Posts Tagged ‘heart disease’

Diabetes mystified researchers and doctors for 3,000 years

posted on May 11, 2012

By Ginny McPartland
Heritage writer

Last in a series

In the 16th century famed Swiss physician Paracelsus theorized that salt in the urine caused diabetes.

With an epidemic of obesity looming in 2012, health care providers like Kaiser Permanente face the sad and intimidating prospect of a burgeoning caseload of patients diagnosed with diabetes, a debilitating disease that unless treated will mercilessly kill its victims, young and old.

A disease that baffled physicians until the early 20th century, diabetes is reasonably well understood today, and research has tied its rising incidence to equivalent increases in overweight and obesity. Treatment is sophisticated and can allow for a normal and long life. But getting to this level has been a long road.

Scientists first identified diabetes about 3,000 years ago. In 1552 B.C. an Egyptian physician described it as “polyuria” or frequent urination. In the 1st century, Greek physician Aretaeus dubbed it “the melting down of flesh and limbs into urine.” Until the 11th century, the disease was diagnosed by “water tasters” who drank the urine of people thought to have diabetes to see if the excretion was sweet like honey. In Latin, diabetes is siphon and mellitus is honey or sweet, hence the disease name that endures to this day – Diabetes Mellitus.

In the 16th century, famed Swiss-born physician and astrologist Paracelsus studied diabetes and theorized that salt in the urine caused the disease. (Wrong! It was that other white substance.) French pharmacist and hygienist ApollinaireBouchardat was spurred to experimentation with diet after noticing diabetes symptoms disappeared when food was rationed in Paris during the Franco-Prussian War in the 1870s.

In the late 19th century Italian diabetes specialist Catoni is said to have locked up his patients to get them to follow their special, low-carbohydrate diets. Before the 1920s, a diagnosis of diabetes was a death sentence for most patients. They usually faded away and died within about 18 months. But a grasp on the underlying medical condition remained elusive.

19th century scientific discoveries confirmed the problem – a diabetic’s pancreas was not manufacturing the normal hormone, now known as insulin, needed to properly turn food into energy. Food converted to sugar (glucose) leaked into the urine because the body could not absorb it from the blood. Researchers began to experiment with dogs whose pancreases had been removed so scientists could better understand how the lack of insulin affected metabolism.

1920s development of insulin revolutionizes diabetes care

Unmanaged diabetes often leads to heart disease. Fotosearch image

Eventually researchers developed experimental pancreatic extracts that allowed diabetic dogs to properly digest food. In 1921, Frederick Banting, a young Canadian surgeon, and his assistant Charles Best, kept a diabetic dog alive for 70 days by injecting it with canine pancreatic extract. The same year, Dr. Banting and other physicians refined the experimental insulin and gave it to a young boy dying of diabetes. It seemed like a miracle when the boy’s blood sugar dropped to within normal limits in 24 hours.

At 13, Elizabeth Hughes, the daughter of the U.S. Secretary of State at the time, Charles Hughes, became one of the first children to be treated with insulin. Although she was fading away at only 45 pounds in 1922 when Dr. Banting began her treatment, she recovered and lived to age 74.

Propelled forward by the milestone discovery of insulin, researchers continued throughout the 20th century to make advances in the quest to control high blood sugar and stave off complications such as heart disease, stroke, kidney disease, and eye problems.  In 1935, physician Roger Hinsworth identified two different types of diabetes, juvenile (Type 1), caused by a malfunctioning pancreas from birth, and adult onset (Type 2), a condition caused by the body’s cells becoming resistant to insulin.

Technical advances improve lives of diabetic patients

Also In the mid-1930s, pork/beef insulin and PZT insulin, a longer acting type, became available. In the 1950s, oral drugs called sulfonylureas for controlling blood sugar for Type 2 diabetes patients were introduced. In the early 1960s, urine test strips were developed to test blood sugar levels. This invention made self-care much simpler for diabetics who had been testing their urine by dissolving a chemical reagent in a test tube and making crude insulin dose calculations based on the chemical reaction. Patients had to wait a week for laboratory blood sugar test results.

In 1969, the first blood glucose meter – weighing three pounds and costing $650 – was developed. In 1979, blood sugar meters for home use became standard. Today, many diabetics wear pager-sized pumps that can be set to administer insulin as needed to control blood sugar.

Incidence of both types of diabetes on the rise

Lollipops are a child’s delight but too much sugar can damage a young one’s future health. Fotosearch image

The enhanced understanding of the disease and emergence of better treatment tools have happily coalesced to give providers more power to face the barrage of new cases in recent decades. Experts have sounded the alarm that we are in the midst of a diabetes epidemic that will likely get worse.

In 1900, the incidence of diabetes (mostly Type 1) was low; only one or two per 100,000 children in the U.S. were afflicted. Today, the number of diabetics, both Type 1 and Type 2, is growing steadily. Researchers are struggling to understand the increase in Type 1 (up to 14.3 per 100,000), a condition believed to be genetic. The hike in Type 2 diabetes is attributed mainly to an increase in the number of overweight and obese people.

