In Daytime TV studios

But before then, it all started on Twitter.  A fellow cigar smoker, Matthew Horbund (@mmwine) introduced me to some foodies he knew in Tampa. Among them were Debbie Frangipane (@dolcedebbie), her husband Barry (@barryfrangipane), Sandi McKenna (@sandimckenna), April Wilson (@producergirl), Jeff Houck (@jeffhouck – and thankfully memorialized this with some photos, that I have shared below), Jackie Silver (@agingbackwards) and a few others.  Debbie and Sandi kept inviting me to dinners in Tampa -a part of an underground food movement.  Hard to imagine, but one day when I was in Alaska I thought- why not? So I re-booked my trip to spend a weekend at the Frangipane’s for their three chef dinner.

As an Alaska Native, a part of our heritage is that when you go to someone’s home you bring something.  This is particularly true if you travel from Alaska to the lower 48 – you want to bring them something special from Alaska. So I brought a fresh King salmon, and some halibut.

The chef’s were happy with the offerings and Chef Gui did a beautiful job with the salmon.

From there a conversation started between April and I about doing a segment, possibly a long-running segment on her show. So we started shooting them.

My good friend, Debbie Frangipane, who kept after me to come to dinner in Tampa – a dinner that changed my life

The segments continued for a while, as I was doing a lot of travel between Tampa and Phoenix, so it became easy to do. The reason for that travel was I fell in love with April, and we had a long-distance relationship for a long time. I knew the flight schedule between Tampa and Phoenix well. April and I married in February of 2010, her contract with WFLA ended in March, and after that we went to Rome for a honeymoon and then had JJ in July. For a bit we filmed some shows from our kitchen.  But mostly April has focused on what she calls her greatest production, our son – who will be 3 years old in July.

On my way to Tampa from Anchorage with a couple of salmon fillets. It is tradition that if you travel to someone’s house you bring them something from your home. The salmon was a hit – the chefs at the dinner did a great job with it.

In that time I have been re-working my cookbook (to where now it is a cookbook with a lot of biology and some interviews from great doctors who love food, as well as chefs, and foodies who love the field – now awaiting more editing).

We are headed back to Tampa, because @DolceDebbie, at whose house we met, the foodie dinner, is opening a restaurant. While April and I have been busy raising and traveling with our son, Debbie Frangipane was getting trained at Culinary Institute of America and cutting her cooking skills at a couple of fine Florida restaurants. It has been a lot longer than we thought, but we are more than happy to be heading back to see our friends. Milestones have passed.  We just know that we cannot let that much time pass again before we connect with the people we love.

Barry Frangipane, April, and Sandi McKenna – the first dinner – courtesy of Jeff Houck 

 

That night they did magic with the salmon I brought. Photo courtesy of Jeff Houck 

We heard great presentations about the wine and food. Here I am, that first dinner, sitting next to Carrie Oliver. Photo courtesy of Jeff Houck

First night in Tampa met two great guys I had been communicating with, Tom Morris, and Matthew Horbund (@mmwine). This photo is on the back cover of “Cigar Talk” a book that I wrote about conversations that go on in cigar shops

Another great friend we met through DayTime- Rick Griffin (@rickgriffin) here he is skydiving – his bucketlist. I think he is signing the new copy of his will

I went on a few shoots with April for Daytime Segments- this one at Titus Vineyards

Shortly after starting our show, we started a romance. Here we are in Sedona

Since we sort of met through Twitter- here is our wedding day when we tweeted our vows. The wedding was officiated by another of our twitter friends Sher (@SherBailey).

One of our other twitter friends, Lori Moreno (@LoriMoreno), not only came to our wedding but was our son, JJ’s first visitor

Dr. Block, the professor of Surgery at The University of Chicago was my inspiration to change from a career of research to one of surgery

She was a beautiful, intelligent lady with a great sense of humor who didn’t mind when we medical students poked and prodded her. But she fit the profile of breast cancer with positive genetics.  She had all of the risk factors, she was of Ashkenazi Jewish background, with aunts with breast cancer – all of whom died in their 40′s. Her mother didn’t have it, and was alive and vibrant in her 60′s. She had an identical twin sister who was spared, at least then.  She had developed breast cancer five years before, had a mastectomy with radiation therapy and reconstruction. Now the cancer was back.

We knew about the genetic inheritance of breast cancer in the 1980′s, but we had yet to isolate or even have the ability to test those genes. Since that time we have isolated the genes that are responsible for that, called BRCA 1 and BRCA 2, and we now can test, and like Angelina Jolie, make a decision about what to do.

Being on the ward, I was fascinated by the genetics of cancer, and at that time was thinking of using my background in genetic engineering to work on those sorts of projects.  Instead a gruff professor of surgery, the kind everyone fears, became my mentor – and instead of looking at ways to test for cancer, I became a surgeon, with the only good tool we have for fighting cancer – surgery.

Genetic Testing
Upon hearing about Angelina Jolie’s decision to undergo surgery to avoid her genetic predisposition to breast cancer my wife asked, “Should I be tested? I had a great aunt who had breast cancer.”  I suspect many women wonder the same thing.

Breast cancer happens to 1 in 9 women, which means if you have an extended family you will know someone in your family with breast cancer. It means that some of your friends, colleagues, or acquaintances have or will have breast cancer. It may mean that you will get breast cancer – because it is not just a disease of women, men get it too.

Should I get a test?

Many wonder if they should undergo the testing for the breast cancer genes

If your family had breast cancer that happened to someone before the age of 50, or breast cancer in both breasts, or cancer in male, or are of Ashkenazi Jewish ancestry and have relatives with breast cancer, you should be tested.  There is a specialty of physicians who are geneticists, and you should talk with them. If you do not meet this criteria, then chances are you don’t need to have gentic counseling or have the tests.

With all that breast cancer running around- people think – must be genetic. It isn’t.  Less than 1% of all breast cancers are genetic, and if you happen to have one of the genetic predispositions for cancer, then doing what Angelina Jolie did is a big decision, but it is the most comprehensive decision.  What is important to note is this:

Having a mastectomy is not a guarantee that you won’t get breast cancer. 
While a mastectomy is designed to get rid of all the breast tissue, sometimes people have breast tissue away from their breasts, and that tissue can turn malignant.  It sounds cruel to go through all that and still develop breast cancer.  The good news is that this is exceedingly rare.

There are other options for those who have the cancer gene – but none of those options are as good as the operation.

What are the Breast Cancer Genes?
They are sequences of DNA that code for a protein that regulates the growth of the cells. Everyone has the genes (BRAc1 and BRAC2) – we have two copies of each gene that we inherit from our parents. If those genes have a mutation the risk of cancer increases, but especially the risk of breast and ovarian cancer.

How do we test?
Testing is genetic – which means the test involves looking at the DNA of the BRCA1 and BRCA2 genes.  If there is a mutation then there is an increased risk of cancer.  The test can be done from blood or saliva and takes three weeks to get the results.

How much is the test?
The test costs anywhere from $500 to $4000 depending on the test. Some insurance companies cover the costs of the test if there is a strong family history of cancer.

What if the test is positive?
This does not mean you have cancer – but it does mean you have an increased risk of cancer. It means that you need a consultation with the appropriate physicians to discuss options.

The Sad Reality:
Listening to a radio station yesterday I heard someone propose that Angelina Jolie should have simply waited and had routine breast screening instead. That an early cancer is easily removed and treated.  I wanted to scream at the radio – and I wanted to scream because I was thinking of the women who I’ve treated over the years that had a small cancer, caught early on mammogram and the lymph nodes had no cancer– who later, many years later, had metastatic cancer.

I also thought of Lisa Adams, a twitter buddy (@adamslisa) who writes a blog about her life as a young mother with metastatic breast cancer.  Her cancer was found early, she made the decision to have bilateral mastectomy and have her ovaries removed, and this last year was diagnosed with metastatic breast cancer.   It is for women like Lisa, and many others, that I look at the lack of funding for the National Institutes of Health, and say that Congress is not just making lives inconvenient with the sequester – they are preventing the work from going forward that will lead to better treatments, and maybe even a cure.

Other than surgery, with adjuvant radiation and chemotherapy, we do not have good treatment of breast cancer. We have one good shot. So if the genes are positive, and you were my wife, daughter, relative- I would recommend what Angelina Jolie did.

While we are working hard for a cure, it will be a while before we know if we have one. There have been cases of breast cancer recurring twenty years after the original diagnosis.

Now, some 30 years later, I think back to that lovely young woman who came into the ward with metastatic breast cancer. Had we had the tests back then, and made the decision she would be an older lady now, enjoying grandchildren. I hope Angelina Jolie is able to enjoy her grandchildren.

In ancient times people were told about hybrid animals: the horse that was half human- the torso and head of a man with the body of a horse, the man that had the head of a dog, the horse that had wings. Some have familiar names, like Pan- who had the hind quarter of a goat and horns of a goat but face of a man.

For some these were an abomination, an unholy thing made from cross breeding and to be cursed.  For some they provided a sense of wonder. The Centaur, half horse half human that were great warriors.

