Guidelines for diagnosing food allergies in flux

December 15th, 2010

I've been tracking down some changes in the diagnosis of food allergies, especially in kids. I started with a Wall Street Journal article, dated Tuesday, December 7, 2010 and titled "New Rules for Food Allergies." That mentioned the National Institute of Allergy and Infectious Diseases, a segment of the NIH under the US Department of Health and Human Services, had recently convened an expert panel on the subject.

The resultant guidelines were published in the "Journal of Allergy and Clinical Immunology." I found a review in WebMD (webmd.com) and then the lengthy report itself online at the NIAID website. I realized it was so voluminous there was a separate 29-page summary for clinicians and a much shorter set of guidelines for patients with a more thorough patient guideline to be published in 2011.

An Epi-Pen for severe allergic reactions

So what's the short version? Well to start with about 5% of kids and 4% of adults have food allergies. If they eat specific foods they may have reactions varying from mild to life-threatening.

The most freguent food allergies are to eggs, milk, peanuts and tree nuts, soy (that surprised me), wheat and some shellfish. Kids often outgrown an allergy to milk, eggs, soy and wheat, but not those to peanuts and tree nuts.

There are no cures to these allergies and having a mild reaction to a food once doesn't mean you won't have a severe reaction on another exposure.

Allergies often are seen in people who have some other diseases, asthma for one example and eczema (a skin disease) for another. Those plus a family history of food allergy may alert you and should alert your physician to your having a greater risk of food allergies.

Neither of the usual office tests used to diagnose food allergies, is definitive. Those include a blood test looking for antibodies to specific food and skin-prick test where a tiny amount of a suspected allergen is paced on a forearm then pricked to see if a wheal result.

The only test that proves you have a food allergy is a food challenge. That must be done, for safety reasons, under the careful direction of an experienced healthcare professional.

Yet all is not as dire as the above sounds. One study published in the Journal of Pediatrics this fall looked carefully at the medical records and testing of 125 children who had been sent to the National Jewish Hospital in Denver for evaluation of eczema and food allergies.

After careful food challenge tests were evaluated, over 90% could go back to eating foods they had been avoiding.

A few other tidbits caught my eye: peanut allergies are especially severe and, fortunately, I'm seeing more and more labels that specify this product is (or is not) produced in a peanut-free environment. Wheat protein allergies are not synonymous with celiac disease, so those having such allergies may not react to gluten in oats, rye and barley. And fish allergies, which tend to start after childhood, can be another very severe problem.

I give my wife her allergy shots at home, so I keep Benadryl and an Epi-Pen handy. Food allergies are nothing to sneeze at (no pun intended), so if there is a family history of them or you or your child have eczema or asthma, make sure you get a thorough evaluation by a qualified physician.

Posted in Governmental Efforts, medically-oriented background info, our kids and their weight issues, Unhealthy eating | 1 Comment »

Two thirds of us can benefit

December 11th, 2010

I just read an article in the Annals of Internal Medicine, the journal published by the American College of Physicians. Although I've been retired since 1998, I still am a Fellow of the ACP and their publication is the only medical journal I subscribe to and read (at least scan) regularly.

Counseling session in progress

This months Annals had a meta-analysis, a review of multiple papers, on the subject of behavioral counselling and its effects on cardiovascular disease. I scanned it and wasn't overwhelmed; then I read it in detail and was highly impressed.

The authors, two physicians, one PhD and a person with a Masters degree in science, reviewed 13,562 abstracts and 481 articles, looking at the effects of low-level, intermediate-intensity and high-intensity counseling that was intended to promote either an increase in physical activity or a healthy diet or both.

They were looking at the effects counseling produced in patients who did not have cardiovascular disease, hypertension, diabetes or abnormal blood lipids. Some did have borderline high blood pressure or other risk factors, most did not.

At first I thought the relatively small results meant that the time wasn't well spent. Blood pressure was reduced in most studies, but not by much; the same was true for lipids.

But there were almost no ill effects (they estimated one heart attack would occur per 1.42 million person-hours of exercise, usually in people who started as couch potatoes.

