An Unexpected Oasis

Today, instead of pointing out yet another dreary problem that confronts our country, I'd like to offer up some good news. For years, we have been hearing about "food deserts," those urban areas that lack sources of healthy foods, but have unhealthy convenience food in abundance. You can see these food deserts everywhere - in inner cities, in small towns along interstate highways, and even in some suburbs where fast food chains and convenience stores line the streets and grocery stores are few and far between. All the nutrition guidelines in the world will not help individuals and families living in food deserts eat as well as they could.

That's why it is exciting to learn that Walgreens is doing something about this lack of healthy food options.  I remember Walgreens as being a Midwestern old-timey five-and-dime chain, best known for its luncheon counters. In recent years, I have noticed more Walgreens stores opening on corners in my Southern city as the chain successfully expanded to become the largest drug store chain in the United States. And now, Walgreens has taken that revitalization to a new level - that of offering groceries and fresh foods in some of its urban Chicago stores.

Food deserts are a big problem in Chicago. The US Centers for Disease Control and Prevention estimates that about 600,000 Chicago residents live in neighborhoods that are either lacking or too far away from conventional grocery stores. And Walgreens has a large presence in inner-city Chicago, making it an ideal partner to get groceries, such as milk, meat, eggs, fruits, and vegetables, into those areas. Of course, this move isn't entirely altruistic - after all, Walgreens is a publicly traded company (NYSE, NASDAQ: WAG) that has shareholders to consider - but it does carry more than a whiff of civic responsibility. You see, Walgreens was founded in Chicago more than 100 years ago and, according to its press release, was asked by Mayor Richard M. Daley's office to start offering groceries in some neighborhoods where grocery stores were scarce. Taking this concept even further, Walgreens has created a partnership with local medical entities to pilot a program designed to educate residents about the link between healthy food choices and preparation and better management of chronic illnesses like diabetes.

This all sounds like a win-win situation to me, one that combines a basic tenet of capitalism of being the first to enter a niche market, and the do-good-ness of a hometown hero. The short-term outcomes may be that individuals and families living near these Walgreens will have expanded food choices and Walgreens may increase its market share over competitors.  It will take awhile to see the longer-term result of better health due to access to healthy foods, but it's not a leap to envision that those results will occur. Research has already shown that people who live in food deserts are more likely to become ill with conditions like diabetes, high blood pressure, and obesity - all conditions that can be helped or prevented with proper nutrition. So it stands to reason that the availability of appropriate foods could counteract or even prevent those conditions.

If you want to read more about food deserts, especially in Chicago, here is a report by Mari Gallagher and Associates, the firm that coined the term. It has some interesting facts, such as many who live in food deserts have incomes over $100,000, as well as important implications for our built environments.

Northwestern University's Medill School of Journalism pulled together a nice video in which residents of food deserts in Chicago are interviewed. The video highlights the lack of access to real food that many people face and allows us to see the type of establishments that residents must frequent if they are limited to shopping in their neighborhoods.

So kudos to Walgreens, the City of Chicago, Northwestern Medicine, and Near North Health Service Corporation for this innovative partnership. Walgreens is keeping a close eye on the initial 10 stores that are offering groceries. If they work well, meaning if they make money from the groceries, the concept could be expanded to other stores, and other cities. Keep your fingers crossed.

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Can This Be True?

Earlier this week, Yale University's Rudd Center for Food Policy and Obesity released a report Evaluating Fast Food Nutrition and Marketing to Youth. Faster than you can say "drive-through window," some startling statistics were racing around the Internet and hitting the mainstream media. The most compelling of those statistics was that 84% of parents taking part in this survey reported feeding their kids fast food in the week prior to their interview.

When I read the 84% statistic, my first thought was, "That can't be true." I thought perhaps it was a sampling error - maybe the researchers asked only parents who lived across the street from a McDonald's, or who didn't know how to cook, or who were employed by Burger King. Or maybe there was some other reason the findings were skewed.