Even in the bible, when the “end times” come the description of the feet of the bear and the mouth of the lion and the body of a leopard – a beast and not something to be trifled with. Or Frankenstein, a chimera of people.

The fear of chimeras is throughout all human mythology – but now, those chimeras are no longer a myth – they are real. Humans  can produce a chimera from the DNA of different species, making crops and animals that are modified to produce a chimera.

Are those same fears, same sense of wonder a part of the human collective conscious? Does that explain the debate about genetically modified organisms?

Since the ancient times the fear of chimeras has been a mix of wonder and horror. Now, with DNA technology, are we opening Pandor’s box? Or can we use the technology to save the world

What’s missing is science education, critical thinking, and the ability to talk the same language 

Perhaps it is my background in genetic engineering that makes the idea of genetic engineering interesting, and not scary. The knowledge that humans have manipulated genes in plants for at least 11,000 years gives some perspective. Genetically Modified Organisms (GMO) that are plants are neither the Frankenstein chimera that some suggest, nor are they the magic bullet for the common problems of feeding the world and saving the environment.

They are but one tool and sometimes that tool has  failed. What bothered me greatly as I researched the issue, was that the people who were anti-GMO did not even speak the same language as those who were proponents of GMO. The logical fallacies in arguments were on both sides: appeal to antiquity, appeal to authority, and ad hominem being the most common. One fact was alarmingly clear: people will say anything, put up any photograph, repeat falsehoods because they think their concern about GMO are valid.

This does not advance a rational discussion, this does not help advance the common quest we all would seek to find a safe way to feed the planet.  It also pointed out that critical thinking is not taught, and science education is lacking. There are rational concerns about some GMO, but those discussions become lost when histrionics replaces a sense of history, when the discussion is not about science but about fear. On the other side, the proponents of GMO, are often dismissive – partly because they lump those who express legitimate concern for GMO with those who are clearly irrational , and partly because they become forced into a position to support science.

Thirty Years of Molecular Engineering Plants

In 1983 a gene, made from DNA not belonging to the plant, was transferred into a plant and this technical feat and outcome reported in the journal Nature.  But genetic modification of  plants by humans has been going on for thousands of years. While at times we will specifically use “molecular engineering” for the modern technology of  modifying existing DNA or inserting new DNA into plants, for most we will use genetically modified (GM) crops to mean those crops which have specifically had their DNA modified by molecular technology. Molecular engineering of plants started 30 years ago, and 35 years since we first showed how the DNA coding for a protein from one species (a chicken) could be put it into the DNA of a virus (Herpes).  That use of a virus to host a DNA led to the idea that a plant virus could be used to insert DNA into a plant. DNA codes for all the proteins of the plant, much like humans. The techniques used then are now considered as outdated as using a floppy disc – and in fact, the ability to molecular engineer DNA can be done in a garage.

When we made our chimera (Herpes -Chicken) the concerns about molecular engineering were not yet articulated.  At that time it was a breakthrough to prove we could move a gene from one bit of DNA to another, and have that new organism make the chicken protein. Prior to that it was theoretically possible, but never proven. Once proven, did we open Pandora’s box or did we find the stairs to heaven?

Would you inject it?

We worry about our foods, a lot. So imagine injecting something like this directly into your body: in addition to an ingredient that has been extracted from a genetically modified organism  it is labeled like this-

People inject this everyday? Did you know that people not only inject this everyday but it keeps them alive? It is called insulin.  So when worried about the food supply, do not forget that GMO also applies to bacteria and yeast that produce proteins that some need daily to keep alive and healthy.

Would you ingest it- and should we Label it

Why not? The insulin above is clearly labeled, it says what it is- where it is from, and what else is in it. The question is- how do you label corn – because corn is a new plant, it wasn’t even around a few thousand years ago. Although most who wish food to be labeled intend those foods that contain proteins from another species. The insulin which the vast majority of Americans take, come from DNA from humans, but grown in yeast or bacteria.

The anti-label side states that most scientists, and the FDA find the food is safe, so why add an additional label to the ingredient. The counter argument: should not people decide for themselves if they wish to have it.  In a way this is an esoteric argument: I have a hard time getting my patients to read food labels- and most Americans do not read labels. But there is nothing wrong with a label, there is nothing wrong with letting people decide what they wish to consume.

Most of the corn and soy grown in the US are genetically modified. There has been no immediate ill effect, and yet, some would argue that trans-fats, once considered to be good fat, were not discovered to have an ill effect until years later.

The anti-label says that some people would shun those foods, wanting non GMO foods. The pro-label says, yes, that is the idea.

The fear of industry that they would have to change or educate the public is paternalistic, and reminds me of the argument at the beginning of the enlightenment that churches didn’t want their flock to learn to read lest they question authority.

What doesn’t help is this: we have lost science journalism. Finding a journalist who can look critically at a paper and present the information in a detached way is gone. Most journalists now, even from The New York Times, are more entertainment-style journalists – flashing a headline, quick quotes from a pool of scientists or physicians, and off with a story. But GMO are too important to leave to such journalists, GMOs are here to stay, but need to have a place where rational discussion can happen from those who are concerned.

Proteins and Plants

DNA is the programing code for proteins that are made by an organism. Even more than just a code for the proteins, it is the program for how the proteins are produced, when they are produced, and how much is produced. The code can  keep a given protein from being made under certain circumstances.  If you take the DNA that codes for a protein  and put it into corn you will have corn that produces that protein (sometimes).  Not all proteins that are in one species can be produced by another species even if we put the proper DNA sequence in the host.

For GM crops, most of the proteins that are manipulated with DNA are either the plants own proteins, or proteins from species that interact with that plant.  Bt cotton, for example, is a cotton plant who has had bacterial DNA  that codes for a protein that discourages bollworms and thus decreases the need for pesticides. This Bt DNA has also been placed in corn, and it was estimated to save 3.2 billion dollars  to farmers in Illinois, Wisconsin, and Minnesota over the past 14 years as well as a savings to non-Bt corn growers of more than 2.4 billion over 14 years – in pesticide costs.  The farmers were able to have higher yields of the corn, reducing loss from insect damage, reducing pesticides (mycotoxins), and providing a simpler and less expensive and environmentally friendly pest management option.

Lovers of organic farming will tell you that soil is a viable, living thing- with many different animals contributing to the balance that allows plants to grow. The most common are organisms called nematodes. A study out of China showed that planting the GM cotton did not affect soil nematodes. Compare that with the non Bt fields, where increased use of pesticides has wiped out a number of the organisms rendering the soil sterile.

On the horizon are crops that produce pheromones that pests interpret as “danger” signals, meaning less pesticides or even the promise of no pesticides would be needed.

Genetic Engineering: Farmers are more concerned with the environment than most know

City folk seem to think they are the only ones who know about industrial and organic farming. Many city folk assume, sometimes correctly, that modern farming has sterilized the land upon which we grow crops and make the assumption that GMO is another step in the destruction of our planet. Yet, if they were to go to farm conferences the most well-attended presentations are about environmental issues.

No one is closer to the land than a farmer, no one cares more about their land than a farmer – including those who own the large agri-business.  It is not the goal of agri-business to destroy the land they get their crops from. The goal of farming production, is to use less fertilizer, less herbicides, less pesticides, and less water. The hard way to do genetic engineering is what the Mayans did.  But over a few thousand years they took one plant, and made it into another species – one that wasn’t recognized until 10,000 years later.

The Promise of Molecular Engineering plants:  The promise of molecular engineering is based upon what Genetic engineering already showed: the ability to make crops that (a) grow faster (b) resistent to pests (c) resistant to weeds. We would add that the new goal of molecular engineered plants would be environmentally friendly, at the least, and helpful to the environment at the most.  The ability of plants to convert carbon dioxide to oxygen may be one of the major ways to diminish green-house gases.

In GMO farms there are less pesticides and less herbicides used. That doesn’t mean it will always be this way. What GMO has done is improve the yields of crops, it has decreased the use of some toxic chemicals on the land, it has provided a mechanism to improve nutrition, and decreased the use of water. But that can change.

The has been widely viewed on the internet – and is a doctored experiment.

In an effort to find the truth about GMO – and avoid the hyperbole on both sides, I did discover some rather disturbing myths out there. One is a photograph that shows a picture of two corn cobs, one eaten, the other not. One labeled GMO corn, the other not – it is a doctored photograph.  To think a squirrel would have more taste or better taste than a human is not only biologically incorrect, it is laughable. The person who put this up is a well known anti-GMO activist. This does nothing to further discussion, but is propaganda to increase fear.

In a rational discussion about the pros and cons of GMO we need a basis of discussion and not myths

Here are some things that are on the internet that are myths

- the tomato fish: They have a tomato which has a gene inserted in it from arctic fish so that the tomato will survive cold weather. This is not true. The cartoon 0f a chimera fish/tomato was a rallying point for some anti-GMO sentiment, but it turns out that such a product is not to be found on any market shelf. I understand one of the main issues was vegetarians who were concerned that having a protein from an animal in a plant would violate their vegetarianism (ok, that one made me scratch my head also). It was an interesting idea, and no one has any idea how far these experiments went, but biology would tell you that a frost resistant fish probably isn’t going to be helping a tomato. When the company who was working on the project was approached they noted that the experiment was a dismal failure. Then again- think about it: a fish has a heart and blood vessels and is pumping things – a tomato, well, doesn’t. Still the idea of transferring proteins from one species to another, much as we did 35 years ago, raises concerns. The problem is that there is too much hyperbole in the debate and the discussion.

