage a series of seminars for the American Cancer Society. These seminars were very high-level. The audiences were top-line national medical and scientific reporters. The presenters were the researchers who push the envelope, like the ones who brought you Gleevac, virtual colonoscopies, and basic knowledge about cancer including oncogenes and suppressor genes. The panel chairpersons were directors of national cancer centers, Nobel laureates, and Mary Lasker Award winners. The seminars were three days of intense science and emerging research.

One presentation in 1996 showcased a scientist from Roswell Park Cancer Institute who presented her research on "Transgenic Plants as a New Vaccine Source." The specific project she was working on was inserting hepatitis B antigens into bananas. Once eaten, the theory was that the antigens would effectively vaccinate the banana eaters against hepatitis B,  a leading cause of liver cancer around the world. This edible vaccine would be especially useful, the scientist postulated, in developing countries, where cost and logistics create obstacles to vaccinating the local population.

Sound familiar?

Fourteen years after that presentation, there is still no banana/hepatitis B vaccine. A quick Google search of "hepatitis vaccine banana" returned 27,000 hits, showing that research is still going strong on this concept. But still no edible vaccine.

I'm sure you can see where I'm going with this. We already have vitamins and vaccines against many diseases. What is being proposed - biofortification of existing plants to enable them to carry vitamins - is expensive research. Then, intensive education programs must be carried out so that individuals in countries that need these plants can learn how to grow, harvest, and cook them. And no one has done the research - asked the individuals who will be expected to grow these plants - if they are interested in changing their social norms to eat orange sweet potatoes instead of the white ones, or golden rice instead of white rice. And, last I checked, these plants are still in development.

So, with all due respect to the researchers and to Mr. Kristoff, I'd rather put my money on creating partnerships between the public health world and Coca-Cola or other global brands to oversee the distribution of vitamins that we already have, instead of investing a lot of money into a more complicated situation. The price seems to be a red herring at some level - after all, individuals seem to have the money to purchase Coke products, as evidenced by Mexico's astonishing 665 per capita ingestion of Coke products in 2009. Or, if you want to go further with this concept, Coca-Cola already makes VitaminWater. Couldn't the public health world work with Coke to develop a VitaminWater to deliver the key vitamins lacking in certain parts of the world?

We already have vitamins. Multi-national corporations have distribution systems and perhaps even products that can be tweaked to provide specific nutrients to children, or pregnant women, or the elderly. What seems simple to me is not the creation of complicated seeds that require costly chemicals and unpredictable weather to grow, but a linkage that would combine the best of the knowledge from the public health world and the infrastructures of big corporations in order to get those vitamins where they can do a lot of good.

PS to Mr. Kristoff. I still think you rock.

###