Health Policy Solutions

By Katie Kerwin McCrimmon

Hovering at just over 4 feet 5 inches, the Broomfield second-grader is a smidge short for the NBA.

But that’s not stopping Caleb Nolan from planning his career as a basketball star and neither is his cystic fibrosis (CF).

Diagnosed at birth with the rare disease, Caleb receives regular care at Children’s Hospital Colorado and happily plays basketball, soccer, baseball and football. Aside from licking salt on the sidelines to thwart dehydration, he’s like any of the other boys on his team.

And thanks to a new medication called Kalydeco that has been fast-tracked to market, Caleb’s lungs are in excellent shape and his future is very bright.

Just decades ago, children born with CF had a bleak outlook and could hope to live only into their teens. Doctors could do little to help them except to treat the frequent infections that attacked and damaged their lungs. Now the official life expectancy for Caleb and kids like him is 37 and Caleb’s doctor expects that number to keep going up.

On Friday, Caleb got the chance to meet Sen. Michael Bennet, the Colorado Democrat who supported the legislation in Congress that is helping drugs like Kalydeco get to patients faster.

Kalydeco received approval last year and has now been designated as a “breakthrough therapy.” This faster pathway for drugs to make it to market is based on a provision that Bennet wrote and that Congress approved last July as part of the FDA Safety and Innovation Act.

“It’s been making a big difference. It’s been helping me a lot by clearing out my lungs,” Caleb said of Kalydeco, one of about 25 pills he takes each day. “I get sick less with Kalydeco. I sometimes don’t even notice I have CF.”

Nolan chatted and joked with Bennet, giving the Senator a hard time when he said that he believes kids should have to go to summer school “all summer long.”

“But I can’t get anybody else to agree with me,” Bennet confided.

“Yeah, I don’t agree with you either,” Nolan said.

“Neither do my daughters,” said Bennet, the former superintendent of the Denver Public Schools.

Charmed by Nolan’s candor, Bennet said the trip to Children’s Hospital Colorado was a refreshing change from the gridlock on Capitol Hill. Seeing the results of the new legislation and meeting Nolan marked one of his favorite days since joining the Senate in 2009.

“This is easily one of the highlights of the last four years,” Bennet said as the 7-year-old schooled him on CF treatments, hoops and his dislike for spelling and vocabulary tests.

Bennet said that speeding safe and successful drugs to market makes sense for both patients and drug developers.

“Essentially what this legislation did was say that if you are finding drugs and they show exceptional results for patients, for heaven’s sake, we should get them to market (faster). There ought to be a priority for those kinds of drugs,” Bennet said.

He said Colorado is home to about 600 bioscience firms and that he’s trying to do all he can to speed the approval of promising drugs. He said it’s getting harder and harder for bioscience firms to attract venture capital since drug approval can take as long as 15 years. In the case of drugs that receive breakthrough designation, approval can come in as few as three to five years.

“Most importantly, it makes a huge difference for patients,” Bennet said. “The rollout has been faster than I expected.”

Kalydeco has been shown to be effective for a small percentage of CF patients who, like Caleb, have a specific gene mutation. But there’s great hope that in the future, the drug can be paired with other new drugs to help a much higher percentage of people with CF.

Children’s Hospital Colorado houses the largest CF clinical care center in the U.S., with more than 500 young patients. Caleb was originally diagnosed with CF as a newborn because Dr. Frank Accurso, Caleb’s doctor, spearheaded legislation to make CF screenings standard at birth. That’s now the case across the country.

CF affects about 70,000 people worldwide and about 30,000 in the U.S. Known as an “orphan disease” because it’s so rare, advocates for people with CF have had to create an entirely new system for drug development known as “venture philanthropy.” (Read more: Venture philanthropy new cure for deadly diseases.)

In essence, they’ve had to raise money and drive the drug development process themselves.

“Even though the number of patients is small, the impact is significant,” said Accurso who helped lead the clinical trials for Kalydeco.

“We all believe it is life-extending and in some cases life-saving. It certainly improves the quality of life,” Accurso said.

Caleb’s dad is a UPS driver and he personally delivered his son’s first treatments of Kalydeco.

Now Caleb’s mom has given herself permission to imagine her son years from now.

“We’ve always held on to hope and faith,” Melissa Nolan said. “Now we can see the future.”

By Diane Carman

It was at the funeral of former teammate Lee Roy Selmon that Dave Stalls confronted his own mortality.

Selmon, who played alongside Stalls on the defensive line of the Tampa Bay Buccaneers in the 1980s, died of a massive stroke on Sept. 4, 2011. He was 56, the same age as Stalls.

As Stalls looked around at the mourners at the service, something struck him. None of the other members of that Tampa Bay starting defensive line was there. Many of them – including the defensive line coach – were dead.

“It gets really personal,” said Stalls.

Dave Stalls in the Sigma Chi music room at the Street Fraternity.

When he realized he was among only a few members of that defensive line left, “I started to think, ‘Do I have six months? A year? Thirty years?’”

Stalls came home and started making some life-changing decisions. He resigned from his position as director of Big Brothers Big Sisters of Colorado and set out to create Street Fraternity, a nonprofit program to help young men overcome their violent past. He hiked the Camino de Santiago in Spain with his son.

And he enrolled in a research project with 99 other former NFL players and 50 other elite athletes at Boston University. The goal: to identify the indicators that could enable doctors to diagnose chronic traumatic encephalopathy, or CTE, in living patients and find ways to treat it.

Questions abound

Before the condition was called CTE, it had many other names, but was most commonly known as “dementia pugilistica” or being “punch drunk.” When it was identified back in 1928, it was thought to occur only in boxers who suffered repeated blows to the head, and since that population was relatively small, little research was done on it for decades.

Over the last 10 years, however, post-mortem studies on the brains of deceased boxers, football players and other athletes in contact sports have found striking evidence of a very specific kind of brain damage.

Dr. Ann McKee, a professor of neurology and pathology at Boston University School of Medicine, has found tau protein and other signs of damage in their brains and, suddenly, concerns about the long-term impacts of concussions and sub-concussive blows to the head have reverberated across our sports-obsessed culture.

Still, there has been no way to diagnose the condition in living patients, guys like Dave Stalls.

Finally, in 2011 the National Institutes of Health awarded its first grant for the study of biomarkers for CTE in living patients. Robert Stern, professor of neurology and neurosurgery at Boston University School of Medicine and a colleague of McKee’s at the Center for the Study of Traumatic Encephalopathy, is leading that study, which is dubbed DETECT (Diagnosing and Evaluating Traumatic Encephalopathy using Clinical Tests).

Stalls said he volunteered to join the study (Stern would not confirm his participation due to strict confidentiality rules), and he spent two days in Boston in January undergoing a battery of tests.

Testing intense

For many years, Stern’s role in CTE research included interviewing family members and friends after a death linked to head trauma. As a result, he became the leading expert on the clinical presentation – the symptoms – of CTE.

For this study, he gets to talk to people who suspect that they might be living with the condition and could help him piece together evidence of possible early signs.

“What we know of CTE is that it has three primary areas of impairment,” Stern said. Those are: cognitive impairment, including memory problems and executive function or planning; behavioral changes, including impulse control, an explosive temperament and being verbally or physically violent; and mood disturbances, such as depression, hopelessness or suicidal tendencies.

So a big part of the testing involves interviewing the participants, administering tests of their ability to remember things and organize information, evaluating them for signs of psychiatric or behavioral problems, and requiring them to report on their own impressions of their condition.

Other tests are designed to evaluate the neurobiology of the participants. They include analyses of blood and spinal fluid, neuroimaging using advanced MRI (magnetic resonance imaging) and MRS (magnetic resonance spectroscopy) technology to perform a virtual biopsy of the brain, and a specialized form of EEG to measure electrophysiological changes in the brain.

“It’s been such an incredible joy and honor to work with these guys,” Stern said of the former players. “These wonderful heroes have been eager to participate, giving of themselves and courageous in all ways.

Robert Stern

“Our mutual goal in all of this is not to ruin or destroy the game of football, but to protect it.”

Stalls said his two days in Boston – ironically the week before the Super Bowl – were packed with examinations of all kinds.

“There were all these tests,” Stalls said. “They’d tell you a story and you had to repeat it. They’d give you a list of words and you’d have to remember as many as you could.”

But the one that Stalls, still an imposing figure with broad shoulders and an athlete’s powerful physique, shivers as he recalls it was when a clinician stuck a needle into his back to draw spinal fluid.

