By Ginny McPartland
The spectacular 75-year-old Golden Gate Bridge shares more stories with the World War II West Coast shipyards than you might think. Both the opening of the bridge in May of 1937 and the gritty toil of Home Front workers are being celebrated this Memorial Day weekend.
The bridge paved the way for major commercial and residential expansion into Marin County and the North Bay counties; the construction of warships in Richmond played a big part in winning the Second World War.
Though the two events took place four years apart, the connection between the two stories in Pacific Coast defense history is strong. After the attack on Pearl Harbor in 1941, the entrance to San Francisco Bay – the Golden Gate Strait – was key in keeping the West Coast safe. Blackouts, battlements on bluffs around the Bay, defense mining of the harbor and a huge net to keep hostile submarines out all figured in the military’s response to the threat of attack.
Fear of an impending enemy strike subsided after a time, but the imposing and graceful Golden Gate Bridge took on epic proportions as a symbol of America, friendly territory, and home. Between 1942 and 1946, innumerable sailors and soldiers gave the bridge a silent kiss goodbye on their way out to war.
When they steamed back into San Francisco Bay at war’s end, most servicemen let out an uncontrollably boisterous shout of joy at the sight of the iconic bridge painted International Orange. Mere boys when they shipped out, they came home as men who had seen it all, or so it seemed.
Kaiser-built ships cruised under bridge on way to hostile waters
Many of those men were traveling in ships built by workers at the Kaiser Richmond Shipyards. In perfect tandem with the Golden Gate Bridge 75th anniversary celebration, Rosie the Riveter Home Front national park is celebrating the grand opening of its long-awaited Visitor Education Center on the Richmond waterfront. The new center, housed in the beautifully refurbished former Ford Company oil house, offers the stories of the Kaiser shipyards, including the health care program that is now Kaiser Permanente. (For more, see “Richmond fans get sneak peek at Rosie Park visitors’ center,” posted May 1, 2012.)
The Rosie park event includes opportunities to walk and bicycle in a ranger-guided parade along the two miles of the San Francisco Bay Trail adjacent to the former Kaiser Shipyard 3. The path, along Canal Boulevard past the restored shipyard cafeteria, will be dedicated Saturday as part of day-long activities sponsored by the Rosie park. The tour will end with an open house at the Red Oak Victory, a Kaiser-built war ship that has been restored as a museum. For more: http://bit.ly/tetBIp
These activities gel nicely with Kaiser Permanente’s ongoing “Every Body Walk!” public health campaign. KP is one of the major sponsors of the Golden Gate Bridge 75th anniversary celebration on the other side of the bay.
The Golden Gate Bridge’s past includes walking activities – the bridge was first opened to pedestrians on Thursday, May 27, 1937, the day before the official opening. About 200,000 pedestrians crossed the spanking new span on that day. During the 50th anniversary in 1987, about 300,000 people traversed the span on foot during “Bridgewalk ’87,” an event that challenged the strength of the structure. Bridge engineers said the heavy human load shifted the bridge’s profile and its “normal convex shape was flattened.” This year’s event doesn’t include a walking opportunity.
You can find out more about the Kaiser Permanente’s walking initiative by visiting the KP tent and bicycle storage area on San Francisco’s Marina Green Saturday and Sunday (May 26-27). See below for details.
Troops swooned over the Golden Gate span
Many war veterans have written memoirs of their experience going overseas to fight a war, and it’s not uncommon to find passages describing emotions connected with the Golden Gate Bridge. John H. Dougherty, a crew man on LST (Landing Ship, Tank) 481 built in 1942 at Kaiser Richmond Shipyard 3 recalls:
“To get to San Diego, we first had to find our way out of San Francisco Bay in a very heavy fog. . . A group of us were standing outside of the galley passageway when someone happened to look through to the other side and saw some fog-shrouded land where there definitely was not supposed to any. Surprise! There was Alcatraz, practically at our door step!