German Cows Die after Eating GM modified Corn: It is true that Syngenta(the supplier of GM corn) reimbursed the farmers for the loss of cows, and that the cows did eat the corn that had been genetically modified.  The investigation of the cow deaths concluded that the GM corn was not the cause of death. In addition, there were extensive feeding studies of that GM corn (Bt 176) which were published in peer review journals and there was no adverse effect. Further, that corn had been planted for a number of years without adverse effect in those fields.  Turns out the cows probably died of botulism.

Did rats get tumors when eating GMO corn?: Rats developed tumors when eating GMO corn – not really. This was a paper that was published- and it had a lot of flaws: (a) These types of rats all develop tumors when they get old (b) severe statistical issues, with a small control group (c) No basic statistical significance (d) No dose response curve. The rats were fed unlimited amount of corn – if you feed this type of rat unlimited food they develop cancer.  Bad study, highly repeated in the internet – not repeated by anyone. Here is a response printed in full to that article: Seralini et al. (2012) claim to have found evidence for the long term toxicity of roundup-tolerant genetically modified maize (GMM). Using one-tailed Fishers exact test we show that there is no statistically significant increase in mortality rates or the number of tumors in rats fed GMM compared to control groups in the original data. Seralini et al. state that “In females, all treated groups died 2–3 times more than controls”. As follows from the figures presented: 2 female rats out of 10 died before the mean survival time in the control group, compared to 29 out of 60 in the six GMM fed groups. This difference is not statistically significant (P = 0.09). Note that this P-value requires a further correction for multiple comparisons due to two groups of rats (of different sexes) being independently analyzed. Among males 3 rats out of 10 died prematurely in the control group, compared to 19 out of 60 rats in the six GMM fed groups. This difference is statistically not significant (P = 0.615). Ironically if we forget about the importance of statistical significance and present the data in a manner used by Seralini et al., we could say that “In males, groups with 22% and 33% GMM in their diet died 3 times less than controls”, however this was not reported. This difference is also statistically not significant (P = 0.291 for each comparison). Seralini et al. state that “In treated males, liver congestions and necrosis were 2.5–5.5 times higher” and that “Females developed large mammary tumors almost always more often than and before controls”. Two male rats out of 10 had liver pathologies in the control group, compared to 30 out of 60 GMM fed male rats. Five female rats out of 10 developed mammary tumors in the control group, compared to 44 out of 60 GMM fed female rats. These differences are not statistically significant (P = 0.076 and P = 0.133). Note that this analysis should be done with care: over 30 different organs were analyzed in this study, but data on only a few was presented, giving rise to the statistical problem of multiple comparisons that was not addressed in the article. However, even despite this problem, all reported differences between the number of rats with specific organ pathologies in control and GMM fed rats are not statistically significant. It is also worth noting that tumors are frequent in Sprague–Dawley Rats: a spontaneous tumor incidence of 45% was previously recorded during a 1.5 year period (Prejean et al., 1973). The images of GMM fed rats with large tumors presented by Seralini et al. are misleading as they imply that such tumors do not normally occur or occur less frequently in untreated rats. Such tumors may occur in rats that are not fed GMM and Seralini et al. provide no statistical evidence that the incidence of tumors in general or any specific kind of tumor is increased in GMM fed rats. The random nature of the observed differences between control and GMM fed rats in the study is consistent with the lack of dose-dependent relationships between the amount of GMM in the diet and the supposed toxic effects of GMM. A news article published in Nature stated that “The controversy over the findings is likely to be settled only after detailed analysis of the paper and its data, and replication of the experiments” (Butler, 2012). Analysis of the data suggests that no statistically significant findings of GMM toxicity were presented in the first place.

Did sheep die from eating cotton with Bt? In a word, no. In almost every anti-GMO site I visited this was repeated over and over again, in spite of the simple evidence against it. This involved a group of sheep who died after grazing on a field of cotton. The accusation was that the sheep died from some unexplained poison – and that part is true. Sheep have been dying from toxins in cotton fields long before Bt cotton, and with the same lesions described by the anti-GMO groups.  In all cases the veterinarians describe that the sheep died of a toxin, probably pesticides used. Veterinarians  could not rule out nitrate or gossypol (a natural toxic ingredient of cotton plants) as toxic agents.  When Bt was fed to laboratory animals there were no deaths. Less pesticides are used on Bt Cotton modified plants, the total use of pesticides in the 10 million farmers who use Bt cotton has gone down.

DISCLOSURE:

I am not, nor ever have received funding support from Monsanto, or any corporation making or considering GMO. The funding received for the original research done with molecular engineering came from a grant from the National  Institutes of Health, and not associated with any industry.  Nor have I been paid any stipend, nor received any accommodation from such industries. Nor am I seeking such.

FUTURE BLOGS:

Allergies and GMO – the real story

GMO and the Third World

REFERENCE:

(1) Areawide Suppression of European Corn Borer with Bt Maize Reaps Savings to Non-Bt Maize Growers W. D. Hutchison, E. C. Burkness, P. D. Mitchell, R. D. Moon, T. W. Leslie, S. J. Fleischer, M. Abrahamson, K. L. Hamilton, K. L. Steffey, M. E. Gray, R. L. Hellmich, L. V. Kaster, T. E. Hunt, R. J. Wright, K. Pecinovsky, T. L. Rabaey, B. R. Flood, E. S. Raun Science 8 October 2010: vol. 330 no. 6001 pp. 222-225 PMID: 20929774

(2) A 2-year field study shows little evidence that the long-term planting of transgenic insect-resistant cotton affects the community structure of soil nematodes. Li X, Liu B. PLoS One. 2013 Apr 16;8(4):e61670. doi: 10.1371/journal.pone.0061670. Print 2013. PMID: 23613899

(3)Beever D and Kemp C (2000). Safety issues associated with the DNA in animal feed derived from genetically modified crops. A review of scientific and regulatory procedures. Nutritional Abstract Reviews Series B: Livestock Feeds and Feeding 70:175–182.

(4)Flachowsky G, Chesson A, and Aulrich K (2005). Animal nutritional with feeds from genetically modified plants. Archives of Animal Nutrition 59, 1–40.

(5)Flachowsky G, Aulrich K, Bohme H, and Halle I (2007). Studies on feeds from genetically modified plants (GMP) – Contributions to nutritional and safety assessment. Animal Feed Science and Technology. 133: 2-30.

(6)Goldstein DA, Tinland B, Gilbertson LA, Staub JM, Bannon GA, Goodman, RE, McCoy, RL, Silvanovich A (2005). Human safety and genetically modified plants: a review of antibiotic resistance markers and future transformation selection technologies. Journal of Applied Microbiology 99:7–23.

One of my favorite events: teaching a cooking class – I get to swap my surgical scrubs for an apron

Doctors ask patients many health related questions: do they smoke and do they use a seatbelt, but I ask patients if they cook. It is not a coincidence that the majority of my patients, when they first meet me, tell me that they don’t cook. They “eat out.” That usually means they eat at fast-food places or chain restaurants. Which means they eat crap. It also means they eat too much.

They have no appreciation for what real food is, and who can blame them? But when they first taste a tree-ripened peach, or cook their first bit of chicken from a chicken that was raised  on a range, or discover that they can make a great taco from lentils – their eyes open.

I tell my patients that my goal, besides the successful surgery, is for them to change their lifestyle.  Every patient knows this, and nods, but then I tell them what I mean by that: I tell them they have to cook.  I tell them that I am going to turn them into food snobs. That in five years they won’t eat the same thing they eat now, that they will have such an appreciation for food and what they eat that they won’t want to go out to eat – unless it is an amazing restaurant.  Imagine- a weight loss surgeon telling a patient with morbid obesity that they want them to really  love food. I believe in this so strongly that it is a part of the surgical consent they sign in their first consultation with me.

Evolution of a Surgeon -Cook

This isn’t common among surgeons today – in fact I know only one other surgeon, also a weight loss surgeon, Garth Davis, who does this. I didn’t always do this – this was a result of years of watching weight loss surgery patients come and go, and then studying the successful ones. When a patient goes from morbid obesity to a normal weight, and then stays that weight for at least five years I enter them into a special data base. Every year I question those patients about what they do.  I also have patients that never leave morbid obesity – they might loose some weight, but they never get to a point where they get out of that dangerous weight group in spite of aggressive stomach surgery and intestinal re-routing.  That group I also question. For years my questions were about eating habits, and how much they exercised – and there were some clear patterns: 77% of patients who kept off their weight for over five years exercised. But then one year I asked two simple questions that I had never asked before – (a) Do you cook – and did you before and (b) What things do you eat today that you didn’t eat before surgery. Over 500 patients who were successful – all of them cooked, and 85% didn’t before (I don’t consider heating things up in a microwave or preparing processed packages cooking). Further, of the successful patients – none were eating the same things they ate before surgery (their diet had changed dramatically). Of the group who were not successful – over 300 patients who had never left morbid obesity – most ate the same foods they ate before, over 80% didn’t cook more than re-heat something – most ate out, at the same places.