“They all hate that one,” said Stern, who insists that it doesn’t hurt … much.

Concussions optional

The 100 former football players who are participating in the study were selected because they played positions that required them to use their heads – literally — for brute force.

Kickers and quarterbacks are not included, Stern said, because while they sometimes get big hits in the game, “they’re not getting hit over and over again.”

A lineman, in contrast, “hits his head against his opponent almost every play in every game and every practice.”

Stern estimated the impact at 15-20 g-force. “It’s the equivalent of driving a car at 35 mph into a brick wall 1,000 to 1,300 times a season.”

The test results of this group will be compared to those of 50 other elite athletes who don’t slam their heads into virtual brick walls as part of their sport – former baseball players, rowers, swimmers.

“These are people who played at the highest level of their sports, had similar lifestyles and similar bodies, but never hit their heads,” Stern explained. “If we know the one variable that is the necessary ingredient – hitting your head over and over again – that’s the one thing we want to control for.”

Other factors that may play a part in the development of CTE include genetics and the age at which the head trauma first occurred.

When the researchers asked Stalls how many times he experienced a concussion in his football career, he said he honestly had no idea.

“I remember one play where I got my bell rung really hard.”

Lee Roy Selmon

He was playing with the Cowboys in 1978 or ’79, and was opposite Earl Campbell. “With a guy his size with legs so huge, there was no good option. I went in low with my head toward his legs and got a knee into my head.

“I lay on the ground for a while and I was in another world,” Stalls said. “Then I got up and got back in the huddle.”

Most of the time, though, the head traumas were so familiar they weren’t even memorable.

“How do you even define a concussion? When they told me their definition, I said it was hundreds. It happened almost every day,” Stalls said. “When they asked me for a number, I said, ‘Let’s just say 200.’”

NFL supports research

In the early days of CTE research, Stern said the NFL leaders “had their heads in the sand.” Officials from the organization issued statements denying the relationship between the repeated head trauma involved in football and brain disease.

Now, with the evidence mounting, the NFL has provided financial support to Stern’s project with an unrestricted $1 million grant. “They really understand that this is a big issue.”

Players’ organizations are watching the research closely as well and with good reason. Several lawsuits against the NFL have been filed, and former players have begun looking to the organization for support.

Stalls is not a part of any lawsuits at this point, but he doesn’t rule out that possibility.

“I made a lot of money for the NFL over the years,” he said. “Can the NFL make sure my kids won’t be bankrupt from taking care of me if I end up with Alzheimer’s or Lou Gehrig’s disease or Parkinson’s?

“Dying is a lot less stressful than losing your mind. To not know your family or even recognize people. To be unable to take care of yourself.”

Results eagerly anticipated

Stern anticipates completing the DETECT study in about 18 months, but further research on CTE will continue.

“We’re always submitting new grants for similar types of studies and offshoots from our research,” he said.

The hope is that real understanding of the disease will be achieved and lead to effective means of prevention and treatment.

“It’s why this research is so critical,” Stern said.

Evidence of CTE was found in the brains of 34 of 35 professional football players who died and left their brains to the Boston University scientists, he said, “so it’s probably very common. But we have no idea how common.”

Brain at left is from a healthy control subject. Brown stains on two brains indicate the presence of tau protein. (Images from Boston University)

Stern said they want to know what other risk factors beyond trauma play a role in developing CTE, how to prevent it and, ultimately, how to treat it effectively.

Once they have answers to these questions, clinical trials can begin on potential drug therapies. “Many scientists and pharmaceutical companies are interested in developing drugs to treat CTE,” Stern said. Among them are concepts for “anti-tau” treatments focused on eradicating the protein that seems to play a critical role in developing the disease.

“If we had adequate funding, we would be able to diagnose CTE in living patients within five years,” Stern said. “But financial support for research is at an all-time low right now, and with sequestration, it’s even worse.”

Living for the present

Stalls has no idea what impact those thousands of hits had on his brain, his memory or his life expectancy.

His memory is “terrible,” he said. In a test a year ago, he was asked to name as many words beginning with the letter “f” as possible in 30 seconds. “I could literally do four. I was embarrassed.”

Dave Stalls launched the Street Fraternity in April.

Despite the fact that playing in three Super Bowls ranks among the most exciting experiences in his life, Stalls said he “can’t remember a single play. I can’t tell you the scores. Is that really normal aging?”

Back when he was playing football, players didn’t know what they were doing to themselves. “Sure, we knew we were giving up our knees, our backs, really every joint in our bodies. But nobody thought he was giving up his cognitive ability. Losing your mind is a whole different deal.”

For now, he wants to live life to the fullest.

He offers a tour of the facility he’s assembling for the Street Fraternity, excitedly describing the various rooms, one designed for the young men to vent their frustration and pent-up physical energy, one for contemplation, one for producing music, another for working on computers.

“I haven’t seen anybody do this, helping people acknowledge their violent selves and learn about the aggressive self that is inside each of us,” he said. “During your teen years and your 20s, for a guy that’s a strong piece of who you are.”

Stalls said that’s apparent in combat veterans, in law enforcement professionals and in athletes, particularly those who play violent sports, like football.

“I know I can do this,” he said of the Street Fraternity project. “It’s important work and nobody else is doing it.”

He looks around at the warren of rooms, all painted vivid colors, and imagines them filled with young men with their whole lives ahead of them, men who need help with something he understands instinctively.

“I know I’m going to die. When is the question,” he said. “I don’t feel morose about it at all. It’s just a reality.

“So I’ve decided to use the time I have left as significantly as I possibly can.”

By Katie Kerwin McCrimmon

The horror of 20 children being shot to death at Sandy Hook Elementary School shocked the nation and the world.

But Colorado researchers — who initially set out to study playground accidents — found that gun violence is harming children every day. Very few people know about these gun injuries because federal law has prohibited funding for research on gun accidents and fatalities.

The Colorado researchers combed through every single injury over an eight-year period at Denver’s two primary trauma hospitals that serve children, Denver Health and Children’s Hospital Colorado. They expected to find information about playground injuries and were surprised to learn that violence was harming a significant number of children every year.

On average, at least 14 children between the ages of 4 and 17 were suffering gun injuries every year between 2000 and 2008 in the Denver area alone. That doesn’t include the number of children who died of gunshot wounds or those who didn’t seek emergency care for their injuries.

Dr. Angele Sauaia is an associate professor at the Colorado School of Public Health. She and a team of researchers found that gun injuries among children are common.

“We realized that there was this horrible pattern of violence in the injuries,” said Dr. Angela Sauaia, a trauma researcher and associate professor of public health and surgery at the Colorado School of Public Health. “A large percent were due to knives, pieces of glass and guns.”

Sauaia and her three research partners found that over one-third of the trauma cases related to violence stemmed from gun injuries. The number of gun-related trauma cases has stayed relatively steady, and Sauaia said she expected that the number would have remained consistent from 2008 to the present.

The findings were published Tuesday in the Journal of the American Medical Association.  (To read a JAMA Q & A with Sauaia, click here.)

“With New Town and the Aurora tragedy happening, we decided it was important for people to know that kids are being injured by guns on a routine basis,” Sauaia said.

The researchers also found that a stunning 14 percent of the gun injuries were self-inflicted. Either the children accidentally shot themselves or some were trying to commit suicide. Self-inflicted gun wounds were more common in children ages 10 to 17.

“We don’t know if they were intentional or by accident,” Sauaia said. “Regardless of intention, these kids managed to get ahold of an unlocked, loaded gun. Nobody would think that children should have unsupervised access to unlocked, loaded guns.

“So, regardless of where you stand, that’s good common ground for all of us to work on,” Sauaia said.

The researchers conducted their work without any federal funding. Sauaia said there are major gaps in knowledge about gun injuries and deaths because funding has been so difficult to attain. She said the number of children and adults who die from guns is small compared to those who suffer injuries. So there’s a great need for new research on gun injuries.

Regardless of how much researchers know about the causes of gun injuries, the consequences are clear and ominous, Sauaia said.

“If your child is hurt and the wound is due to a firearm, they are 10 times more likely to die than any other injury,” she said. “Most victims of trauma don’t die, but they suffer consequences for the rest of their lives.

“People tend to only pay attention to gun safety issues after these mass killings but this is happening all the time to our children and it’s totally preventable,” Sauaia said. “Are we as a society willing to accept that 14 or more children shot each year is an acceptable number?”