So I dug up the report, certain I would spot some methodological weakness. And, I'm sad to say, I was wrong. It's a whopper (sorry) of a report, but a good, thorough one. The methods section (on page 33 for those who care) convinced me that the sample of parents was, in fact, nationally representative. The researchers took pains to include appropriate racial/ethnic diversity and had a reasonable sample size.

The next thing I wanted to know was why. Why would all those parents take their kids to fast food restaurants so frequently? I thought the answers might be cost and convenience, two factors that could influence any parent's decision on where to eat. This time I was partially correct. A useful bar chart (page 118) shows the main reason parents take their kids to the following restaurants:

• McDonald's and Burger King: the kids like it
• Wendy's: convenience
• Subway: nutrition (as an aside, of the 3,039 food combinations evaluated, Subway had the most choices that met the nutritional criteria for kids. Burger King didn't do so badly, either. But scoring well means choosing milk or juice with the meal, substituting fruit for french fries, and eschewing cheese, among other choices.)

This brought up another question: How did the kids know about the restaurants?

And this time, I got the answer correct. Kids know about these restaurants because of amazingly effective advertising and marketing.

Check this out: In 2009, preschoolers saw an average of 2.8 fast-food television commercials each day, kids aged 6-11 saw an average of 3.5, and teens saw 4.7. And that's just TV, not exposure to radio, billboards, online banner ads or pop-ups, bus ads, airport kiosks, and all the other places that fast food is advertised.

So what's a parent to do?

Even though I'm not a big proponent of TV, especially for small kids, I don't think isolating your kids from popular culture is the answer. Sure, sitting around watching the tube is obviously not exercise, and the exposure to the noxious advertising makes the kids want what they don't have  - clothes, food, and toys included. I also don't think we can sit around and wait for government regulations that would limit marketing to kids. After all, it took almost a decade before Congressional pressure and private lawsuits brought about the retirement of Joe Camel despite his obvious intention of selling cigarettes to kids - intentions that were pointed out by a 1991 article in the Journal of the American Medical Association that showed that 5 and 6-year-old kids could identify him more readily than Mickey Mouse or Fred Flintstone. This wasn't a benign situation. A companion article noted that during Joe Camel's reign, one-third of all cigarettes sold illegally to underage buyers were Camels - up from less than one percent before Joe Camel.  So even though it was clear (and later proven by internal RJR Nabisco documents) that tobacco was being marketing to kids, lawsuits and government action still took years to be effective.

Therefore, I think the most important thing parents can do to counteract the marketing messages targeting our kids is to teach them, from a very young age, that they are being manipulated. Put your kids in the driver's seat and teach them how to make choices. PBS has a "Question the Commercial" guide that is a good start to opening conversations with young kids about commercials.

And don't forget moderation. There is room in a healthy diet for treats: a donut here, couple of cookies there, an outing to a fast food restaurant every once in a while. But when 8 out of 10 parents willingly tell researchers that they took their kids to fast food restaurants in the past week, we know that kids aren't the only ones who need to learn moderation.

The reality is that we live in a world where marketing is everywhere. We can't keep our kids away from it. So we have to teach our kids - and ourselves - how to live with it.

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Not Really a Surprise, But Still...

A super shout-out to Michael Moss's excellent investigative reporting on how conflicted the government is when one of its agencies is charged with both promoting business and promoting health. Moss's article, published on the front page of yesterday's New York Times, focused on the United States Department of Agriculture's schizophrenic mission of encouraging consumption of US agricultural products while also being in charge of nutrition guidelines.

 In his article, Moss explains how the USDA created an organization called Dairy Management, which is a marketing entity charged with increasing the consumption of dairy products in the United States. Dairy Management has achieved its goals magnificently - it is the group responsible for the brilliant marketing campaigns that have boosted Domino's pizza sales, convinced Americans that drinking milk is part of a good weight-loss strategy, and  ingrained "Got Milk?" into our national consciousness. All while one of the main contributors to obesity is saturated fat - yes, the fat found in dairy products.

Therein lies the conflict. You can't encourage Americans to eat more fat and address the obesity epidemic at the same time.

