A New Contraceptive and HarvestPlus

The U.S. Food and Drug Administration has approved a new contraceptive for women developed by the Population Council.  Annovera; (segesterone acetate and ethinyl estradiol vaginal system) is a combined hormonal contraceptive for women of reproductive age and is the first vaginal ring contraceptive that can be used for an entire year. It is a reusable donut-shaped (ring), non-biodegradable, flexible vaginal system that is placed in the vagina for three weeks followed by one week out of the vagina, at which time women may experience a period (a withdrawal bleed). This schedule is repeated every four weeks for one year (thirteen 28-day menstrual cycles).  It is not felt during sex.  It does not prevent sexually transmitted diseases.  

Annovera is washed and stored in a compact case for the seven days not in use. It does not require refrigeration prior to dispensing and can withstand storage temperatures up to 30°C (86°F).  This new contraceptive is considered suitable for women who do not always remember to take the pill regularly, or who used the previously available contraceptive ring that had to be replaced every month. Women in developing countries may find this method convenient, as they are often unable to find other contraceptives on a regular basis.  The Population Council plans to make it available in Latin America, Asia and Africa as well as in the US.   It will be released in 2019.

The efficacy and safety of Annovera were studied in three, open label clinical trials with healthy women ranging from 18 to 40 years of age. Based on the results, about two to four women out of 100 women may get pregnant during the first year they use Annovera.

All hormonal contraception carries serious risks. Annovera carries a boxed warning relating to cigarette smoking and serious cardiovascular events. Women over 35 who smoke should not use Annovera. Cigarette smoking increases the risk of serious cardiovascular events from combination hormonal contraceptive use.

HarvestPlus is an international organization that uses ‘biofortification’ to make plants more nutritious. Its work is in Asia, Africa and Latin America. It uses conventional plant breeding rather than genetic modification, and focuses on three crucial micronutrients that are most limited in the diets of the poor—vitamin A, zinc, and iron, breeding these into key staple crops. Harvest Plus screens thousands of different types of crop seeds stored in seed banks that have naturally higher amounts of iron, zinc, and vitamin A. They use these more nutritious seeds to breed new crop varieties with higher micronutrient content that are also high yielding and have other traits farmers want. Together with farmers, they test these new varieties in the target region. The national government then officially releases the best-performing varieties of micronutrient-rich crops for farming communities to grow, eat, and sell in local markets.

Iron deficiency during childhood and adolescence impairs mental development and learning capacity. In adults, it reduces the ability to do physical labor. Severe anemia increases the risk of women dying in childbirth. Five hundred million women aged 15 to 49, at the peak of their productive years, are anemic due to iron deficiency. This condition reduces their productivity, decreases their economic potential, and affects their reproductive health outcomes.

Zinc is involved in more body functions than any other mineral. Its role includes acting as a necessary component of more than 200 enzyme systems, normal growth and development, the maintenance of body tissues, sexual function, vision, and the immune system. Zinc is essential for survival, and zinc deficiency has serious consequences for health, particularly during childhood when zinc requirements are increased. In addition, zinc deficiency also causes stunting. Randomized controlled trials showed that zinc supplementation can reduce the severity of morbidity from a number of common childhood infections, including diarrhea, pneumonia, and possibly malaria, by one-third. 

Vitamin A is essential for good vision and cell differentiation. Deficiency results in growth retardation, damage to mucous membrane tracts, reproductive disorders, eye damage—and ultimately blindness. Children with vitamin A deficiency are often deficient in multiple micronutrients and are likely to be anemic, have impaired growth, and be at increased risk of severe morbidity from common childhood infections such as diarrheal diseases and measles. Pregnant women with vitamin A deficiency may be at increased risk of mortality.

Today, biofortified crops, including vitamin A orange sweet potato, iron beans, iron pearl millet, vitamin A yellow cassava, vitamin A orange maize, zinc rice, and zinc wheat, have been grown in more than 40 counties in Asia, Africa and Latin America. Crop improvement continues to develop varieties with higher levels of vitamins and minerals that are adapted to a wide range of agro-ecological conditions, and ensuring that the best germplasm for climate-adaptive and consumer-preferred traits continues to be used in breeding biofortified crops.

The take home message from this column is: despite the suffering in our world due to climate change and political chaos, efforts to improve situations of poverty are underway. As far as iron, zinc and Vitamin A are concerned – do not start to take these micronutrients as supplements, get them from your healthy diet and possibly a multi vitamin/mineral pill – not more! Talk to your health-care provider.

HarvestPlus is supported by several sources: the UK Government, the Bill & Melinda Gates Foundation, the US government’s Feed the Future Initiative, the European Commission and donors to the CGIAR Research Program on Agriculture for Nutrition and Health. HarvestPlus is also supported by the John D. and Catherine T. MacArthur Foundation.