Conducting the research with Sauaia were Joshua Miller, a former student at the Colorado School of Public Health; Dr. David Partrick, a pediatric trauma surgeon at Children’s Hospital Colorado; and Dr. Ernest “Gene” Moore, head of surgery at Denver Health.

By Katie Kerwin McCrimmon

Wellness and weight loss programs that target adults may come decades too late.

Secrets to curbing the obesity epidemic and reversing skyrocketing diabetes rates may be hidden in the womb.

Ironically, babies starved of nutrients for a variety of reasons in utero may grow up to have defective metabolic and organ systems that crave calories and can cause obesity, diabetes and high blood pressure.

Researchers have found that “a striking 25 to 63 percent of adult diabetes, hypertension and coronary heart disease (cases) can be attributed to the effects of low birth weight.” (Click here to read more.)

This phenomenon is called “fetal programming” and once encoded in the genes, these metabolic malfunctions can carry forward to future generations.

Understanding and preventing uterine growth problems — which then may cause chronic illnesses in adulthood — is the central focus of research now.

“That’s the million-dollar question,” said Dr. Laura Brown, a pediatrician and assistant professor with a sub-specialty in neonatology. She cares for preemies in the neonatal intensive care unit at University of Colorado Hospital and the Colorado Institute of Maternal Fetal Medicine at Children’s Hospital Colorado. She conducts her research at the CU Anschutz Medical Campus.

“What a lot of people are working on is why this happens. Why does the fetus that doesn’t get enough nutrients in utero maintain these long-lasting effects?”

Too many born too small and too soon

The question is critical since both obesity and diabetes rates are rising at a fast clip. And Colorado has long struggled with a disproportionate number of babies born at low birth weights. Colorado ranks 37^th in the country with nearly 9 percent of babies born at low birth weight, defined as less than 5.5 pounds, according to the just-released 2012 Colorado Health Report Card.

Some of these babies were growing well in utero but were born premature and therefore small. Other fetuses were not growing properly in the womb. Once born, these are the infants who face higher risks for later-life obesity and diabetes.

Dr. Laura Brown conducts research at her lab at the CU Anschutz Medical Campus. She is studying the links between low birth weight babies and later-life health problems. (Photo courtesy Laura Brown. Click on image to enlarge.)

The problem of low birth-weight babies is especially profound in the African American community. Among blacks in Colorado, 13.6 percent of infants are born at low birth weights. According to the Colorado Health Foundation’s Report Card, one in five low-weight births can be attributed to mothers who do not gain enough weight or who smoke during pregnancy.

Too many babies in Colorado are born too soon and too small. The causes are complex. An increasing number of twins and multiples, along with high altitude and other complications contribute to the problem.

Low birth weight newborns are often sick and therefore costly. But now scientists are looking far beyond the early months.  as they link low birth weight to health problems later in life, including both child and adult obesity.

While a raft of new wellness programs targeting adults is vital to driving down obesity and diabetes rates, researchers are trying to trace these chronic health problems to their origins.

“We have to continue to encourage healthy living especially since we don’t know how to intervene early on,” Brown said. But she said researchers, policymakers and doctors must frame questions in new ways.

“Why is this person struggling with diabetes? It could have a lot to do with how they grew in utero.”

Tiny babies at higher risk for chronic health problems

Brown said one of the most common causes of low birth weight babies is a condition called Intrauterine Growth Restriction (IUGR).

Some babies are born early for other reasons and while they are small, they are appropriate in size for their gestational age.

IUGR babies, on the other hand, are disproportionately small for their gestational age. In 2011, according to the most recent data from the Colorado Department of Public Health and Environment, nearly 10 percent of babies were classified as “SGA” or “small for their gestational age” the measure that corresponds with IUGR babies.

“IUGR is one of the most common disorders in fetal growth,” Brown said.

The babies are at risk in utero and can die if they are not delivered on time.

“They do not get enough nutrients from the placenta,” Brown said.

Health providers are getting much better at identifying pregnant moms at risk of having an IUGR baby as long as the mom is getting prenatal care.

“They usually are measuring small. Then we get an ultrasound,” Brown said.

Laura Kent had two IUGR babies. Meghan is now 13 and Duncan is 9. Both are healthy now, but weighed just over 2 pounds each and were born 8 weeks early. The cause of their uterine growth problems remains a mystery.

Sometimes, moms have health issues themselves such as high blood pressure or pre-existing diabetes. Or sometimes an infection or an inherent genetic problem can cause IUGR. About half the time, a healthy mom appears to be having a normal pregnancy and the cause of IUGR is a mystery.

That’s what happened to Laura Kent and her husband, Rob MacLaren of Denver. Twice.

“Everything was normal,” Kent recalled of her pregnancy with her daughter, Meghan, who’s now 13.

The couple went in for their 32-week appointment and Kent’s doctors rushed her in to an emergency delivery.

“The baby is under stress and not measuring well. The baby needs to be delivered right away,” Kent recalls her doctors telling her.

Born eight weeks early, Meghan weighed just 2 pounds 14 ounces. Kent had never heard of IUGR, but soon learned that for some inexplicable reason, Meghan had not been absorbing nutrients well.

Premature girls often do better than boys and fortunately, Meghan was a fighter.

Meghan MacLaren weighed just 2 pounds 14 ounces after having to be delivered at 32 weeks. She’s now in 7th grade and enjoys reading and Irish dancing. (Photo courtesy Laura Kent.)

“She was feisty as all get out,” Kent recalled.

Meghan spent five weeks in the NICU and came home weighing just 4 pounds.

When Kent had her second child, she knew she’d have a high-risk pregnancy, but she hoped to avoid having a second IUGR baby. Unfortunately Duncan, who is now 9, also began to struggle in utero.

Doctors put Kent on bed rest and tried to delay the birth as long as possible. Kent hoped to make it past 32 weeks. But, Duncan entered the world slightly earlier than his sister.

“They get to the point where their heart rate is irregular and they won’t grow any more in utero,” Kent recalled.

Duncan was slightly smaller than his sister: 2 pounds, 12 ounces.

Duncan MacLaren, now 9, weighed just 2 pounds 12 ounces when he was born. He was tinier than his stuffed tiger. Duncan and his sister both suffered from IUGR, a condition that compromises uterine growth. (Photo courtesy Laura Kent.)

“He had more breathing issues. That can be typical of boys,” Kent said.

She struggled to breastfeed her babies but both were so weak that they had trouble staying awake and gathering the strength to breastfeed. Kent, who had no underlying health problems or history of low birth weight in her family, had imagined perfectly healthy pregnancies, full-term deliveries and easy breastfeeding. Instead, she pumped her milk for a year for each of her babies and spent countless hours tearfully wondering why she had not one, but two preemies.

Today the children are healthy, bright, active and fit. Worries about obesity or diabetes seem irrelevant.

“It’s so ironic. Although my kids did pack on the weight as babies, they’ve never been above the 25^th or 30^th percentile,” Kent says. “We don’t know what will happen later in life. It’s interesting to me and it kind of makes sense that the part of the brain that controls weight can be off balance.”

Duncan MacLaren with the stuffed tiger that used to be bigger than he was. Sitting next to him are his mom, Laura Kent and sister Meghan MacLaren.

Memories of those early years are distant enough now that Kent has recovered from the trauma. But, she says, “There are no real answers. I still don’t understand why my placenta malfunctioned. This kind of thing doesn’t usually happen twice. I always wanted to understand why this happened.”

Her hope for her children is that they will remain healthy and active and will avoid any health challenges as adults.

No treatment yet for IUGR

For now, there is no treatment for IUGR, Brown said.

In her lab at CU, Brown and her colleagues are looking for ways to improve the growth either during pregnancy or during the neonatal period.

They’re trying to determine if changes that affect brain satiety and muscle and organ development and growth can be reversed in the earliest months of a baby’s life.

“How does the fetus adapt to low nutrient supply? Is it already too late by the time a baby is born? Or can we intervene?” Brown said.

“People think that there are programmed adaptations. The fetus doesn’t get enough nutrients and slows its growth. The fetus becomes thrifty, if you will. They only use what they need to survive.”

In general, a starved fetus preserves brain growth, but organ and muscle growth is compromised, Brown said.

Often IUGR babies are born with full-sized heads and skinny bodies.