But the unimpressive decrements in blood pressure, especially in those with borderline BPs to start and the relatively small changes in cholesterol and LDLs, when translated to large population groups, were stunning.

A decreased incidence of coronary heart disease (CHD) of 6 to 16%, 30% in those more at risk, from what seemed a tiny change in BP, was impressive. A 25% decrease in CHD from a 10% decrease in total serum cholesterol was also striking.

Most of these counseling session, of course, especially the more intensive and repetitive ones, would be done by someone other than the physician involved.

But I finished reading the article and said, "Counsel on, nurses and therapists." it certainly seems worth it in both normal-weight and overweight, but not obese people. I'm less sure of the results in that group and they didn't appear to be involved in these research projects.

I had thought that most of us blow off the words directed to us in these kinds of medical encounters. Maybe that's changing and it's about time.

Posted in Exercise possibilities, Healthly lifestyle, Healthy eating, medically-oriented background info | No Comments »

When all else fails

December 7th, 2010

Most of my posts are written for those of us who are of normal weight and want to stay there or those who are overweight and would like to lose a few pounds or twenty or forty. As of this morning, for example, I'm twenty-four pounds under my May 2009 peak and sixty-five under my obese 1970 lifetime maximum.

It's the holiday season with Thanksgiving and Hanukkah and Christmas thrown in to a jumble of other parties, gourmet club dinners, symphony events and theatre events. I'm at my upper limit of 153 pounds and have to really watch carefully to avoid all the temptations.

Many of you are in the same mode, I bet, but overall doing okay with your weight.

Then there's an entirely different group. I saw an article on Lap-Band surgery for those people who are obese and haven't managed with diets, counselling, support groups and perhaps even medication to lose the pounds they desperately need to shed.

Does this man need Lap-Band surgery?

Now I'm an Internal Medicine doc and a retired one at that, so I looked at the Mayo Clinic website, an Australian website, one for a nearby hospital and MedlinePlus, an online information source sponsored by the NIH and the National Library of Medicine. I wanted to know more about this surgical strategy for the obese.

First off it's not cheap with prices varying from $13,000 to $25,000 in the United States. Some people go south to Mexico where the prices are lower, but I wouldn't be likely to do that if I were seeking out this procedure.

It's done under general anesthesia using a laparoscopic approach. That means several small incisions are made in the abdominal wall and a small camera in inserted to allow the surgeon to see what he or she is doing. A band is then positioned around the stomach so that the upper portion of that organ forms a small pouch with a narrow opening to the rest of the stomach.

It doesn't require internal staples or cutting and, if the surgeon is experienced may take only 30 to 60 minutes. The 2,700-person Australian series I read about reported no deaths.

Lap-Band surgery has been restricted to the very obese with a Body Mass Index over 40 (mine is 20.5), or the fairly obese who have complicating diseases such as diabetes, heart disease or sleep apnea.

But, after the surgery people have to stick to a diet and should exercise. Plus there are complications with half the patients in one large series reporting nausea and vomiting, a third having reflux, a quarter of the bands slipping and requiring repositioning and perhaps 10% experiencing some blockage near the band.

The band is adjustable; the physician can tighten or loosen the stricture by adding or removing saline.

And this is the least invasive surgery for severe obesity. I also read where some proponents (and the company that makes the device) want to loosen restrictions on its use. They'd like it to be approved for use in people with a BMI over 35 or over 30 with complicating diseases. That would include over 25 million Americans.

I'll certainly stay out of that debate and stick to my diet and exercise concepts.

Posted in Complications of Obesity, Dieting, Governmental Efforts, medically-oriented background info, Obesity | 2 Comments »

Two successes, one failure and a lesson

December 3rd, 2010

My newest reminder card

Travel is tough on my dieting, but, I've learned recently, so are the events I go to. I had weighed 153 when we left for our trip to Texas where friends hosted dinners, fed us well, too well. I returned at 157 pounds, four over what I now consider my upper limit. I know that I re-started my diet at 177 in May of 2009 and so I'm considerably slimmer, but 157 annoyed me.

So I was concerned; we had Thanksgiving dinner, a series of parties, a Thank the Donors event for the capital campaign I've been running and then would come some holiday events. What could I do to not only lose the four pounds at least, (my real goal weight is 149-150), but to also avoid gaining more. I needed a gimmick.