Sadja Greenwood MD, MPH   Sub

Legumes Lower Blood Sugar, Diet to Reduce Breast Cancer Risk, Work Related Email after Hours

Legumes Reduce Blood Sugar Levels: Researchers at the University of Guelph (Ontario, Canada) have found that adding legumes to your diet can significantly reduce blood sugar levels.  They experimented with swapping out half a portion of white rice or white potatoes with green or red lentils.  Replacing the half portion of rice with lentils reduced blood glucose levels by 20%. Replacing a half portion of potatoes with lentils reduced blood glucose levels by 35%, compared to the levels found when lentils were not used.  Details of the study were recently published in the Journal of Nutrition.  Lentils can slow digestion and slow the release of glucose into the bloodstream from the starch of white rice or potatoes.  Other legumes with similar properties include beans of all kinds, garbanzo beans, soy beans and peas.  These legumes are nitrogen-fixing, thereby improving soil fertility.  

A Diet to Ward off Breast Cancer:  Results from the Nurses Health Study have indicated that women who had five and a half servings of fruits and vegetables daily, compared to those who had less than two and a half servings, had an 11 percent lower breast cancer risk.  A serving is about one cup.  The effect was especially significant with the most aggressive types of breast cancer. Cruciferous vegetables (broccoli, cauliflower, Brussels sprouts, kale, and cabbage) were especially strongly associated with reduced risk, as were yellow and orange vegetables such as carrots, winter squash, yams and sweet potatoes.  This study has recently been published in the International Journal of Cancer.

A study entitled :Killing me Softly…electronic communications monitoring and employee and spouse well-beinghas shown that when employers expect workers to monitor their work related emails during non-work hours, the result is a problem for the employees and their families.  William Becker, a Virginia Tech associate professor of management in the Pamplin College of Business, wrote that "The competing demands of work and nonwork lives present a dilemma for employees, which triggers feelings of anxiety and endangers work and personal lives."  Their study shows that employees do not need to spend actual time on work in their off-hours to experience the harmful effects. The mere expectations of availability increase strain for employees and their significant others -- even when employees do not engage in actual work during nonwork time. "The insidious impact of 'always on' organizational culture is often unaccounted for or disguised as a benefit -- increased convenience, for example, or higher autonomy and control over work-life boundaries," Becker said. "Our research exposes the reality: 'flexible work boundaries' often turn into 'work without boundaries,' compromising an employee's and their family's health and well-being."   Prospective employees should be told clearly whether or not email availability in off-hours is expected, so they can decide on the suitability of the job.  Employers should establish boundaries on when they expect off-hour work to be done, and how it will be compensated.  

There are several take-home messages from this paper that apply to all of us.  The digital world of screens and phones has taken over most of our lives, even when work demands are not the issue. It is wonderful and amazing to have the knowledge of the world, past and present, in your pocket.   However, making time for talking face to face, reading or writing a book, doing art and playing music are still important ways of being human.  Gardening, walking, hiking and running outdoors, playing sports and watching the sky – name your favorite and leave your screen behind for a while.  But – you might want to turn it on to listen to – Killing me Softly with his Song – its haunting.  

Sadja Greenwood MD, MPH  

w

Listen to Your Daily Rhythms

The body has been found to have many time clocks – one governing the sleep-wake cycle in response to light and dark, and others in most of our body organs.  These daily (circadian) rhythms are coordinated by the brain’s hypothalamus –which links the nervous system to the endocrine system  via the pituitary gland.  The pancreas secretes insulin during the day and slows down at night, meaning that blood sugar levels are better controlled in the morning than evening. The gut has a clock that controls nutrient absorption, and removal of waste.  The microbiome –the trillions of bacteria in our digestive tract – also have a daily rhythm.  

Dr. Satchin Panda of the Salk Institute is an expert on circadian rhythms research.  He has just published a book on this subject – The Circadian Code - Lose Weight, Supercharge Your Energy and Transform Your Health from Morning to Midnight. He has studied genetically identical mice and divided them into two groups.  One group could eat a diet of high fat, high sugar foods around the clock. The other group ate the same foods in a daily 8 hour window.  Calories were similar for both groups.  Those who ate around the clock became fat and sick, while those who ate in a time restricted fashion were protected from obesity, fatty liver and metabolic disease. 

Courtney Peterson at the University of Alabama at Birmingham has also studied this subject and published several papers on her findings.  She took a group of prediabetic men, and had them eat their meals in a 12  hour window for five weeks.  In the next phase, these men were fed the same meals in a six hour window beginning each morning.  They were eating enough calories to maintain their weight, to see whether time restricted eating had health benefits unrelated to weight loss.  The men on the time restricted program had lower insulin, reduced levels of oxidative stress, less nighttime hunger, and significantly lower blood pressure – their systolic pressure dropped by roughly 11 points and their diastolic by 10 points.  These are very significant results.

In other papers Dr. Peterson and colleagues have reviewed evidence that the circadian system plays a pervasive role in regulating glucose, insulin, lipid levels, appetite and energy metabolism in humans. Eating at the wrong times – late in the day – disrupts the circadian system and adversely affects metabolic health.  Chronobiology is important in preventing and treating type 2 diabetes, obesity and high blood fats (hyperlipidemia).