“We think they’re only using what they need. Then those changes become programmed,” Brown said. “Those don’t go away and when the baby is born and gets all the nutrients it wants, we think the organ systems don’t have the capacity to use all those nutrients like they should.”

Brown is particularly interested in muscle growth. Scientists have learned, for instance, that the number of muscle fibers is set when you’re born.

“These babies are born small and thin,” she said. “Even when they got lots of nutrients, this muscle never catches up. One of my hypotheses is that muscle can’t grow to its potential. So the body lays down fat instead.”

The body’s ability to use glucose also may be compromised into adulthood and for generations to come, leading to multi-generational diabetes.

“Their muscles may be programmed not to use the glucose. The pancreas that makes insulin is also severely affected by IUGR. It doesn’t compensate and produce enough insulin and the liver probably plays in quite a bit as well. It may be that the liver makes too much glucose.”

Brown said animal studies show that the effects pass from generation to generation.

Researchers began to pinpoint the connection between fetal deprivation and later-life health problems in the 1990s. They started studying adults whose mothers had faced starvation during pregnancy. For instance, epidemiologists studied people born during the “Dutch Hunger Winter” from 1944 to 1945 and found links between maternal starvation, low infant birth weight and higher levels later of obesity, insulin resistance, hypertension and coronary heart disease. Another study of men and women born in Hertfordshire, England between 1911 and 1930 found links between low birth weight and later increased risk of death from cardiovascular disease and stroke.

While Brown says the problem is bleak and the solutions are complex, she’s pleased that researchers are now focusing on fetal growth.

One of her most exciting findings focuses on trying to find ways to improve nutrition for the growing fetus.

“We’re experimenting with giving extra nutrients during pregnancy and at birth. We’re good at making babies in the NICU fat, but we would like to help them grow their muscle too,” she said.

The dilemma is how to have nutrients enrich organs and be absorbed properly.

Brown’s hunch is that the “programming” is set very early in the womb and that interventions someday could focus on tiny fetuses. Changing the ways babies are genetically wired could have far greater impacts than later-life interventions.

“It’s hard to change lifestyles. My argument would be that interventions early in development before that predisposition (to later health problems) is ever even put into place would help people enter adulthood with lower risks,” Brown said.

“We’re at the stage of trying to figure out what’s wrong. You have to know that before you can even think about a treatment.”

By Dr. Christian Thurstone

Because Colorado Gov. John Hickenlooper appointed me to serve on a task force charged with recommending to the state legislature how to implement a constitutional amendment making recreational marijuana use legal in this state, I have become more aware of potential harms to public health and safety that Coloradans should know about.

In the interest of full disclosure, I have not hidden my thoughts about marijuana legalization. It is wrong not only for the health and well-being of Colorado, but for our nation — and I have every reason to believe many people will learn this the very hard way.

I am working to help other states understand the myriad mistakes Colorado has made — and is on track to make — through my work on the board of a new national organization, called Smart Approaches to Marijuana (SAM). That group seeks, in part, to help Americans understand the dangers of marijuana use, and that they can reform marijuana laws sensibly without legalizing the drug, which drives more of our nation’s youth into addiction treatment than any other substance.

The disconnection between what science has told us about marijuana and what the burgeoning — but highly funded and organized — marijuana industry trumpets is painfully obvious in Colorado, where debates are far more focused on money than on matters of public health and safety. When members of the governor’s task force ranked eight primary “principles” on which our deliberations are to be focused, “Be responsive to consumer needs and issues” was placed second only to “Developing guidance for certain relationships, such as employer/employee …” Last on the list? “Promote the health, safety and well-being of Colorado youth.” What else ranked lower on the list than “consumer needs?” This principle: “Ensure our streets, schools and communities remain safe.”

The public needs more education and information immediately. I remain unconvinced that many Coloradans who voted in favor of Amendment 64 fully understood what they were supporting. Though my evidence is anecdotal, it is significant. For example, last week, I participated in a professional meeting where a Denver city official explained that an informal poll revealed Denverites want fewer marijuana shops, not more. Residents will be very surprised by what Amendment 64 unleashes unless the Denver City Council steps in to ban retail shops and other pot-related events and entities as other Colorado cities have.

Then there are dozens, maybe even hundreds, of Coloradans who have told me they had no idea the amendment would:

• permit the “pot clubs” that already are springing up.
• usher into Colorado the pot tourism much like what the Dutch city of Amsterdam is now trying to rid itself. The marijuana industry in this state already is lobbying hard against a residency requirement that would limit the drug’s sale only to Coloradans.
•  allow for marijuana concentrates — which means there’s really no THC limit on the potency of marijuana and marijuana-infused foods and drinks, also called edibles, that could be sold in Colorado.
• allows for a 1 oz. marijuana-possession limit that feasibly translates into hundreds — yes, hundreds — of THC-infused candies, cookies and other edibles. In other words, there really is no possession limit either.

And that’s just for starters. I hope scientific polling of the state’s residents will begin in earnest because I strongly suspect many of them will say they wanted Coloradans age 21 and over to have the right to use marijuana in small amounts, in privacy (and in strictly private environments) and without fear of prosecution.

I think many voters supporting Amendment 64 believed they were supporting far more stringent regulation that would clean up the mess they have come to know as medical marijuana. I think many voters thought the amendment would result in more rigorous analysis and inspection of the content of marijuana-infused foods and drinks.

Amendment 64 pretty much gives the state the opposite of all of those things.

As an addictions scientist and treatment provider, I am especially troubled that this cleverly worded amendment makes it very hard, if not impossible, for the public to control the THC content of marijuana and the potency of foods and drinks infused with it. Because Colorado already essentially has lost control of this aspect of marijuana legalization (the state legislature will not be able to change these allowances now carved into the Colorado constitution), it is vitally important for this state to devise a regulatory framework that protects public health and safety — and puts it far ahead of financial and political interests.

It is just as important for the federal government to act in the interests of the rest of the country because responsible drug policy is national policy, not policy decided for the nation by one or two states (and certainly not policy decided in the rushed manner and timeline Colorado is forced to honor — again because of Amendment 64′s clever wording). I join many other organizations, including the Colorado chapter of the American Academy of Pediatrics and the National Association of Drug Court Professionals, in calling on President Obama, Attorney General Eric Holder and other federal officials to enforce federal law, put an end to these slapdash state initiatives and engage the country in a reasonable and far more informed national discussion about marijuana use and the enforcement of marijuana-related laws.

Let’s put public health and safety first this time. Let’s put taxpayers’ interests ahead of private business owners’ interests. If our nation truly wants to launch another industry peddling another addictive substance for recreational use, we must not repeat the mistakes we have made with Big Tobacco and Big Alcohol — whose products are responsible for our nation’s No. 1 and No. 3 causes of preventable death, respectively.

Unfortunately, the regulatory frameworks presented to the governor’s task force so far don’t reflect much concern for Colorado’s health and safety, much less the nation’s. One regulatory framework — loosely referred to as the “open model” — is essentially a free-for-all that could, feasibly, allow marijuana to be sold in convenience stores and encourage tobacco behemoths champing at the bit to dive into the marijuana business to set up shop in the Rocky Mountain state.

Because the governor’s task force on marijuana regulation has been asked to consider one of the loosest regulatory frameworks imaginable, I decided to try to identify a far more conservative framework — which has led me to question a model that is either partly or fully controlled by the State of Colorado.

Yes, state control — a model that has scientific merit, at least where alcohol regulation is concerned. Marijuana-legalization advocates insist “regulation works,” and they say weed needs to be regulated like alcohol, right? After researchers at the U.S. Centers for Disease Control examined 37 state-run models in the United States and other countries, they concluded in a peer-reviewed paper published in 2012 in the American Journal of Prevention Medicine that “government control of off-premises sale of alcoholic beverages is one of many effective strategies to prevent or reduce excessive consumption.”

In other words, as destructive as marijuana use is, directly involving the state in marijuana production and/or sale might reduce some harms to public health and safety. If people want to live with marijuana legalization, they also should consider a regulatory framework that stands to serve in the state’s financial interests and protect the greatest number of people. They should demand that their elected officials give it serious consideration. At this point, I am not calling for a state-run model. I only am calling for more research and thoughtful analysis of a state-controlled framework — which could assume many forms.

Colorado’s privatized medical marijuana industry already has failed miserably. A state-run system at least stands to be a far more responsible approach. If we’re going to do something unwise, let’s at least do it in a manner that could protect the health and safety of the most people — and the financial interests of taxpayers.