One of the background books I've been reading is on "mindless eating," the kind of frenzy of ingestion I recognized well. I used to get into this pattern frequently, forty years ago in when I weighed 218.

What I needed was another STOP sign. I already had my red 1/3 cup measure sitting on my kitchen island. Now I needed something for events and occasions. And, when I thought about it, one of those is my weekly writers' critique group. Most of us bring something edible to share and sometimes I get hooked on cookies or something else I wouldn't normally eat.

So I took two three by five inch cards and wrote "Don't Snack!" on one of them and "Don't Eat or Overeat" on the other.

my other card

One card leans up against my popcorn holder which itself is surmounted by the red measuring cup. Eating at home hadn't usually been a problem, but it wouldn't hurt to have an extra reminder.

The other I put into the cup holder of my car. I'd look at it just before going into a house where we were joining an ongoing party or before entering, twice this week alone, the local country club, where we were attending a luncheon for symphony donors and, later in the week, the Thank the Donors event.

Oh, and there was one more event, a baby shower I wouldn't normally have attended. In this case it was for the wife of a young relative. We hadn't seen him since his high school graduation and I felt it was important to go to his spouse's shower.

So here's my score card and the lesson I learned. I looked at the card in my Prius just prior to entering the country club for the luncheon. I ate three fourths of my salad and half my entree and said, "No thanks" to the dessert. I did even better at the donor event. I pre-ate a bowel of cereal and a piece of fruit. At the event itself I ate nothing and drank one third of a glass of Merlot.

But the shower, held at a pizza parlor, was another matter entirely. I didn't remember to look at the card hat evening, shared an appetizer with my nephew and his fiancee and had three large slices of pizza, even eating the dry crusts.

Actually the donor event was last night and today I'm down in my safe zone again. I'm going to lunch with friends at our favorite Thai restaurant, but before I leave my car I'll look at the card.

Lesson learned. I'll bring the "Don't Snack" card to my writers' group next week and look at it just before I leave my car.

Posted in Dieting, Holiday/travel eating, tricks and gimmicks, Unhealthy eating | No Comments »

Water, water everywhere and how much should we drink?

November 29th, 2010

My wife was really looking out for me yesterday. She read and clipped out an article from USA Weekend's HealthSmart section with the title "4 crucial tips for managing

A standard eight-ounce glass of water

your weight." They came from THE DOCTORS, a daytime TV show I've never seen (I don't watch much TV anyway).  The show apparently has four physicians, a pediatrician, an Ob-Gyn doc, an ER doc and a plastic surgeon.

The tips seemed reasonable: drink water; stay consistent; get good sleep and log on to keep pounds off. I've written a post on sleep and weight, believe in consistency (but it's my one sore spot, especially on vacations ), keep a record of my weight on a regular basis (but not online) and drink lots of water.

Now that one caught my eye; I drink three very large glasses (30 oz each) of lime water a day and often drink water before starting to eat. I've read that some think that even the standard recommendation of eight glasses a day is excessive, but my habit started when I had vocal cord issues and a senor speech therapist suggested I drink a large quantity lime-flavored water every day.

my 30-ounce glass next to the standard one

Now there's some data to support my idiosyncrasy of having some water at the start of a meal. A study done by researchers at Virginia Tech and reported at a recent national meeting compared two groups of subjects aged 55 to 70. Both groups were on a low-fat, low calorie diet. The research subjects in one group drank two cups of water before each meal; those in the other group didn't.

This was a twelve week study and the water drinkers lost more weight. Then the scientists followed their progress for a year. Not only did they keep weight off, they even lost a little more.

There's a catch; this doesn't work for young dieters. The speculation is that older people's stomachs empty slower and I'd tie that in with feeling full and choosing not to eat more.

Several other university groups commented on the subject. One said that those who drink water don't drink sugar-filled beverages and, on the average, consume 75 to 90 calories less a day. That adds up over the course of a year; 100 calories less a day would equal a little over ten pounds of weight loss. The other wondered if people who aren't on an actual diet would keep up their water-drinking pattern longterm.