The take home message from these findings is that eating early in the day will synchronize with your sleep-wake cycle and bring you many health benefits.  If you are never hungry for breakfast,  start by having a very small supper around 5 pm, and you will be hungrier in the morning.  Have a healthy breakfast after waking, and aim for a 10 hour time for eating .  As you get used to this new schedule, you can restrict your time further, depending on what results you are aiming for. You may worry that such a schedule will be a problem for your social life, and if you frequently meet friends for dinner and drinks in the evening, this is true.  Perhaps you can socialize around lunch on the weekends, or break your schedule occasionally to be with friends, but eat lightly at dinner so you can return to your new way in the morning. 

 I suspect that the Marin County library system will purchase copies of Dr. Panda’s book – remember that they bought over 50 copies of Michael Pollan’s   How to Change Your Mind. Stop by the library to find out.  

Sadja Greenwood, MD, MPH

The links between yoga, breath-focused meditation and brain health

If you have practiced yoga and learned about ‘pranayama’ , or breathing to regulate the life force, or if you have practiced meditation with a focus on following your breath, you may be intrigued by the findings of a new study from Trinity College in Dublin, Ireland.  Even if you have never tried yoga or meditation this study may impel you to find your own version of intentional breathing to help you focus and relax.  

The new study, published in the journal Psychophysiology, explains for the first time some of the links between breathing and attention. Breath-focused meditation and yogic breathing practices have long been known to have cognitive benefits, including increased ability to focus, decreased mind wandering, and more positive emotions. To date, however, no direct neurophysiological link between respiration and cognition has been suggested.

The new research shows that breathing -- a key element of meditation and mindfulness practices -- directly affects the levels of a natural chemical messenger in the brain called noradrenaline. This chemical messenger is released when we are challenged, curious, exercised, focused or emotionally aroused, and, if produced at the right levels, helps the brain grow new connections. The way we breathe, in other words, directly affects the chemistry of our brains in a way that can enhance our attention and improve our brain health.

The study, carried out by researchers at Trinity College Institute of Neuroscience and the Global Brain Health Institute at Trinity, found that participants who focused well while undertaking a task that demanded a lot of attention had greater synchronization between their breathing patterns and their attention, than those who had poor focus. The authors believe that it may be possible to use breath-control practices to stabilize attention and boost brain health.

Michael Melnychuk, PhD candidate at the Trinity College Institute of Neuroscience, Trinity, and lead author of the study, explained: "Practitioners of yoga have claimed for some 2,500 years, that respiration influences the mind. In our study we looked for a neurophysiological link that could help explain these claims by measuring breathing, reaction time, and brain activity in a small area in the brainstem called the locus coeruleus, where noradrenaline is made. Noradrenaline is an all-purpose action system in the brain. When we are stressed we produce too much noradrenaline and we can't focus. When we feel sluggish, we produce too little and again, we can't focus. There is a sweet spot of noradrenaline in which our emotions, thinking and memory are much clearer."

"This study has shown that as you breathe in locus coeruleus activity is increasing slightly, and as you breathe out it decreases. Put simply this means that our attention is influenced by our breath and that it rises and falls with the cycle of respiration. It is possible that by focusing on and regulating your breathing you can optimize your attention level and likewise, by focusing on your attention level, your breathing becomes more synchronized."

The research provides deeper scientific understanding of the neurophysiological mechanisms which underlie ancient meditation practices. Further research could help with the development of non-pharmacological therapies for people with conditions such as ADHD and traumatic brain injury and in supporting cognition in older people.

According to the authors of this study, there are traditionally two types of breath-focused practices -- those that emphasize focus on breathing (mindfulness), and those that require breathing to be controlled (deep breathing practices such as pranayama). In cases when a person's attention is compromised, practices that emphasize concentration and focus, such as mindfulness, could possibly be most beneficial. In cases where a person's level of arousal is the cause of poor attention, for example drowsiness while driving, a pounding heart during an exam, or during a panic attack, it should be possible to alter the level of arousal in the body by controlling breathing. Both of these techniques have been shown to be effective in both the short and the long term.

Ian Robertson, Co-Director of the Global Brain Health Institute at Trinity and Principal Investigator of the study added: "Yogis and Buddhist practitioners have long considered the breath an especially suitable object for meditation. It is believed that by observing the breath, and regulating it in precise ways -- a practice known as pranayama -- changes in arousal, attention, and emotional control that can be of great benefit to the meditator are realized. Our research finds that there is evidence to support the view that there is a strong connection between breath-centered practices and a steadiness of mind."

"Our findings could have particular implications for research into brain ageing. Brains typically lose mass as they age, but less so in the brains of long term meditators. More 'youthful' brains have a reduced risk of dementia and mindfulness meditation techniques actually strengthen brain networks. Our research offers one possible reason for this -- using our breath to control one of the brain's natural chemical messengers, noradrenaline, which in the right 'dose' helps the brain grow new connections between cells. This study provides one more reason for everyone to boost the health of their brain using a whole range of activities ranging from aerobic exercise to mindfulness meditation."