Let’s be honest. We need more research.

So far, some members of the governor’s task force have dismissed the idea of state control — and before a state-run model even has been defined and studied. This is unwise especially if we care about public health and safety.

Remember: every regulatory scheme presented for consideration is outside the bounds of federal law — so state control also deserves full and fair review, especially when science tells us it stands to be better for public health and safety than any of the other (also federally illegal) models Colorado legislators will be asked to debate and decide.

During its Feb. 14 meeting, the Regulatory Framework Working Group, a committee of the task force, crafted an explanation for its rejection of a state-run model — which came with little to no formal study of the idea. I invite you to read the full explanation, found on page 12.

I remain unconvinced that the amendment’s language expressly prohibits the state from commercial activity — and I know some lawyers who have examined this matter are as well.

However, below is the passage that caught my eye because it brightly underscores the degree to which people are hard at work to create an industry that not only operates outside the bounds of federal law, but also operates in a manner that encourages the federal government to continue overlooking what is happening here.

“As an additional matter, we note that adopting a regulatory model which called for state-run retail stores would raise serious federalism concerns. Under such a model, the state would be actively violating federal law rather than merely licensing others to do so. Such open defiance of the Controlled Substances Act might be seen by the federal government as an intolerable obstacle to the enforcement of federal law and could lead to a suit to enjoin such conduct. A state-run distribution system is thus far more antagonistic to the federal government than one in which the state merely licenses private conduct and should be rejected for that reason as well.”

Even if something is politically inexpedient and inconvenient, I support doing the right thing.

Dr. Christian Thurstone is a child and adolescent psychiatrist in Denver who specializes in addictions. He is medical director of one of Colorado’s largest youth substance-abuse-treatment clinics and an associate professor of psychiatry at the University of Colorado Denver, where he conducts research on youth substance use and addiction. An extended version of this op-ed appeared on his website at www.Dr.Thurstone.com.

By Katie Kerwin McCrimmon

Spend less on health care and much more on preschool.

That’s the prescription that an international expert on health disparities gave Thursday in Denver to help reverse inequities that leave low-income racial and ethnic minorities much sicker and facing shorter life expectancies than wealthier whites.

“Health care should get less (funding) and education should get more,” said Dr. Paula Braveman. “Early childhood development should get the lion’s share. Having a strong social safety net would make health indicators look a lot better.”

Braveman is director of the Center on Social Disparities in Health at the University of California, San Francisco School of Medicine. She spoke at an event that The Colorado Trust hosted called “From Health Disparities to Health Equity.”

A new report from The Trust has found that racial and ethnic minorities make up more than 346,000 of Colorado’s 829,000 uninsured people. Not only are minorities less likely than the general public to have insurance and access to health care, but they also suffer worse health outcomes, the report found.

One of the greatest frustrations about health disparities, said Braveman, is that they seem to persist despite some well-intended policies to reverse them.

For instance, she said that babies born to African American moms are two or more times as likely as white babies to be born too small. Low birth weight is closely linked with infant mortality, childhood disability and chronic disease in adulthood.

In the 1980s and ’90s, Braveman said there was great hope that expansions of Medicaid would bring better medical care to African American moms and in turn, lead to better outcomes for their babies.
 

Expansions of Medicaid coverage “dramatically narrowed the gap between African American and white women but did nothing to narrow the disparities” in babies’ health, Braveman said.

She said one of the only health programs that seems to work is called CenteringPregnancy. Developed by a nurse-midwife in Connecticut, the program brings pregnant moms together for group visits throughout their prenatal care. The model is being used at community health centers in Colorado where the mothers often keep meeting long after their babies are born and offer positive role models and support to each other. Both the mothers and babies do better.

Aside from group maternity care, the greatest hope seems to lie in education. Braveman said study after study has shown that high quality Head Start programs change lives. She’d like to see the much-praised Harlem Children’s Zone in New York used as a model throughout the U.S.  The program provides every kind of service a family could need to help children within a 100-block area of Harlem succeed from birth through college. In order to reverse disparities there, HCZ workers address everything from “crumbling apartments to failing schools to violent crime and chronic health problems.”

Braveman said reversing health disparities is as fundamental as protecting human rights.

“We’ve got an obligation to focus on those with the greatest obstacles,” she said. “Disparities are health differences that are closely linked with social or economic disadvantage.”

T.R. Reid, a journalist and author who made the PBS documentary, “Sick Around the World,” led a discussion with Braveman and asked how the wealthiest country in the world stacks up with other countries when it comes to health disparities.

“We rank at the bottom among affluent countries,” Braveman said. She referred to a Jan. 9 report that she helped author from the Institute of Medicine that found that Americans die at younger ages than people in almost all other high-income countries.

“This health disadvantage prevails even though the U.S. spends far more per person on heath care than any other nation,” the report authors found.

Braveman said the newest hypothesis among scientists is that chronic stress that African Americans experience from birth on — regardless of whether they are born to poor or fairly wealthy families — takes a toll on health.

“There’s reason to believe that people carry around with them this awareness, this vigilance,” Braveman said.

Chronic stress could bring lousy health. She said racial and ethnic disparities are relatively small among poor women. But, college-educated black woman fare much worse than college-educated white women.

“Everybody’s looking for the magic bullet,” Braveman said.

When she looks at health around the world, she said the one potential answer is that most other countries provide universal preschool.

“It’s very disturbing that we still don’t have universally high-quality Head Start types of programs. It’s been effective for kids of all social classes, but particularly for kids (from low-income families).”

“Readiness to learn leads to lower incarceration, higher employment and lower poverty. We know those will in turn lead to better health. The science is there. We don’t need any more studies to show that this works.”

Braveman also said the new trend of Health Impact Assessments that view development and urban planning through the prism of health is also promising. (Click here  to read about a public housing project that uses health metrics for every decision managers are making.)

In Colorado, providers at community health centers say they have the best luck in reversing disparities when they make it easier for patients to get health care.

Jessica Sanchez is chief quality officer for the Colorado Community Health Network, which serves more than 600,000 people through 17 health systems around the state. Sanchez is also a nurse practitioner at Denver Health’s Park Hill Clinic.

She said offering flexible hours including evening and weekend appointments is working well. Group visits and help with both transportation and child care also are very attractive to patients. She said several of Colorado’s community clinics including Clinica Family Health Services, Salud Family Health Centers and Valley-Wide Health Systems in the San Luis Valley are experimenting with methods to reduce health disparities.

“The other great thing they are doing is putting together patient advisory groups. They want their patients to be more active and involved in their health care decisions,” Sanchez said.

Better feedback from patients helps clinics provide better services.

“Everyday challenges that patients face, from taking care of children to having to take three buses to get to a clinic” can have profound affects on a patient’s health, Sanchez said.

Providers and health managers also need to be realistic and accept incremental improvement. For instance, Sanchez said her patients often refuse to take their medications. The reasons can be complex. Perhaps they can’t afford it or can’t read the instructions. She had one patient who wasn’t remembering to take blood pressure medication and also wouldn’t quit smoking. Sanchez decided to tackle the first problem first. So, she helped the woman tape her medication to her cigarette pack.

“It worked for her. It’s not perfect. Then you work on the cigarettes when she’s ready. The big success was getting her to take her medication.”

A January study published in the Journal of Ambulatory Care found that Community Health Centers reported lower disparities for racial and ethnic minorities on various quality measures compared to national rates.

“This study shows that the efforts invested by health centers to deliver the highest quality care in culturally appropriate ways works to help lessen health disparities and helps people of all racial and ethnic identities to become empowered to manage their own health care,” Sanchez said.

By Mary Winter

Few foods say “good times” like a sizzling 16-ounce rib eye.  For generations, Americans have celebrated milestones, successes and summer get-togethers with a juicy slab of fat-marbled beef, and for most of us, a trip to a pricey steak house is still an occasion.

If that occasional steak were the only red meat we ate, many health experts would be thrilled.

But today, Americans consume an average of 74 pounds of red meat (beef, veal, pork and lamb) per person each year – much of it in the form of fast-food burgers and processed meats such as bacon, deli meats and hot dogs.

That’s too much red meat, and it’s sending us to early graves, according to a growing body of medical evidence.