The story is not new. The USDA has long been conflicted about its role in business versus health. Remember the four basic food groups that the USDA touted until 1992? Meat, dairy, grains, fruits and vegetables - the foods most grown by American farmers (disclosure: I grew up on an American grain farm).  The food pyramid came next. This fascinating article, written by a nutritionist who worked on the original food pyramid, shows just how overt the USDA has been in promoting certain foods regardless of their effect on health.

It's unfortunate that we can't look to our government to provide unbiased nutrition information. That's why others, such as the good docs at Harvard's School of Public Health, have created their own food pyramid. Harvard's pyramid and the USDA's pyramid are similar in that both have their foundations in science. But Harvard stops there, without adding the heaping helping of influence from special interest groups that can sour even the best intentions.

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Don't eat the oil

Sorting through my kids' candy bounty after the recent national holiday of Halloween got me to thinking about how slowly change comes to the food industry. It's been fairly well accepted for years now that some food dyes cause adverse reactions, especially in children. After all, children may weigh a fraction of what an adult weighs, but still consume the same level of artificial chemicals in a bag of Skittles. Way before  the EU mandated that foodstuffs carry warning labels if they contain certain artificial colors, the Feingold Association has been publicizing the sensitivities some kids have to artificial colors, flavorings, and preservatives - sensitivities that have been misdiagnosed as conditions as severe as ADHD, bipolar disorder, and obsessive-compulsive disorder. More recently, the Center for Science in the Public Interest has adopted artificial colors as a project, and is lobbying the US Congress to remove some of them from our food supply.

But still, here I sit at my kitchen table, sifting through the Nerds, Skittles, and Starbust Chews for some good old chocolate that hasn't been too adulterated with artificial flavorings (synthetic vanillin is cheaper than vanilla) or colorings. The rub is that having travelled overseas many times in the past few years, I've eaten Starbusts and M&Ms made with natural colors so I know that we don't have to settle for foods that are colored with dyes made from petroleum products.

It bewilders me why the United Kingdom is way ahead of us on this issue. Mars, the company that makes M&Ms, was so sensitive to the public's concerns over red dye #2's possible link to cancer that it removed red M&Ms in 1976, despite the fact that its candies did not contain that specific dye.  However, the company seems resolute in in its use of red #40, the synthetic chemical that has colored its red candies since the late 1980s, even though red #40, is not recommended for consumption by children in Europe and is outright banned in Denmark, Belgium, France, Germany, Switzerland, Sweden, Austria, and Norway.

And it's not just candies that are affected by the regulations in Europe. The syrup in a strawberry sundae from McDonald's in London is colored with real strawberries, whereas a strawberry sundae in Atlanta carries a hefty dose of red #40. Nutri-Grain bars, a snack food many parents consider healthy, are vastly different here and abroad, as the illustration below shows.

                                                    Illustration: Center for Science in the Public Interest                                                       

The issue isn't just one for little kids. Research is showing that you don't outgrow these sensitivities. Teens may act aggressively. Adults may get headaches. The list goes on and on. One of the most compelling real-life examples of the link between poor food and negative behaviors comes from Appleton, Wisconsin. By replacing typical cafeteria fare, sodas, and processed foods in its high school lunchroom and vending machines, this school - which serves troubled youths - has experienced drops in truancy and aggression, as well as increases in attention and learning. Foodie Alice Waters wrote about this school in The Nation, and it has received coverage on Good Morning America as well as numerous other places.


There really is a lot of research out there showing that some people are sensitive to artificial flavorings, colors, and preservatives, and that those sensitivities can be so extreme that they interfere with normal functioning. That's why it is upsetting that the pace of change in this industry is so glacial.   My point is that we don't have to accept impurities in our foods - our European counterparts don't. I encourage everyone to read the labels on their foods and evaluate what is in them. The Center for Science in the Public Interest maintains an excellent food coloring database that lists the synthetic colorings found in common foods. Bagels, cake mixes, cereals, you name it. Most foods that are prepackaged have been tarted up with a rainbow of colors intended to fool us into thinking the foods are purer, freshers, and healthier than they are. Then let your Congressional representatives know that you would rather have the more natural alternative that our friends across the pond enjoy.