Journal Reference:

Michael Christopher Melnychuk, Paul M. Dockree, Redmond G. O'Connell, Peter R. Murphy, Joshua H. Balsters, Ian H. Robertson. Coupling of respiration and attention via the locus coeruleus: Effects of meditation and pranayama. Psychophysiology, 2018; e13091 DOI: 10.1111/psyp.13091

 Sadja Greenwood, MD, MPH   Past issues on this blog. Feel free to leave me a message.

How Five Habits Can Make a Huge Difference

According to a new study led by the Harvard T.H. Chan School of Public Health, five healthy habits maintained during adulthood may add more than a decade to your life expectancy.  The bad news - Americans have a shorter average life expectancy — 79.3 years — than almost all other high-income countries. The U.S. ranked 31st in the world for life expectancy in 2015. This is disgraceful. It is probably due to our income inequality, racism, and lack of universal health care.  The good news – you can make a big difference in your health and life expectancy by consistently doing the things you already know are important. 

The new study, published in the journal Circulation, aimed to quantify how much healthy lifestyle factors might be able to boost longevity in the U.S.  Data came from Harvard Chan researchers and colleagues looking at 34 years of data from 78,865 women and 27 years of data from 44,354 men participating in, respectively, the Nurses’ Health Study and the Health Professionals Follow-up Study. The researchers looked at how five low-risk lifestyle factors might impact mortality:

1. not smoking

2. keeping a low body mass index (18.5-24.9 kg/m2)

3. doing at least 30 minutes or more per day of moderate to vigorous physical activity

4. having a moderate alcohol intake (for example, up to about one 5-ounce glass of wine per day for women, or up to two glasses for men) 

5. keeping a healthy diet.

Women and men who checked all five boxes had an average life expectancy that was 14 years and 12 years longer than the life expectancy of people with none of those healthy habits. And the researchers found a dose-response relationship, meaning that for each healthy habit a person adopted, life expectancy increased.   As you can see – these are very large numbers.

Researchers also found that American women and men who maintained the healthiest lifestyles were 82 percent less likely to die from cardiovascular disease and 65 percent less likely to die from cancer when compared with those with the least healthy lifestyles over the course of the roughly 30-year study period. For study participants who didn’t adopt any of the low-risk habits, the researchers estimated that life expectancy at age 50 was 29 years for women and 25.5 years for men. But for those who adopted all five, life expectancy at age 50 was projected to be 43.1 years for women and 37.6 years for men. In other words, women who maintained all five healthy habits gained, on average, 14 years of life, and men who did so gained 12 years, compared with those who didn’t maintain healthy habits.

Compared with those who didn’t follow any of the healthy lifestyle habits, those who followed all five were 74 percent less likely to die during the study period. The researchers also found that there was a dose-response relationship between each individual healthy lifestyle behavior and a reduced risk of early death, and that the combination of all five healthy behaviors was linked to the most additional years of life.

“This study underscores the importance of following healthy lifestyle habits for improving longevity in the U.S. population,” said Frank Hu, chair of the Department of Nutritionat Harvard Chan School and senior author of the study. “However, adherence to healthy lifestyle habits is very low. Therefore, public policies should put more emphasis on creating healthy food, built, and social environments to support and promote healthy diet and lifestyles.”

Other Harvard Chan School study authors included Yanping Li, Dong Wang, Xiaoran Liu, Klodian Dhana, Meir Stampfer, and Walter Willett.

Let’s look at the healthy habits realistically.  They are sensible and well known, but not easy for many people. 

1. Quitting smoking can be hard and should be done early in life.  Vaping is not the answer as it has its own hazards, including nicotine dependency and toxins in the vaping liquid.  For help to quit smoking the Centers for Disease Control has a good website and a line to call for advice – 800 784 8669.  Your primary care provider should also be a good source of help.

 2. Find your body mass index at your doctor’s office or at nhlbi.nih.gov.

 Achieving a healthy weight may be difficult if you are overweight and have tried dieting without success. Some plans being advertised on TV are quite costly.  Weight Watchers is considered one of the most effective because of its healthy diet and group support.  The book The Ultimate Volumetrics Dietby Barbara Rolls at Pennsylvania State University provides a healthy diet that works with minimal hunger.  Visit the National Weight Control Registry to read about over 10,000 people who have successfully lost weight and kept it off, and find out about their techniques. 

3. Doing 30 minutes or more per day of moderate to vigorous physical activity may be hard for sedentary people.  Check with your primary care provider first.  Find friends to go on regular walks with you, join a gym that is friendly and has trainers to give sound advice, exercise to stimulating music that you love (for me its Cajun and Zydeco).  Plan ways to put the half hour  into your day – breaking into 2x15 or 3x10 is OK. Wear a ‘Fitbit’ or similar device if that helps you.  Do chair exercises in a class or in front of television if standing is too difficult.