In March, researchers at the Harvard School of Public Health published results of a groundbreaking study that made headlines around the world.  The massive, 120,000-subject, 28-year study showed that people who consumed a serving of beef, pork or lamb per day had a 13 percent increased risk of death, compared with people who ate very little or no red meat.  Those who ate a daily helping of processed meat, such as bacon and hot dogs, had a 20 percent increased risk of death from diseases, including cancer and heart disease.

In an interview on National Public Radio, Frank Hu of the Harvard School of Public Health, a co-author of the study, called the statistics “staggering.”

Dr. Frank Hu

“This study provides clear evidence that regular consumption of red meat, especially processed meat, contributes substantially to premature death,” Hu said in a release issued by the Harvard School of Public Health.

The livestock industry has pushed back, arguing that the Harvard study was flawed and that lean meat actually improves heart health by lowering cholesterol.

This week, many of the country’s biggest livestock producers are gathering in Denver for the 107^th National Western Stock Show.  As the city gears up to host the annual event – which will bring some 15,000 animals, 600,000 show-goers and millions in revenue to town – the voices grow louder: Americans must sharply curb their appetites for hamburgers, chops, hot dogs and deli meats or suffer the potentially lethal consequences.

Evidence overwhelming

The landmark Harvard study reinforced numerous earlier findings.

In March 2009, a 10-year National Cancer Institute study of more than half a million Americans showed that those who ate the most red meat boosted their overall risk of death 30 percent.  It found that men who were big meat eaters had a 22 percent increased risk of death from cancer and a 27 percent higher risk of cardiovascular disease compared with men who ate the least.  For women who ate the most meat, the risk of cancer death increased by 20 percent and the risk of heart disease increased by 50 percent.

A 2005 study found a strong association between red meat and cancer.  As reported in the June 14, 2005 Guardian newspaper:

“International scientists yesterday delivered a long-awaited verdict on red meat, concluding in a definitive study of the eating habits of half a million people that beef, lamb, pork, veal and their processed varieties such as ham and bacon, increase the risk of bowel cancer.

“Those who eat two portions a day — equivalent to a bacon sandwich and a filet steak — increase their risk of bowel cancer by 35 percent over those who eat just one portion a week, the study found. The World Health Organization’s international agency for research on cancer (IARC) called for everybody to eat more fish and less meat.”

Because of its size and duration, this March’s Harvard study was in a class by itself.  Researchers followed 37,698 men from the Health Professionals Follow-up Study for up to 22 years and 83,644 women in the Nurses’ Health Study for up to 28 years. All were free of cardiovascular disease and cancer at the start of the study.

Every four years, the participants answered questionnaires about their diets.  The amount of meat they ate was divided into five categories, ranging from the most — up to about three servings daily — to the least, or less than half a serving daily.

Over the course of the study, 23,926 test subjects died — 5,910 from cardiovascular disease and 9,464 from cancer.

Researchers concluded that a daily serving of unprocessed red meat (about the size of a deck of cards) carried a 13 percent increased risk of death, and one daily serving of processed red meat (one hot dog or two slices of bacon) carried a 20 percent increased risk.

Dr. James Ehrlich, clinical associate professor in the Department of Medicine at the University of Colorado, called the findings “highly significant,” owing mainly to the huge sample size and the unassailable credentials of the investigators.

“These particular individuals at Harvard School of Public Health — Frank Hu, An Pan, Walter Willett, JoAnn Manson and others — have been major contributors to our understanding of the relationship of risk factors to mortality and cardiovascular disease over many years… and lead me to believe that the numbers they came out with are probably true.

“If there’s a weakness, it’s the fact that the study was done primarily by (self-reported) questionnaires, and there are confounding factors that always make it a little difficult to believe the exact results of the study,” said Ehrlich, who practiced anesthesiology for 20 years and is an advisor to Premier Micronutrient Corp.

Cattle yards at National Western Stock Show
(Photo courtesy of NWSS)

“For example, in general, the people who are red meat-eaters also have a higher prevalence of smoking and lack of exercise, so they’re not able to completely separate some of these confounding factors that contribute to results of the study. But having said that, I found the results somewhat surprising but highly significant.”

Ehrlich said that perhaps the most exciting aspect of the study was its replacement analysis.

“That’s what is unique to this study … It showed that replacing one serving of red meat with fish, poultry, nuts, legumes, low-fat dairy or grains was associated with a 7 percent, 14 percent, 19 percent, 10 percent, 10 percent and 14 percent lower risk of total mortality, respectively. So the group estimated that nearly 1 in 10 deaths in men and 7.6 percent of deaths in women could be prevented if the population consumed fewer than a half a serving of red meat per day … That’s a lot, actually.  There are very few things in life that you can show that kind of mortality benefit from an intervention.  In this case, the intervention is replacement, something that all of us can do. Most interventions we talk about in medicine are surgical procedures or lifelong drugs, but this is a simple lifestyle maneuver that doesn’t cost us money.  It’s not as if grains are more expensive than red meat.”

The second conclusion from the study is that processed meat “probably should be totally eliminated from the diet,” and red meat should be limited to three servings per week, Ehrlich said.

Bonnie Jortberg, Ph.D., assistant professor in the Department of Family Medicine at the University of Colorado School of Medicine, hailed the study as “extraordinarily well done.” She had a slightly different interpretation of the study’s recommendations.

Bonnie Jortberg

“What I have learned over the years, working in nutrition, is there are no good foods or bad foods,” said Jortberg, who’s also a registered dietician. “Some you should eat less often and some more often.  Red and processed meat fit in the category of less. It doesn’t mean you should NEVER eat them. And I think that’s where we run into a lot of trouble. People say, ‘Oh I just have to swear off bacon.’ But if you love bacon, that’s not realistic.”

Jortberg said she limits her red meat consumption to two days a week, and processed meat to a strict “two servings a week, or fewer.”

Dr. Dean Ornish, author and longtime advocate of plant-based diets, wrote a commentary accompanying the Harvard study results in the Archives of Internal Medicine.

Ornish began his piece:  “Is red meat bad for you?  In a word, yes.” He ended his piece with the characteristics of what he considers the healthiest diet:

• Little or no red meat.

• High in “good carbs” — vegetables, fruits, whole grains, legumes and soy products.

•  Low in “bad carbs” — simple and refined carbohydrates, such as sugar, high-fructose corn syrup and white flour.

•  High in “good fats” — omega-3 fatty acids found in fish oil, flax oil.

•  Low in “bad fats” — trans fats, saturated fats and hydrogenated fats.

Fat, sodium, heme-iron implicated

Why red meat appears to increase mortality is not understood, but it contains a significant amount of saturated fat and cholesterol, two risk factors for cardiovascular disease.  Processed meats also have high levels of sodium and nitrates. Sodium can raise blood pressure, increasing the risk of stroke and heart disease, while nitrates may damage blood vessels.

We put the question to An Pan, lead author of the Harvard study, and he responded in an email that there are multiple potential explanations or causes, including:

“Red meat has a high amount of heme-iron, (which) when overloaded, is associated with insulin resistance and oxidative stress; 2) high saturated fat and dietary cholesterol in red meat; 3) carcinogens produced by high-temperature cooking; 4) salt and nitrate contents in the processed meat; 5) other compounds added during the production of red meat to the market; 6) unhealthy lifestyles associated with red meat consumption (for example, in the general population, people who eat red meat generally are less likely to eat more fruit and vegetables and whole grains, so they are lacking good foods, and they might be more likely to smoke and physically inactive, etc.); 7) we found an association, not causation, it is still possible that other unmeasured factors linked with red meat consumption could explain the association.”

Producers reject findings

The meat industry, meanwhile, maintains that a balanced diet – one including lean meat – is still the healthiest diet.

In response to a Solutions request to talk to a spokesperson from the National Cattlemen’s Beef Association about the Harvard study, the Centennial-based group provided a written statement it issued shortly after the study was released.

“Overall lifestyle patterns including a healthy diet and physical activity have been shown to affect mortality, not consumption of any individual food,” wrote Shalene McNeill, Ph.D., R.D., of the National Cattlemen’s Beef Association.

“Additionally, it is significant to note that this was an observational study. Observational studies cannot be used to determine cause and effect.

“If there is one thing scientists agree on, it is that responsible dietary advice must be drawn from a look at the entire body of evidence, including rigorous, gold standard randomized control trials when they are available. In the case of beef, there are several randomized control trials which have convincingly shown that lean beef, when included as part of a healthy, balanced diet, improves heart health by lowering cholesterol. Most recently, the BOLD (Beef in an Optimal Lean Diet) study showed that eating lean beef every day, as part of a heart-healthy diet, could reduce LDL cholesterol by 10 percent — as much as any other recommended heart healthy diets.”

