Recommendations for new school meal nutrition standards

The nutrition standards behind the National School Lunch Program and the School Breakfast Program have not been updated since 1995. Today, the federal Institute of Medicine is issuing a report recommending new standards, calling for more produce, more whole grains. And for the first time, a limit to calories.

Thirty million children eat school lunch, and 10 million eat school breakfast -- and the IOM panel says it hopes new standards will help those children develop good habits that they carry into adulthood. That, the panel says, should help curb obesity and other health problems associated with diet.

The panel's recommendations go to the U.S. Department of Agriculture for possible implementation. It was the USDA which requested the report.

The panel says new standards would cost money -- for food as well as for training and capital improvements. But it says food costs would go up by less than 10% for breakfast and 25% or less for lunches. The government now spends $8.7 billion a year in reimbursements for school meals to school districts.

The recommendations are meant to bring school food in line with the dietary guidelines the government issues for Americans. It seeks to have the amount of sodium in school meals reduced by more than half over the next decade.

Among its recommendations: that calories be limited, based on age level, for breakfast and lunch, and that the sodium level for a typical lunch be eventually reduced to 740 milligrams. It also sets out targets for weekly servings of fruits and vegetables, and it calls for more whole grains.

"It's about time," says Matthew Sharp of the California Food Policy Advocates and one of the people who testified before the panel. Meals, he says, should be nutritious and affordable and they also should "teach kids healthy habits" and expose them to a variety of foods.

-- Mary MacVean

The toll of living in a concrete jungle

People who live in rural areas appear to have a major health advantage compared with city-dwellers. Living close to green space improves one's mental and physical health across a wide range of disease states, according to a new study.

Researchers in the Netherlands looked at the health records of people registered with 195 family doctors across the country. The percentages of green space within a 1-kilometer and 3-kilometer radius (that's 0.68 of a mile to 1.86 miles) of their homes were calculated.

Overall, the prevalence of 15 of 24 diseases was lower among people living with more green space, particularly those with more green space within 1 kilometer. The prevalence of anxiety disorders among those living in an area containing 10% green space within a 1-kilometer radius was 26 per 1,000. For those living in an area with 90% green space, the rate was 18 per 1,000. Depression rates in the first group were 32 per 1,000 compared with 24 per 1,000 for people living around more green.

The researchers also found that the impact of living near green space was greatest for people who spent the most time at home, including children and people of lower socioeconomic status.

The presence of green space may influence health through several mechanisms, the authors said. It could assist with recovery from stress, allow for more social interactions with neighbors and create more opportunities for physical activity. Air quality may be better, too.

"Our study shows that the role of green space in the living environment for health should not be underestimated," the authors wrote.

The study was published today in the Journal of Epidemiology and Community Health.

-- Shari Roan

Photo credit: Bryan Chan / Los Angeles Times

Those with less severe symptoms of celiac disease may be at a higher risk of death [Updated]

Those who suffer from celiac disease have much to contend with. The immune-related disorder causes digestive symptoms when gluten is eaten, making flour-based foods such as breads and pasta problematic. Eating gluten can injure the surface of the small intestine, not allowing the body to absorb some nutrients. Previous studies have shown an increased risk of death among people with celiac disease.

But a new study in this week's Journal of the American Medical Assn.reveals there also might be a moderately increased mortality risk for those who have less significant levels of symptoms related to the disease, such as intestinal inflammation or latent celiac disease.

Researchers from Sweden and England looked at data from biopsies done between 1969 and 2008 that included biopsies on the small intestine. Data on all cases of celiac disease, inflammation and latent celiac disease were matched with controls.

The data revealed 3,049 deaths among patients with celiac disease, 2,967 deaths in patients who had inflammation, and 183 deaths in patients with latent celiac disease. In all three groups the risk of death was higher--those with inflammation had a 72% increased risk of death, those with celiac disease had a 39% increased risk, and those with latent celiac disease had a 35% increased risk of death. Researchers believe that the higher mortality rate for those with inflammation could be due to the fact that they were older at the beginning of the study.

Among causes of death were cardiovascular disease and malignancy.

The same issue of the journal features an editorial by Dr. Peter H.R. Green, director of the Celiac Disease Center at Columbia University College of Physicians and Surgeons. In it, Green emphasizes the importance of doctors diagnosing celiac disease, and argues more attention should be paid to intestinal inflammation and gluten sensitivity.