4. Having a moderate alcohol intake can be hard for regular drinkers.  Much of our social life centers around alcohol – people who drink enjoy the taste of wines, beer and whiskey/gin/ rum and also like the feelings of relaxation and the ‘buzz’. At social gatherings it is easy to exceed a one drink level for women and two drinks for men. You should be extra careful if you are taking medications that do not mix well with alcohol or have a condition, such as high blood pressure, that is worsened by drinking.  Do not drink if you are going to drive a car or operate any machinery.  Do not drink if you are pregnant, or planning to become pregnant.  For many good ideas about moderating your alcohol use, go to the NIH website ‘Rethinking Drinking’.

5. Keeping a healthy diet is the fifth habit that will help you.  On this website, go to the upper left corner and type in ‘The Mind Diet’.  You will find a detailed description of what healthy foods to eat, and which others to avoid.  People who don’t use the internet can look at The Ultimate Volumetric Diet by Barbara Rolls or the Mind Diet Cookbook by Kristin Diversi.

Sadja Greenwood MD, MPH

Leave me a comment or a question 

Chocolate Lovers – Read On!

New research from Loma Linda University indicates that there are possible health benefits to eating certain types of dark chocolate. The studies were recently presented at the 2018 Experimental Biology meeting in San Diego; they showed that consuming dark chocolate that has a high concentration of cacao (minimally 70% cacao) has positive effects on stress levels, inflammation, mood, memory and immunity. While it is well known that cacao is a major source of flavonoids, this is the first time the effect has been studied in human subjects to determine how it can support cognitive, endocrine and cardiovascular health.  (Flavonoids are a diverse group plant chemicals found in fruits and vegetables. Along with carotenoids, they are responsible for the vivid colors in these foods. Flavonoids are antioxidants with anti-inflammatory and immune system benefits.)

Lee S. Berk, DrPH, associate dean of research affairs, School of Allied Health Professions and a researcher in psychoneuroimmunology and food science from Loma Linda University, served as principal investigator on both studies. "For years, we have looked at the influence of dark chocolate on neurological functions from the standpoint of sugar content -- the more sugar, the happier we are," Berk said. "This is the first time that we have looked at the impact of large amounts of cacao in doses as small as a regular-sized chocolate bar in humans over short or long periods of time, and are encouraged by the findings. These studies show us that the higher the concentration of cacao, the more positive the impact on cognition, memory, mood, immunity and other beneficial effects."  

Here are the results presented during the Experimental Biology meeting:

Dark Chocolate (70% Cacao) Affects Human Gene Expression: Cacao Regulates Cellular Immune Response, Neural Signaling, and Sensory Perception

This pilot feasibility experimental trial examined the impact of 70 percent cacao chocolate consumption on human immune and dendritic cell gene expression, with focus on pro- and anti-inflammatory cytokines. Study findings show cacao consumption up-regulates multiple intracellular signaling pathways involved in T-cell activation, cellular immune response and genes involved in neural signaling and sensory perception -- the latter potentially associated with the phenomena of brain hyperplasticity.  (Greenwood’s explanation - Neuroplasticity is the brain's innate ability to adapt to training and learn new skills - from foreign languages to math, and, for an athlete, physical movement and strength. By stimulating the motor cortex during athletic training, the brain enters into a state of heightened plasticity known as "hyperplasticity," during which the brain adapts to training most effectively.)

Dark Chocolate (70% Organic Cacao) Increases Acute and Chronic EEG Power Spectral Density (μv2) Response of Gamma Frequency (25-40Hz) for Brain Health: Enhancement of Neuroplasticity, Neural Synchrony, Cognitive Processing, Learning, Memory, Recall, and Mindfulness Meditation

This study assessed the electroencephalography (EEG) response to consuming 48 g of dark chocolate (70% cacao) after an acute period of time (30 mins) and after a chronic period of time (120 mins), on modulating brain frequencies 0-40Hz, specifically beneficial gamma frequency (25-40Hz). Findings show that this superfood of 70 percent cacao enhances neuroplasticity for behavioral and brain health benefits.

(Greenwood – Many chocolate bars with 70% cacao contain about 48g in half a bar. Read the label carefully.  An Endangered Species bar with 72% cacao has 43g, 210 calories and 12 g of sugar in half a bar. Lily’s 70% cacao bars are sweetened with stevia – available at some specialty stores and on the internet. )

Berk said the studies require further investigation, specifically to determine the significance of these effects for immune cells and the brain in larger study populations. Further research is in progress to elaborate on the mechanisms that may be involved in the cause-and-effect brain-behavior relationship with cacao at this high concentration.

Take home message from these studies – while chocolate is a delicious treat with valuable properties for health, it often comes with too much added sugar.  If you eat part of a 70% cacao bar regularly, avoid other sources of sugar and satisfy your sweet cravings with multicolored fruits.   If you have an elevated blood sugar, go for the Lily’s brand and follow the dietary advice of your health care provider.

Sadja Greenwood, MD. MPH   back issues on this blog

---

Gun Violence and School Shootings

If you think you are hearing more about gun violence and school shootings, you are right. According to our Bolinas Assemblyman, Marc Levine, every day in the U.S. almost 300 people are shot in murders, assaults, suicides, suicide attempts and unintentional shootings, and almost 90 people die as a result of gun violence. According to a new study from Clemson University in South Carolina, more people have died or been injured in mass school shootings in the US in the past 18 years than in the entire 20^th century. This finding was published in the Journal of Child and Family Studies.