“The ship was so close that the screws stirred up a lot of muddy water as we passed the island. At 0845 hours, the anchor was dropped just off Alcatraz to wait for the fog to lift.
“By 0920, we were under way once more, and at 10:46 we headed out under the Golden Gate Bridge into the mighty Pacific Ocean. Any doubts the crew might have had about the ability of the ship to sail out of sight of land and return safely were erased when we successfully sailed into San Diego Bay on May 26.”
Quoted in a recent Nob Hill Gazette article, Peter Robinson, a World War II Navy veteran, remembered:
“I sailed out for the South Pacific, uprooted from the comfortable life I had known and suddenly, at 18, I was going to war. I was scared. In the early morning my ship approached the Golden Gate Bridge, lighted by the dawn, dappled by wisps of fog. I looked at the bridge and smiled, ‘I’m going to come back and see you again.’ And I did.”
Navy veteran Michael Gioseffi of Healdsburg, California, tells a similar story, also quoted in the Nob Hill Gazette:
“I was 17 in 1944 and joined the Navy. In 1945, I shipped out for the Philippines. It was a warm, sunny day; and it was the first time I had seen the Golden Gate Bridge. I was surprised that the color was orange. I looked up at it and asked myself, ‘What’s going to happen to me?’ I sailed under the bridge again the following year, on my way home, pleased to be alive and unhurt.
“And every time I see the bridge today, I think about my question in 1945, ‘What’s going to happen to me?’”1
Richmond Shipyard 3-built LST 481 returns from war duty
When LST 481 returned to the San Francisco Bay in December 1945, Dougherty was not on board having been transferred to another ship at the end of the war. But he watched the ship leave Pearl Harbor bound for California and recounts the story of the ship’s final trip home:
“The final leg of her journey would take her to San Francisco, starting from Pearl Harbor at a speed of 9 knots, soon increased to 10.5 knots, and finally to 11.1 knots, all the way to her destination. This was probably the fastest the old ship ever traveled, but everyone was anxious to get home.
“The day everyone had been looking forward to came on December 15, as the old 481 passed under the Golden Gate Bridge at 09:15, and came to anchor in San Francisco Bay.”
In her career, LST 481 travelled about 75,000 miles delivering tanks, troops and other essentials for battles in the Asiatic-Pacific Theater of War, including Kwajelein, Guam, Iwo Jima and Okinawa. She earned six battle stars for World War II service. LST 481 was one of 13 LSTs (476-488) built at the Kaiser Richmond Shipyards. For more about Henry Kaiser and the Golden Gate Bridge, http://bit.ly/KFQIU3
Memorial weekend events galore celebrate Bay Area history
It will be a bit difficult to choose how to celebrate Memorial Day this weekend. Below is the schedule of some of activities marking the 75th anniversary of the Golden Gate Bridge opening and the festivities at the Rosie the Riveter/World War II Home Front National Historical Park in Richmond.
Rosie the Riveter national park: All events are on Saturday; the day begins at 10 a.m. with the ribbon cutting at the new Visitor Education Center, 1414 Harbour Way South, Richmond, adjacent to the Craneway Pavilion and the Boiler House Restaurant. At 11:30 a.m., the center opens to the public. Family activities, 1 to 5 p.m. at the visitors’ center. At 2 p.m., a park ranger will lead a walk around the park; at 3 p.m. visitors can meet Park Ranger Betty Soskin, who knows the shipyard history because she was there!