Recently a new at-home test for celiac disease was introduced. MyCeliacID is a do-it-yourself saliva-based test that uses genetics to determine if someone has a gene that is linked to the disease, but does not diagnose the active disease. [Update 1:40 p.m.: An earlier version of this article said the test determines presence of the disease.]

-- Jeannine Stein

Photo credit: Anne Cusack / Los Angeles Times

Is HPV vaccine worth it? Researchers weigh in; you may have to decide

Perhaps you've heard of the relatively new HPV vaccine, Gardasil. If you have a preteen or teenage daughter -- or if you've simply been conscious since the vaccine was approved in 2006 -- we'll assume you have. The vaccine has been marketed, quite heavily, as a way to protect against four strains of the human papilloma virus -- two types blamed for 70% of cervical cancers, and two types blamed for 90% of genital warts.

Almost as soon as doctors and their medical organizations began recommending it, however, push-back from consumers started -- with questions about the vaccine's effectiveness plus complaints about the cost, the number of shots required (three) and, oh right, the negative reactions. Some patients say they became dizzy after getting the vaccine; others reported headaches, fever and fainting. The vaccine was even suspected in some seizures and deaths.

Now, with more than 23 million doses having been administered in the U.S. by the end of last year, researchers with the federal Centers for Disease Control and Prevention, which recommended Gardasil, and the Food and Drug Administration, which approved Gardasil, have taken a look at the data on the adverse reactions to the vaccine. And they've found ... eh, it's safe.

They write: "Most of the AEFI rates [adverse events following immunization] were not greater than the background rates compared with other vaccines, but there was disproportional reporting of syncope [fainting] and venous thromboembolic events [blood clots]."

They conclude that most of the adverse events weren't very serious and that the vaccine has the potential to greatly reduce global HPV-related illnesses and deaths. (The number of deaths from cervical cancer is much higher elsewhere in the world; in the U.S., the pap smear screening reduced such deaths 74% between 1955 and 1992. The American Cancer Society expects just over 4,000 deaths from cervical cancer in the U.S. this year. More of that info here.)

Here's the short version of that new report, published today in the Journal of the American Medical Assn.

A related article, however, takes issue with the marketing of the vaccine and the professionalism of the doctors and medical groups who jumped behind it. Sheila Rothman and David Rothman of Columbia College write:

"By making the vaccine's target disease cervical cancer, the sexual transmission of HPV was minimized, the threat of cervical cancer to adolescents was maximized, and the subpopulations most at risk practically ignored. The vaccine manufacturer also provided educational grants to professional medical associations (PMAs) concerned with adolescent and women's health and oncology. The funding encouraged many PMAs to create educational programs and product-specific speakers' bureaus to promote vaccine use. However, much of the material did not address the full complexity of the issues surrounding the vaccine and did not provide balanced recommendations on risks and benefits. As important and appropriate as it is for PMAs to advocate for vaccination as a public good, their recommendations must be consistent with appropriate and cost-effective use."

And that's just when they're getting warmed up.

Taking into account both articles is a related editorial. It states: "Whether a risk is worth taking depends not only on the absolute risk, but on the relationship between the potential risk and the potential benefit. If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to a woman is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened. So rationally she should be willing to accept only a small risk of harmful effects from the vaccine."

Here's the full version of that essay. 

And here's the Gardasil website, in case you're interested. And the "One Less" commercial, courtesy of  YouTube.

Also instructive, as a timeline, is previous L.A. Times coverage of the vaccine and the reaction to it.

December 2008: Low allergic reaction rate seen in Gardasil study

October 2008: Immigrants' advocates decry Gardasil requirement

August 2008: Gardasil's chorus of doubters 
 
May 2007: Benefits of HPV vaccine questioned

March 2007: HPV: Men can get it too

February 2007: Millions of women carry HPV strains that vaccine can block

February 2007: HPV vaccine: Who chooses?

February 2007: Texas requires HPV vaccine

January 2007: Vaccine industry is being revived

June 2006: For women already exposed to HPV, shots may not be as helpful

June 2006: Cervical cancer vaccine approved

-- Tami Dennis

Top photo: A teen gets a shot of the HPV vaccine. Photo credit: Associated Press

Lower photo: Gardasil. Photo credit: AFP/Getty Images

 

Where there's swine flu, there's a pitch. Seat protection anyone?