The recent killing of 17 people at Marjory Stoneman Douglas High School in Florida is not an isolated occurrence, but part of a deadly epidemic that needs to be addressed. During the 20th century, mass school shootings killed 55 people and injured 260 others at schools especially in America's Western region. Most of the 25 shooters involved were white males who acted alone, and only nine were diagnosed as suffering from mental illnesses at the time. Sixty percent of shooters were between 11 and 18 years old.  

Since the start of the 21st century there have already been 13 incidents involving lone shooters; they have killed 66 people and injured 81 others. In less than 18 years, we have already seen more deaths related to school shootings than in the whole 20th century. One alarming trend is that the overwhelming majority of 21st-century shooters were adolescents, suggesting that it is now easier for them to access guns, and that they more frequently suffer from mental health issues or have limited conflict resolution skills.

The authors explain that such violence can be mitigated through deliberate and sensible policy and legislative actions. These include expanded background checks of potential gun owners, and a ban on assault weapons. Mental health issues among adolescent students and adults should also be addressed more thoroughly. School personnel should also implement tiered models of support and school-based mental health services to support students' social, emotional, and behavioral well-being in order to prevent school violence.

Preventative efforts not only require policy and legislative action but increased and targeted funding across federal, state, local and private sectors,, according to the authors. 

Our Assemblyman, Marc Levine, our State Senator Mike McGuire, our national Congressman Jared Huffman and California Senators Diane Feinstein and Kamala Harris are all actively in favor of gun control.  You can find their telephone numbers in the Bolinas Hearsay News Local Zone Phone Directory, so ably put together by Jenny Pfeiffer.  You can support the students nationwide who are demonstrating for gun control by working to register voters.  

Here are some national organizations to support with your donations if you are able: The Brady Campaign (honoring Jim Brady, shot and left disabled after an assassination attempt on Romald Reagan), Americans for Responsible Solutions (honoring former Congresswoman Gabby Giffords, who was shot and left disabled while giving a talk in Arizona in 2011), Coalition to Stop Gun Violence ( a group of religious, labor and educational non-profits with thoughtful stands on stopping gun violence), Everytown for Gun Safety (an organization started by former NYC Mayor Michael Bloomberg to counter the strength of the NRA and promote gun violence prevention nationwide).  Please look them up and decide how to give your support.  Any amount will be helpful.

Sadja Greenwood MD, MPH past issues on this blog

Who is Dr. Bennet Omalu?

 You are doubtless aware of the serious unrest occurring in Sacramento following an independent autopsy performed on 22 year old Stephon Clark.  The autopsy showed that Clark, who was in this grandmother’s back yard, carrying a cell phone, was shot eight times in the back by police officers. You may not know the remarkable story and credentials of the man who performed this autopsy, Dr. Bennet Omalu

 Omalu was born in Nigeria in 1968, the 6^thof 7 siblings.  He entered school at 3 and went to Medical School at 16.  After doing 3 years of medical service in Nigeria, he became disillusioned with the politics of his country and looked for further training in the U.S. He completed a fellowship in epidemiology at the University of Washington, and then went to work at the Columbia University Harlem Hospital Center in New York, completing residency training in anatomic and clinical pathology.  In Pittsburgh he completed fellowships in pathology and neuropathology, gained a Master of Public Health degree in epidemiology and an MBA at Carnegie Mellon University.   Omalu became the chief medical examiner in San Joaquin County, California from 2007 to 2017. He resigned after accusing the county’s sheriff of repeatedly interfering with death investigations in order to protect police officers who had killed suspects.  Currently he is a Professor at the UC Davis Department of Medical Pathology and Laboratory Medicine. 

Omalu became interested in chronic traumatic encephalopathy  (CTE) after doing an autopsy on the Pittsburgh Steeler Mike Webster in in 2002.  He found ‘tau protein’ in the brain – that affects mood, emotions and executive functions. These findings had previously been seen in boxers.  He published his findings in the journal Neurosurgery in 2005.  The National Football League called unsuccessfully for the article’s retraction. Omalu published similar findings on at least 5 other NFL players who died in their 30’s and 40’s.  He also discovered CTE in the brains of military veterans.   In 2016 the National Football League testified before Congress that they did believe in a link between football and CTE.

A book entitled Concussion, by Jeanne Marie Laskas, was published in 2015. It was made into a riveting movie, Concussion, with Will Smith playing the part of Omalu. Omalu has written several books – his latest is Truth Doesn’t Have a Side: My Alarming Discovery about the Dangers of Contact Sports.  He defines contact sports as football, ice hockey, mixed martial arts, boxing, wrestling and rugby.  Non-contact sports include swimming, tennis, track and field, volleyball, basketball, table tennis and badminton. Soccer is all right if  ‘headers’ are banned.   Steer your children into these.