At noon the event shifts focus to Kaiser Shipyard 3 where a ribbon will be cut at 1 p.m. to officially open two new miles of the San Francisco Bay Trail. At 1:30 p.m., a park ranger will lead a walking and bicycling parade along the trail to the SS Red Oak Victory for an open house and free tours. For more: www.nps.gov/rori or call: 510-232-5050. To RSVP, send an email to: email@example.com
Golden Gate Bridge 75th anniversary celebration: Kaiser Permanente will have a booth on the SF Marina Green 10 a.m. to 6 p.m. both Saturday (May 26) and Sunday (May 27). KP staff will share information about the “Every Body Walk!” public health campaign and the health benefits of walking. KP actors from the Educational Theatre Program will perform Sunday under the KP tent. On Sunday evening at 9 the celebration concludes with a fireworks display at Crissy Field. http://goldengatebridge75.org/celebrate/golden-gate-festival.html
For more information about the Marina Green schedule and other activitites in SF: http://bit.ly/KD7hu
1 “A Symphony in Steel,” Charles A. Fracchia, Nob Hill Gazette, San Francisco, May 2012
By Lincoln Cushing
The Golden Gate Bridge, which opened May 27, 1937, is celebrating its 75th anniversary this year with a myriad of community events around the Bay Area. The iconic Golden Gate span that connected San Francisco to Marin County and the North Bay area has been called the “most photographed bridge in the world” and from the vantage point of history it is an architectural and engineering marvel.
As the largest and most enduring locally based health plan, Kaiser Permanente shares space in mid-century Bay Area history with the bridge. From its beginnings as a public plan in the East Bay in 1945, Kaiser Permanente quickly spread to San Francisco in 1946 and crossed the bridge to San Rafael in Marin County in 1958.
KP is a sponsor of “Bridging Us All,” a free community event on Sunday, May 27, seeking to honor this amazing landmark in a way that reflects the “ingenuity, inclusiveness, and creativity of the entire San Francisco Bay Area.” For details of the festival: http://goldengatebridge75.org
When the Golden Gate and the San Francisco-Oakland Bay Bridgeswere planned, San Francisco was the largest American city still served primarily by ferry boats. The project was controversial, the technical challenges were mighty, and the stakes were high. Just the sort of project one would expect Henry J. Kaiser to step in to.
Did Henry Kaiser’s companies work on the Golden Gate?
Henry J. Kaiser was a man of indomitable spirit and energy, considered one of “America’s boldest, most spectacular entrepreneurs.” By the mid-1940s he helped build the Hoover (Colorado River, Nevada/Arizona) and Grand Coulee (Columbia River, Washington) dams, the San Francisco-Oakland Bay Bridge, and over 700 ships during World War II. But did he ever contract to work on the iconic Golden Gate Bridge?
The answer is yes . . . and no, and reveals some interesting aspects of the enormous construction boom of the mid 1930s.
At approximately the same time as the Golden Gate project was getting underway, the American West was experiencing a frenzy of public infrastructure projects that we are still benefitting from today. To name a just a few, tax dollars were building the San Gabriel Dam #1 (“the world’s largest rock fill dam”), the Grand Coulee Dam, Hoover Dam, Bonneville Dam, Hetch Hetchy Dam (San Francisco’s water source), the Colorado River Aqueduct, the “highest voltage transmission line in the world” (on the line from Boulder Dam to Los Angeles), and the San Francisco-Oakland Bay Bridge.
During that period Kaiser Companies construction entities often operated in short-term partnerships, a common practice to ensure that necessary resources and skill specialties could be applied to a large and complex project. Boulder Dam (later called Hoover Dam) project was built by the “Six Companies” (although always called that, the number grew to eight). These were Utah Construction Company, Morrison-Knudsen, Pacific Bridge Company, J. F. Shea, McDonald and Kahn, Bechtel Company, Henry J. Kaiser Company, and Warren Brothers Company.
In 1931 Henry J. Kaiser assembled Bridge Builders, Inc., as a consortium when contracts were being posted for the two huge bridge projects in San Francisco Bay.
Kaiser gets contract to build substructure for the Bay Bridge
One of the main authoritative sources describing the vast scope of Kaiser Industries and construction companies is Alma Lindbergh’s succinctly named “History,” an unpublished two-volume record of all Kaiser projects and businesses through 1934. Lindbergh’s document describes two projects under “Bridge Builders, Inc.,” both for the San Francisco-Oakland Bay Bridge – the contract to build the East Bay Substructure (the 21 piers between Yerba Buena Island and the Oakland shoreline, completed 12/24/1934) and painting the bridge (completed 1/11/1934).