Perhaps on the surface, this product might make some kind of sense to people overly alarmed about the H1N1 outbreak, who don't like to be slowed down by facts and who have $14.99 burning a hole in their pocket. But to everyone else, using the Sure Fit Transit Cover to protect against the flu would have to defy logic.

As the e-mailed pitch goes: "Searching for an option to keep people safe and protected, Sure Fit, the nation’s leading slip cover and accessories provider has created the newest must-have item to ease fears of catching the flu en route with the Transit Cover."

The cover does what it sounds like it does. It slips over the back (just the back) of an airplane or bus seat.

It's up to you to avoid touching the arm rests. And tray table. And bathroom door. And the seat while taking the cover on or off. And the cover itself once you take it off, because presumably you'd want to reuse it... Airborne transmission is a less reliable way to spread the flu, but it might be a good idea to not breathe while you're on the plane too.

Just ignore the fact that not even toilet seat covers do much to protect against the spread of disease. And one is presumably not touching multiple surfaces in a toilet stall. Here's an answer to that much-wondered-about public health question, courtesy NYU Langone Medical Center: True or False: It Is Possible for a Person to Get a Sexually Transmitted Infection from a Public Toilet Seat.

Users don't even have to take those things with them when they leave.

If you really want to know how to reduce the chances of contracting so-called swine flu, or any other flu, here's some advice from the federal Centers for Disease Control and Prevention. Soap and hand sanitizers are featured prominently; seat covers are not.

For more on disease transmission, here's a report from the L.A. Times earlier this year: Cold and flu viruses travel a tricky route, plus a sidebar: Discovering how flu is transmitted may give clue to prevention.

The first story states: "The mere presence of a virus doesn't necessarily mean it is still infectious. But a Swiss study published in Applied and Environmental Microbiology in May showed that influenza virus not only can remain on paper money for up to 17 days, but also that it can be alive and ready to infect."

Separating consumers from their money? Maybe there is something to this seat cover. And if that's what it takes to "ease fears of catching the flu en route," please, go ahead.

-- Tami Dennis

Photo: Don't touch anything. Don't even look at anything.

Credit: Richard Derk / Los Angeles Times

Anarchy would loom if we couldn't trust hand sanitizer

They're everywhere. Little bottles of hand sanitizer, big bottles of hand sanitizer, dispensers of hand sanitizer. Who needs soap when we have miracle goo? Apparently everyone counting on Clarcon skin sanitizers and skin protectants.

The products contain bacteria, says the Food and Drug Administration, which is also none too happy with the company's manufacturing processes. The agency is telling consumers not to use any Clarcon products, some of which were promoted as treatments for damaged skin and open wounds. 

Here's the news release from the Food and Drug Administration. The involvement of U.S. Marshals is an exciting touch.

So's this: "Some of these bacteria can cause opportunistic infections of the skin and underlying tissues. Such infections may need medical or surgical attention and may result in permanent damage."

Some of the goo products were sold as:

Citrushield Lotion
Dermasentials DermaBarrier
Dermassentials by Clarcon Antimicrobial Hand Sanitizer
Iron Fist Barrier Hand Treatment
Skin Shield Restaurant
Skin Shield Industrial
Skin Shield Beauty Salon Lotion
Total Skin Care Beauty
Total Skin Care Work

These may not be the most common brands. And they may not be what you have in your cabinets. But who knows how many people you encounter were counting on them to prevent transmission of something to you?

This news does not suggest that other hand sanitizers are not perfectly effective. It does suggest you should have your own non-Clarcon bottle on standby.

-- Tami Dennis

Photo: Good old soap and water ...

Credit: Gary Friedman / Los Angeles Times

Pneumonic plague is no stranger to L.A. -- we've had our own epidemic

With China moving to control an outbreak of pneumonic plague, it's worth noting that the disease doesn't occur only in places for which Americans need a passport to visit. In fact, Los Angeles has dubious bragging rights to the United States' most recent rat-borne epidemic.

Here's a review of that epidemic from the Yale Journal of Biology and Medicine.

The recap begins: "On October 29, 1924, a physician requested an ambulance from the Los Angeles
County General Hospital for Two Mexican patients critically ill of a malady which he could not definitely diagnose, but which he knew to be highly contagious since several others in the neighborhood were also affected with similar symptoms of very high fever and pains in the back and chest. The following day 13 other cases displaying the same symptoms were detected and subsequently admitted to the hospital,
where they all developed signs of severe pneumonia, with bloody expectoration and marked cyanosis."