In 2003, the Centers for Disease Control and Prevention researchers reported that the incidence of diabetes in America had increased by 40 percent between 1990 and 1999, from 4.9 percent to 6.9 percent. In the same article in the Journal of the American Medical Association, authors predicted that the number of diabetics would increase 165 percent between 2000 and 2050. In 2011, the American Journal of Managed Care reported the shocking statistic that 25.8 million Americans are suffering from diabetes. That is 8.3 percent of the U.S. population. High and going higher.

KP Care Management Institute addresses diabetes care

In 1998, the Kaiser Permanente Care Management Institute (CMI) developed the Integrated Diabetes Care Program (IDC) that incorporated the best practices already in use into a uniform, team approach to treating all KP patients with diabetes. New categories of staff were established to specialize in diabetes care; diabetic clinics were set up; and a registry was started to keep track of each patient’s needs and to follow up when necessary.

Diabetes wordcloud. Fotosearch image

More than 70 KP experts worked together to develop a comprehensive program that addressed all aspects of diabetes care. These include:  patient education and self-care, long-term control of blood glucose levels, screening for kidney disease, regular examination of the feet for peripheral vascular disease or nerve damage, screening for heart disease, and periodic checks for vision problems.

A tough prescription: Get active and forsake sugar

Research has for the most part verified that a lack of exercise, excessive consumption of sugary snacks and sodas and refined carbohydrates such as white bread, rice, and potatoes, are to blame for the rise in diabetes diagnoses. The challenge for society, medical science and individuals is to reverse this trend. How can we do that?

Kaiser Permanente has been promoting healthy eating and exercise – the prescription for weight loss and prevention of chronic disease such as diabetes – since World War II in the Kaiser Richmond Shipyards. In the late 1960s, a new emphasis was placed on wellness and prevention of chronic disease when KP Northern California opened the first health education center in Oakland. The idea soon caught on in all KP regions, and today a core curriculum is offered in most medical center service areas across the country.

KP’s core Healthy Living courses offered include: healthy lifestyle and weight management, a 10-session program that addresses good nutrition, stress management and physical activity; Weight Watchers TM, a balanced diet program that encourages exercise; Pilates; Personal Health Coach, a program that offers individual support for members to reach their health goals; Fitness for Women 40 and Over; and discounted memberships in community health clubs.

Specifically for members with diabetes or concerns of developing diabetes, KP health education core classes include:  diabetes basics; diabetes foot care; blood glucose meter training, diabetes nutrition, Type 2 diabetes support group, diabetes update, carbohydrate counting for diabetes; prediabetes; insulin pump support group and even a healthy grocery shopping tour for people with diabetes.

Weight of the Nation - HBO series on obesity

Home Box Office series premiers May 14

Kaiser Permanente also offers on-line Healthy Lifestyles programs that include: CareTM for Diabetes, BalanceTM for weight loss; RelaxTM to reduce stress; NourishTM for healthy eating; BreatheTM to stop smoking; Care for Your HealthTM for managing chronic conditions, including diabetes; and Care for PainTM for chronic pain management. Members can also access SucceedTM a total health assessment that offers advice on how to achieve your health improvement goals. http://bit.ly/dmza66

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) documentary series the obesity epidemic and its consequences. The four-part series airs on May 14 and 15. For more about KP’s fight against obesity: http://bit.ly/IJHVhm

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Century of scientific discovery beats down heart attack rates

posted on May 11, 2012

By Ginny McPartland
Heritage writer

Fourth in a series

In 1772, Edward Jenner, an English physician, was the first to postulate that hardened coronary arteries in autopsies was a probable cause of heart disease. Photo courtesy of Jenner Museum in Berkeley, England.

In 1956, my grandfather died suddenly of a heart attack. He was 56.   I never got to know him.  Grandpa Barr, a life-long inhabitant of rural Iowa who had weathered the Great Depression and sent a son to war, didn’t know what hit him. He had no idea he had heart disease, and even if he had been diagnosed, his small town doctor had little in his black bag to prevent his early demise.

In the 1950s, physicians and researchers had no more than an inkling of how they could treat cardiovascular disease. In fact, physicians weren’t sure of the causes of heart attacks, and researchers were struggling to put together the heart disease puzzle.

Fifteen years later my mother told me she would probably die of a heart attack in her 50s like her father. Almost true to her prediction, she developed heart disease in her 60s. In her 70s she told me she was living on “borrowed time.” Maybe she was, but with lots of drugs, plenty of visits to the medical center and the installation of a pacemaker, she made it to the age of 87.

The difference between my mother’s fate and her dad’s is an amazing body of research and advances in technology that makes it routine in 2012 for doctors to be able to extend the lives of heart disease victims by decades.

A kernel of evidence emerges in the 18th Century

The earliest recognition of what might cause heart attacks was documented in 1772 when Edward Jenner, an English physician, noted hardening of the coronary arteries in the autopsy of a heart attack patient under his care.

