A Pop Health Book Review of "Deadly Outbreaks"

I was always a fan of "House, MD", a medical TV drama that followed a team of physicians tasked with diagnosing patients with mystery symptoms that stumped every other doctor.  I loved the twists and turns, the hypotheses, the puzzles.

I kept being reminded of House as I read Dr. Alexandra Levitt's new book, "Deadly Outbreaks".  She profiles seven cases where real life medical detectives (aka: field epidemiologists) solve mysteries involving exotic viruses, unexplained deaths, and occupational safety (just to name a few!)

As I thought about the relevance of "Deadly Outbreaks" to Pop Health, I kept coming back to the role of communication between these medical detectives and the public.  This communication is heavily impacted by the media (which can help or hurt an investigation!)  I was fascinated to read about this relationship in the cases presented (from 1976-2007) and think about how it will evolve in the future along with our health communication channels.

Several cases offered particularly striking lessons in health communication:

Lesson 1:  The Role of Communication in Promoting Fear or Stigma

Chapter #4:  Obsession or Inspiration
This case (1976) chronicled the discovery of what would later be named "Legionnaires Disease". With U.S. citizens already worried about a possible influenza epidemic (due to a suspicious death earlier in the year), the medical detectives had to contend with media coverage that fueled public fear:

"The U.S. public, bombarded by daily news stories, was disturbed and frightened by the outbreak in Philadelphia, even though swine flu was quickly ruled out as a possible cause."

(Page 84)

"The public was primed and ready to believe that something big and scary was about to arrive, and it had."

(Page 84)

Chapter #7: A Normal Spring
This case (1993) followed the trail of a virus affecting people in New Mexico (later discovered to affect people in the four corners (New Mexico, Arizona, Colorado, and Utah). This case was interesting because it presented the challenge of managing the intersection of media coverage and local culture (Navajo people were disproportionately impacted by the condition).

"The Navajos were also unhappy at being linked to the disease in Four Corners. The newspapers not only printed the names of dead relatives, but also referred to the disease as the "Navajo flu," stigmatizing an entire people."

(Page 174)

Lesson 2: The Role of Communication in Promoting Health and Safety

Chapter #5: Deadly Desserts
This case (1994) which involved a Salmonella outbreak, highlighted a successful public awareness campaign! After Salmonella was linked to their products, the Schwan Company conducted a recall and asked customers to discard or return all uneaten products that may be affected.

"Schwan's even sent their trucks door-to-door to retrieve ice cream from each household."

(Page 124)

"Schwan's public awareness campaign- advising its customers not to eat its ice cream -was unprecedented and has been praised and studied as a model of good corporate citizenship."

(Page 124)

Lesson 3:  What's In A Name?  The Importance of Language

Chapter #4: Obsession or Inspiration

The newspapers called it "Legionnaires Disease" first. This popular name would later become official (and was approved by the American Legion).

"It was named Legionella pneumophila ("lung-loving"), in honor of the American Legionnaires.  Although many affected groups do not want the stigma of having an organism or a disease named after them, the leaders of the American Legion decided that the name would honor their fallen colleagues."

(Page 111)

Chapter #7: A Normal Spring

It is customary to name a newly isolated animal-borne pathogen after a geographic feature around the place it was discovered.  Therefore, names such as the "Four Corners virus", "San Juan virus", and "Muerto Canyon" were proposed.

"...the Navajo community was uncomfortable with names that would tie them to the new disease..."

(Page 181)

In response to this concern, scientists settled on a neutral name for the pathogen: Sin Nombre, the No Name Virus.

Overall Thoughts

I highly recommend this book. While I highlighted some of the health communication lessons here, there are lessons for a variety of public health disciplines. It is a great resource for public health students:  Dr. Levitt does a wonderful job of defining key public health terms (e.g., case control study) and providing lots of practical examples. It is a great resource for current public health practitioners who should re-visit lessons from past outbreaks as we tackle the challenges of disease surveillance, domestic/international outbreaks, and the disturbing anti-vaccine movement. This book gives us a good idea of the diverse skill set needed by today's public health workers....and I believe communication skills are at the top of the list. We need scientists who can do the work and also negotiate the media and the challenges of communicating risk to the public. As online news and social media become ubiquitous, I'm curious to see how public health handles the challenges of the 24-hour news cycle where health myths or facts can be spread in the blink of an eye.

What Do You Think? Would love to hear from others who have read the book!

Disclaimer: I was invited to review "Deadly Outbreaks" by the Council of State and Territorial Epidemiologists (CSTE) and provided with a copy of the book.

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What Can “Chronic Resilience” Teach Public Health Practitioners? An Interview With Author Danea Horn

Last month I had the pleasure of receiving an advanced review copy of "Chronic Resilience: 10 Sanity-Saving Strategies for Women Coping with the Stress of Illness".  As I read through the book, I made note of many issues that are relevant to public health practitioners.  Therefore, it is a pleasure to have Danea Horn expand her comments on these topics for Pop Health readers. 

If you would like to connect with Danea, you can visit her website or twitter.

Leah:  In public health, we talk a lot about how our society’s “culture” can promote or harm health.  In several places in your book, you talk about the connection between our societal values and our health.  For example:

Page 33: “Part of the reason we try to be all things to all people is our culture.  Have you ever sat through a business meeting while someone is sniffling and sneezing and exposing everyone else to their cold?  In that moment they are valuing achievement, money, or appearances above their health and the health of everyone else in the room.”

How can we expand your strategies beyond the individual level?  How can we identify and live our health values at the neighborhood, community, and organization levels?

Danea:  It only takes one person to start a conversation that can become the catalyst for big changes. Start talking to people at your work and in your community to get a feel for what is valued currently. The policies (written and unwritten) in our offices and items at our potlucks will say a lot about what we collectively value. If you find inconsistency or confusion in your conversations, open up a dialogue with the leaders in your organization or community to discuss what you would like to collectively choose to value. From here you can brainstorm together ways to influence change. They can be small changes like creating a healthy living block party where people share nourishing dishes and swap good-for-you recipes or larger changes like paid sick leave (which is not mandatory in every state…yet). Never be afraid to speak up. A big theme in Chronic Resilience is controlling what you can control and talking is in your control. 