Then it hit me- it became personal. I realized that there was a time in my life when I had gained far more weight than I care to admit to. I spent almost a year eating out at chain restaurants.  At my highest weight I was over 230 pounds. I got away from those places, and started to cook at home again – and started to loose the weight.  Mind you, it is still an ongoing process – but every year for the last ten years I weigh less than the year before.  The only significant time that changed was when my wife was pregnant two years ago and I gained weight helping her eat her way through pregnancy (she is back to a size 2, I am ten pounds away from where I was then – but still less. )

Checking the Sous Vide at one of our Weight Loss Fest Events

It All Changed

The focus of support group for patients went from chatting about healthy foods, to teaching them to cook. In fact, we now have mega events where we give patients a cooking lesson and do a lot of menu planning.

When patients come in the office we have a questionnaire about what they have eaten lately, and we talk about cooking. When someone who hasn’t been successful wants to get back into it, we tell them they must cook (not their significant other, not their mom, them).

Adolescent Obesity

One of the hardest groups to deal with are teenagers. They want to loose weight – they are desperate for it. For years we would watch motivated teenagers with highly supportive families come in, get weight loss surgery, and a few years later regain weight (usually when they left home). I vividly recall one 20 year old who came to my office wanting her Lap-Band out because she wanted to eat like her boyfriend (who was, at 21, over 300 pounds at 5’6″).

So I changed my approach. Now when a teenager comes in wanting weight loss surgery the answer is simple: they have to cook, they have to cook their meals and show me a meal plan. Sometimes they have to come with me on field trips to the Farmer’s Market. Up front they are told that eating at the mall is no longer an option, if they want to loose weight.  That my goal for them is to be so good at cooking, that when they go to college their friends won’t want to go out for for pizza, but have them cook. I’m up front in my skepticism of them, but tell them if they are serious, they will do this. Those teenagers who have embraced this, have loved it- one even went to culinary school.

If a Busy Surgeon Can Do It – So Can You

You can imagine the excuses I hear for not cooking. You can imagine what I tell them. And when people say they just can’t do this because of work- I show them this neat invention: the lunch box.

Culinary Medicine

There are a few of us out there – physicians who cook, who teach their patients to cook, who ask what they eat. It is growing – slowly. Some of my fellow physicians who do this include Garth Davis, a weight loss surgeon from Houston, John La Puma, a fellow alum and internist, and more.  There is more press about this than doctors who do it. And cooking healthy isn’t about what people think: it isn’t eating chicken wraps, flavorless fish, or waxy vegetables. What people think is healthy is often more fad than fact. 

So my life and career changed and today:

I’m a Cook who Does a little Surgery

I still use a fine scalpel but I have a lot more tools now

Here is A Bit More From My Upcoming Book:

I’m a surgeon. I have seen bodies inside and out- from blocked arteries, worn out knees, herniated back discs, fatty livers, cancers, or pancreases that no longer function. When people come to me, or to my colleagues, they need our help, our intervention to get them back to health, or a functioning place. And most of the time we can help them.

The question is: how long can we keep them healthy before they need us again? What can we do to keep them healthier, longer? Is there a diet, or a food, or a program that we can prescribe our patients that will help them stay out of our operating rooms for a long time? Then, to those who have not yet gotten to the stage where they need us, is there a diet, or a group of foods, that they consume that will keep them from ever getting to us?

People who have undergone complex operations for their health, such as heart surgery, cancer surgery, hip replacement, back surgery, weight loss surgery, all need their operations- but it serves as a wake up call about their health. When we see those patients back in the office they want to know what they can do to avoid having us operate on them again – and the answer is simple: Just Cook! Those who learn to cook, some simple dishes, are doing the single best thing to avoid coming back to the operating room – besides taking their medicine.

But make no mistake about it; there are those who assume when doctors fix them they can resume their former lifestyle. Have you ever heard of a person who goes through weight loss surgery, such as gastric bypass or LAP-BAND, and regains their excess weight? They may blame the operation, instead of embracing the operation as a call to change their old habits—such as eating out and eating junk. I remember the heart surgery patient who, with new vessels in place, went right back to eating out his favorite meals of burgers and cheese. Or the cancer survivor who balks at chemotherapy yet thinks nothing of eating from restaurants that serve through a window

But my other goal is to teach patients a bit about how their body works, and what we know about the foods and nutrients. That’s not easy, because science doesn’t always agree with popular perception – and there are a lot of myths that we shatter. Every day on my Facebook page and Twitter stream I see nonsense about food: what it can cure, nonsense about what you should eat to avoid cancer, heart disease, or loose weight – posted by people who mean well and want others to be healthy, but who have no idea how the body really works.

Knowing what a body does with food, where things work is a part of the simple recipes we teach – along with a few bringing in friends of mine,  from fellow doctors, foodies, chefs, and writers who will share their own myths.

We’ve lost a generation of home cooks and gained a generation of people who eat out. Starting in the 1970s, people took less interest in learning to cook, opting instead for chain restaurants that substituted convenience for quality. Today there are five times as many restaurants opening as grocery stores- in the 1960’s there were five times as many grocery stores as restaurants. In 1986, there were fewer than 100 surgeons in the United States doing weight loss surgery. Today there are more than 2,000. In 1976 no one did angioplasties in the United States, today over 1 million angioplasties and stents are performed in the United States.

When a bariatric group consistently gets poor results from a procedure they should not do that procedure.  In this case, a number of bariatric surgeons have had poor results with patients who underwent the Lap-Band. Those groups often blame the Lap-Band as the problem- but with the band it isn’t the procedure, it is how the surgeons take care of their patients after they have the operation.The results from those centers are in stark contrast to Lap-Band surgeons who prefer the band, who have great results with their patients, who see their patients often.

There is an essential difference between weight loss surgeons: those who think the surgery should do everything, and those who think surgery is a tool and we should teach lifestyle changes

One key to teaching patients about how to take care of the band is to enforce that the band is NOT ABOUT RESTRICTION. The band does not, and should not restrict food. Instead the band should allow food to go freely past the band. If food stays above the band too long, it will become uncomfortable. Ultimately this causes stretch with the stomach on top of the band and begins a process of dilation and as the stomach above the band dilates, it begins to pull stomach from below up to the band.

Once this happens there is what is called a band slip.  It is at this stage that some surgeons mistakenly believe it is the band that has failed, and then remove the band and convert patients to a gastric sleeve. Converting to a sleeve in these circumstances comes with a 5.5% leak rate- meaning, it is far more deadly to convert these patients to a sleeve if they have a dilated stomach.

There are two better alternatives, however.  One alternative is to remove all the fluid from the band and place the patient on a strict liquid diet for a week.  Recheck an x-ray and often times the band will be back in a normal position. During this time the patient needs to be educated about how to use the band, and not use the band. Behaviors that cause slips include: relying on the band to feel full, eating too fast, getting foods stuck too often. The worst way a patient can use the band  is to rely on the band to make them feel full.  If they do this, they will cause the stomach above the band to stretch, as it stretches stomach is pulled from below the band to above the band and result in a slip or dilation of the upper pouch — early on giving symptoms of reflux and heartburn.

The second alternative is a surgery to unbuckle the band.  This takes the pressure off the upper stomach.  There is scar tissue from where the band and the stomach were and that scar tissue must be opened up.  This is a quick operation, takes about ten minutes, and allows the person who could not eat or drink to immediately be able to.  Then, in two months the patient has a choice to have the band re-buckled, leave it alone, or if they wish to go to another weight loss operation there is much less risk of a leak. We have done over 20 patients with unbuckling the band, and later repositioning it. All with great results, no morbidity or mortality in that group.

The key, however, is having a band surgeon who knows how to take care of the band, and not a surgeon who is quick to abandon the band and not wish to teach the patient how to use it.

Gastric Sleeves Stretch over time:
The problem with the gastric sleeve: it will stretch over time. Having done hundreds of sleeves, after four or five years we see that they stretch, and sometimes will stretch back to the size of a normal stomach. That same behavior that caused the stretching of a pouch above a Lap-Band will ultimately lead to stretching of the sleeve — then the patient is faced with another choice.  A number of my patients who underwent duodenal switch, or gastric sleeve, years ago and had their stomachs stretch, have had the lap-band placed over them, with great results – again, being taught that the band and the sleeve are tools, and not tools to make you feel full.

Great results are not from the procedure: it is from teaching patients about aftercare and lifestyle.
That is the key to having success with the least invasive operation – and after 20 years of doing all the weight loss operations – the key to success in all operations is teaching patients a new lifestyle. Not that there are not complications with surgery- as there are with any operation – but it is quite clear: there is a huge difference in the results of those who have a band done from a center where they specialize in the band and the aftercare of the patient, and those centers where band is an afterthought.