“. . .after having examined the most remote parts of the heart, without finding any means for which I could account for his sudden death, or the symptoms preceding it, I was making a transverse section of the heart pretty near its base when my knife struck against something hard and gritty, as to notch it. I well remember looking up at the ceiling, which was old and crumbling, conceiving that some plaster had fallen down. But on further scrutiny the real cause appeared: The coronary arteries had become bony canals,” Jenner wrote to his colleague, Caleb Hillier Parry.

In 1938, O.F. Hedley, MD, a Philadelphia public health official, discussed Jenner’s letter in an article in the American Journal of Public Health (AJPH). “The opinion Jenner expressed concerning the progressive nature of the underlying changes was prognostically prophetic, for medical science still waits methods for preventing coronary artery disease or satisfactorily postponing its more serious consequences.”

Long journey to understanding heart disease

Many decades have gone by since Jenner first implicated atherosclerosis (hardening of the arteries) as a culprit in heart disease. In the intervening years, researchers have inched forward in their quest to bring down the heart disease death toll.

In 1921, heart disease became the leading cause of death in the United States, according to mortality data collected by the Census Bureau. New York’s heart attack rate was soaring at the time.

In a 1927 AJPH article, William Munley, a New York physician, reported that between 1910 and 1925, New York City’s deaths from heart disease had increased by 50 percent – from 175 per 100,000 population to 266 per 100,000. He estimated that 2 million Americans were afflicted with heart disease at that time.  The statistics had shifted so that atherosclerotic heart disease accounted for 40 percent of the deaths while rheumatic heart conditions made up 25 percent. (Syphilitic heart disease made up 10 percent with the rest in the category of unknown cause.) Rheumatic heart disease, thought to be the main cause of heart attacks and failure until the 1920s, had been largely conquered through public health efforts to eradicate rheumatic fever, which often left a damaged heart.

Munley wrote: “We have no established facts concerning the prevention of the degenerative types of heart disease. It is true that much has been written of the physical stress and nervous strain of the present-day (1927) mode of living as a factor in the production of high blood pressure and hardening of the arteries.  .  . While no preventive methods are at present known for this type of disease, people can be taught the right way to live. Though we cannot cure this disease, we can hope to relieve some of the suffering produced by it and thus hope to prolong life.”

So that was medical researchers’ mission for the next six decades: find ways to treat coronary atherosclerosis and high blood pressure to prevent early death. Technical advances in the 1920s and 1930s gave birth to the first blood pressure monitor and the electrocardiogram (EKG), both useful diagnostic tools. Researchers also forged ahead to discover ways to prevent heart disease, and other chronic conditions, through exercise and dietary and lifestyle changes.

Federal government gets into the act

A wise advertiser suggested eating salad for good health as early as 1929.

In 1948, the federal government, recognizing heart disease as a growing threat to public health, sponsored the Framingham Heart Study, a compilation of the health data of thousands of ordinary people in Framingham, Massachusetts. Data collected initially from 6,000 residents was used to make the connection between the study group’s health, diet, medical history and lifestyle and the eventual development of heart disease. The now-legendary project has followed three generations and spawned over 1,200 research articles, shedding light on many aspects of heart disease.

In the early 1960s, the Framingham researchers published results that showed cigarette smoking, high cholesterol levels, high blood pressure and abnormalities in EKG results indicated increased risk for heart disease.  In 1967, they found that physical activity reduced the risk of heart problems while obesity increased the probability.

In 1970, they published studies that identified high blood pressure and atrial fibrillation (uncontrolled fast heart rate) as risk factors for stroke.  In 1976, they found menopause increased the risk of heart disease; in 1988, they learned that high levels of the “good” cholesterol HDL (from fats such as avocados, olive oil, fish oil and nuts) reduced the risk of heart disease.

KP researchers undertake key studies

Longshoremen queue up for their KP multiphasic health screening in 1961 on the San Francisco waterfront.

Meanwhile, other organizations, including Kaiser Permanente, were conducting studies of their own. In 1959, KP joined with the Public Health Institute and UC Berkeley for the Child Health and Development Studies (CHDS), a collection of data from 15,000 East Bay pregnant health plan members from 1959 to 1967. CHDS scientists continue to use the data collected 50 years ago to study biologic, behavioral, genetic and environmental factors in early family life and how they affect the health of the subjects as adults.

In 2010, these researchers published a study that established a connection between preeclampsia (high blood pressure and protein in the urine) in pregnancy and heart disease later in life. Of the women who participated in the early study, 481 developed preeclampsia and 266 of them died of cardiovascular disease many years later. This link gives physicians and patients knowledge of an increased risk that can be ameliorated with preventive measures. CHDS researchers are taking the longitudinal study to a new level today by following up with the adult children whose mothers participated in the initial study.

In 1971, researchers in the California Department of Public Health and the University of California at Berkeley published an 18-year follow-up study of 3,263 Oakland and San Francisco longshoremen who participated in the Kaiser Permanente  multiphasic (comprehensive health check-up) examinations in 1951. The study revealed that 350 of the participants – all male –  had died of heart disease and 93 of stroke by 1970.