Leah:  In Chapter #6, you write “It is up to you to decide how public to make your health.”  You and several of the women you interviewed for your book have blogs that document your health journey in a very public way.  Public health researchers Ressler et al (2012) have identified many benefits of patient blogging (e.g., patients report a decrease in feelings of isolation).

What benefits have you experienced as a result of writing about your health?  What challenges have you encountered during the process of sharing your story publicly?

Danea:  Writing helps me process what is going on from a different perspective. I am all about learning from our challenges, so each post I write is a search for a lesson or message that my diagnosis is pointing me toward. I can feel frustrated about the progression of my disease and start out writing a rant, but I find that I naturally end up with a message about letting go of my ideals or acceptance. Reframing my health in this way has been very empowering.

I haven’t encountered many challenges by being public with my health journey. Commenters have been very supportive. That said, I am discerning about what I choose to share and do keep some things private. Challenges I know other people have faced, and someone who blogs publicly about their health should be prepared for, are people sharing remedies, treatment recommendations, cure-all solutions and pleas to have faith in a deity they may or may not believe in. While these all come from a caring place they may feel intrusive. Also, you may want to give a heads-up to your close family and friends before you post anything particularly revealing, emotionally or otherwise, that you haven’t shared with them in private first.

There are a number of ways to benefit from writing about your health. Doing it publicly on a blog can create a sense of support and community, but if that feels too invasive, you can join support forums anonymously, create a private blog or journal pen and paper old school style.

Leah:  In Chapter #7 (“Empower Yourself With Research”), I was thrilled to see your emphasis on helping patients evaluate the validity and safety of medical information found on the Internet.  This is a huge challenge in public health!  Our evidence-based messages and guidelines often compete online with anecdotal evidence and unscientific studies.

Why did you decide to dedicate a portion of your book to this discussion?  Why is it so important for patients to discuss what they find online with their medical team?

Danea:  Before I became discerning about what I read online about my diagnosis, I was completely stressed. I read way too much from too many random sources to properly sort out what I should believe. I also noticed that I was searching for how I was going to become sicker (the side effects, complications, and progression of my illness) instead of searching for how I could support my heath. Fortunately, I realized most of my stress was coming from worry created by endless Internet searching, and I decided to take a different approach.

I found a few sources from trusted physicians and nutritionists to study and implement. I decided to stay focused on my personal symptoms, medications and prognosis instead of what other people I didn't even personally know had experienced. I also started a more open dialogue with my doctors about the diet I wanted to try and some of the studies I had read. When we research and experiment with our health without informing our doctors, we may have conflicting approaches which can create drug interactions or other harmful complications. Doctors are there to support us. If you are uncomfortable talking with yours, it’s time to find one that you trust enough to be completely open and honest with. We should all have a doctor who will work with us to find treatment solutions we feel comfortable with.

Leah:  A big thank-you to Danea for making the time for Pop Health!  "Chronic Resilience" is a great read for those with a personal and/or professional connection to chronic illness.  For public health clinicians, practitioners, and researchers who work in the chronic illness arena:  I think you will get a unique first-hand view into (1) the mental, physical, and emotional challenges that affect this population, (2) the incredible resilience that those with chronic illness show on a day-to-day basis (what can we learn from them??), and (3) specific strategies that can be employed to support patients with chronic illness.  As Danea and I discuss above, these strategies have the potential to be expanded from the individual level to offer support to entire communities.

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A Pop Health Book Review of “My Foreign Cities: A Memoir”

I cannot remember the last time I was so engrossed in a book that I looked up with shock to see the clock read 2:00am.  Well, that happened to me on both Friday night (when I started) and Saturday night (when I finished) the book “My Foreign Cities”.  The memoir chronicles the love story between author Elizabeth Scarboro and Stephen Evans.  In late high school/early college, their friendship grew into love and Elizabeth chose to be with Stephen, even though she knew his cystic fibrosis (CF) would limit his life expectancy (30 years old on average), impact her choices, and reduce their time together:

"In comparison to Stephen, most things would be there.  If I wanted him, I had to hurry up" (page 36).

While there were numerous public health topics of interest in this book, I was most struck by the strength, resilience, and creativity that Elizabeth brought to her role as a caregiver.  While the focus was on Stephen's health, we also learned how and when she needed to take care of herself.  Many of her words have stayed with me, so I'm weaving her eloquent quotes into this review.

Throughout the book, I was surprised by how she could both focus on the present and think about her future.  Even though she knew that future would not include Stephen at some point:

"Back then, this was my plan to get through Stephen's death: I'd have a life, a self, I wanted to continue after he was gone.  But I couldn't invent that on the spot- it would have to already be there, which meant I'd need to live it while he was here too" (page 79).

Because of this mindset, the reader gets to hear about the risks and adventures they took- both big and small.  The big being the trips to Mexico, Hawaii, Scotland, and Ireland- the moves to San Francisco, Boston, and back to San Francisco again- going to graduate school- and getting married.  The small being the clandestine escapes to the hospital roof for privacy during a long stay and their wonderful hikes around their homes in Denver and San Francisco.  Elizabeth's writing is so vivid that you can see the scenery, feel the air on your face, and sometimes hear Stephen's labored breathing.

When Stephen struggles with a dangerous addiction to his pain medication, we are reminded that caregivers deal with all the side effects and dangers that surround an illness- not just the disease itself.  Stephen managed to hide the addiction from Elizabeth for almost a year.  Their relationship and communication were challenged as she tried various solutions to the problem- locking up the medications, alerting his physicians. Elizabeth talks about how his withdrawal symptoms and subtle disclosures were often lost on her because she always viewed things within the larger context of CF:

"But that was the great thing, and the dangerous thing, about life-threatening illness- every other problem appeared like a sideshow when cast in its light" (page 108).