So far I have, for twelve years, but for different reasons. I think I'll be more deliberate in my pre-meal water drinking and see how that helps.

Don't overdo this if you try the idea; too much water intake can be dangerous. Two cups before meals sounds reasonable, but my large water intake isn't for everyone.

Posted in beverages, Dieting, Healthy eating, medically-oriented background info, Weight Loss | 2 Comments »

Too much cheer for the holidays and other times

November 26th, 2010

We had a family Thanksgiving dinner for nineteen people yesterday and served beer, wine, non-alcoholic punch with fresh fruits and some sparkling fruit drinks. I had a glass of Riesling and later tried some of the fruit punch, I didn't pay much attention to what others were drinking, all but four were adults ranging in age from early twenties to mid-seventies.

Fat Tire beer, my favorite

When we cleaned up later, it seemed there were a lot of beer bottles, but I realized at least five adult men drank beer and nobody had more than two bottles. I don't usually drink beer myself (although I'll make an exception for Fat Tire, a superb locally-brewed beverage) and normally have one glass of wine with a meal three times a week. Once in a great while, if we're at home, I'll have a second glassful.

I realize we don't drink much compared to some of our friends, but haven't seen anyone drink to excess or appear drunk at any of the parties we've been to in years.

Then I read the December issue of the Harvard Heart Letter and saw that a South Korean study had revealed the hazards of binge drinking. I'd thought of that as primarily a problem for college students; we live in a university town and over the years have read of several binge drinking tragedies.

I found the original article online in a publication called Science News and then followed a link to another article, this one an Irish study. Both were sobering, to say the least.

I've read a number of articles that say drinking in moderation may be heart-healthy. The key word is moderation and we're talking about one drink a day for women and two for men. Binge drinking implies much more alcohol consumption, four to five or more drinks a day or six at any time.

It's not just an issue for teens and college students; a CDC study said one in seven adults admitted to binge drinking.

The Korean study focused on men with poorly controlled hypertension and said their risk of cardiovascular death or  stroke was markedly increased, more so if they drank very heavily. It followed over six thousand people for twenty-one years.

The Irish study compared middle-aged men's drinking patterns in Belfast and France, with the Irish men drinking two to three times as much. Those who were binge drinkers had almost twice the risk of a heart attack or death from heart disease over a ten-year followup period.

The French more typically drink wine with meals; The Irish drink more beer and spirits and I would think they do so in pubs without much food being consumed.

So I personally think it's okay for most adults to drink in moderation (that's assuming they don't have a personal or family alcohol problem and understand what moderation means).

But drinking to excess, especially binge drinking, is a totally different matter. These new studies show yet another hazard for those who overly imbibe.

So if you plan to have a glass of holiday cheer, keep it at a minimum and, of course, don't drive if you drink.

Posted in beverages, Food-related disease, medically-oriented background info | No Comments »

Vitamins in general

November 23rd, 2010

Vitamins for seniors

I've written several posts on calcium intake and, in reviewing them for the book I'm working on, noted I had mentioned, but not detailed, my thoughts about vitamin D. So I've been researching source material on the subject and wanted to bring you up to date on my take on the new recommendations for how much we should be getting.

Let's begin with vitamins in general. A reasonable starting definition of  a vitamin is an organic compound that is required in tiny amounts and can't be synthesized by the body. So until the 1930s, when vitamin C was first made by chemical means, all our vitamins came from our diet.

Vitamins are divided into water-soluble and fat-soluble varieties. The former include vitamin C and the B vitamins, B1, 2, 3, 5, 6, 7, 9, and 12; the latter include vitamins A, D, E and K. Various others have been proposed and later found to be capable of synthesis by humans, thus accounting for the missing letters and numbers.

Water-soluble vitamins are not well-stored by the body and must be regularly replenished. Vitamin C, for instance, in studies conducted on conscientious objectors in Britain during WW II and in Iowa on prisoners in the 1960s, is depleted in a few weeks to as long as six to eight months depending on the degree of "pre-loading". The British Navy started giving lime juice to its sailors in 1795 to prevent them from developing scurvy on long voyages.

On the other hand excess intake of these is less likely to have toxic effects.