Researchers separated out the high- and low-risk populations and identified four categories associated with cardiac death: already having heart disease and/or high blood pressure, smoking one or more packs of cigarettes a day and being overweight. The study also found that the heart attack rate was less for men who had physically demanding jobs.

Total Health Project focuses on prevention

Kaiser Permanente researcher Steve Sidney, MD, tests a CARDIA participant on a treadmill. KP Division of Research photo.

By 1981 the understanding of what causes heart disease had progressed far enough to spur KP founding physician Sidney Garfield to launch a study essentially to test patients’ willingness to change their lifestyle to prevent chronic disease. He invited new KP members to complete a health self-assessment and to have a comprehensive physical at the experimental Total Health Center in Oakland. The participants were encouraged to avail themselves of expanded groundbreaking health education services to learn more about how to preserve their good health.

The Total Health Project gave rise to enhanced health education services throughout the KP health system so physicians could refer their patients to programs that could help them prevent disease and to manage chronic disease when it struck.

In 1985 the Division of Research (DOR, Oakland, CA) collaborated on a study of young adult men and women, black and white, from Oakland, Chicago, Minneapolis and Birmingham, Alabama. The Coronary Artery Risk Development in Young Adults (CARDIA) followed 5,000 Americans who were 18 to 30 years of age in 1985-86 to middle age 20 years later.

The 20-year follow-up study showed that the participants gained an average of 30 to 35 pounds. Testing of the participants, now 38 to 50 years of age, showed that 18 percent had calcification of the coronary arteries (atherosclerosis, a precursor to cardiac disease).

Evidence of early disease was most common in those whose high fat diet and lifestyle increased their risk. The CARDIA researchers also found that individuals who continued to be physically active into middle age, particularly women, gained less weight over the years compared to those who were sedentary.In 1998, a KP Division of Research team worked with UC San Francisco to study the usage and effectiveness of beta-blocker drugs prescribed for patients after an acute myocardial infarction (heart attack). The research team focused on 396 patients who took beta-blockers and compared their experience with the rest of the 1,050 study group. They concluded the use of beta-blockers, even in a lower dose than initially recommended, resulted in 38 percent fewer heart attack deaths.

Kaiser Permanente South Sacramento Planning for Health newsletter graphic promoting a preventive medicine class, 1990.

Physicians associated with Kaiser Permanente’s Center for Health Research (Hawaii and Oregon) collaborated in studies in 1995, 1997 and 1999 to assess the success of the Dietary Approaches to Stop Hypertension (DASH) trial involving Americans with high blood pressure. Ethnically diverse study subjects followed one of three diets in the research carried out in four clinical centers across the country.

In the 1999 study, hypertensive participants who followed the DASH fruit and vegetable diet or the expanded combination diet, which also included whole grains, low-fat dairy, fish, poultry and nuts, experienced significant reductions in 24-hour blood pressure. The others who continued to eat a regular American diet of red meat, sweets and sugary soda saw no reduction in blood pressure.

KP’s aggressive approach to heart disease two-pronged

In the past decade, Kaiser Permanente has made great strides in attacking heart disease. On the research front, studies have been done to validate drug therapies (i.e. beta blockers, aspirin, etc.) that stave off heart attacks and keep heart disease patients alive. This research includes a major study between 1999 and 2008 that showed a marked decrease in the number of KP patients who died following a heart attack.

In 2010, KP’s Division of Research published “Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction,” in which they reported a 24 percent decrease in heart attacks among KP patients during the study period. They also reported a 62 percent decrease in serious heart attacks that do permanent damage in the same time frame. This decline in heart attacks contributed to the KP Northern California region’s status as an island where heart disease is no longer the number one cause of death, as it is in the rest of the country.

KP’s second approach is prevention with a capital “P.” In the literature it’s sometimes called “primordial prevention.” This is defined as the individual’s commitment to improve his or her lifestyle to maintain a healthy weight, exercise and avoid heart disease. Kaiser Permanente’s “Thrive” campaign, launched in 2004, was initiated to highlight the health education and prevention programs that help KP members to keep their risk of chronic disease low.

Weight of the Nation - HBO series on obesity

Home Box Office series premiers May 14

Farmers’ Markets sponsored in every KP region, Community Benefit programs to reach out to underserved populations living in healthy food “deserts,” online Healthy Lifestyle programs, “Everybody Walks,” “Safe Routes to School,” and other exercise campaigns, as well as participating in community health promotion events, all contribute to KP’s Community Health Initiative.

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) documentary on obesity in America that premiers on May 14 and 15. For more information about KP’s part in fighting this epidemic: http://bit.ly/IJHVhm

Next time: Diabetes mystified researchers and doctors for 3,000 years.

 

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Obesity: a runaway trend predicted to sabotage health of the nation

posted on May 8, 2012

By Lincoln Cushing
Heritage writer

"Fear of Fat" in the March 1984 KP Reporter newsletter warned of going too far with weight consciousness.

Second in a series
Efforts to combat obesity, childhood obesity in particular, are making news. Examples include First Lady Michelle Obama’s signature public health campaign “Let’s Move!” the Home Box Office (HBO) documentary series “The Weight of the Nation,” and the popular charge to incite health providers, schools and communities to join the fight to stop the spread of obesity.