When Elizabeth battles depression during Stephen's recovery from a double lung transplant, we are reminded that caregivers have their limits and that self-care is incredibly important:

"And then I crashed.  Not in the way that Stephen might have, with none of the magnitude or danger, but in the way of a healthy person, slipping slowly, with the strong sense that it couldn't be happening, I could fix it if I just tried hard enough.  Maybe I crashed because I finally could, because Stephen was okay" (page 188).

During her recovery from depression and later- as Stephen's condition worsens, the reader is introduced to Elizabeth's amazing support network.  I can only hope that every caregiver has a group of friends/family like hers:

"Back home, my friends converged to take care of me, like incredibly skilled dancers, hiding the work of it, moving so seamlessly that I barely noticed the details, I just felt, underneath me, a solid floor" (page 273).

I would highly recommend this book to public health professionals, clinicians, patients, and caregivers.  While some parts are heartbreaking, the theme of resilience dominates.  We also get an inside view to patients and caregivers that should help us think about access to health care, quality of life, and the empowerment of patients.

I would also recommend this book because Stephen was one of us.  After college, he enrolled at the Harvard School of Public Health to pursue his interest in health care policy:

"Stephen was most concerned about how people without insurance would be managed, or worse, not taken into account at all.  He felt indebted to the California state system that covered CF, and he wanted to give back" (page 103).

I hope this book helps continue this legacy for Stephen.  I hope the book ignites conversation about access to care, coverage for the uninsured, and support for chronic illness patients, transplant patients, and their families.

Supplemental Information:

• My Foreign Cities: A Memoir- Facebook Page
• Pew Internet & American Life Project- New data on caregivers and how they use technology to find health information

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Book Review: Salt, Sugar, Fat

Michael Moss is a Pulitzer prize-winning journalist who has made a career writing about the US food system.  In his latest book, Salt, Sugar, Fat: How the Food Giants Hooked Us, he attempts to explain how the processed food industry has been so successful at increasing its control over US "stomach share".  Although the book doesn't focus on the obesity epidemic, the relevance is obvious.  Salt, Sugar, Fat is required reading for anyone who wants to understand why obesity is becoming more common in the US and throughout the world.

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A Pop Health Book Review of “In the Kingdom of the Sick: A Social History of Chronic Illness in America”

In 2009 I read "Life Disrupted: Getting Real about Chronic Illness in Your Twenties And Thirties".  Since the book inspired me personally and professionally, I was delighted that Twitter enabled me to connect directly with the author Laurie Edwards.  I was even more delighted when she asked to interview me for her new book, "In the Kingdom of the Sick: A Social History of Chronic Illness in America".  Since Pop Health focuses on health communication and the coverage of public health issues in the media, we had plenty of mutual interests to discuss!

"The very nature of chronic illness- debilitating symptoms, physical side effects of medications, the gradual slowing down as diseases progress- is antithetical to the cult of improvement and enhancement that so permeates pop culture." 
("In the Kingdom of the Sick", page 34)

Early in the book, I found this quote incredibly powerful.  It is true.  Our society values and spotlights those that overcome adversity- those that inspire us- those that beat the odds.  Before his fall from grace, we can all remember the worldwide cheering for Oscar Pistorius- making history last summer for being the first double-amputee to compete in the Olympic games.  Edwards highlights those societal values in her book by drawing on the imagery found in many commercials for breast cancer research and fundraising.  Those commercials show an unforgettable image, a "cancer survivor triumphantly crossing the finish line in her local fund-raising event surrounded by earnest supporters."  That triumphant image is a far cry from what Edwards and colleagues term the "Tired Girls" (i.e., female patients suffering with "invisible illnesses" like fibromyalgia, chronic fatigue syndrome, and migraines).  "The Tired Girl stands for so much that society disdains:  weakness, exhaustion, dependence, unreliability, and the inability to get better" (page 103).

The good news is that many of the "Tired Girls" (and Guys) are getting connected and getting empowered.  Edwards dedicates a significant portion of her book to the discussion of "patients in the digital age."  She describes the emergence of "e-patients" (those that are empowered, engaged, equipped, enabled) and how they are using technology to actively participate in the development of their care plans, connect with patients with similar diagnoses, give voice to their experiences, advocate for policy change, and debate controversial topics like vaccinations.

As a public health professional with significant interest in health communication, I was fascinated by a recurring theme that Edwards highlights from these conversations among empowered patients and writers:

"How does language influence the illness experience?"          

The reader is led through an intriguing discussion of the use and implications of terms such as:

• Illness vs. Disease
• Illness vs. Chronic Condition
• Illness vs. Disability
• Military Metaphors (e.g., "the battle against disease")
• Chronic Pain Patient vs. Patient with Chronic Pain
• Healthy Disabled vs. Unhealthy Disabled
• Patient (does it connote passivity?)

"In the Kingdom of the Sick" is a fascinating read for anyone with a personal and/or professional connection to chronic illness.  It begins by giving you a strong foundation in the history of illness, research, and patient advocacy movements.  It then challenges you to consider the impact of advances in patient rights, science, communication, and technology on the incidence, treatment, and perception of chronic illness.  I highly recommend this book to my Pop Health readers, friends, and colleagues.

If you are interested in connecting with Laurie Edwards:

Website:  http://www.laurieedwardswriter.com

Blog: http://www.laurieedwardswriter.com/blog

Facebook:  http://www.facebook.com/laurieedwardswriter

Twitter:  https://twitter.com/achronicdose 

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Book Review: The End of Overeating

The End of Overeating was written based on the personal journey of Dr. David A. Kessler (MD) to understand the obesity epidemic, and treat his own obesity in the process.  Dr. Kessler was the FDA commissioner under presidents George HW Bush and Bill Clinton.  He is known for his efforts to regulate cigarettes, and his involvement in modernizing Nutrition Facts labels on packaged food.  He was also the dean of Yale medical school for six years-- a very accomplished person. 