Not everyone should be doing the band: that is clear from the literature of those centers that have removed bands.

Still, the Lap-Band is the most researched weight loss surgery to this day. In part because it is the least invasive, in part because it does not remove stomach, and in part because it is the only surgery that is approved for patients who have less weight to loose- meaning it is much safer.

If you had your band and find that you are having issues, but the place that did your band wants it removed – get a second opinion from a surgeon who does a lot of bands. Go to lapband.com and see the surgeons who are listed there. At one time your surgeon may have been listed there, but the results may have them removed from that list.

The lap band is placed at the top of the stomach – here is a diagram of the band placed in its normal position

This is a normal band x-ray. The band is the faint outline in a 8oclock to 2 oclock position, there is normal contrast going through it.

Relying on food to go slowly through the band, and having the band too tight means food stays above the band. Some people say this makes them “feel full” but it ends up causing a band slip

Once there is enough stomach above the band, it flops over the band – like a muffin top. At this point patients experience heartburn, reflux, sometimes night cough

The x-ray shows the band now in a 10 oclock to 4 oclock position, with the stomach pulled above the band, and the muffin top

Here is a diagram of an unbuckled band. Below the band, on the stomach is the scar tissue which must be lysed (or cut) to allow healing

New Jersey Governor Chris Christie gets a LapBand

The governor of New Jersey had a Lap-Band installed in February and has already lost 40 pounds- which is a little over 10 pounds a month. He had the band installed by a great surgeon, Dr. George Fielding, who himself has a Lap-Band Of all the weight loss operations, the Lap-Band is the least invasive- with Governor Christie going in on a Saturday and leaving the same day.

The Lap-Band, while it is the easiest to install is like all other weight loss operations and requires:

(a) That the lifestyle of the patient change quite a bit. We discovered of our patients who are the most successful they made one change – they cooked. In fact, of all the variables of success, the ability to cook was number one.

(b) Measuring foods: the band does not “restrict” the amount of food you can eat. You can eat as much as you want. What the band does is allow you to eat less without being hungry later. This is an important feature. This means it is up to the person to eat less, it is up to the band (which we can adjust) to make it so you won’t be hungry later.

(c) What the band does not do is: make you feel full. The band does not change the size of the stomach. Some people have the “illusion” they feel full, but that is just it – an illusion. If people use the band to “feel full” they will end up disappointed. It was concerning that Governor Christie said he felt full with less.

The advantage of the Lap-Band are many:

It is the least invasive of all the operations. It does not change your stomach or intestines.

It is the only weight loss surgery that is been tested and approved for patients who are not morbidly obese. We were one of the FDA test sights for that study- which we just completed. Patients who have as little as 30 pounds to loose were successful with the operation.

It still has risks – it is surgery, and with surgery comes complications. But the complications are less in centers where they specialize in the Lap-Band and taking care of patients after the surgery.

It is clear that those centers which don’t do many Lap-Bands have neither the good outcomes, and have more complications than centers that do more.

So if you are considering a band, be sure to go to a center that specializes not only in placing the band, but in taking care of you after. Especially if the surgeon is the one who takes care of you after the operation – not sending you to a staff member for adjustments.

Governor Christie talked with the NY Jets head coach, Rex Ryan about the band. Ryan managed to keep off 100 pounds since lap band surgery in 2011. He shared his tips for success.

1. Ask for help. Exercise and diets weren’t cutting it for me, and there came a time when I had to decide that enough was enough. I asked for help, and ultimately underwent the LAP-BAND AP(R) System procedure in 2011, which forced me to make a commitment to change my behavior for the long-term. I’ve lost a total of 115 pounds since the procedure, and I still have a ways to go. The bottom line is I now have a tool that keeps me on track and helps me stay disciplined with my eating habits.

2. Research your weight loss options.

3. Quick fixes don’t last. We all know people who have had the sleeve procedure, and probably lost a lot of weight effortlessly. But because the sleeve doesn’t require adjustments, many don’t follow up with their surgeons and don’t change their behaviors and therefore have regained their weight. The fact is, all weight loss surgeries will fail if you don’t change your behaviors.

4. Look for solutions that are right for you.

5. Set yourself up for success.

6. Go outside and get active. A healthy lifestyle includes smart eating and consistent exercise

7. Find a support network. For men, it’s easy for us to believe that we “choose” to be heavy and that all we need to do is get off the couch and go for a run to be healthier or leaner, but it’s not that simple. Whether it’s a family member, friend or nutritionist, finding allies who support your healthy lifestyle will help you maintain your weight goals.

8. Cut back on the snacks and junk food. That doesn’t mean that you need to eliminate your favorite foods altogether, but be smart about your choices and enjoy them in moderation. I’m a huge fan of Mexican food, so instead of depriving myself I’ll eat smaller portions and leave out sour cream.

9. Stay disciplined and change your behavior. When I’m on the road during the football season, it’s definitely more challenging to watch my weight, but I’ve been able to stay on track and even lose a few additional pounds by paying attention to portion size and incorporating exercise into my day. I also eat with the team when we’re on the road instead of going out

Below is Dr. Fielding’s commercial he did for the Lap-Band.  Dr. Fielding, like myself, does all the operations: the sleeve, the imbrication, but like Dr. Fielding, we recommend the Lap-Band for almost all cases of obesity.  Dr. Fielding is not only a surgeon, he is a patient – and a friend.

This is a series about genetically modified organisms. We anticipate there will be three parts. It will be comprehensive, but if you are truly interested in this field, we hope you enjoy this.

Genetically Modified Organisms are bad. Monsanto is evil. These crops are killing us. 

Well, not really. This is not a simple topic – that is, it is not as simple as “this is bad and we shouldn’t do it” or “its not natural, so it must be bad.”  Nor is it “corporate evil.”

My background about this topic:

I did genetic engineering as a graduate student  at The University of Chicago.  What we did with  genetic engineering, people have been doing for thousands of years, the difference is we did it in a laboratory. You will see in the first part of this series how the majority of genetic engineering was done thousands of years before the field of genetics was understood by Europeans. My name is on a landmark paper where the first eukaryotic gene was inserted into a Herpes Simplex Virus and regulated like by the genetic regulation of the gene it replaced – obscure, but an important and first paper about the topic.

I left most bench research for a while to become a physician (I liked people better than petri dishes). As a physician who spends most of his time researching food, talking to patients about food – the politics of food fascinates me. We have shown that the single most important variable with success for surgery patients who have had weight loss surgery, is their willingness to cook. Patients who learn to cook, to appreciate food, at five years post surgery do much better than those who fall back into their habits.

Genetic Engineering was Started by Native Americans

Corn is genetically engineered, there was no corn 10,000 years ago.  Corn was genetically engineered  by Native Americans,  not done in a lab – it was done by methods that Europeans would discover, and call genetics. Corn had been already engineered thousands of years before the “father” of genetics, Gregor Mendell was born, and the first Europeans were given this food from Columbus onward.

Thousands of years of selective breeding changed how corn looks. Photo from Robert S Peabody Museum of Archeology, Andover MASS – all rights reserved

It all began with a grass  called Teosinte (pronounced “tA-O-’sin-tE”).  Teosinte does not look like corn today, but the DNA shows they are alike, and it was this grass that Native Americans 10,000 years ago began to engineer. In fact it wasn’t until a few years, 2005,  ago that modern molecular geneticists discovered that this grass, Teosinte, was the father of corn.  For years people who study plants, botanists, assumed the evolutionary predecessor to had long since died out. And while Teosinte is widely spread throughout central America, it was not even considered in the same family as corn.

What modern molecular biology has done to corn is nothing compared to what the ancient Native Americans did.

The original ear of Teosinte is 2-3 inches long with 5-12 kernels. The kernels were hard, and most human teeth would break trying to eat them. Teosinte is inedible for people. Contrast Teosinte with modern corn with a cob that is 12 inches long, with over 500 kernels.  The coating on the kernel was selectively bred from the rock-hard protecting seed to, now, where corn has an easily chewable,  paper thin, but still indigestible membrane.  This was breeding at its finest.

Ten thousand years ago there was not a plant that anyone would recognize as corn. In fact, there was no corn. By 4500 years ago corn was throughout all the Americas, with carbon dating of kernels in Arizona from over 3000 years ago, Canada 700 years ago.. It allowed the Mayan people to go from a people who foraged, to a people who could stay and cultivate.

Teosinte is a hard, inedible kernel – this grass and corn share the same DNA, with some simple modifications one becomes the other

You can see from the photos how as time went on corn changed: both Teosinte and corn have the same number of chromosomes, they have the same genes that code for the same proteins. Teosinte and corn can be bred, because they are so close genetically.  The difference between the grass, Teosinte, and modern corn is about five genes.  Corn didn’t “evolve” corn was “genetically” engineered by early Native Americans.