But the current attention devoted to this issue in a culture obsessed with fad diets and alarmist health news raises the question: Is this really a significant problem?

To begin with, medical experts do not universally acknowledge “obesity” as a disease, like AIDS or lung cancer. There have always been overweight people, and for many the driving concern for weight loss has been more about the aesthetics of body image than physical health.

But two significant and disturbing facts have changed over the past two decades. First, for reasons not fully understood, there has been a measurable increase in the numbers and demographic distribution of obese people. And second, there has been an accumulation of research linking excess body weight to bad health.

The obesity epidemic

Data reveal our population’s progressive ponderosity over time. Medical concern over weight and obesity show up in the mid-1960s. A 1965 UC Berkeley student paper by a physician noted “Estimates run as high as 25 million overweight Americans (based on desirable weights taken from actuarial tables). Some epidemiologists might consider that we have an epidemic of obesity in America. . . A tremendous amount of time, effort, and money is being devoted to the understanding of the problem of obesity and its significance and solution. Diet foods are a multimillion dollar industry. The military attempts to legislate weight and physical fitness with compulsory standards.”1

A 1984 article in Kaiser Permanente’s KP Reporter noted that the Metropolitan Life Insurance Tables showed that a “surprising” 40% of American men and 55% of American women were overweight, currently defined as those having a Body Mass Index (BMI) between 25 and 29.9. The more serious condition is obesity, with a BMI over 30. (BMI is computed by dividing a person’s weight by the square of his or her height.)

A 1987 Planning for Health Kaiser Permanente (KP) member newsletter article stated that “Obesity is our nation’s number one nutritional problem.”  Last year the Centers for Disease Control and Prevention reported that between 1980 and 2008, obesity rates had doubled for adults and tripled for children. During the past several decades, obesity rates for all population groups — regardless of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region — increased markedly. More than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are considered obese.

KP promotional brochure for its Oakland weight control program in 1973

The main reasons proposed for this alarming phenomenon include a more sedentary lifestyle, unhealthy diet, a proliferation in the use of sweeteners (first the “white death” sugar, eclipsed now by high-fructose corn syrup) in food products, and lack of exercise.

Even greater use of worksite microwave ovens during the 1980s was described as adversely affecting healthy eating habits. But other, more complex, causes have been proposed as well, and Kaiser Permanente has embraced a range of treatment modalities and education techniques to help keep members healthy.

Nutrition and health

Doctors advise patients to eat right and in moderation, with increasing medical evidence supporting the case that excess weight contributes to life-shortening conditions such as diabetes, heart trouble, and high blood pressure. Kaiser Permanente early on recognized that the changing dietary behaviors of its members were having a negative effect on waistlines.

Fast food chains, offering cheap high-fat, high-sugar, and high-salt meals, grew enormously during the 1960s and 1970s. Soon KP challenged this trend as an unhealthy one.  A 1987 Planning for Health newsletter posed the question, “Burger King, McDonald’s, Wendy’s, Jack-In-The-Box. Everyone is familiar with the names of these fast food restaurants. But how many of us are aware of the ingredients found in their food? Take a few moments to complete our Fast Food Facts quiz.”2

Mary Wheeler, PhD, with young Ohio patient enrolled in the Optimal Growth Center weight management program. KP 1979 Annual Report photo.

Influencing young people to eat a healthy diet and control their weight is crucial. In 1975, developmental psychologist Mary Wheeler, PhD, and pediatrician Karl Hess, MD, in KP’s Ohio Region started the Optimal Growth Center to help overweight children learn new eating habits. They addressed the social stigma of being overweight, with the long-term view that if they didn’t change their condition they would face significant risks of hypertension, heart disease, and diabetes as adults. 3

Education and outreach

As early as 1956, the Oakland Kaiser Permanente staff realized that peer groups could help people lose weight, and they instituted a group treatment program for overweight patients. In small, informal, round-table support groups of eight to 10 participants, physicians offered information and the group discussed mutual problems.

How much should you weigh? An illustration from "The Importance of Diet" in Planning for Health KP member newsletter, Spring 1965.

In the late 1980s, Kaiser Permanente Nutrition Services Departments hosted workshops for members on subjects such as “The Right Way to Good Nutrition.” One Health Plan member who benefitted from the program commented, “When I had a physical last fall, my physician said I was showing signs of arteriosclerosis (hardening of the arteries). After taking three nutrition workshops, I recently had another physical. My cholesterol count was down 20 points and I’ve lost 11 pounds.”4

One successful medium for reaching youth is KP’s Educational Theatre Project. For 25 years the troupe has used live performances at public schools to engage youth audiences on a range of health subjects, including childhood obesity in “1½” and “Give Peas a Chance.” In 2007 KP partnered with educational publisher Scholastic, Inc., to launch an online game based on another play, “The Amazing Food Detective,” teaching children about healthy eating and maintaining an active lifestyle. The game automatically shut off after 20 minutes and encouraged players to get up and exercise or perform some activity away from the computer screen.