Dr. Kessler's book focuses on 1) the ability of food with a high palatability/reward value to cause overeating and obesity, 2) the systematic efforts of the food industry to maximize food palatability/reward to increase sales in a competitive market, and 3) what to do about it.  He has not only done a lot of reading on the subject, but has also participated directly in food reward research himself, so he has real credibility.  The End of Overeating is not the usual diet book. 
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A Pop Health Book Review of "The Immortal Life of Henrietta Lacks"

This book is not brand new; it has been out for about a year. However, it continues to pick up momentum and be read by book clubs across the country. Therefore, after it was recommended to me by my mother-in-law, I thought it would be perfect for a Pop Health Book Review.

As someone who works in public health, I collaborate with our University's Institutional Review Board (IRB) on a daily basis to ensure the safety of our research (for the good of our research team, funder, and participants). And even though I know and understand the importance of the collaboration, it can still feel like a burden to address and document each question that is asked by our IRB (I know many of you would agree!) I see the students I work with roll their eyes and sigh when they have to take the IRB and HIPAA trainings. HIPAA stands for Health Insurance Portability and Accountability Act of 1996 Privacy and Security Rules. The students say, "Yeah...we already know this stuff".

However, this book takes what you "already know" and puts a face on it. It reminds you that it wasn't long ago that people (especially vulnerable people) were experimented on and/or used for research without their consent. Often with sad and deadly outcomes.

Rebecca Skloot, an award-winning science writer, takes the reader on her personal journey (lasting over a decade) to learn about the woman behind HeLa cells. The woman's name was Henrietta Lacks. The original cells were taken from her cervix shortly after she was diagnosed with cancer and before her death. HeLa cells have been vital for many scientific advances, including the development of the polio vaccine.

Henrietta's story, pieced together through more than a thousand hours of interviews conducted by Rebecca, touches on the most essential and controversial aspects of public health and research:

1. Treatment/Research on Vulnerable Populations:

• Henrietta Lacks was a poor Southern tobacco farmer, seeking medical care from Johns Hopkins "colored" ward in the early 1950s. A sample of her tumor was taken and given to researchers without her consent. She was treated with radiation without a discussion about the side effects. Henrietta had no idea the radiation would cause her to be infertile. The hospital convinced her husband David to agree to an autopsy (after he already refused) by saying that the exam "could help his children one day". The autopsy results were later given to a writer who published all the details in his book.

• It is no wonder that the IRB now requires specific training and attention to address research that focuses on vulnerable populations. These include pregnant women, fetuses, neonates, prisoners, children, and other special classes of individuals such as minorities and those that are mentally ill.

• It is no wonder that it can be incredibly difficult to recruit members of these vulnerable groups to participate in research, even today! Henrietta's family spoke of their fears of being snatched off the streets around Johns Hopkins by doctors wanting to experiment on them. Rebecca found research that tales of "night doctors" had filled black oral history since the 1800s. These doctors would kidnap black people for research.

2. Ethical Issues

• This book examines the ethical issues of sharing human tissue. Consent to share human tissue (e.g., those you have "discarded"after a blood test or biopsy), is not the same as consenting to participate in research. Often consent is not required.

• But do researchers and doctors have an ethical responsibility to disclose to the patient if (1) their cells/tissues are unique and valuable in some way, (2) the researcher or doctor has a financial interest in their tissue, (3) the patient's tissue will be used in any way that is contrary to their beliefs?

3. Informed Consent

• Times have certainly changed since 1951 when Henrietta Lacks was subjected to tests and procedures without giving informed consent. Unfortunately, it took about 50 years to get there. Her husband and children were still left in the dark regarding the purpose of blood tests in the years after her death. Scientists wanted to map their genes. The family thought they were being tested for cancer. They waited years for results that never came.

• Most of Henrietta's family only completed school until their early-mid teenage years. Even when the doctors explained parts of procedures, it was not at a level or in a way that was familiar to them.

• This book emphasizes the importance of being "informed" in the consent process. If the participants don't understand, their verbal or written consent means nothing.

All of these important issues are discussed with beautiful storytelling by Henrietta's family and Rebecca's careful research. It is a must read, especially for my fellow science and public health friends out there.

You'll find yourself cheering for Henrietta's daughter Deborah and her siblings, who have all endured more than their share of suffering. And probably most important, you'll find yourself making a pact to never sigh when it is time to complete the annual IRB training.

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A Pop Health Book Review of “Unbearable Lightness”

Welcome back readers! After a holiday, bronchitis, and work travel hiatus- Pop Health is back with a new feature- reviews of books which examine public health and popular culture issues.

Over the weekend I finished reading “Unbearable Lightness- A Story of Loss and Gain”, by Portia De Rossi. I actually mentioned this book back in a November post when it first came out. The story chronicles Portia’s struggle with both Anorexia and Bulimia from approximately age 12 to the present. The strength of the book is in its ability to portray the absolute complexity of an eating disorder. Sometimes these disorders (and other mental or physical health issues) are over simplified. For example, the commonly held belief that someone is Anorexic simply because she/he needs to “have control over something”. However, in Portia’s case, she wove an incredible story that examined causes at multiple levels. And in public health, this multilevel thinking is essential for the development of effective interventions. I have decided to begin with the causes most closely associated with Portia herself and work my way out.

Intrapersonal:

Portia endured a complete lack of healthy coping mechanisms. She dealt with a lot of sorrow and changes in a short amount of time as an adolescent growing up in Australia. Her father passed away and she changed to a more affluent school district. She worked to cope with these challenges by identifying a way to be “special” and “stand out”. She chose modeling because models are special. She also changed her name when she was 15. There was another girl her age with the same name (Amanda Rogers), so she changed it to Portia De Rossi to be more unique.

Portia also felt intense guilt and shame over being gay. Although she realized her sexual orientation early on, she kept this secret until her late 20s. Much of her self hatred focused on feeling as if she was disappointing her family and would ultimately ruin her chances to have a successful career and “normal” life.

Interpersonal:

Portia’s relationship with her mother is examined in quite a bit of detail. Throughout her modeling career as a teenager, her mother was definitely her accomplice in yo-yo dieting. Her mother taught her “dieting tricks” to lose the weight quickly for jobs, but also rewarded her with McDonald's after auditions. However, her mother’s strongest influence seemed to be over the guilt and shame she felt over being gay. After she came out to her mother, the response was “let’s just keep this to ourselves”. Portia was told to keep it from the family and from employers/co-workers.