It all started in an area that we know today as El Salvador, where the Mayans discovered the plant in the mountains of Chalatenango. Recently a damn revealed a village in the area, which was one of the original four Lake Island villages of the Mayans, and on this land one can see the range of corn from the grass to the modern corn.  If you hike there  you can see places where the Mayans would grow special crops, where they would harvest the Teosinte with the kernels they could eat, and over time they would breed it and cross breed it until they had an agricultural system that was based on this plant.

The first genetic engineers cultivated a grass called Teosinte – in the region now known as El Salvador. Credit: Library of Congress, LC-USZ62-46945

So sacred was corn, that they called it the “grain of the gods.” To this day the people in Santa Ana,  in western El Salvador, still plant little plots of primitive corn that they called something like “ulupiche”. This is not to eat but simply to please the ancestors. It is from these Mayans that corn was selectively bred, or genetically engineered for better taste, different colors, ability to withstand pests.

Thousands of years later in Europe and the United States: 

For over 5000 years there was no change in corn, until the Europeans discovered the field of genetics, and began to reapply what the ancient Mayans had done.  About 8000 years after the Mayans engineered Teosinte to corn, in 1865, Gregor Mendel presented a paper about his experiments with peas – and ultimately developed the early laws of genetics. Genetics became a new biologic field, and the first major publications about corn were in 1908 when a University of Chicago graduate, George  Harrison Shull,  began researching genetics using corn while at Cold Spring Harbor laboratory. His interest in maize was taking purebred lines and crossing them, and discovered they were more vigorous than the original strains. This increased vigor, and ability to increase yield meant a lot to farmers growing corn. As a result several companies developed corn and yearly would sell the seed to farmers. Some strains were developed and distributed to farmers without cost, such as The University of Wisconsin.

The hybrid corn was uniform, strong, and rapidly began to replace the open-field pollinated corn. This uniformity allowed for mechanized harvesting, and increased yield from 20-30 bushels per acre to over 120 by the year 2000. Currently, corn growers have changed emphasis from increased production to environmentally sound productions.

In early, pre-molecular biology, days, corn was used to study genetics. In those days biologists, like Shull, would breed corn to examine the determine genetics of the corn. The genes that were commonly manipulated either by geneticists, included the genes responsible for the color of corn, it can be yellow, white, blue, orange. In addition genes responsible for its resistance to pests, genes responsible for the taste of the corn (sweet corn is different than popcorn, which are different than corn grown for cattle, or that grown for fish).

More recently, using the techniques of modern molecular biology, the DNA has been mapped for the corn, and certain proteins have been allowed to be expressed more than others. Working in the laboratory, where the entire DNA sequence of maize is available, the genes can be manipulated to increase various proteins. How this is done, and whether this is good is for the next blog

All corn has been genetically engineered

There is no corn on this earth that is not genetically modified. Corn was the example we used here, it can also be said for wheat, tomatoes, papaya, and a few other crops. All have been genetically modified – and if one begins to label GMO foods, then all those crops, and more, will need to have a label.

Here the debate gets ugly:

You may have seen photos on the internet: people show two ears of corn, one, they call GMO the other is “organic” and one is eaten by squirrels and the other is not. None of those photos has been truthful. Or the little girl who as a science project showed how bees avoided some genetic engineered produce. These are sad anecdotes from people who have an agenda. We don’t need anecdotes in this debate, we need truth. The truth is simple: all corn has been engineered for years. We will answer some of the claims which are valid, and some are irrational.

(a) Should they be labelled – no reason not to be. This may be a problem, because we have to decide at what point do we label – which crops, and what. Since all corn is new from humans harvesting, it would all have to be labelled.

(b) It is bad for diversity. All crops today are uniform, and yes, they represent a non-biodiverse species. This has led to problems – the Irish famine, for example- but that wasn’t because of molecular genetic manipulation, that was how potato crops are.  All corn, all wheat, all soy- when you look you will see single hybrid lines. Think of Teosinte – it had far more biodiversity than corn. The wild grass could adapt to different places, but in choosing the genes to express, corn now has a wider range than Teosinte ever could imagine. Some might say that this grass has done a good job of getting humans to spread it around the globe.

(c) It can lead to greater famine and weeds. The constant threat since humans began to cultivate plants was the threat of famine, or pests, or weeds that would wipe out crops. GMO does not change this. Having a modification of a plant can help it.

(d) Animals avoid GMO food. Most of the photographs have been faked. But remember, most GMO foods you will avoid also. You won’t be eating the vast majority of corn because it is meant for animal feed. If you tried to eat that you would find it unpleasant. You would eat sweet corn, but a cow would avoid that.

(e) The genes can get into and affect humans. This is one of those things that is “possible” but not probable. Any bit of DNA anywhere in the world can infect humans – but it is highly unlikely. The GMO crops do not change that simple fact. Any DNA from any organism can get into our DNA- it simply doesn’t happen that ofen.

(f) GMO leads to increased use of herbicides and pesticides that are bad for the environment.  Turns out that most agriculture isn’t that great for the environment. A large farming system depends on chemicals to fertilize it, to replenish nitrogen and phosphorus, and to get rid of weeds as well as any molds, fungus, insects, or parasites that will consume the harvest. This is not new – this is the state of agriculture. The good news is that they are starting to work on growing things differently. More about this later.  The idea behind many of the crops is to have those that are resistent not to the pesticides and herbicides, but to the pests and the weeds themselves.

BUT ITS NOT THE SAME:

Someone is bound to say that there is a difference between what we do in the laboratory and what the Mayans did to Teosinte. There isn’t. Not one bit. There might even be those among you who wear tin hats who would say – an advanced civilization did genetic engineering – except we have the ruins to show the Mayans did in fact do this. It is exactly the same. We are just more efficient at it.

Industry affiliations:

I have never received a grant, money, dinner, or stipend of any kind from any agricultural company (Monsanto, Dupont, etc). No research I have been involved with, no writing supported by, no television advertisement paid for by any agri-business ever.

REFERENCES:

A lovely view of the archeology of the area see this: http://inclusivebusiness.typepad.com/indigenous_elsalvador/corn-and-teosinte/

The NSF announcement of Teosinte as corn:  http://www.nsf.gov/news/news_summ.jsp?cntn_id=104207

90 years ago: the beginning of hybrid maize. Crow JF. Genetics. 1998 Mar;148(3):923-8.  PMID: 9539413

The mechanism is a byproduct of the metabolism of some bacteria called TMAO (trimethylamine N-oxide) which, in some studies, is correlated with an increased risk of heart disease.

In the experiments conducted they took meat eaters and vegans and fed them steaks. Why I wasn’t invited to participate is clearly an oversight – after all, steaks…. They discovered when red meat eaters ate steak their level of TMAO went up, but not if vegetarians ate it. They even discovered it wasn’t the meat, but rather the carnitine in the meat that did this (a common supplement in protein drinks for those who want to look like Arnold Schwartzeneger on steroids).

Takes a bit of presumption doesn’t it. But lets work backwards from this hypothesis and start with a favorite saying:

Correlation does not equal Causation
The evidence that red meat causes an increase in coronary artery disease is mixed, at best. The latest study showed there was no evidence that this was an independent risk factor. Smaller studies such as the Nurses Health Study and Health Professional Follow-up study showed an association with a relative risk factor of much less than 2. I blogged a summary of those studies.

Your Gut and Bugs
The bacteria in your gut are important. They protect you- by simply occupying space, they prevent bacteria that are harmful to you from finding a home, as well as  parasites, yeast, and perhaps some viruses.  It has been estimated we have over four pounds of bacteria in our gut. Just a few other numbers that are fun: it is estimated there are over 100 trillion bacteria in our gut (the human  being is made up of about 10 trillion cells, so there are more of them than there are of us – or, a philosopher might ask – who are we really).  We have grown only about 70% of the bugs found in our gut, or so we guess. The byproducts of these bacteria include chemicals that prevent fungus from taking hold,  prevent other bacteria from getting close, and they alter the pH of the gut to keep it comfortable for us and our friendly bacteria, but not so much for the bad bacteria.

These friendly bacteria help produce vitamin K, and biotin. In addition to helping ferment other substances that our body cannot break down, and by breaking down those substances make them available for us to get nutrients from them. While humans cannot digest fiber, some of the bacteria in the gut can digest fiber, and the byproduct of that digested fiber is an agent that decreases the risk of colon cancer (our poop has stuff that bacteria eat and bacteria poop keep us from getting cancer). Is it possible that the bacteria in our gut could create something that makes it more likely for us to have heart disease, or cancer? Yes, it is quite possible.  What you eat does alter your gut bacteria. Who you kiss alters your gut bacteria. Who your parents are alter your gut bacteria. When you get an antibiotic, your gut bacteria change.

With some antibiotics and a combination of stomach acid reducing agents (Prevacid, Nexium, etc) a bacteria that overgrows the colon called Clostridium difficile  (C diff).  This bacteria so overgrows the colon and as a result people can develop ulcers, bleeding, toxic mega-colon, and perforation as well as death. This is a concern for surgeons, something we encounter far too often.