Kaiser Permanente was also quick to acknowledge the role that gender and social (rather than medical) standards played in defining “desirable” weight.  Second-wave feminism of the 1970s challenged the standard guidelines, noting that women were particularly susceptible to exaggerated concerns about weight that could have negative health consequences of their own.

A 1984 KP Reporter article “Fear of Fat” asked: “Why have we saddled ourselves with an ideal of beauty which torments most women over the age of 20, not to mention many teenagers? One reason is purely commercial. Fifth Avenue has chosen human clothes-hangers who can model any style of clothing.” It goes on to say: “Kaiser-Permanente offers weight-loss programs that do not make a fetish about fat but rather stress good nutrition, exercise, and behavior modification.”

Obesity as a shield against attention

Another connection between self image and weight came out of research conducted by the Southern California Permanente Medical Group. In 1982 Vincent J. Felitti, MD, then a San Diego Kaiser Permanente internist, developed a program to help obese people lose weight, which matured into the Positive Choice Weight Loss Program in 1985. He was confounded by the observation that many of those who experienced success began to drop out. After studying hundreds of patients he learned that many were unconsciously using their obesity as a shield against unwanted sexual attention, a behavior based on experiencing physical or sexual abuse as children.

Subsequent research resulted in a comprehensive assessment protocol, Adverse Childhood Experiences (ACE), that examines the hidden legacy of childhood trauma and helps identify patients for whom conventional weight reduction programs don’t work. More than 17,000 San Diego KP members have been diagnosed using ACE and the study has produced 72 scientific publications thus far.

Weight of the Nation - HBO series on obesity

Home Box Office series premiers May 14

As Dr. Felitti describes it, “The program involves the essential linkage of two disparate elements: prolonged absolute fasting using the supplement “Optifast” to preserve health in the absence of food intake, and a psychodynamic approach whose function is to help each person discover the unconscious forces underlying their use of eating for its psychoactive benefits and the possible advantages of obesity in their life. Using this approach it is possible to reduce a person’s weight about 300 pounds in a year and help them tolerate that emotionally.”5

Kaiser Permanente has supported efforts to make fresh fruits and vegetables available to more people, helping local convenience stores stock healthier products and bringing grocery stores to “food desert” neighborhoods. Preston Maring, MD, started the first KP-sponsored farmers’ market at Oakland Medical Center in 2003. These efforts are now successfully replicated in many community and KP facilities, often coupled with nutrition information and other healthy lifestyle outreach. For more about KP farmers’ markets: https://members.kaiserpermanente.org/redirects/farmersmarkets/in-northwest.htm

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) upcoming documentary series “Weight of the Nation,” which covers the issue of obesity in America. For more information about KP’s involvement in the fight against obesity: http://bit.ly/kptwotn

Next time: Kaiser Permanente was about fitness before fitness was cool

1 “Obesity and its Measurements as it Relates to a Multiphasic Screening Program,” by Clarence F. Watson, MD; student paper from UC Berkeley public health class PH274A, Fall, 1965. Dr. Watson’s essay makes the case that “skinfold measurement” using calipers rather than BMI is a more accurate indicator of obesity.

2 “Fast Food Facts,” Planning for Health newsletter (Richmond edition), Winter 1987-1988

“Helping Overweight Children,” KP Annual Report 1979

4 “The Path to Good Nutrition,” Planning for Health newsletter (Vallejo/Napa/Fairfield edition), Summer 1988

5 Email correspondence from Dr. Felitti 3/22/2012. For more about Dr. Felitti’s California Institutes for Preventive Medicine: http://www.caipm.org/about/index.html

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Researchers strive for decades to solve mysteries of Total Health

posted on May 6, 2012

President Dwight D. Eisenhower had a heart attack in 1954 and lived to urge all Americans to change their diets and exercise habits to avoid heart disease and other chronic disease. In the early 1960s, John F. Kennedy called us “soft” and in danger of losing our physical and intellectual edge. He referred to Americans’ documented lack of muscle tone as a trend that had to be reversed. For a time, we took his message seriously and began to exercise, some of us furiously.

But despite the heavily publicized advice of these powerful men – and God knows the urgings of our doctors – we find ourselves in 2012 with a startlingly high rate of obesity, overweight and resultant chronic illness, including heart disease and diabetes.

Understanding the connection between healthy living and good health didn’t come easy. Over the last 100 years, physicians and researchers have been studying chronic disease and looking for ways of saving and lengthening lives. They’ve made a lot of progress.

This “History of Total Health” series spotlights the milestones in the journey of scientists and physicians, including Kaiser Permanente practitioners, to help patients achieve Total Health, a concept KP has embraced since World War II in the Kaiser Shipyards. In five parts, we describe the evolution of knowledge of the causes of chronic disease and how it can best be prevented and managed. Below is the first part in the series.