The East Bay Substructure was no simple task, and included digging E-3, “the deepest pier known to man,” located 1,400 feet west of Yerba Buena Island and embedded 242 feet below the surface of the bay.
“History” includes details such as the 143,000 tons of paint used to protect the San Francisco – Oakland Bay Bridge under “Painting Contract number 9” and how many coats (“West Bay Towers – last 2 coats; Cables & Accessories – paste on cables, 4 coats of paint on balance; West Bay Spans – last three coats; East Bay Spans – last three coats”).
The partners and partnership involvement of “Bridge Builders, Inc.,” for the Bay Bridge project were:
Henry Kaiser’s group withdraws from Golden Gate project
We know that in 1932 Bridge Builders bid against former Six Companies ally Pacific Bridge Company for work on the Golden Gate Bridge. Pacific Bridge won the larger substructure contract, but Bridge Builders got the approach work.
Bridge Builders, Inc., a syndicate of contractors, bid low on anchorages with $1,859,854. The bid was contingent on the syndicate receiving awards of the other features of the project and was withdrawn. Barrett & Hilp, San Francisco, with a bid of the same figure, was given the contract. Other awards [included] San Francisco and Marian [sic, “Marin”] county approach spans, Bridge Builders, Inc., $934,800.
– “San Francisco Span Contracts Awarded,” The Bulletin (San Francisco) November 4, 1932
One would assume that a prestigious project such as the iconic Golden Gate Bridge would be recorded in Lindbergh’s “History,” but it is not. The reason was revealed in this small article in a local paper:
Bridge Builders, Inc., of San Francisco[was awarded the contract for] the steel superstructures for the San Francisco and Sausalito approaches, $934,800. The company has asked to assign this contract to one of its partners in the undertaking, the Raymond Concrete Pile Co.
– “S.F. Firms Win Big Contracts Largest Job, Construction of Superstructure Awarded on $10,494,000 Bid,” San Francisco News, Feb. 23, 1933
So there we have it. Kaiser Construction, as part of Bridge Builders, Inc., did bid on part of the Golden Gate Bridge construction, and was awarded a contract – but pulled out, and relinquished the work to one of its partners. The likeliest reason is that Kaiser Construction realized it far had too much on its plate with multiple other construction commitments.
Further evidence comes from a full page ad in the July, 1934 trade publication Western Construction News. It announces “FOR SALE – The entire construction plant & equipment of Bridge Builders, Inc.”
But before then Kaiser Industries, in various capacities, maintained a distinguished performance in significant Bay Area construction projects. Those included the Caldecott Tunnel east of Oakland, the distinctive San Francisco Transamerica Pyramid office building, and Bay Area Rapid Transit (BART), but as we now know, it passed on the most iconic regional structure of all.
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By Ginny McPartland
Last in a series
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
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
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.
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.
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
By Ginny McPartland
Fourth in a series
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 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
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
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
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.
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.
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.
By Wendy Edelstein
Third in a series
Getting regular exercise plays a key role in staying physically and mentally healthy. A given in 2012, the relationship between physical activity and good health has only been well understood for the past few decades.
While work once involved physical labor for a majority of Americans, early 20th century technological advances changed most jobs into something requiring much less exertion. Henry Ford introduced the assembly line into his Detroit factory to produce cars more rapidly, and mechanization spread to other industries, including farming.
Getting workers into ship-shape
The man behind California’s Richmond Kaiser Shipyards understood the value of good health. Industrialist Henry J. Kaiser knew that keeping workers and their families healthy and happy was vital for the success of his business. Competition among Kaiser teams to produce the most ships at the fastest pace was intense.