And So It Begins

CDC, Public Health Image Library

I am fortunate to have the Dengue Vaccine Initiative as a client. Through this group, I have traveled the world, meeting with doctors and scientists, working to lay the groundwork for a coming vaccine against dengue fever. As our work has progressed from discussing issues with surveillance and diagnostics, we have moved into communication issues - the need to raise awareness among politicians, healthcare professionals, and consumers of a coming vaccine, and the lifesaving (and cost saving) benefits such a vaccine will confer on countries in which dengue sickens hundreds of thousands of people annually.

One of the issues that confronts us is anti-vaccine activism. This is a worldwide phenomenon. Activists' concerns range from what we see in the United States - concerns about autism - but also include cultural-specific worries. For example, in Argentina, a branch of the Catholic church warns that vaccines will cause women to abort their fetuses. In parts of Asia with large Muslim populations, there are concerns that some vaccines are made with cells from dogs or from pork gelatin. It is stiff opposition that can usually be satisfied with factual answers.

But overall, countries outside of the United States are hungry for vaccines. When PATH and The Gates Foundation worked with India to quickly distribute a vaccine against Japanese Encephalitis - a mosquito-borne disease common in rural areas that causes paralysis and death in high numbers - they were able to vaccinate 32 million children in a year and a half because people were desperate for protection. From the safety of the United States, it may be difficult to understand that polio still cripples hundreds of children in India each year or that measles killed over 160,000 people worldwide in 2008. We have become used to a childhood without those terrible diseases.

This is likely a generational issue. My mother remembers having to stay indoors during the hot summer months, away from other people, when polio epidemics were raging throughout the countryside. Isolating her family was the only way my grandmother could protect her children.  As a kid, probably around 3 years old, I stood in line in a school gymnasium - a very long line snaking around the gym and outside the door - to receive a dose of the Sabin polio vaccine on a sugar cube. I have a fuzzy memory of the darkness of the gym but really what I remember is the solemnity of the occasion. Granted, it was a long time ago, but I like to think I was feeling the resolve of all those moms who brought their kids in to protect them against the seasonal fear of fever, paralysis, iron lungs. And I, too, am part of the generational divide: I have a round and dimpled scar on my upper left arm from a smallpox vaccination, a badge that signifies me as a woman of a certain age, to be sure, because today's kids don't get vaccinated against smallpox because it is no longer a threat.

Unlike smallpox, most vaccine-preventable diseases are not eradicated, just kept under control. That control, however, is tenuous because we rely on herd immunity - keeping a high proportion of our population vaccinated in order to prevent diseases - to protect our society. In other words, all those families who don't vaccinate their kids can be reasonably assured that their kids won't get childhood diseases because so many other families do vaccinate their kids. However, there is always a tipping point, where diseases can race through unvaccinated kids and infect those with partial immunity, such as the elderly who have lost their immunity, children who have not received boosters, or infants who have not received vaccinations.   Recent news carried a report of a death from whooping cough, not in Nigeria, not in Bangladesh, not in Cambodia. But here, in the great state of California. And it's the 10th one in California this year. This infant's death is attributed to families not vaccinating their children against pertussis, thus allowing this potentially deadly disease to spike again.

Recent estimates show that over 7.0% of children entering kindergarten in Marin county, a wealthy suburb of San Francisco, have waivers exempting them from childhood vaccinations based on their parents' beliefs. A private school in San Diego reports that 51% of its kindergartners had such exemptions. These are shockingly high numbers because once these percentages reach the tipping point, we will lose our herd immunity. And evidence is growing that we are approaching that that point: For each one percent increase in exemptions at a school, the risk of having a pertussis outbreak went up by 12%, a 2000 study in the Journal of the American Medical Association found. The study, which was conducted in Colorado, also found that at least 11% of the vaccinated children in measles outbreaks were infected through contact with somebody who was exempt.