— Ginny McPartland

Childhood artery changes may signal heart disease in later life

By Bryan Culp
Director of Heritage Resources

First in a series
In 1965, Martin Reisman, MD, a Kaiser Permanente pediatric cardiologist and clinical professor at UCLA School of Medicine, warned of the danger of a fatty diet in childhood leading to early onset of coronary heart disease. His supposition that this disease may begin in the young and that pediatric intervention is called for was not the prevailing view.

“The present standard American diet is a major contributing factor in the etiology of atherosclerosis [the fatty deposits of plaque that accumulate in arterial walls]. “The larger part of the ‘incubation period’ of this disease may very well be the first two decades of life, and a modest change in diet, instituted early and sustained through life, might be clinically significant.”

In the future, Reisman said, “our pediatric nutritionists will have to concern themselves . . . with the long term consequences of prevailing childhood diets.”  Studies of the disease “should begin to appear in the table of contents of our pediatric journals and on the agenda of our meetings and conferences.  It is time for us to join intellectually with our colleagues in adult medicine, and concern ourselves with a disease that is probably a mutual responsibility.”

The doctor confessed that his speculations though shared by a few pediatric cardiologists were a “personal groping in a yet incompletely charted field of possible pediatric responsibility.” 1

Kaiser Permanente pediatric cardiologist Martin Reisman, MD, published in the Journal of Pediatrics in 1965.

Reisman’s warnings seem prescient today

If Reisman’s recommendations 50 years ago were “speculative,” they seem prescient today.  The alarm sounds on the incontrovertible evidence that empty calories and sedentary lifestyles have dramatically increased the incidence of overweight and obesity, a known driver in heart disease. One third of the nation’s young, ages 2 to 19, and two-thirds of the adults 20 years and older are overweight or obese.

The impact of overweight or obesity on the quality of life for both the young and older is real.  The afflicted often suffer from high blood pressure; higher rates of joint, kidney, and gall bladder disease; from issues in infertility; and higher rates of psychological depression.  Worse, overweight and obesity factor into five of the 10 leading causes of death in this country, including coronary heart disease, Type 2 diabetes, cancer, stroke and kidney disease.

“Obesity has become one of the most serious threats to the health of the American people,” says Harvey Feinberg, MD, President of the Institute of Medicine.  And Francis Collins, MD, director of the National Institutes of Health, has said that we must face this or “face, for the first time in our history, a situation where our children are going to live shorter lives than we do.”

Debate on nutritional intervention

In 1959, R.L. Holman, MD, titled his address to the Ninth International Congress of Pediatrics provocatively: “Atherosclerosis – A Pediatric Nutrition Problem?” He said any disease that is responsible for 54 percent of the deaths in the U.S. “is a pediatric problem, but whether it is a nutritional problem, I am not too certain.”

Citing autopsy studies, Holman traced the progress of the disease in a four-stage development starting in infancy with the presence of fatty streaks in the aorta; the development of fibrous plaque in the second decade of life; lesions and ulceration follow in the coronary arteries; then as early as the fourth decade of life, atherosclerosis and the onset of clinical manifestations like heart attack and stroke.

Absent in his concluding remarks are the words so familiar in today’s lexicon on coronary heart disease – mention of the preponderance of empty calories, and worrisome lipids and cholesterols in the blood.  Holman concludes saying fatty streaks in the aorta occur in infancy, are universal the world over, appear to be independent of ethnicity, and accelerate down the path to aggravation and illness beginning in puberty.  He offered no dietary recommendations in pediatric
care. 2

Isidore Snapper, MD, (1889 --1973) discovered benefits of a diet low in harmful cholesterols and rich in polyunsaturated fats. Photo courtesy of the Mount Sinai Hospital Archives.

Snapper compared Eastern and Western diets

There were others at the time who joined the debate citing evidence of the role of diet in the progression of coronary heart disease, prominent among them the irrepressible Isadore Snapper, MD, Chief of Medicine at Mount Sinai Hospital in New York City.  Snapper is remembered for throwing clinical light on the benefits of a diet low in harmful cholesterols and rich in polyunsaturated fats.

A physician of international reputation in service to royalty in his native Holland, Snapper was recruited by the Rockefeller Foundation in the 1930s to become chief of medicine at the University of Beijing where he did research and published on the  causes of cardiovascular disease.

In popular work, Chinese Lessons to Western Medicine (1941), Snapper contrasted the rates of heart disease among Chinese and Westerners, their different levels of blood cholesterols and attributed the cardiovascular health in the Chinese population to diets rich in plant foods.

In 1963 Snapper weighed in on the debate on the prevention of the disease in children in the American Journal of Cardiology.  If Holman were reticent on the effects of diet and nutrition in the onset of the disease, Snapper was anything but.  He said the disease could only be prevented early if a diet high in a ratio of polyunsaturated to saturated fat (P/S ratio) is “introduced in early childhood immediately or soon after the child is weaned, as is the custom in the Orient.

“The difficulties of the implementation of this proposal may well be insurmountable.  The myth that a daily intake of 800 cc of milk rich in saturated fats is mandatory for normal calcium metabolism can probably never be destroyed.  This, despite the fact that most clinicians today recognize that it is dangerous to encourage children to stuff themselves with milkshakes, ice cream and other foods with unsatisfactory P/S ratios.” 3

Debate among pediatric cardiologists continued in the 1960s

The debate among experts in pediatric cardiology on the role of diet and nutrition continued through the 1960s, and discussions continued on the pediatrician’s responsibility in preventing heart disease.