To keep workers fit, and to boost morale, the Kaiser Shipyard management provided many opportunities for employees to be active. Softball and basketball games were scheduled so that day, swing, and graveyard workers could participate. And bowling, skating, swimming, tennis and horseshoes were available any time.
Most able-bodied American men were away fighting on the war front, so women workers (who became collectively known as “Rosie the Riveter” and “Wendy the Welder”) took on jobs that in peaceful times would have been considered men’s work. The work was demanding – and early on women found their jobs requiring more strength and stamina than they could muster.
When shipyard gynecologist Hannah Peters recognized many of the women were resigning because the work was too hard, the yard began providing them with strength training. The women learned how to climb ladders, lift loads, and how to combine the two skills to climb with loads.
A mid-century check-up
By the early 1950s, the effect of industrialization began to show, and Americans were judged to be less physically fit than previous generations. “Muscular Fitness and Health,” a 1953 article published in the Journal of the American Association for Health, Physical Education, and Recreation, asserted that the sedentary 20th century American lifestyle had led to a loss of muscle tone in this country’s citizens.
Co-authors Hans Kraus, MD, and Bonnie Prudden cautioned that Americans needed to adopt physical fitness regimens to regain the level of fitness of earlier generations who used their feet to get around and sweated through their work day.
Kraus and Prudden’s message gained traction when mainstream publications such as Newsweek, U.S. News & World Report and Sports Illustrated picked up on a study Kraus had done that showed American youth to be significantly less fit than their European counterparts.
In the early 1950s Kraus studied students between the ages of 6 and 16 and measured their strength and flexibility as they performed sit-ups, leg lifts and toe touches.
A startling 56 percent of the 4,400 American students tested by Kraus and his colleague Sonja Weber, MD, failed at least one of the fitness components. In contrast, only 8 percent of the 3,000 European students (who hailed from Switzerland, Italy or Austria) failed even one part of the test.
Kraus blamed the American students’ poor showing on their pampered lifestyles: Their parents typically drove them to school, and they did only light chores and played within their own neighborhoods. Their European peers, on the other hand, typically walked miles to school, rode bicycles and performed strenuous chores such as chopping wood.
When President Dwight D. Eisenhower suffered a heart attack in 1954, America received a lesson in preventive care from Dr. Paul Dudley White, the president’s physician. Dr. White used television – 65 percent of Americans had a TV at home by 1955 – to tell Americans they could stave off heart attacks by exercising more, giving up cigarettes, and by eating healthier food, and less of it. President Eisenhower followed his doctor’s advice and went on to establish the President’s Council on Youth Fitness in 1956.
Sowing the seeds of a fitness revolution
In December 1960, then President-elect John F. Kennedy spearheaded a public awareness campaign promoting physical fitness. In “The Soft American,” an article he wrote that appeared in Sports Illustrated, Kennedy cited the results of the Kraus-Weber Test as well as an annual physical fitness exam at Yale University: 51% of the class passed in 1951, 43 percent passed in 1956 and 38 percent passed in 1960. http://sportsillustrated.cnn.com/vault/article/magazine/MAG1134750/index.htm
“Physical fitness is not only one of the most important keys to a healthy body; it is the basis of dynamic and creative intellectual activity,” wrote Kennedy. “The relationship between the soundness of the body and the activities of the mind is subtle and complex. Much is not yet understood. But we do know what the Greeks knew: that intelligence and skill can only function at the peak of their capacity when the body is healthy and strong; that hardy spirits and tough minds usually inhabit sound bodies.”
Once he took office, President Kennedy’s message reached an even wider audience via a public awareness campaign, President’s Council-sponsored pilot projects to test children’s fitness levels, clinics and educational films and booklets.
When Kaiser Permanente (KP) opened the doors of its Health Education Research Center in Oakland in 1969, its overarching educational theme was, “You have only one life to live – live it in good health.” The experimental center featured a patient health library and health exhibits. “Story of Life,” one of the most popular displays about human reproduction and family planning, used life-size, three-dimensional models and color slides.