Fat-soluble vitamins are stored in the liver and various fatty tissues, need not to be taken quite as regularly  and conversely are more likely to be toxic when taken in excess.

Those are, of course, sweeping general statements.

So let's go back to how we get our vitamins and a few controversies. The famous chemist and two-time Nobel pre winner Linus Pauling, proposed in 1970 that taking larger doses of vitamin C could reduce the incidence of the common cold. He later expanded his claims to include mega-dose vitamin C as beneficial for a variety of ailments, including cancer.

A large series of well-designed and double-blind studies disproved the former claim and the Mayo Clinic conducted three controlled studies from 1979 to 1985 that showed patients with advanced cancer who were given 10,000 milligrams of vitamin C a day had no improvement when compared to pateints given a placebo.

So we take 500 milligrams of vitamin C a day. Can you get enough of the 13 vitamins from your diet? Sure if you work at it. Does the requirement for various vitamins change with age? I think the answer if clearly yes and, for instance, we're now taking a large dose of B12 daily as recent data suggests seniors may malabsorb this crucial vitamin.

And B12 is water soluble, so if I take a little bit more than I need I'm not going to worry about it.

But then there are the fat-soluble vitamins and I'll write more about them and especially about vitamin D in my next post.

Posted in Food Additives, medically-oriented background info, supplements | 1 Comment »

I'd never heard of the ketogenic diet

November 19th, 2010

Reading the New York Times breaking news on my Kindle this afternoon, I came across a diet that was new to me, one that most of us will never go on. But for a small group of kids it can have an incredible impact.

The story was about a nine-year-old boy who has severe epilepsy. In his case his seizures were resistant to all the major drugs that might usually have been effective. He was having them as frequently as 150 times a day.

His parents were desperate until they finally found Dr, Elizabeth Thiele at the Massachusetts General Hospital for Children. She's a specialist in pediatric neurology, an Asoociate Professor at Harvard Medical School and heads up a program for pediatric epilepsy.

One of her interests is keto as the diet is called. When children have drug-resistent seizures, keto can be effective in a significant percentage of cases.

The diet is high-fat, quite the opposite from many of those used by adults for weight loss. The kids on it start in the hospital, starving for a relatively brief period. But our bodies only have enough glucose, our primary source of energy, to last about 24 hours.

After that we burn fat reserves and our livers convert those fats into fatty acids and ketones. The latter pass into the central nervous system and become the brain's source of energy. Somehow, it's not exactly known how, that can reduce how often epileptic seizures occur.

The diet has been around for over eighty years, but when anti-seizure medications were developed and shown to e efective in most kids, keto fell by the wayside.

In the mid 1990s a Holywood producer brought it back. His son had severe epilepsy and drugs weren't helping. Keto did and the producer started a foundation to promote the use of the diet. He got his friend Meryl Streep to star in a film called First Do No Harm and the foundation sponsored a scientific study of the diet.

Since then it's been offered by over 100 hospitals for kids with drug-resistant epilepsy and two randomized, controlled studies showed it can be effective.

The boy in the article eats four times as much fat as protein or carbohydates. He's on a tightly controlled program and even his snack are calcualted. One of those snacks included two slices of bacon, seven macadamia nuts and less than one eighth of an apple. His urine would be checked for ketones as in the slide.

There are diets to lose weight and gain health; there are also diets to help with specific medical problems. I'll never try keto and hopefully, like many kids, the boy in the article will outgrow his need for it.  For now it's been an wonderful asset for his health.

Posted in Food-related disease, medically-oriented background info, Unhealthy eating | No Comments »

Even more fat for our taste buds

November 17th, 2010

A new and expensive burger

I picked up my copy of The Wall Street Journal this morning, opened it to "Personal Journal," the section I usually read first, and gasped. The lead article was titled  "Bring On the Fat, Bring On the Taste."

That certainly caught my attention... negatively. Then I started reading the rest of the article and got even more upset. The subtitle was "Celebrity Chefs Join Burger Wars, Baste Beef Patties in Butter." The text went on to describe how some of the top chefs in America are now getting into the burger business. Some say they are using only the best kinds of beef and specialty ingredients, but a number of food specialists, among them university professors, say what they're chef really doing is serving high-fat burgers.