The beef industry argues that beef today is leaner than ever, due to breeding improvements and better trimming practices at the retail level.

The Alliance for Natural Health, a Maryland-based group that advocates for dietary supplements and alternative medicine, also took issue with the Harvard study because it relied on self-reported data and didn’t differentiate between organic, grass-fed beef and feedlot-raised beef.

The group argued that conventional grain-fed beef may contain over 20 times the amount of omega-6 fatty acids (associated with arthritis, chronic inflammation and cancer) than healthful omega-3 fatty acids (which help blood circulation, reduce inflammation and strengthen the heart). “By contrast, grass-fed beef typically has nearly seven times more omega-3s than omega-6s,” the ANF statement read.

Dr. Walter Willett, another co-author of the Harvard study, told the Los Angeles Times it’s not yet known if grass-fed beef is healthier to consume than grain-fed.

“The total fat (in grass-fed beef) may be a bit lower. But we don’t see that the fat per se is really related to the risk of getting heart disease or cancer,” Willett said. “Cholesterol is more in the lean part of the red meat, so that’s going to be just as high and maybe even higher in the grass-fed animals. I think it would be nice to be able to study grass-fed beef directly, but I think in the meantime it’s reasonable to assume that the answer is probably not going to be very different from what we saw here.”

Finally, P.J. Skerrett, managing editor of Harvard Health, cautioned readers to keep the study results in perspective.

Recently released findings of a Japanese study of 51,000 subjects over 16 years found no connection between moderate meat consumption (up to three ounces a day) and premature death, Skerrett wrote, and last year, a study by different researchers from the Harvard School of Public Health found no connection between eating unprocessed red meat and the development of heart disease and diabetes, though there was a strong connection with eating processed red meat.

Meat consumption in decline

So how much meat DO we eat?

Red meat consumption has been declining for 40 years.

Average annual per capita consumption of red meat (beef, veal, pork and lamb) in the United States in 2010 was 74 pounds, adjusted for loss, according to the USDA.

The amount 40 years earlier — in 1970 — was about 96 pounds per person, and consumption has declined fairly steadily since then.

In 2012, the USDA refined its calculations of Americans’ meat consumption to better reflect loss due to spoilage, cooking and meat left uneaten on the plate.

While the government collects several sets of data on meat, the loss-adjusted food availability estimates ”more closely approximate the actual intake of meat” than the core food availability data, said Jean C. Buzby, economist with the USDA’s Economic Research Service.

Buzby said she does not know why red meat consumption has declined, but points out that chicken consumption has gone up as red meat has declined.

So how does Americans’ average of 74 pounds of red meat annually stack up against health experts’ recommendations?

It’s double what we should be eating, according to many.

Heart disease expert Dr. Dean Ornish believes we should eat little or NO red meat, while others, including Frank Hu of Harvard, say one 3- to 4-ounce serving every other day is acceptable.  Many experts recommend red meat be limited to 8 ounces weekly.

If a person went with Hu’s advice, he would eat, at most, 12 ounces of red meat a week, in contrast to the 23 ounces the average American now eats weekly.

In addition to health concerns, there’s been a shift in public attitudes about meat production.

Increasingly, the public is concerned about the welfare of animals raised in factory-warehouse conditions, and there’s growing awareness of the toll that livestock takes on the environment in the form of water and land use, and fuels and fertilizers needed to grow corn for feed.

“Rather than considering meat requisite at every dinner or an indication of wealth, many people are deliberately choosing to eat less meat than before, often citing concerns about health, the environment, and the ethics of industrial meat production,” states the Earth Policy Institute, a proponent of sustainable environmental policies.

According to EPI, total U.S. meat consumption peaked in 2007 at 55 billion pounds and has fallen each year since. In 2012, consumption is expected to drop to 52 billion pounds, the lowest level in more than a decade.

More vegetables recommended

Today, it’s hard to find a nutritionist who doesn’t believe America needs to eat less meat and more plants.

“It doesn’t mean you’re a vegetarian,” said CU’s Jortberg. “What is means is the majority of what you eat in a day is from a plant source – whole grains, fruits and vegetables. The Asians, for example, eat fish, but it’s mostly rice with a little bit of fish.  In this country, we do the opposite – lots of fish, little rice.  We need to make (protein) more of an accoutrement than the main course.”

Jortberg is not encouraged.  Americans aren’t changing their habits fast enough, she believes, continuing to forgo healthful food in favor of convenient food larded with extra fat, sodium and sugar.

“We’re still a fast-food nation,” she said, a reference to the 2003 book of the same title by Eric Schlosser, which detailed the depth of America’s love affair with processed foods, and exposed conditions in the meatpacking industry.

Jortberg said big agriculture is to blame, in part, for lobbying to keep processed foods cheaper than fruits and vegetables.

“But I also tell people is that food manufacturers make certain kinds of foods because people buy them. If you stop buying pork skins, they’ll quit making them. We do have look at our own personal responsibility:  no one twists your arm to buy that Big Mac and fries.”

By Dr. Amanda Dempsey

After lunch on a typical clinic day, I review my schedule for the afternoon and see that Danny S. is scheduled for his 4-month well child check-up.  His name rings an alarm bell in my head.  Looking through the chart I see why. Danny’s parents have been adamantly against vaccines at past visits.  At Danny’s 2-month visit, they declined getting any of the recommended vaccines, despite my strong suggestions otherwise.

“OK,” I think. “Maybe today will be the day,” and I resolve to try again to change their minds.  However, the moment I bring up vaccines during his visit, Danny’s dad produces a notarized document written in legalese indicating that because of their “religious beliefs,” the parents plan to continue to refuse all vaccines, and by the way, PLEASE stop asking them to sign the “vaccine refusal” waiver at every one of Danny’s visits!

The document goes on to state a long list of reasons why vaccines are “harmful.” One of the most interesting includes the notion that giving Danny the Hepatitis B vaccine will cause him to be sexually promiscuous. I guess they’re talking about 12 to 18 years from now when he might actually be thinking of sex?  I’ll keep trying to get Danny vaccinated at every visit, but I already know that I’m most likely not going to make any headway with his family.

Danny’s parents’ views provide an example at the extreme end of the vaccine hesitancy spectrum, and show the lengths that some parents will go to keep their child from getting vaccinated.

Vaccine hesitancy can be broadly defined as having “concerns about the safety and/or necessity of vaccines.” These concerns often give parents significant pause when deciding whether to have their child vaccinated, and can lead to vaccine refusal or delay.

Vaccine hesitancy has been rising steadily over the last several years, with the proportion of parents with concerns about vaccines increasing from 19 percent to 50 percent between 2000 and 2010.  Similarly, the number of non-medical vaccination exemptions (i.e. those for religious or philosophical reasons) for school-required vaccines has also increase steadily during this time, while medically based exemptions have remained stable.

When looking at vaccine hesitancy across the U.S., one piece of good news is that the proportion of parents who refuse ALL vaccines for their child has been consistently low at 1 to 2 percent for the last several years.  Far more commonly, vaccine hesitancy manifests as one of two scenarios: 1) parents have a vague sense of unease about vaccines in general (Are they safe?  Does my child REALLY need them?  Aren’t we going to “overwhelm” my child’s immune system?), or 2) parents agree to vaccination in general, but with strong hesitations for one or more specific vaccines (for example, those who say, “Sure, I’ll get all the vaccines – except the flu”).

Among the nearly 50 percent of U.S. parents with some degree of vaccine hesitancy, it is the “fence-sitters” (i.e. those who DO follow the recommended vaccination schedule, but with reservations), that may be the most significant group when it comes to how their action (or inaction) affects public health.

A recent study showed that among fence-sitting parents, about one in four do not believe that the recommended vaccine schedule is either the safest or best schedule to use.  This indicates to me that the problem of vaccine hesitancy and subsequent vaccine refusal and delay is likely to get worse with time.

I think we can all agree that all parents strive to do what is best for their children. From my standpoint as a parent AND a doctor, vaccines are a “no brainer” – tons of benefit and little to no risk.  So why the vaccine hesitancy problem?

A primary reason is that most people make decisions via heuristics (i.e. their “gut feeling”) rather than rationalization.