Besides 1-2 friends and her brother, Portia is very isolated. In addition, her relationships with co-workers on Ally McBeal and other colleagues in the industry seem to have contributed to her eating disorder as well. For example, two of her co-stars (Calista Flockhart and Courtney Thorne-Smith) were famously accused of being Anorexic and underweight throughout the show’s run. So Portia was constantly working with and compared to an unrealistic ideal. In addition, many people who could have and should have recognized the problem and intervened- stayed silent. For example, as Portia dropped from a healthy 130 lbs to sub-100s, her costume designer told her she looked fantastic and asked for her secrets to weight loss. Portia also sought the help of a professional nutritionist. Even though she confided to binging and purging on the first visit, she was still given a food scale and a diet to help her lose weight. The nutritionist did not try to intervene until Portia was almost down to 82 lbs.

Community/Society:

Portia’s existence in several “communities” contributed to her struggle with eating disorders. Her first professional affiliation in the modeling community in Australia is where she developed a strong knowledge of dieting, purging, and excessive exercise. The “older girls” taught her this. It was the norm in that group to be unhealthy in order to get ready for a job.

From Australia, Portia traveled to the United States and the “Hollywood Industry”. Unfortunately, it was a smooth transition from the unrealistic expectations of the modeling to the acting industry. She describes a particularly gut-wrenching fitting that she endured when a photo shoot had to be rescheduled after the client realized that she was in fact a size 8- so no selected clothes would fit her.

In addition to body size, she also felt Hollywood was not accepting of a homosexual lead actress. Several times she spoke of the paralyzing fear she felt after seeing how quickly Ellen DeGeneres’ show was canceled after she came out in the late 1990s.

This is just a brief overview of these complex contributors to Portia’s eating disorder- I could easily go on for many more pages. Overall, I think the book is a fascinating read…for those of us interested in public health, eating disorders, and/or Hollywood. It portrays Portia’s struggle, self hatred, and self destruction with brutal honesty- so be prepared.

A closing word of caution: this book may not be appropriate for someone with a current or recently recovered eating disorder, since it outlines her eating, binging, and exercise rituals in incredible detail.

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Book Review: The Primal Blueprint

Mark Sisson has been a central figure in the evolutionary health community since he began his weblog Mark's Daily Apple in 2006. He and his staff have been posting daily on his blog ever since. He has also written several other books, edited the Optimum Health newsletter, competed as a high-level endurance athlete, and served on the International Triathlon Union as the anti-doping chairman, all of which you can read about on his biography page. Mark is a practice-what-you-preach kind of guy, and if physical appearance means anything, he's on to something.

In 2009, Mark published his long-awaited book The Primal Blueprint. He self-published the book, which has advantages and disadvantages. The big advantage is that you aren't subject to the sometimes onerous demands of publishers, who attempt to maximize sales at Barnes and Noble. The front cover sports a simple picture of Mark, rather than a sunbaked swimsuit model, and the back cover offers no ridiculous claims of instant beauty and fat loss.

The drawback of self-publishing is it's more difficult to break into a wider market. That's why Mark has asked me to publish my review of his book today. He's trying to push it up in the Amazon.com rankings so that it gets a broader exposure. If you've been thinking about buying Mark's book, now is a good time to do it. If you order it from Amazon.com on March 17th, Mark is offering to sweeten the deal with some freebies on his site Mark's Daily Apple. Full disclosure: I'm not getting anything out of this, I'm simply mentioning it because I was reviewing Mark's book anyway and I thought some readers might enjoy it.

The Primal Blueprint is not a weight loss or diet book, it's a lifestyle program with an evolutionary slant. Mark uses the example of historical and contemporary hunter-gatherers as a model, and attempts to apply those lessons to life in the 21st century. He does it in a way that's empowering accessible to nearly everyone. To illustrate his points, he uses the example of an archetypal hunter-gatherer called Grok, and his 21st century mirror image, the Korg family.

The diet section will be familiar to anyone who has read about "paleolithic"-type diets. He advocates eating meats including organs, seafood, eggs, nuts, abundant vegetables, and fruit. He also suggests avoiding grains, legumes, dairy (although he's not very militant about this one), processed food in general, and reducing carbohydrate to less than 150 grams per day. I like his diet suggestions because they focus on real food. Mark is not a drill sergeant. He tries to create a plan that will be sustainable in the long run, by staying positive and allowing for cheats.

We part ways on the issue of carbohydrate. He suggests that eating more than 150 grams of carbohydrate per day leads to fat gain and disease, whereas I feel that position is untenable in light of what we know of non-industrial cultures (including some relatively high-carbohydrate hunter-gatherers). Although carbohydrate restriction (or at least wheat and sugar restriction) does have its place in treating obesity and metabolic dysfunction in modern populations, ultimately I don't think it's necessary for the prevention of those same problems, and it can even be counterproductive in some cases. Mark does acknowledge that refined carbohydrates are the main culprits.

The book's diet section also recommends nutritional supplements, including a multivitamin/mineral, antioxidant supplement, probiotics, protein powder and fish oil. I'm not a big proponent of supplementation. I'm also a bit of a hypocrite because I do take small doses of fish oil (when I haven't had seafood recently), and vitamin D in wintertime. But I can't get behind protein powders and antioxidant supplements.

Mark's suggestions for exercise, sun exposure, sleep and stress management make good sense to me. In a nutshell: do all three, but keep the exercise varied and don't overdo it. As a former high-level endurance athlete, he has a lot of credibility here. He puts everything in a format that's practical, accessible and empowering.

I think The Primal Blueprint is a useful book for a person who wants to maintain or improve her health. Although we disagree on the issue of carbohydrate, the diet and lifestyle advice is solid and will definitely be a vast improvement over what the average person is doing. The Primal Blueprint is not an academic book, nor does it attempt to be. It doesn't contain many references (although it does contain some), and it won't satisfy someone looking for an in-depth discussion of the scientific literature. However, it's perfect for someone who's getting started and needs guidance, or who simply wants a more comprehensive source than reading blog snippets. It would make a great gift for that family member or friend who's been asking how you stay in such good shape.