For information on the plague in general, check out the plague home page from the Centers for Disease Control and Prevention. (It's fascinating stuff.) If you're pressed for time, there's also a more succinct fact sheet -- and some details about California's and the West's brushes with the disease and how the forms of the disease differ. (Of note: Ground squirrels are not your friend. Please stop trying to make them eat from your hand.)

A highlight from the fact sheet: "About 14% (1 in 7) of all plague cases in the United States are fatal. Most cases in the U.S. receive some antibiotic treatment during their course of illness and deaths typically result from delays in seeking treatment or misdiagnosis. Reportedly, about 50-60% of bubonic plague patients who fail to receive any antibiotic treatment die. Untreated septicemic or pneumonic plague is almost always fatal."

Sounds dramatic, doesn't it? Of course, 14% of U.S. cases is still a very, very small number -- the disease is reported in only about five to 15 people each year.

Here's a look at some of the more recent cases in the United States. (About 90% of the 362 cases from 1944 through 1993 were in Arizona, California, Colorado and New Mexico.)

In general the plague is spread by rats and rodents. Well, fleas on the rats and rodents. Even more specifically, the bacterium Yersinia pestis, which is carried by those fleas. This is the same culprit responsible for the bubonic form of plague that ravaged Europe in the 1300s. Then, it was known as the Black Death. Here's an account from writer Giovanni Boccaccio, who was in Florence at the time. 

In the current China outbreak, the bacterium is causing the lung-focused pneumonic form, which is less common than the bubonic form but more lethal. The disease can also be picked up by inhaling respiratory droplets  from an infected person or animal. (Those how-to-sneeze-and-cough lessons in the current swine flu outbreak would serve you well; and, given the choice of droplet-borne diseases, take swine flu.)

This column on the plague, from the Los Angeles Times, sums up the disease's current status in the United States: Now it's more of a fluke than a plague

And here's today's L.A. Times story, which prompted this digression: Pneumonic plague reported in remote western China

-- Tami Dennis

Photo: Sure, they're cute enough, until you remember that they and their naked-tail counterparts can carry plague-filled fleas.

Credit: Los Angeles Times

To reduce the risk of genital herpes, use a condom -- every time

We've assumed that condoms can reduce the spread of genital herpes -- but without complete, or at least well-quantified, confidence in the assumption.  

This fact sheet from the federal Centers for Disease Control and Prevention sums up the reason for such hesitation: "Genital ulcer diseases can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered."

Then there's the problem of transmission without visible signs of infection. As the National Institutes of Health states: "Most people get genital herpes by having sex with someone who is shedding the herpes virus either during an outbreak or an asymptomatic (without symptoms) period. People who do not know they have herpes play an important role in transmission because they are unaware they can infect a sexual partner."

Researchers at the University of Washington, the federal Centers for Disease Control and Prevention and elsewhere decided to try to clarify just how much condoms can reduce the spread of genital herpes, known medically as herpes simplex virus 2 (or HSV-2).
 
They analyzed six studies of various types, all of which featured data on individual condom use and on HSV-2 acquisition.

They found that people who always used condoms had a 30% decreased risk of acquiring genital herpes when compared with people who never used condoms.

In clarifying further, the researchers stated: "Risk of HSV-2 acquisition decreased by 7% for every additional 25% of the time that condoms were used during anal or vaginal sex. Risk of HSV-2 acquisition also rose steadily and significantly with increasing frequency of unprotected sex acts, and our findings were consistent throughout multiple analysis strategies."

The results were published today in the Archives of Internal Medicine. Here's the abstract.

The upshot of the study: "Although the magnitude of protection was not as large as has been observed with other STIs, we found that condoms offer moderate protection against HSV-2 acquisition in men and women."

Here's more information on genital herpes from the National Institutes of Health, including details on asymptomatic shedding:

"Sometimes, the virus can become active but not cause any visible sores or any symptoms. During these times, small amounts of the virus may be shed at or near places of the first infection, in fluids from the mouth, penis, or vagina, or from barely noticeable sores. This is called asymptomatic shedding. Even though you are not aware of the shedding, you can infect a sexual partner during this time. Asymptomatic shedding is an important factor in the spread of herpes."