Epidemics start with a whisper. A case of pertussis here, a few cases of measles there. But make no doubt about it: we are on the cusp of an epidemic of many diseases that we thought we left behind. What is it about human nature that makes us reinvent the wheel again and again? If you don't want to vaccinate your kids, I recommend you travel to poor countries around the world. Tell a mother who fears seasonal outbreaks of diseases that you turned down the opportunity to vaccinate your kids against those diseases. Of course, many who don't vaccinate their kids point out that we don't live in developing countries, and that many vaccine-preventable diseases are rare in the United States. That is true. These diseases are rare because people vaccinate their kids. And they won't stay rare if we don't.

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Hurts So Good

Welcome to the month of pink. For those who have been living in a cave for the past decade, October is National Breast Cancer Awareness Month.  It's the one month out of the year in which the word "breast" is spoken freely and clearly and without any tinge of sexuality and pink is everywhere: on hats, billboards, and the shirts of the evening news anchors.

I know the ad I chose to illustrate this post isn't pink (except for the tasteful pink ribbon in the word "breast"). But it is funny! And it played off of my second point about how breasts are icons of sex. The fact that the ad is from India also points out how ingrained this month is in the world's consciousness. Way to go, India!

Anyway.

In honor of this great month, I got my annual mammogram.

Mammograms have to be in the top 10 of weird diagnostic tools. Most medical procedures find you sitting, or reclining, with only the part in question exposed to light. But for a mammogram, you have to stand up while your breasts, one at a time, are clamped in a vice. The rest of your body is free to move (as if!), but you are literally held in place by a machine that is gripping your boob. So there you stand, in your regular shoes (which in my case happened to be high heels) while your top half is draped in a hospital gown, in a cold room (the machines have to stay cool). In summary: you're half naked, in heels, with your nipples announcing the temperature. Maybe breast cancer awareness month is about sex after all?.

Hmmm.

But that's all foreshadowing of what's to come. Because once the real procedure begins, the train of mild discomfort and indignity moves on into the station of painful because mammograms hurt. Like holy heck. But, not to sound all twisted about it, it's a good hurt. Because a mammogram that captures the bits off to the sides - the chest wall, the underarm area - requires a lot of pulling and squeezing and manipulating of the breast tissue. And squeezing. And more squeezing. But all those machinations are important because you really want those parts shown on your mammogram. So I don't mind.

Fourteen years ago, when I was pregnant with my first child, I felt a lump in my breast. As my pregnancy progressed, the lump grew. Daily. I brought it to my doctors' attention, we decided that an excisional biopsy - one that would remove the entire lump - was the way to go. I remember being on the operating table under local anesthesia thinking how strange it was to be carrying new life while being worried about my own. I remember the smells - the sharp, medicinal smell of the sterilizing fluid followed by the warm, metallic smell of blood as the surgeon first sterilized, then sliced into my breast. I turned my head away from the surgeon, while he engaged me in chatter. Fortunately, the lump was not cancerous. But it was a very scary time.

So that's why I don't mind that mammograms hurt. Because I want every inch of my mammary tissue exposed so the radiologists can look for cancer.

Over the years, as I've aged, mammograms have become a fact of life for me. Every other year at first, and now, every year, with a scary year during which I had one breast checked three times because of irregularities on the mammograms. So far so good.

Why don't all women get mammograms? The reasons are as varied as the women themselves. Some women don't have time (or don't think they have time). Some women don't have insurance and don't realize there are places to get free, or reduced price, mammograms. Some women are afraid: of the procedure, or of the possible bad news it can bring. All completely understandable reasons, but not very valid. Because catching cancers early gives you the best options for treatment.

So, happy October, friends. Take care of yourselves, and get your mammogram. Even though it hurts, it really could save your life. And that's good.

The Drumbeat Grows Louder

More on overuse of antibiotics in livestock production.

Typical push/pull of health vs economics. At some point, we're all going to have to take the long view and realize that health = economics. We're going to have to pay for all those sick people somehow, so we might as well avert problems when we can. Right?