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Paleopathology at the Origins of Agriculture

In April of 1982, archaeologists from around the globe converged on Plattsburgh, New York for a research symposium. Their goal:

...[to use] data from human skeletal analysis and paleopathology [the study of ancient diseases] to measure the impact on human health of the Neolithic Revolution and antecedent changes in prehistoric hunter-gatherer food economies. The symposium developed out of our perception that many widely debated theories about the origins of agriculture had testable but untested implications concerning human health and nutrition and our belief that recent advances in techniques of skeletal analysis, and the recent explosive increase in data available in this field, permitted valid tests of many of these propositions.

In other words, they got together to see what happened to human health as populations adopted agriculture. They were kind enough to publish the data presented at the symposium in the book Paleopathology at the Origins of Agriculture, edited by the erudite Drs. Mark Nathan Cohen and George J. Armelagos. It appears to be out of print, but luckily I have access to an excellent university library.

There are some major limitations to studying human health by looking at bones. The most obvious is that any soft tissue pathology will have been erased by time. Nevertheless, you can learn a lot from a skeleton. Here are the main health indicators discussed in the book:

• Mortality. Archaeologists are able to judge a person's approximate age at death, and if the number of skeletons is large enough, they can paint a rough picture of the life expectancy and infant mortality of a population.
• General growth. Total height, bone thickness, dental crowding, and pelvic and skull shape are all indicators of relative nutrition and health. This is particularly true in a genetically stable population. Pelvic depth is sensitive to nutrition and determines the size of the birth canal in women.
• Episodic stress. Bones and teeth carry markers of temporary "stress", most often due to starvation or malnutrition. Enamel hypoplasia, horizontal bands of thinned enamel on the teeth, is probably the most reliable marker. Harris lines, bands of increased density in long bones that may be caused by temporary growth arrest, are another type.
• Porotic hyperostosis and cribra orbitalia. These are both skull deformities that are caused by iron deficiency anemia, and are rather creepy to look at. They're typically caused by malnutrition, but can also result from parasites.
• Periosteal reactions. These are bone lesions resulting from infections.
• Physical trauma, such as fractures.
• Degenerative bone conditions, such as arthritis.
• Isotopes and trace elements. These can sometimes yield information about the nutritional status, diet composition and diet quality of populations.
• Dental pathology. My favorite! This category includes cavities, periodontal disease, missing teeth, abscesses, tooth wear, and excessive dental plaque.

The book presents data from 19 regions of the globe, representing Africa, Asia, the Middle East, Europe, South America, with a particular focus on North America. I'll kick things off with a fairly representative description of health in the upper Paleolithic in the Eastern Mediterranean. The term "Paleolithic" refers to the period from the invention of stone tools by hominids 2.5 million years ago, to the invention of agriculture roughly 10,000 years ago. The upper Paleolithic lasted from about 40,000 to 10,000 years ago. From page 59:

In Upper Paleolithic times nutritional health was excellent. The evidence consists of extremely tall stature from plentiful calories and protein (and some microevolutionary selection?); maximum skull base height from plentiful protein, vitamin D, and sunlight in early childhood; and very good teeth and large pelvic depth from adequate protein and vitamins in later childhood and adolescence...
Adult longevity, at 35 years for males and 30 years for females, implies fair to good general health...
There is no clear evidence for any endemic disease.

The level of skeletal (including cranial and pelvic) development Paleolithic groups exhibited has remained unmatched throughout the history of agriculture. There may be exceptions but the trend is clear. Cranial capacity was 11% higher in the upper Paleolithic. You can see the pelvic data in this table taken from Paleopathology at the Origins of Agriculture.

There's so much information in this book, the best I can do is quote pieces of the editor's summary and add a few remarks of my own. One of the most interesting things I learned from the book is that the diet of many hunter-gatherer groups changed at the end of the upper Paleolithic, foreshadowing the shift to agriculture. From pages 566-568:

During the upper Paleolithic stage, subsistence seems focused on relatively easily available foods of high nutritional value, such as large herd animals and migratory fish. Some plant foods seem to have been eaten, but they appear not to have been quantitatively important in the diet. Storage of foods appears early in many sequences, even during the Paleolithic, apparently to save seasonal surpluses for consumption during seasons of low productivity.

As hunting and gathering economies evolve during the Mesolithic [period of transition between hunting/gathering and agriculture], subsistence is expanded by exploitation of increasing numbers of species and by increasingly heavy exploitation of the more abundant and productive plant species. The inclusion of significant amounts of plant food in prehistoric diets seems to correlate with increased use of food processing tools, apparently to improve their taste and digestibility. As [Dr. Mark Nathan] Cohen suggests, there is an increasing focus through time on a few starchy plants of high productivity and storability. This process of subsistence intensification occurs even in regions where native agriculture never developed. In California, for example, as hunting-gathering populations grew, subsistence changed from an early pattern of reliance on game and varied plant resources to to one with increasing emphasis on collection of a few species of starchy seeds and nuts.

...As [Dr. Cohen] predicts, evolutionary change in prehistoric subsistence has moved in the direction of higher carrying capacity foods, not toward foods of higher-quality nutrition or greater reliability. Early nonagricultural diets appear to have been high in minerals, protein, vitamins, and trace nutrients, but relatively low in starch. In the development toward agriculture there is a growing emphasis on starchy, highly caloric food of high productivity and storability, changes that are not favorable to nutritional quality but that would have acted to increase carrying capacity, as Cohen's theory suggests.

Very interesting.