Some people can get overgrowth of bacteria in their small bowel that can lead to malabsorption of nutrients including bloating, nausea, diarrhea, constipation, and long term problems like  anemia from iron malabsorption, and has been linked with some auto immune diseases.

Think of your gut like an eco-system. If it is in perfect harmony, you benefit from it. If not, an overgrowth of one or another bacteria can lead to problems. 

Diet certainly affects which bacteria inhabit your gut. The big question remains, is there a diet, or set of foods, that will encourage the gut to have more “friendly” bacteria and less “bad” bacteria. Here is the realm of speculation – other than a diet rich in fiber being healthy, we don’t have a great answer.  This doesn’t stop people from speculating about one diet or another being better.  In this case, the speculation would be that vegans and vegetarians eat a diet that keeps the bacteria that produce TMAO to a minimum.

And the colon- remember, people have been telling you for years about how bad the colon is- from Kellog and his enemas (he died in his 60′s from heart disease, was a perfect vegetarian and loved colonics) to modern day colon cleansers.  No doubt there will be on Walgreen’s supplement shelves a pro-biotic that will get rid of the bugs that make TMAO.

Gut bugs and Diet
There are three types of gut flora that have been described based on the diet that people have. The “enterotypes” are descried as Prevotella, Bacteroides, and Ruminococcus.  Each one associated with a specific type of diet. Prevotella comes from diets with lots of simple sugars, or high-glycemic index carbohydrates. Bacteroides is associated with animal proteins, or the typical western diet. It is those people who have the Prevotella species that had a higher TMAO blood level. Oddly 3 our of 4 of the subjects that had the Prevotella species were omnivores.

In another study showed that these broad enterotypes were associated with long-term diets. When people were fed a controlled diet the enterotypes remained the same during the ten day study. While some bugs changed quickly, it appears your gut ecology takes a while to change – which, if you think about it, is not surprising.

You are probably thinking- 100 trillion bacteria, and the population of some types more than others?  Think of the United States with its population and other countries with their population. In Norwegian countries there are more Scandinavians, in Italy there are more Latins – now think of your gut. In Vegans, there are going to be more bacteria that do well with their host who eats vegetables – and in omnivores, the bacteria that populate it will likely be more of those that like chewing on remnants of meat.  The hypothesis here is that those bacteria produce more TMAO, and thus meat eaters, when given meat, make that harmful substance that leads to more cardiac deaths (forget that this is a poor correlation in any study looked at, just go with it for a bit). Now- bacteria don’t just eat meat and poop out TMAO – there are enzymes involved in the conversion to this “deadly” substance – and one of them is Vitamin B2, which is typically LOW in vegetarians.

What about TMAO and the Nature Article?
One arm of the human study was with six people.  Five of them were meat eaters and there was one vegan. This is little more than an observation, and hardly  enough of an observation to make headlines.  That one vegan didn’t make TMAO means nothing. It could be that the vegan had antibiotics recently, it could be that they are an exception, it could be a lot of things. The one vegan was a male, and the non-vegans were females – and when the statistics were examined carefully – well, not a difference. But significant, even as an observation – nope.

Of course of the 23 vegans/vegetarians and 30 omnivores they looked at the bacteria in their stool (reminds me of the movie The Madness of King George – when they were obsessed with his stool) – and found the different types of bacteria attempting to correlate those bacteria with meat eaters or vegetarians. The problem was, some of the individuals with the “good bacteria” were omnivores.

The Nature article also looked at a mouse study. Mice are not humans, but with mice they didn’t feed them steaks. Instead they used carnitine. Carnitine is an amino acid, often used in supplements, but your body makes this amino acid naturally. To date there have not been studies that show that carnitine rich foods increase TMAO, in fact the one food that elevates TMAO is some seafood. Seafood, by the way, is associated with decreased risk of heart attack.

In the mouse study they fed them enough carnitine to the equivalent of a human eating about a thousand steaks a day. And I would submit if you eat that many steaks a day you might have some problems. The other issue is this: the gut bacteria of the mouse are not the same as the gut bacteria of the human. Are you a man or a mouse can apparently be answered by checking your fecal bacteria.

AND NOW EGGS?

It is the same argument and discussion for eggs. Turns out that the correlation with eggs and heart disease is zip. In fact, one of our patients finished a month of eating nothing but eggs and saw his cholesterol drop! Again, this is just a bad article with a lot of bad press.

A House of Cards
This study and news report is a part of a house of cards. Conclusions built upon conclusions, with a benign observation from one vegan, and a study in mice. In their conclusion the Nature paper stated that this went along with evidence of risk reduction for non red meat eaters and they cited the Mediterranean diet study in NEJM.  What they fail to grasp is that diet didn’t show a decrease in heart attacks, or heart related events, only a decrease in risk of dying from a stroke – and no absolute decreased risk of dying.

This study again falls into the “red meat is bad,” and shows two things: studies that make headlines in newspapers show that in the slow death spiral of print media they fired their science reporters first  and second, if you want your study to get headlines, find something that shows what the popular press thinks is true.

Saturated fat and cholesterol in beef don’t cause heart problems, and your body makes more carnitine than you get from your diet by a factor of six (unless you are a mouse that is force fed).  TMAO is a huge byproduct of fish, and fish eaters seem to have longer lives and less heart disease.

So- this study make sense to you? Is there maybe a message here? One thing is certain: vegetables are not bad things for you. While some of the omnivores in this group had “good gut bacteria” it could be because they ate a lot of vegetables. So- if I were you, I’d make sure I had plenty of that good old fashioned fiber in my diet.  Who knows, maybe that helps the good bacteria from having heart attacks.

REFERENCES:

The red meat article, published originally on Nature.com

Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013 Apr 7  Koeth RA, Wang Z, Levison BS, Buffa JA, Org E, Sheehy BT, Britt EB, Fu X, Wu Y, Li L, Smith JD, Didonato JA, Chen J, Li H, Wu GD, Lewis JD, Warrier M, Brown JM, Krauss RM, Tang WH, Bushman FD, Lusis AJ, Hazen SL. PMID: 23563705

Here is the article showing that fish and other sea products give rise to increases in TMAO more than meats.

Dietary precursors of trimethylamine in man: a pilot study. Food Chem Toxicol. 1999 May;37(5):515-20.  Zhang AQ, Mitchell SC, Smith RL. PMID: 10456680

Here is an outstanding article by Chris Masterjohn that gives a far more in depth analysis than I did.

To this, Katherine Gottlieb, President of South Central Foundation responded, “We already have that, but instead of an avatar we use a real person.”

A hologram will never replace a real doctor

South Central Foundation, the primary care provider for 50,000 Alaska Natives (indigenous Alaskans, or Indians as some of you may call us) won the Malcolm Baldridge award in 2011 for Health Care.  The key to the system is it is built on a relationships. Healthcare improves if you have a relationship with your doctor.

What they have done in health care is remarkable – winning awards, having many healthcare systems coming to learn their model – but here is my story:

For a doctor to see a doctor they really have to be sick 
It started with a bit of congestion for the nose, and the drip made a little bit of a sore throat. Thought it was a cold for a bit then realized, it was allergies so I started to take the antihistamine,  Zyrtec.   During the day my nose was running, voice was hoarse, and eyes were itching.  I started to cough, violently – and realized that the pollen had now reacted with my reactive airway disease (asthma) and I needed to use my inhaler.

Dr. Steve Tierney – my doctor, a real doctor not an avatar or hologram

The symptoms became worse. If I stayed inside it was tolerable. But going outside  made every symptom worse. Every breath I took outside felt as if I was sandblasting my nose, mouth, eyes, sinus, and lungs.  My sleep was interrupted multiple times a night by waking up with fits of coughing.  I had to sleep on four pillows just to get some rest with a cough drop between my teeth and cheek, hoping not to choke on it.

It was from this that I started to look up allergists in Phoenix. But there wasn’t time to get an appointment, as I was leaving town in a day.

Looking forward to the meetings in Anchorage, because it meant a break away from allergy season in Phoenix.  As soon as I stepped off the plane in Anchorage I took a big gulp of air.  The air didn’t hurt, it was fresh, cool.  But my lungs, still inflamed from my body fighting the pollen, had yet to heal.  That night, slept on three pillows.  Couldn’t even get to sleep without coughing. I looked at the clock at 1:30 am, tired and finally sleep took over. But still I woke up every hour, coughing.

The Best Health Care System

It struck me as I woke up in a coughing fit that I was sitting on the board of the greatest health care system in the United States, maybe the world. They were known for same-day appointments, keeping people out of the hospital, and had great doctors. Why not contact one of the doctors here?

I knew Steve Tierney for years. Besides being one of the primary care doctors who had taken care of a number of my friends, I liked him. His wife is also a vice president of South Central, she had a good sense of humor and had put up with my rantings as a board member in good cheer.

Email your doctor?

Sometime in the early morning I sent him an email with the subject “Maybe this Dr needs a dr.” and described by symptoms and asked if I might need some medicine. I was hesitant, concerned, wondered if I would get brushed off, ignored, told to call for an appointment.  I got ready to head to the meeting.