The name Omalu is a shortened version of the family name Onyemalukwube, which means “He who knows, speaks”.  Dr. Omalu became a U.S. citizen in 2015; fortunately before Trump’s restrictions on nonwhite immigrants.  He received the Distinguished Service Award from the American Medical Association in 2016 – its highest honor.  

The take home messages for readers of this column – Protect your brain and your children’s brains from repeated blows to the head.  Insist that soccer be played without  headers. The brain is what makes you – you. Keep it safe.

Watch the movie Concussion if you haven’t seen it.

Sadja Greenwood, MD, MPH   past issues on this blog

Phthalates – what are they, and what you can do to avoid them

Phthalates are chemical substances widely used in plastics to increase their flexibility, transparency, and durability.  They are of concern because recent studies have shown that they may affect human health by being endocrine disruptors.  This means that they may affect the fetus during pregnancy, and my also be implicated in reduced fertility, obesity, diabetes, endometriosis and some cancers.  There is concern that the development of the male fetus and male fertility may be especially affected.  

A recent study from the University of California in Berkeley and San Francisco, and George Washington University,found that people who ate out more regularly tended to have significantly higher levels of phthalates in their urine.  Researchers looked at people consuming food from restaurants, cafeterias, fast-food locations, or other dining establishments. They analyzed data on 10,253 people who were 6 years and older that was collected from 2005 to 2014 as part of the National Health and Nutrition Examination Survey (NHANES). This data included phthalate concentrations from their urine samples and the frequency at which they ate out versus at home. Those who regularly ate out had 35% higher phthalate levels than those who did not. This difference was even higher for adolescents: 55%. The culprit didn't seem to be the core ingredients of the food, but possibly something involved in the preparation of the food. For example, the study revealed that eating sandwiches (including cheeseburgers) prepared outside the home was associated with higher urine phthalate levels compared to eating sandwiches prepared at home. Many eating establishments use plastic containers, machine parts, packaging, and other items to handle, process, and store food. Phthalates are chemicals used in many plastic items to help them become more flexible. Therefore, phthalates may be leeching from all of these plastic items into the food that subsequently goes into your mouth.   

Here are some ways to decrease your exposure to plastics, according to the Natural Resources Defense Council . You can’t eliminate all plastic, but you can take some easy steps to reduce your plastic use. Swap plastic food storage containers with glass or stainless steel; if you do keep plastic ones, don’t use them to store fatty foods, and never microwave them. Replace plastic bags with reusable lunch bags, and plastic cling wrap with beeswax-coated cloth. Choose hard wood blocks and cotton baby dolls over plastic ones. In short, anytime you’re in the market for something plastic, research whether safer alternatives exist. Canned foods can make meal prep a breeze, but those cans are likely lined with BPA to keep them from corroding. Even cans labeled “BPA-free” may use a similar chemical that hasn’t been proved any safer. Choosing fresh, frozen, or dried foods (like beans) that aren’t packaged in cans is a smart preventive measure. Aseptic “brick” cartons or glass packaging are both better than cans.  Finally – eat at home!

Sadja Greenwood, MD, MPH

The Mind Diet – Rush University Medical Center

Rush University Medical Center dates back to March 2, 1837, when Rush Medical College received its charter. The college is named for Benjamin Rush, a signer of the Declaration of Independence and a Pennsylvania physician, who counted George Washington among his patients. He became a medical and humanitarian leader after the Revolutionary War. He was also a social activist, a prominent advocate for the abolition of slavery, for scientific education for the masses— including women—and for public medical clinics to treat the poor.

The Mind Diet, created by researchers at Rush University Medical Center, may help substantially slow cognitive decline in stroke survivors, according to preliminary research presented on Jan. 25 at the American Stroke Association's International Stroke Conference 2018 in Los Angeles. The findings are significant because stroke survivors are twice as likely to develop dementia compared to the general population.

The MIND diet is short for Mediterranean-DASH Diet Intervention for Neurodegenerative Delay; it is a hybrid of the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets. Both have been found to reduce the risk of cardiovascular conditions such as hypertension, heart attack and stroke.

"The foods that promote brain health, including vegetables, berries, fish and olive oil, are included in the MIND diet," said Dr. Laurel J. Cherian, a vascular neurologist and assistant professor in Rush's Department of Neurological Sciences. "We found that it has the potential to help slow cognitive decline in stroke survivors." Cherian is the lead author of the study, which was funded by the National Institute of Aging. "I was really intrigued by the results of a previous MIND study, which showed that the people who were most highly adherent to the MIND diet cognitively functioned as if they were 7.5 years younger than the least adherent group," Cherian said. "It made me wonder if those findings would hold true for stroke survivors, who are twice as likely to develop dementia compared to the general population." "The Mediterranean and DASH diets have been shown to be protective against coronary artery disease and stroke, but it seems the nutrients emphasized in the MIND diet may be better suited to overall brain health and preserving cognition."  Cherian said that studies have found that folate, vitamin E, omega-3 fatty acids, carotenoids and flavonoids are associated with slower rates of cognitive decline, while substances such as saturated and hydrogenated fats have been associated with dementia. "I like to think of the MIND diet as a way to supercharge the nutritional content of what we eat. The goal is to emphasize foods that will not only lower our risk of heart attacks and stroke, but make our brains as resilient as possible to cognitive decline.”  Cherian cautions, however, that the study was observational, with a relatively small number of participants, and its findings cannot be interpreted in a cause-and-effect relationship.