One of the interesting things I learned from the book is that Mesolithic populations, groups that were halfway between farming and hunting-gathering, were generally as healthy as hunter-gatherers:

...it seems clear that seasonal and periodic physiological stress regularly affected most prehistoric hunting-gathering populations, as evidenced by the presence of enamel hypoplasias and Harris lines. What also seems clear is that severe and chronic stress, with high frequency of hypoplasias, infectious disease lesions, pathologies related to iron-deficiency anemia, and high mortality rates, is not characteristic of these early populations. There is no evidence of frequent, severe malnutrition, so the diet must have been adequate in calories and other nutrients most of the time. During the Mesolithic, the proportion of starch in the diet rose, to judge from the increased occurrence of certain dental diseases [with exceptions to be noted later], but not enough to create an impoverished diet... There is a possible slight tendency for Paleolithic people to be healthier and taller than Mesolithic people, but there is no apparent trend toward increasing physiological stress during the mesolithic.

Cultures that adopted intensive agriculture typically showed a marked decline in health indicators. This is particularly true of dental health, which usually became quite poor.

Stress, however, does not seem to have become common and widespread until after the development of high degrees of sedentism, population density, and reliance on intensive agriculture. At this stage in all regions the incidence of physiological stress increases greatly, and average mortality rates increase appreciably. Most of these agricultural populations have high frequencies of porotic hyperostosis and cribra orbitalia, and there is a substantial increase in the number and severity of enamel hypoplasias and pathologies associated with infectious disease. Stature in many populations appears to have been considerably lower than would be expected if genetically-determined maxima had been reached, which suggests that the growth arrests documented by pathologies were causing stunting... Incidence of carbohydrate-related tooth disease increases, apparently because subsistence by this time is characterized by a heavy emphasis on a few starchy food crops.

Infectious disease increased upon agricultural intensification:

Most [studies] conclude that infection was a more common and more serious problem for farmers than for their hunting and gathering forebears; and most suggest that this resulted from some combination of increasing sedentism, larger population aggregates, and the well-established synergism between infection and malnutrition.

There are some apparent exceptions to the trend of declining health with the adoption of intensive agriculture. In my observation, they fall into two general categories. In the first, health improves upon the transition to agriculture because the hunter-gatherer population was unhealthy to begin with. This is due to living in a marginal environment or eating a diet with a high proportion of wild plant seeds. In the second category, the culture adopted rice. Rice is associated with less of a decline in health, and in some cases an increase in overall health, than other grains such as wheat and corn. In chapter 21 of the book Ancient Health: Bioarchaeological Interpretations of the Human Past, Drs. Michelle T Douglas and Michael Pietrusewsky state that "rice appears to be less cariogenic [cavity-promoting] than other grains such as maize [corn]."

One pathology that seems to have decreased with the adoption of agriculture is arthritis. The authors speculate that it may have more to do with strenuous activity than other aspects of the lifestyle such as diet. Another interpretation is that the hunter-gatherers appeared to have a higher arthritis rate because of their longer lifespans:

The arthritis data are also complicated by the fact that the hunter-gatherers discussed commonly displayed higher average ages at death than did the farming populations from the same region. The hunter-gatherers would therefore be expected to display more arthritis as a function of age even if their workloads were comparable [to farmers].

In any case, it appears arthritis is normal for human beings and not a modern degenerative disease.

And the final word:

Taken as a whole, these indicators fairly clearly suggest an overall decline in the quality-- and probably in the length-- of human life associated with the adoption of agriculture.

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Book Review: Dangerous Grains

Dangerous Grains is about the health hazards of gluten grains. It's co-written by James Braly, an M.D. who specializes in food allergies, and Ron Hoggan, a celiac patient who has written widely on the subject.

Celiac disease is a degeneration of the intestinal lining caused by exposure to gluten. Gluten sensitivity is a broader term that encompasses any of the numerous symptoms that can occur throughout the body when susceptible people eat gluten. The term gluten sensitivity includes celiac disease. Gluten is a protein found in wheat, its close relatives (kamut, spelt, triticale), barley and rye. Wheat is the most concentrated source.

Dangerous Grains is a good overview of the mountain of data on celiac disease and gluten sensitivity that few people outside the field are familiar with. For example, did you know:

• An estimated one percent of the U.S. population suffers from celiac disease.


• Approximately 12 percent of the US population may suffer from gluten sensitivity, according to blood antibody tests.


• Gluten can damage nearly any part of the body, including the brain, the digestive tract, the skin and the pancreas. Sometimes gastrointestinal symptoms are absent.
  


• Both celiac and other forms of gluten sensitivity increase the risk of a large number of diseases, such as type 1 diabetes and cancer, often dramatically.


• The majority of people with gluten sensitivity are not diagnosed.


• Most doctors don't realize how common gluten sensitivity is, so they rarely test for it.
  


• Celiac disease and other symptoms of gluten sensitivity are easily reversed by avoiding gluten.

That's an enormous disease burden coming from a single type of food. I suspect the true incidence may actually be higher, although it's difficult to be sure.

Dangerous Grains also discusses the opioid-like peptides released from gluten during digestion. Opioids are powerful drugs, such as heroin and morphine, that were originally derived from the poppy seed pod. They are strong suppressors of the immune system and quite addictive. There are no data that conclusively prove the opioid-like peptides in gluten cause immune suppression or addiction to wheat, but there are some interesting coincidences and anecdotes. Celiac patients are at an increased risk of cancer, particularly digestive tract cancer, which suggests that the immune system is compromised. Heroin addicts are also at increased risk of cancer. Furthermore, celiac patients often suffer from abnormal food cravings. 

I know several people who have benefited greatly from removing gluten from their diets. Anyone who has digestive problems, from gas to acid reflux, or any other mysterious health problem, owes it to themselves to try a gluten-free diet for a month. Gluten consumption has increased quite a bit in the U.S. in the last 30 years, mostly due to an increase in the consumption of processed wheat snacks. I believe it's partly to blame for our declining health. Wheat has more gluten than any other grain. Avoiding wheat and all its derivatives is a keystone of my health philosophy.

Another notable change that Sally Fallon and others have pointed out is that today's bread isn't made the same way our grandparents made it. Quick-rise yeast allows bread to be fermented for as little as 3 hours, whereas it was formerly fermented for 8 hours or more. This allowed the gluten to be partially broken down by the microorganisms in the dough. Some gluten-sensitive people report that they can eat well-fermented sourdough wheat bread without symptoms. I think these ideas are plausible, but they remain anecdotes to me at this point. Until research shows that gluten-sensitive people can do well eating sourdough wheat bread in the long term, I'll be avoiding it. I have no reason to believe I'm gluten sensitive myself, but through my reading I've been convinced that wheat, at least how we eat it today, is probably not healthy for anyone.