This is problematic because heuristic decisions are particularly sensitive to recall bias and personal experience. For example, the “representativeness heuristic” means that when people are faced with an unknown risk they look for similarities in their surroundings to estimate that risk.

Using this heuristic, a parent who feels unsure about whether it is “worth it” to get the flu vaccine for her daughter may note that a friend’s daughter became sick after her flu vaccine.  Because the mother and daughter share many similarities with the friend and her daughter, the mother concludes that her daughter will also get sick after getting the flu vaccine, so she refuses.

The “availability heuristic” describes how a person judges the probability that an event will occur based on the ease with which examples of that event come to mind. This helps to explain why parents who are inundated with the media’s scare stories about how vaccines “cause” autism, seizures and a variety of other health problems easily conclude that these problems are a common side effect to vaccination.

When faced with these heuristic biases, facts, figures and rational arguments may do little to make vaccine hesitant parents feel at ease.

So what can we do then?

We are increasingly seeing the public health impacts of this steady rise in vaccine hesitancy.  Widespread outbreaks of several diseases like measles, hemophilus meningitis, and pertussis are occurring more and more frequently, fueled in large part by those who are unimmunized or under-immunized.

However, because no vaccine is 100 percent effective, even those fully vaccinated are at risk during these outbreaks.

Though I would never wish anyone sickness, a small part of me wonders what would happen if one of these outbreaks affected someone famous.  Ideally, it would be someone with enough “street cred” to meaningfully connect with today’s parents, and also willing to step up to the plate and speak out nationally about the experience and why childhood vaccination is so important.

Given the way things are going, it seems like only matter of time before something like this happens.

Until then, we all need to be immunization champions in our own way. This means getting ourselves and our own kids vaccinated, promoting the benefits of vaccination to others, cracking down on media that promulgate stories that unnecessarily scare the public, enforcing compliance with school-mandated vaccines, and looking for opportunities to push the policy agenda to minimize the ease with which a religious or philosophical exemptions can be obtained.

For me, the issue has  become deeply personal. I just found out my best friend’s daughter has leukemia. Her treatment will wipe out all the prior benefit she received from her childhood vaccines and her weakened immune system will put her at very high risk for getting infected with vaccine preventable diseases.

I am already trying to plant the seed with her parents to make sure that ALL of her visitors and caretakers are fully vaccinated.   However, that will only go so far.

I can only hope and pray that she doesn’t encounter Danny, or someone like him, when she leaves the house.

Dr. Amanda Dempsey is an associate professor of pediatrics at the University of Colorado School of Medicine. She graduated from the  University of Rochester in 1991 and earned her doctorate at Vanderbilt University in 2000. Dempsey’s areas of interest include immunization delivery, vaccine refusal, human papillomavirus and mathematical modeling.

By Katie Kerwin McCrimmon

The MacArthur Foundation has honored a Colorado doctor with a $500,000 “genius grant” for his work to help chronically ill older adults stay well.

University of Colorado School of Medicine geriatrician, Dr. Eric Coleman, has won the prestigious MacArthur fellowship for creating the concept of low cost “transition coaches.” The coaches provide relatively simple support to chronically ill older adults and their caregivers for a month after hospitals release the patient. His program is called Care Transitions Intervention.

The issue is critically important because hospital readmissions are costing taxpayers an estimated $17.5 billion dollars a year. Studies have found that nearly one in five Medicare patients returns to the hospital within a month of discharge. In the past, hospitals have had no incentive to reduce those repeat visits. Starting this week, the federal government will fine hospitals that repeatedly readmit patients.

Ironically, Coleman has had trouble in the past attracting federal funding for his work.

“Pursuing a relatively high-risk research portfolio that challenges existing paradigms has translated into being ahead of the federal funding opportunities,” he said. “This has required identifying philanthropic funding partners that have been willing to take this risk together.”

Coleman said he’s thrilled with the award and has not yet decided how to spend the money, which comes with no strings attached.

“I am deeply honored and humbled to receive this recognition,” said Coleman, a CU professor who practices at University of Colorado Hospital.

The MacArthur Foundation announced 23 grant winners. The grants support people who show exceptional originality and creativity.  The awards have become known as “genius” grants, although the foundation does not call them that. This year’s crop included writers, an economist and a maker of bows for stringed instruments.

Coleman’s innovation is deceptively simple. The coaches do a home visit and make three phone calls to patients and caregivers.  Studies have found that patients were significantly less likely to be readmitted to the hospital and that the benefits lasted at least five months after the one-month program ended. Coleman’s conservative estimates have found that a typical group of coaches helping 350 chronically ill adults could save at least $300,000.

Patients also reported being more satisfied with their recovery and achieving their personal post-hospitalization goals. The model taps patients and family caregivers and helps them become more comfortable and competent in handling their own care.

In essence, the model involves making an investment in helping patients and family caregivers become more comfortable and competent in participating in their care during care transitions. So far, more than 750 health care organizations n 40 states have adopted the Care Transitions Intervention.

A study in Colorado conducted by the Centers for Medicare and Medicaid Services found that the program cut hospital readmission within 60 days of release by 50 percent.

Patients report that the home visit made them feel like someone “cared” about them. Many were confused about medication and their coaches helped them organize and better understand their prescriptions.

Said one participant:

“It made me feel like someone cared and was paying attention to me, that people are interested in you, that there’s somebody who has the ability and is trained and interested in your welfare.”

By James O. Hill

Every day we get inundated with information about what to eat, but unfortunately, that information is often confusing and conflicting. Eat a diet high in carbohydrate and low in fat. No wait.  Eat a diet low in carbohydrate and high in fat. I don’t blame the public for being confused. What is the best diet?

You may be surprised to know that the best diet for you depends on whether you are an athlete or a couch potato. Being physically active keeps your metabolism working optimally and affects the way your body uses food for fuel. It starts with how much food you need.

If you are physically active, like many people in Colorado, you get to eat more food without gaining weight than your sedentary neighbors. This means that you get to have some fun with your diet — you don’t have to obsess over every morsel that passes through your mouth. You don’t worry about limiting carbohydrate, since carbohydrate is the preferred fuel for active muscles. During the day, an active body will use more total fat for fuel than a sedentary body, allowing you to eat more dietary fat without negative consequences. Physically active people have a metabolism that is flexible, which means they shift quickly to using carbohydrate for fuel after meals and fat for fuel between meals. This is an advantage to maintaining a healthy body weight. Finally, appetite regulation is more precise in active than in inactive people.

It is possible to be sedentary and have a healthy weight, but it requires significant and permanent food restriction. While a calorie-restricted, low carbohydrate diet would be fine for a sedentary person, such a diet would not be adequate for an active person.

Researchers now understand that being sedentary is an abnormal state and leads to many adverse consequences to your metabolism that affect how your body uses food for fuel. You are not expending calories in exercise, so your body needs less total energy. This means you have to pay close attention to your diet in order not to overeat and gain weight. Getting adequate amounts of carbohydrate is not a problem since your muscles aren’t moving as much and can use either fat or carbohydrate as fuel. Eating too much carbohydrate leads to weight gain, but eating too much fat does as well since sedentary bodies burn less fat than active ones. Finally, being sedentary seems to disrupt your appetite regulation, so you may actually be hungrier than if you were more active.

Unfortunately, we have become a nation of overweight, sedentary people and as a result are experiencing high rates of diabetes, heart disease, cancer, orthopedic problems and cognitive decline. Our lifestyles are the major determinant of whether or not we suffer from these maladies.

This has been clearly shown in many research studies. For example, a large clinical trial demonstrated that producing a 5 percent weight loss and modest increases in physical activity resulted in a 68 percent decrease in the risk of developing diabetes in those who were most susceptible. If we want to prevent these diseases, we have to change our lifestyles.

Being overweight or obese puts you at a much higher risk of getting a chronic disease and your weight is related to how much you move and what you eat.

I believe our goal is not to identify the best diet for our current sedentary population, but to get people more active and promote the best diet for an active lifestyle. Being well and living a healthy life should not be about deprivation — counting calories and constantly restricting food intake. It should be about building a physically active foundation for wellness and enjoying the food that allows you to maintain a healthy body weight and improves all aspects of mind and body.

This is the lifestyle many people in Colorado lead and should be the lifestyle for everyone in order to maximize wellness.

James O. Hill, Ph.D., is executive director of the University of Colorado Anschutz Health and Wellness Center. He is a global leader in the fight against obesity. This article was first published in the Vail Daily