Five minutes before the meeting started I received a text from Steve, asking how I was doing and where I was. I told him where I was he said he would be there in five minutes. Still worried – every doctor does, we don’t just have asthma we have lung cancer.  For me a special worry, since I saw my brother die from lung cancer a few years before. Coughing and unable to catch his breath, as I was doing. Or perhaps it could be I had heart failure, and what I thought was asthma keeping me up was simply my heart finally rebelling against years of eating red meat (if only I had stayed a vegetarian).  If you think you know a hypochondriac, look at your physician, they are the worse – we know everything that can happen, and it can happen to us. We don’t get headaches, we get brain tumors — untreated and they go away. We don’t have plaque on our teeth causing gum irritation and need a dental cleaning, we get leukemia – untreated and it goes away. It starts in medical school with every disease we hear about we personalize it and get the disease. When, as a second year medical student, I was hearing about how overactive adrenal glands can cause a belly, I went to the professor and said I had this disease, and that explained my midline — in his thick German accent he told me, “Yes, you do have an overactive gland causing that. ” Relieved that he understood me, until he finished the thought, “You have an overactive mouth gland, eat less and move more.”

The hypochondria of disease never leaves a doctor, and at this point I wasn’t sure if I should arrange for hospice because of heart failure or lung cancer, but the doctor was coming and I was going to get my sentence.

Steve walked up with a smile and re-assuring tone. He asked a few questions, and paid very close attention to the answers. Told me he wanted to prescribe some prednisone to cool down the inflammation, add another anti-histamine, and an oral steroid, and get me a new inhaler (since my inhaler was about five years old).

Enrolling in the Greatest Health Care System

He said he could call in the prescriptions to a local pharmacy, or, if I wanted, I could enroll as a patient. Why not enroll? He arranged to send up the two page form, it took me two minutes to fill out. My wife sent the appropriate BIA card, they took a copy of my divers license and insurance card.

An hour later four prescriptions were delivered to me, at no cost, no co-pay, no deductible.

Two days later I was much improved.

Here is the thing: I have insurance and can go to any hospital, any healthcare system in the world. As a physician in Phoenix I could easily get into Mayo Clinic, or any clinic with a phone call or two. Here is the difference:

SouthCentral is built on relationships. I got to see that relationship first hand. You are not a “patient” at SouthCentral, you are a “customer-owner.”

My system- my healthcare system. Built on relationships.

And, Dr. Tierney, I can never thank you enough – not only did you treat my asthma and allergies – but cured the lung cancer and heart disease!

A few notes:

SouthCentral reported a reduction in children going to the emergency room for asthma because they see the customer-owners the same day.

SouthCentral has the lowest cost of healthcare per capita

Same day ability to see patients in the primary care center.

Fast Track in the ER

No co-pay or deductible for insurance

No out-of-pocket expense

Highlights

Southcentral Foundation’s unique Nuka System of Care is a relationship-based health care delivery system. Nuka’s organizational strategies and processes; medical, behavioral, dental and traditional practices; and supporting infrastructure work in partnership with the Native Community to support physical, mental, emotional, and spiritual wellness. The system is owned, managed, directed, designed, and driven by Alaska Native people.

In 2010, SCF achieved the highest level of Patient Centered Medical Home™ recognition from the National Committee on Quality Assurance (NCQA) for creating a strong primary care system that engages customer-owners and offers a broad range of preventive services and treatment.

Overall, SCF has achieved significant improvements in a number of key areas, including same-day access to care which has led to a 50 percent decrease in costly emergency room and urgent care visits; a decrease in specialty care by about 65 percent; a decrease in primary care visits by 20 percent; and a decrease in hospital admissions by 53 percent.
Overall staff turnover has decreased from 37 percent in 2008 to 17 percent in 2011. Turnover rates for Alaska Native and American Indian employees (who make up 53 percent of the SCF workforce) for the same period decreased from 29 percent to 15 percent.

Southcentral Foundation (SCF) is a nonprofit health care organization established in 1982 to improve the health and social conditions of Alaska Native and American Indian people, enhance culture, and empower individuals and families to take charge of their lives. SCF provides a wide range of programs to address physical, mental, emotional, and spiritual wellness for about 55,000 Alaska Native and American Indian people. Of these, 45,000 reside in the Anchorage area and 10,000 live in 55 remote villages accessible only by plane. SCF’s total coverage area, known as the Anchorage Service Unit (ASU), spans some 100,000 square miles. The ASU is served by a network of 24 health care facilities, including SCF’s two primary care centers (Anchorage and Wasilla) and two clinics (Iliamna and McGrath), and 16 subregional centers that SCF partners with to provide regional support. SCF employs 1,487 people—of which 53 percent are Alaska Natives or American Indians—and reported $201.3 million in revenues in 2010.

‘Nuka’ Means Strength in Health Care

• Southcentral Foundation’s unique health care delivery system, the Nuka System of Care, brings together organizational strategies and processes; medical, behavioral, dental, and traditional practices; and infrastructure that work together to support wellness. “Nuka” is an Alaska Native name given to strong, giant structures and living things. The system is owned, managed, directed, designed, and driven by Alaska Native people, referred to as “customer-owners.”
• The Nuka System of Care is based on four principles: (1) customers drive everything, (2) customers must know and trust the health care team, (3) customers should face no barriers in seeking care, and (4) employees and supporting facilities are vital to success.
• In 2010, SCF achieved the highest level of Patient Centered Medical Home™ recognition from the National Committee on Quality Assurance (NCQA) for creating a strong primary care system that engages customer-owners and offers a broad range of preventive services and treatment.

 Superior Performance to Improve Wellness

• Overall, SCF has achieved significant improvements in a number of key areas, including same-day access to care, which has led to a 50 percent decrease in costly emergency room and urgent care visits; a decrease in specialty care by about 65 percent; a decrease in primary care visits by 36 percent; and a decrease in hospital admissions by 53 percent.
• Same-day access is achieved through a system that allows customer-owners to arrange to see their primary care provider on the same day as long they call by 4 p.m. and arrive by 4:30 p.m. This ensures that 70 to 80 percent of appointment slots are open at the start of each day.
• Among the family wellness objectives set forth by SCF is a strong effort to reduce the incidence and improve the management of diabetes, a condition experienced by Alaska Native and American Indian people at twice the national rate. Since 2009, performance levels for diabetes care exceed the 90th percentile of the Healthcare Effectiveness Data and Information Set (HEDIS), a tool used by the majority of America’s health plans to measure performance on important dimensions of care and service. HEDIS measures different areas of diabetes prevention, diagnosis, and treatment such as ensuring that diabetic patients receive their annual HBA1c screening (a test that measures blood sugar levels over a period of three months), and treating diabetic nephropathy (kidney disease and damage).
• SCF manages performance data through a state-of-the-art database dubbed DataMall. Balanced Scorecard, operational, voice-of-the-customer, and clinical information is collected, aggregated, trended, and segmented by the system, which then makes it readily available to managers, clinicians, customer-owners, and employees. Information in DataMall is used for tracking performance, driving improvement and innovation, and sharing best practices.
• SCF senior leaders have created an environment for organizational learning, performance improvement, and the accomplishment of strategic objectives through the use of an internal functional committee structure. This structure incorporates quality assurance and performance improvement committees, external benchmarking, and leadership development into corporate processes.

A Modern Alaska Native Tradition: Satisfaction

• In a 2010 survey, SCF received an overall customer satisfaction rating of approximately 91 percent.
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys ask consumers to report on and evaluate their experiences with health care. Using CAHPS TopBox scores (which display the percent of respondents reporting the most positive response for a composite, rating, or question item) as a benchmark, SCF’s overall satisfaction rating was 73.3 percent in 2011. This significantly exceeds the CAHPS TopBox benchmark of 46 percent.
• Overall staff turnover has decreased from 37 percent in 2008 to 17 percent in 2011. Turnover rates for Alaska Native and American Indian employees (who make up 53 percent of the SCF workforce) for the same period decreased from 29 percent to 15 percent.
• SCF administers the Morehead Associates’ Workforce Commitment Survey annually to all employees. The survey uses a five-point scale to measure employee response to a number of questions about the workplace. From 2005 to 2009, SCF improved its satisfaction scores for benefits (from 3.69 to 3.89), balancing work and personal life (from 3.67 to 3.87), interest in employee health and wellness (from 3.58 to 4.02) and management’s concern with employee safety (from 3.88 to 4.30).

Increasing Revenue While Cutting Costs

• SCF’s total revenue has consistently increased from $120.2 million in 2003 to $201.3 million in 2010, exceeding the Medical Group Management Association (MGMA) 90th percentile in 2010. Third-party payer revenue increased from $7.4 million to $17.9 million in the same time period, also exceeding the MGMA 90th percentile in 2010.
• SCF’s per capita expenditures percentage change has been lower than the MGMA benchmark since 2005. Even with phenomenal growth in the last decade, the per capita cost remains lower than the percentage increase in national health care or MGMA multi-specialty practice spending.
• Overhead expenses have decreased in recent years, meeting SCF’s target of 15 percent in 2010 and 2011.