The American Academy of Pediatrics’ Committee on Nutrition took up for consideration the newly released “Report of the Inter-Society Commission for Heart Disease Resources: Primary Prevention of the Atherosclerotic Diseases” (1970) and issued its recommendations on it in 1972.

In its report “Childhood Diet and Coronary Heart Disease,” the academy concluded that dietary intervention was experimental at the time and recommended against sweeping changes in children’s diet.

“Unproven preventive measures should be tested first in a group at exceptionally high risk of disease,” the committee reported.  Though children at excess risk should receive preventive therapies, “a nationwide alteration in diet may well impair the sense of well-being of the general public.” 4

The academy’s caution surfaced a view within the pediatric community that early screening for heart disease risk may do more psychological harm than medical good.

Also in 1972, others were reporting research studies and looking up the road. “The technologic revolution has provided a surfeit of food at the same time that physical activity has been curtailed.  Eating habits, indolence and sedentary living habits, propensity to obesity, and possibly the cigarette habit” require pediatric intervention, wrote the authors of one study.

With food choices conditioned in childhood, they argued, “It would seem reasonable for pediatricians to counsel mothers on the feeding of a diet emphasizing skim milk, cottage cheese . . . legumes, fruits, starches, lean meats, poultry and fish.”

Citing evidence that atherosclerosis has its origins in childhood, the authors concluded that the prevention of obesity, early screening for lipid abnormalities, nutrition and diet intervention, the promotion of exercise, and the discouragement of cigarette smoking should involve the intervention of the pediatrician. 5

Bogalusa Heart Study confirms childhood diet and disease connection

Also in 1972, researchers at Tulane University School of Medicine launched what has become a definitive long-term study of the early natural history and development of coronary artery disease.  The Bogalusa Heart Study (1972 – present) has tracked vital data on children’s heart health in Bogalusa, Louisiana, a black/white rural community on the Louisiana/Mississippi border. More than sixteen thousand individuals have been tracked over three decades from infancy into adulthood. From the study emerges a clear picture of the beginnings of cardiovascular disease in the young.

Among the study’s key findings:

    • Heart disease may begin in childhood and there is a clear relationship between diet and cardiovascular health;
    • Autopsies of young participants who were killed in accidents provide clear evidence that fatty buildup forms in the aorta in the first decade of life with documented anatomic changes occurring by 5 to 8 years of age;
    • Cholesterol levels are predictors of arterial plaque;
    • Children who are overweight have a high risk of becoming overweight adults – excess weight tracks from childhood to adulthood;
    • Obesity in children and adolescents is related to elevated cholesterol and elevated blood pressure and these track from childhood to adulthood. 6
Weight of the Nation - HBO series on obesity

Home Box Office series premiers May 14

The Bogalusa Heart Study confirmed pediatric responsibility in the prevention of coronary heart disease.  Though atherosclerosis is “a silent disease” with clinical manifestations occurring later in life, the pediatrician, as Dr. Reisman understood, should intervene with clinical guidance in sound nutrition, the control of overweight and obesity and recommendations for regular physical activity.

The Bogalusa Heart Study is featured in “Consequences,” the first episode of “The Weight of the Nation,” a documentary series on the national obesity epidemic airing on Home Box Office (HBO). The series will air May 14 and 15.

Sponsors of the series include Kaiser Permanente, The Michael and Susan Dell Foundation, the Institute of Medicine, the National Institutes of Health, and the Centers for Disease Control. For more about the “Weight of the Nation” series: http://bit.ly/kptwotn

Next time: Obesity: a runaway trend predicted to sabotage health of the nation

1 Reisman M, Atherosclerosis and Pediatrics, Journal of Pediatrics, 66, no. 1, 1965.
2
Holman RL, Atherosclerosis – A Pediatric Nutrition Problem? American Journal of Clinical Nutrition, 9, 1961.
3
Snapper I, Diet and Atherosclerosis: Truth and Fiction, The American Journal of Cardiology, 11, no. 3, 1963. See also Snapper I, Chinese Lessons to Western Medicine, Grune & Stratton, New York and London, 1941 and 1965.
4
Childhood Diet and Coronary Heart Disease, Committee on Nutrition, American Academy of Pediatrics, 49, no. 2, 1972.
5
Kannel, WB, et al., Atherosclerosis as a Pediatric Problem, Journal of Pediatrics, 80, no. 4, 1972. See also Voller RD, Pediatric Aspects of Atherosclerosis, American Heart Journal, June 1981.
6
Berenson, GS, et al., Atherosclerosis: A Nutritional Disease of Childhood, American Journal of Cardiology, 82 (10B), 1998. See also Tulane University Center for Cardiovascular Health, “History of the Bogalusa Heart Study, 1972-2005,” at www.tulane.edu/som/cardiohealth.

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