Study co-author Martha Clare Morris, ScD, a Rush nutritional epidemiologist, and her colleagues developed the MIND diet based on information from years of research about what foods and nutrients have good, and bad, effects on the functioning of the brain. The diet has been associated with reduced Alzheimer's risk in seniors who adhered to its recommendations. Even people who moderately adhered had reduced risk of AD and cognitive decline.

Rush, in Chicago, is currently seeking volunteers to participate in the study, which aims to show whether a specific diet can prevent cognitive decline and brain changes with age. From 2004 to 2017, Cherian and colleagues studied 106 participants of the Rush Memory and Aging Project who had a history of stroke for cognitive decline, including decline in one's ability to think, reason and remember. They assessed people in the study every year until their deaths or the study's conclusion, for an average of 5.9 years, and monitored patients' eating habits using food journals.

The researchers grouped participants into those who were highly adherent to the MIND diet, moderately adherent and least adherent. They also looked at additional factors that are known to affect cognitive performance, including age, gender, education level, participation in cognitively stimulating activities, physical activity, smoking and genetics. The study participants whose diets scored highest on the MIND diet score had substantially slower rate of cognitive decline than those who scored lowest. The estimated effect of the diet remained strong even after taking into account participants' level of education and participation in cognitive and physical activities. In contrast to the results of slower decline with higher MIND diet score, stroke survivors who scored high on the Mediterranean and DASH diets, did not have significant slowing in their cognitive abilities. "This is a preliminary study that will hopefully be confirmed by other studies, including a randomized diet intervention study instroke survivors," say the authors. "For now, I think there is enough information to encourage stroke patients to view food as an important tool to optimize their brain health."

 The MIND diet has 15 dietary components, including 10 "brain-healthy food groups" and five unhealthy groups.
Foods to enjoy include
1) green leafy vegetables – 2 cups raw or one cup cooked, daily.
2) Berries – at least 2 cups a week.  Bananas count as a berry.
3) Vegetables and fruit – at least one serving daily -2 cups raw vegetables or one cup cooked, one cup fresh fruit or ½ cup dried.  An apple equals one cup.
4) Nuts  - almonds, pecans, walnuts et al. 1-2 ounces at least 3 times a week
5) Whole grains – 3 servings a day.  Oats, quinoa, spelt, rye, brown rice, whole grain pasta, buckwheat, 100% whole grain bread.
6) Seafood – at least one serving a week of salmon, sardines, trout or other seafood you enjoy.  4-6 ounces.
7) Beans – a serving every other day – fresh or cooked.  Wash canned beans to eliminate extra salt.  Unsweetened non-dairy milk: soy, almond, cashew or rice milk.
8) Poultry – at least 2 four  ounce servings a week, skin removed.  Poultry provides protein and vitamin B12, iron and zinc, important for cognitive health. 
9) Olive Oil – Use as primary oil for cooking and for salads and cooked vegetables.  Olive oil has many anti-oxidant and anti-inflammatory properties.  Use low to moderate heat when cooking with olive oil.  Grapeseed oil is also good for cooking and can be used at higher heat.
10) Wine – one 5 ounce serving of wine – containing alcohol or not. Wine has micronutrients such as resveratrol that help prevent degenerative diseases.  Red or purple grape juice may have same effects of wine on health – to be verified.

The diet also specifies limiting intake of the designated unhealthy foods
1) Red meat – beef, lamb, pork and duck – limit intake to 3 ounces less than 4 times per week. Look for lean, organic an/or grass fed options.  Avoid all cured and processed meats.
2) Pastries and Sweets – less than 5 servings a week – such as one small cookie.  Try to enjoy whole fruit instead.
3) Butter and stick margarine – Avoid any fat that is solid at room temperature, including palm oil, coconut oil and other shortenings.  No hydrogenated oil.  Limit butter to less than 1 ½ teaspoons daily.
4) Full-fat cheese – limit to 1.5 ounces, less than once a week.  Try low or no fat options, or vegan cheese.
5) Fried or fast food – limit to one small serving of fries twice a month at most.

Greenwood’s addenda:  1) Studies from Oxford University and elsewhere have shown that levels of vitamin B12 decrease with age and low levels can affect leaning and memory adversely.  B12 is only found in animal food.  Supplements are advisable in vegans and older people.  50 micrograms a day should suffice.

2) Alcohol use disorders are the most important preventable risk factors for the onset of all types of dementia, especially early-onset dementia, according to a nationwide observational study of over one million adults diagnosed with dementia in France.  Red or purple grape juice my have the same effects as wine on health – to be verified.

3 ) A cookbook based on the Mind Diet by Kristin Diversi is published by Ulysses Press: The Mind Diet Cookbook

Sadja Greenwood, MD, MPH   Past issues at sadjascolumns.blogspot.com