I'm not aware of any truly healthy traditional culture that eats wheat as a staple. As a matter of fact, white wheat flour has left a trail of destruction around the globe wherever it has gone. Polished rice does not have such a destructive effect, so it's not simply the fact that it's a refined carbohydrate. Hundreds, if not thousands of cultures throughout the world have lost their robust good health upon abandoning their traditional foods in favor of white flour and sugar. The medical and anthropological literature are peppered with these stories.

Overall, the book is well written and accessible to a broad audience. I recommend it to anyone who has health problems or who is healthy and wants to stay that way!

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Book Review: "The Human Diet: Its Origins and Evolution"

I recently read this book after discovering it on another health site. It's a compilation of chapters written by several researchers in the fields of comparative biology, paleontology, archaeology and zoology. It's sometimes used as a textbook.

I've learned some interesting things, but overall it was pretty disappointing. The format is disjointed, with no logical flow between chapters. I also would not call it comprehensive, which is one of the things I look for in a textbook. Here are some of the interesting points:

• Humans in industrial societies are the only mammals to commonly develop hypertension, and are the only free-living primates to become overweight.
  
• The adoption of grains as a primary source of calories correlated with a major decrease in stature, decrease in oral health, decrease in bone density, and other problems. This is true for wheat, rice, corn and other grains.
• Cranial capacity has also declined 11% since the late paleolithic, correlating with a decrease in the consumption of animal foods and an increase in grains.
• According to carbon isotope ratios of teeth, corn did not play a major role in the diet of native Americans until 800 AD. Over 15% of the teeth of post-corn South American cultures showed tooth decay, compared with less than 5% for pre-corn cultures (many of which were already agricultural, just not eating corn).
  
• Childhood mortality seems to be similar among hunter-gatherers and non-industrial agriculturists and pastoralists.
  
• Women may have played a key role in food procurement through foraging. This is illustrated by a group of modern hunter-gatherers called the Hadza. While men most often hunt, which supplies important nutrients intermittently, women provide a steady stream of calories by foraging for tubers.
• We have probably been eating starchy tubers for between 1.5 and 2 million years, which precedes our species. Around that time, digging tools, (controversial) evidence of controlled fire and changes in digestive anatomy all point to use of tubers and cooked food in general. Tubers make sense because they are a source of calories that is much more easily exploited than wild grains in most places.
• Our trajectory as a species has been to consume a diet with more calories per unit fiber. As compared to chimps, who eat leaves and fruit all day and thus eat a lot of fiber to get enough calories, our species and its recent ancestors ate a diet much lower in fiber.
  
• Homo sapiens has always eaten meat.
  

The downside is that some chapters have a distinct low-fat slant. One chapter attempted to determine the optimal diet for humans by comparing ours to the diets of wild chimps and other primates. Of course, we eat more fat than a chimp, but I don't think that gets us anywhere. Especially since one of our closest relatives, the neanderthal, was practically a carnivore.
They consider the diet composition of modern hunter-gatherers that eat low-fat diets, but don't include data on others with high-fat diets like the Inuit.

There's some good information in the book, if you're willing to dig through a lot of esoteric data on the isotope ratios of extinct hominids and that sort of thing.

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Book Review: Blood Sugar 101

I just finished reading "Blood Sugar 101" by Jenny Ruhl. It's a quick read, and very informative. Ruhl is a diabetic who has taken treatment into her own hands, using the scientific literature and her blood glucose monitor to understand blood sugar control and its relationship to health. The book challenges some commonly held ideas about diabetes, such as the notion that diabetics always deteriorate.

She begins by explaining in detail how blood glucose is controlled by the body. The pancreas releases basal amounts of insulin to make glucose available to tissues between meals. It also releases insulin in response to carbohydrate intake (primarily) in two bursts, phase I and phase II. Phase I is a rapid response that causes tissues to absorb most of the glucose from a meal, and is released in proportion to the amount of carbohydrate in preceding meals. Phase II cleans up what's left.

In a person with a healthy pancreas, insulin secretion will keep blood glucose under about 130 mg/dL even under a heavy carbohydrate load. The implications of this are really interesting. Namely, that blood glucose levels will not be very different between a person who eats little carbohydrate, and one who eats a lot, as long as the latter has a burly pancreas and insulin-sensitive tissues.

Most Americans don't have such good control however, hence the usefulness of low-carbohydrate diets. This begs the question of why we lose blood sugar control. Insulin resistance seems like a good candidate, maybe preceded by leptin resistance. As you may have noticed, I'm starting to think the carbohydrate per se is not the primary insult. It's probably something else about the diet or lifestyle that causes carbohydrate insensitivity. Grain lectins are a good candidate in my opinion, as well as inactivity.

Diabetics can have blood glucose up to 500 mg/dL, that remains elevated long after it would have returned to baseline in a healthy person. Ruhl asserts that elevated blood sugar is toxic, and causes not only diabetic complications but perhaps also cancer and heart disease.

Heart attack incidence is strongly associated with A1C level, which is a rough measure of average blood sugar over the past couple of months. It makes sense, although most of the data she cites is correlative. They might have seen the same relationship if they had compared heart attack risk to fasting insulin level or insulin resistance. It's difficult to nail down blood sugar as the causative agent. More information from animal studies would have been helpful.

Probably the most important thing I took from the book is that the first thing to deteriorate is glucose tolerance, or the ability to pack post-meal glucose into the tissues. It's often a result of insulin resistance, although autoimmune processes seem to be a factor for some people. Doctors often use fasting glucose to diagnose diabetes and pre-diabetes, but typically you are far gone by the time your fasting glucose is elevated!

I like that she advocates a low-carbohydrate diet for diabetics, and lambasts the ADA for its continued support of high-carbohydrate diets.

Overall, a good book. I recommend it!

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