Another area of the center presented information about health hazards: weight problems, smoking, venereal disease, cancer, and alcohol and drug abuse. The “Pathway to Positive Health” exhibit focused on how visitors could stay well by paying attention to nutrition, dental hygiene and the physical, mental, emotional and social aspects of good health.
The Health Education Research Center was an outgrowth of a pilot project that explored education’s role in increasing the effectiveness of preventive care. This was a new approach to prevention; it spread through the Kaiser Permanente system and beyond. By 1987, 85 percent of all U.S. hospitals offered health education programs.
From aerobics to yoga – 1970s ushered in fitness craze
Unofficial estimates in the early 1980s suggested that more than half of all Americans pursued some sort of recreational exercise, such as bicycling, swimming, tennis or running. This new dedication to physical activity signaled a change.
“Until recently, modern generations of Americans by and large failed to act on a compelling accumulation of knowledge linking individual lifestyle with individual health. As a nation, our eating habits violated accepted standards of nutrition. We shunned devoting our leisure time to regular physical exercise,” declared the writers of Kaiser Permanente’s 1984 annual report.
During the 1970s and 1980s many Americans got swept up in the fitness craze. Wearing leotards, neon spandex and leg warmers, they headed to health clubs and performed leg lifts and side bends and hoisted dumbbells to upbeat music. Or they popped Jane Fonda’s Workout in the video cassette recorder (VCR) and worked up a sweat at home. Others jogged their way to good health after reading Jim Fixx’s 1977 bestseller The Complete Book of Running.
Americans had different motivations to exercise, according to a 1978 Harris poll. Twenty-four percent of regular exercisers cited their reason was to strengthen their heart and/or lungs, 41 percent sought to lose weight, 24 percent wanted to become healthier, and 45 percent hoped to stay healthy.
A 1976 Centers for Disease Control and Prevention study of the 10 leading causes of death in the United States looked at the importance of four factors. Lifestyle, including exercise and diet, figured most prominently at 51 percent, followed by heredity (20 percent), environment (19 percent) and inadequate access to health care (10 percent).
Garfield’s Prescient Total Health Care Project
KP founding physician Sidney Garfield’s crowning achievement, the Total Health Care Project, came towards the end of his life in 1984. Among the Total Health Care Project’s goals was “to provide comprehensive primary care services for both wellness and illness and to provide incentives to professional staff to keep members well rather than just treating them when they are sick.”
An aggressive outreach plan to new members encouraged them to schedule a health evaluation appointment to review their current health and to develop a personalized Health Improvement Plan (HIP).
Members received a mailing with the instructions: “If you are feeling fine, we also want to see you to make sure you are in good health and assist you in preventing future problems. We really think the BEST time for you to get acquainted with us is when you’re feeling good, without the pressure of illness.”
Members who visited the Total Health Care Center for initial and periodic examinations assessed their own health via a questionnaire. They were asked about their eating habits, their lifestyle and how frequently and intensely they exercised. Part of the assessment was a treadmill endurance test to determine cardiovascular fitness.
Through the Total Health program, the center staff guided members in their quest for good health. Handouts offered tips such as how to select an activity that you will stick with as well as how to take your own pulse.
In the 1980s, popular health books included Pritikin Program for Diet & Exercise, Better Homes & Gardens’ Good Food & Fitness and Covert Bailey’s Fit or Fat? Fitness programs and initiatives began to take root throughout Kaiser Permanente’s regions. For instance, in 1984, the Ohio Region launched its “Annual Frost Belt Classic,” a series of five-, 10-, and 15-kilometer cross-country ski races. The race drew 500 skiers in 1987.
In the early 1980s, every KP region sponsored or supported a race or fun run. As part of its Dr. Wizardwise health education program, the Hawaii region sponsored a run for children.
Also in the 1980s, Kaiser Permanente’s Northern California Region established partnerships with about 15 local health clubs, enabling its members to join for a low or no initiation fee and a reduced monthly rate.