Another new burger

They're also charging much more than the fast food restaurants. One of the burgers, made from Japanese Kobe beef and served with foie gras and truffles, costs $39. And that's not the most expensive pattie. Another has truffles, foie gras and Madeira sauce and goes for $60.

Why would anyone eat these cardiovascular time bombs? Well they presumably taste good and perhaps they are status symbols. But they also use beef that has up to 30% fat content, or is basted in butter or, in one iteration, has a double layer of beef with potato chips in between to increase the crunchiness.

As for the chefs, they've realized the high-profits creating the monster burgers can bring. Hubert Keller, a French-trained, high-levl chef, makes 9 to 12% margins from his haute cruisine restaurants. His marginal profit on his first burger unit is 37.5%, so he's opened his second and third and has four more in the planning stage.

So let's go back to why this might be a problem, to our bodies even more than to our wallets. The 2010 Dietary Guidelines for Americans (DGAC) hasn't been released  in its final form yet, but the expert panel's preliminary report, available online, wants us to cut our intake of staurated fats to less than 7% of our total calories.

That makes enormous sense; saturated fats are associated with cardiovascular disease (CVD) risk and people who either have this problem or are at high risk for it need to minimize their intake of these lipids.

We're in the midst of an epidemic of obesity, hypertension, type 2 diabetes (T2D) and 50 million Americans are said to have the metabolic syndrome (a combination of abdominal fat, high blood pressure, insulin resistance (T2D), abnormal blood lipids and several other blood factors making one prone to CVD).

My opinion is the last thing we need is these expensive new high-fat burgers.

But I'd bet they sell well and make the chefs a bundle of money. When it comes to following the DGAC, we don't have a good track record.

Posted in cooking: new ideas, Governmental Efforts, Unhealthy eating | No Comments »

Miscellaneous ramblings, centered on portion size and vacations

November 16th, 2010

Today I read a book on "Mindless Eating" and eventually I'll write more about it. But first off it rang a cord for me with a section from a Harvard Health Publication on cutting down on salt. We eat too much salt, too much sugar and too much fat. One of the simplest ways to cut down on those is to diminish your portion sizes.

I don't weigh in on any of the fad diets except to say they won't solve the long-term problem that two out of every three of us have in the United States. I think eliminating something you like won't work very well over the years. So instead, I diet by cutting off a portion of everything on my plate. I can still have a small amount of almost anything; I just don't overeat..except on vacations.

We spend six days on a trip to Texas recently. Our surrogate dad had turned 90 and we wanted to visit him. So part of that trip was with an elderly couple living in a retirement community. Part of it was visiting other friends. Everyone wanted to make sure we were well fed.

We went to restaurants, clubs and dining facilities in the retirement village. There were abundant choices and generally quite good food (though I did miss our fresh fruits and vegetables from our CSA). The problem was my lack of the ability to say NO.

I left home at 150.6 pounds, well within my comfort zone. I returned at 157 pounds and have had to play catch up ever since. I'm almost back to where I started at. I do fine at home; I even mamage local parties and restaurants without a problem. So what happens with a trip?

Ah, I think I have figured out some of the issue; we were with good friends who wanted to treat us to their favorites places to eat. Or, in the case of our older friends, we were eating buffet style. Both situations are diet traps. They require some extra punch in my diet resolve.

So one of my coping mechanisms, one that I have to strengthen for vacations, is portion control. I really didn't eat anything on this trip that I wouldn't otherwise; I just ate more. I have a four by six card that says "Don't overeat." It may appear a little silly, but it's saved me countless times at home or in our area. Even that simple device makes me pause, eliminate the extra scoop of frozen yogurt or the second piece of bread with butter and jam. it's time for the card to be on my packlist.

The pause is the real necessity. In the book I was reading today, just moving a dish of food a distance away, or as we do serving everything in the kitchen so seconds require a trip back from the dining room can help.

Dieting or, in my case, maintaining a weight you've worked to get at, requires some thinking. The pause can let you move away from the mindless eating trap.

Posted in Dieting, Healthy eating, Holiday/travel eating | No Comments »

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