And here's the aforementioned fact sheet on genital herpes from the CDC.

The key here is consistent use. Not sometime use, but consistent use.

-- Tami Dennis

Photo: A health worker in the Philippines conducts a seminar recently on the proper use of a condom.

Credit: Francis R. Malasig / EPA

If the doctor doesn't call, don't assume those tests turned out fine

“No news is good news” seems to be what most patients assume when they're waiting to hear about test results. But for 1 out of 14 of them, “no news” may in fact mean “bad news” that their doctor didn't inform them about, according to a study published in Archives of Internal Medicine on Monday.

The study, led by Dr. Lawrence Casalino of Weill Cornell Medical College, looked at more than 5,000 records of randomly selected middle-age patients from 23 primary care practices. 

The patients had received common blood and screening tests, including mammograms, pap smears,  cholesterol tests and red blood cell counts. “Abnormal results” that fell well outside the normal range  were reported in roughly one-third of patients. But in 7.1% of these cases, practices did not inform — or document that they had informed — patients.

Communication failures like this could have serious, even lethal, consequences, Casalino says.  “We weren’t looking for cholesterol levels that were trivially high,” he notes. Some patients weren't informed of total cholesterol levels as high as 318 mg/dL (above 200 mg/dL is considered high). If left untreated, such levels could eventually mean a stroke or a heart attack for some patients. 

Adds coauthor Dr. David Meltzer of the University of Chicago, seeing the numbers “would clearly require a doctor at the very least to have a discussion with the patient” — about lifestyle changes, medication or other forms of intervention.

You might think that switching to electronic medical records would be the solution -- but that's not necessarily so: Computerizing a process that is already being done poorly may yield even worse results, Casalino says. Good processes, using either electronic or paper-based methods, seem to be the key to fewer mistakes.

Casalino and colleagues propose common-sense procedures physicians could use to manage test results, including having the doctor sign off on all results and telling patients to call after a certain time interval if they have not been notified of their results.

Making a few simple changes to automate the system could reduce errors without necessarily making costs higher, Meltzer adds.  “A great example would be what happens in an airplane cockpit,” he says.  “There are certain pieces of information that are only considered transmitted if they are confirmed.  When a co-pilot says to the pilot, ‘We’re running out of fuel,’ the co-pilot’s job isn’t done until the pilot actually says ‘I heard you tell me that.’ ”

Until that happens, however, the study’s authors recommend that patients play an active role in their own care. The single most important message: Don’t assume no news is good news. Know which tests have been done, know when to expect them back -- and if you don’t hear anything, call. 

“It’s not hyperbole to say it could save your life,” Casalino says.

-- Shara Yurkiewicz

Swine flu? The plague? What's up in San Diego?

Tony Perry reported today that a 9-year-old girl in Imperial County and a 10-year-old boy in San Diego County both were identified as having swine flu. Luckily, neither child needed hospitalization and both have recovered. Health officials, however, are puzzled and looking for the source of the infection.

What is the swine flu, you ask?

Just like human beings, pigs get influenza. Swine flu refers to four different types of flu strains that circulate among pigs. Under normal conditions, typically humans don’t contract swine flu. Unless, of course, they have direct contact with pigs.

Historically, the swine flu epidemic of 1918 hit the U.S., killing more than 500,000 that year. In 1976, the U.S. was scared again by swine flu. A national vaccination program was launched and fewer people died. In 2007, in the Philippines, the National Meat Inspection Service raised a red alert warning over hog cholera.

(Here’s a Q&A from the Centers for Disease Control and Prevention, in case you can’t get enough facts about the swine flu.)

This afternoon, we learned that the plague has hit squirrels on Palomar Mountain. Although chances of human infection are slight, officials are warning campers to take precautions.

The plague, in this case, refers to a bacterial disease found in wild rodents. The disease can be passed to humans via the bite of an infected flea. At the moment, no human cases of the plague have been reported.

Here are some tips to prevent contact with fleas, and how to protect yourself and your pets from the plague.

Oddly, both of these diseases have hit in or near San Diego. A strange coincidence? Perhaps.

Until there are more answers, the take home lesson is: don’t play with pigs and avoid squirrels like the plague.

-- Lori Kozlowski

Photo credit: Los Angeles Times