The current picture of health
Today medical assistants in Kaiser Permanente’s Southern California, Northern California, Colorado and Northwest regions ask patients about their exercise habits as a matter of course. Exercise as a Vital Sign was launched in Kaiser Permanente’s Southern California region first in 2009 to capture information about members’ physical activity.
Medical assistants routinely ask two questions: 1) On average, how many days a week do you engage in moderate or greater physical activity (like a brisk walk)? 2) On those days, how many minutes do you engage in activity at that level? Those answers are entered into the KP member’s computerized health record, and his or her physician can view that information along with the rest of the patient’s vital signs.
Kaiser Permanente also promotes healthy living through its Every Body Walk!, Thrive Across America, Healthy Eating Active Living and KP Healthworks programs and by sponsoring walks, runs and cycling events and offering an array of fitness classes at its medical centers.
With Exercise as a Vital sign in the exam room and a broad array of healthy living initiatives, Kaiser Permanente’s longtime fitness message endures: regular exercise is one of the cornerstones of preventive care and ultimate good health.
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. The four-part series will be aired May 14 and 15. For more information about KP’s involvement in the fight against obesity: http://bit.ly/kptwotn
By Lincoln Cushing
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.
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
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.
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.
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 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
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
3 “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
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
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
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
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.
By Ginny McPartland
It’s not quite ready yet, but a group of proud fans of Richmond, California, got an early tour of the resurrected Ford Company Oil House on the Richmond waterfront Saturday. The industrial brick building that once powered the Ford motor vehicle plant has been morphed into what promises to be a gorgeous visitors’ center for Rosie the Riveter national park. The center is scheduled to open to the public next month.
Evidence that construction crews planned to return after the party to finish their work was everywhere in the three-level renovated space, but no one seemed to care. Partygoers sipped sparkling wine and relished the fulfillment of a decade-old dream.
The Rosie the Riveter/World War II Home Front National Historical Park was established by an act of Congress in 2000. The National Park Service (NPS), the Rosie the Riveter Trust and many community groups have been working toward the opening of the visitors’ center since that time.
The park encompasses the Kaiser Richmond Shipyards and other World War II sites in the area. The restored Red Oak Victory ship, which houses a museum and gift shop, can be seen across the water from the old Ford plant.
Modern design for historical structure
The Oil House was constructed in 1931 as part of the Ford Motor Company Assembly Plant Complex (where tanks were manufactured during World War II). Although not shown in the complex original plans, the style of the building indicates it was designed by Albert Kahn Associates. “The construction, brickwork, industrial metal sash windows and detailing of the building clearly indicate that it was designed by the same architect,” explained the Rosie the Riveter Park Chief of Interpretation Morgan Smith.
“The function of the building was essential to the assembly line operation, housing multiple large oil tanks that fueled the boilers that, in turn, ran the steam powered conveyer system and equipment of the plant.” The lower level of the Oil House was only accessible through a tunnel from the main plant building and from a narrow enclosed ladder from the upper levels.
The Visitor Education Center to open in the refurbished Oil House will feature a theater, classroom and traveling exhibits. The park service’s goal was to create a modern facility yet retain the historical integrity of the original construction.
The reception at the Oil House was a preliminary to the annual Rosie the Riveter Trust Annual Dinner, a fundraiser for the national park. A number of Kaiser Shipyard workers attended the dinner and were recognized from the podium by Diane Hedler of Kaiser Permanente, vice president of the Rosie Trust board. John August, executive director of the Coalition of Kaiser Permanente Unions, was the keynote speaker. Jane Bartke, president of the Rosie Trust board, was chair of the event.
The dinner was staged in the Craneway Pavilion, formerly the Ford Assembly Plant, which was converted into an event space in 2008. Developer Eddie Orton and architect Marcy Wong won an American Institute of Architects national award in 2011 for the restoration of the 40,000-square foot Craneway, which also houses the Boiler House Restaurant.