Congratulations Mississippi!  You are the fattest state in the Union.   Approximately 34% of the people in Mississippi are obese; but don’t get too smug California and Hawaii you are not far behind.   In both states 23% of the population is obese.   Over the past 10 years the number of obese people in all states has increased alarmingly.   If you want to see a very scary graphic, follow this link (http://www.cdc.gov/obesity/data/trends.html) to the CDC map on obesity.  It charts the average weight of the population of each state over the past ten years.   The map changes from light blue (normal weight) to orange/brown (obesity) in just a matter of years.  I am ashamed to say that I am part of this color change.

But before I go to “my obesity”, let me state three very important, true but cruel points:

1. The number one cause of death in the U.S.A. is heart disease…not cancer.  And the number one cause of heart disease is obesity and the artery clogging grease that comes along with it.
2. Technically, obesity is defined as having a Body Mass Index (B.M.I.), a number derived from your height and weight, over 30.   But you don’t really need a BMI to know if you’re obese.  Do you?  You know.
3. There is no such thing as being obese but healthy!   Describing yourself as such is just finding an excuse to eat more donuts.

I tried to make the last point a little humorous (albeit true) because losing weight requires a bit of humor; a bit of lightness if you will.  Pun intended.  There is little doubt in my mind that we become obese because to some degree we are depressed.  Call it “stressed” if it makes you feel better; but we use food as a sedative; and a damned good one it is too.

Last year, while writing “The Acid Reflux Solution” (which comes out March 27, 2012 and is on pre-order now on Amazon.com   Plug.  Plug.  Plug.)  I was living the recommendations I wrote about in my book.   I lost over thirty pounds and brought my BMI down to an average level.   I was eating solely from the recipes that we created for the book and from the simple recommendations.  But since finishing the book, life has become hectic and I have abandoned those lifestyle changes and myself.   My weight has slowly crept up.  Not all the way to where it was, but I am on a slippery slope.  So today, I am putting an end to that slide and I want you to join me.

Every few days I will write a blog about my progress and I will explain more about nutrition and how to incorporate healthier habits into your life.   There are 21 days until Thanksgiving and I plan to lose at least 6 pounds by then.   You can too.

Here are the first six rules that WE are going to follow:

1. NO FAST FOOD   Seriously…no fast food!   Do not drive through and place your order in the clown’s mouth.   Most, if not all, fast food is cooked with sugars and oils that your body does not metabolize.  It ends up slowing down YOUR metabolism.   Cook at home or go to a restaurant.   We will talk about portion size in the near future.  For now, take murderous fast food out of your diet.
2. NO EATING AFTER 8 PM  What your body can’t burn it stores.   Might as well tape that pint of ice cream to your butt because that is where it’s going if you snack at night.
3. CUT YOUR CAFFEINE IN HALF  (Or better yet, stop it all together)  This is a tough one for me, since I’m Cuban and we love our coffee.   But, caffeine stimulates insulin.  Insulin not only uses sugar as energy, but if there is too much sugar around it will store it.
4. DRINK WATER.   Drink at least 6 glasses of water a day.   Water is necessary to burn fat.   It is cold water you actually burn extra calories.
5. EXERCISE 20 MINUTES A DAY, AT LEAST THREE DAYS A WEEK   I don’t want to hear any excuses about this one.   You don’t have to go to a gym.   Just walk.   But let’s start getting that heart pumping.
6. BE GOOD TO YOURSELF   Do not take anyone or anything too seriously.  This is not the end of the world.  This is not about deprivation.  This is about having more in your life than you have ever had before:  more energy, more happiness, more joy.   Learn to say NO.   Right now, you must be your first priority.   If no one can do your job, then make sure you are healthy enough to do it.  If your family can’t live without you, then be sure you are healthy enough to be around for them.  So say NO to extra work.  Right now it is about you.  Be at peace with yourself.

Tomorrow is Day 1.  Weigh yourself tomorrow morning.  Follow my suggestions for a few days.  On Day 3 I will blog again and let you know how I did.  Let me know how you did too.

1. G.E.R.D.  and the symptoms of heartburn occur when the acidic and/or bile-like contents of the stomach are pushed up into the esophagus.
2. The Lower Esophageal Sphincter and the diaphragm separate the stomach from the esophagus.  If either of these is not functioning correctly it is more likely that normal meals will cause G.E.R.D.
3. Food stimulates your stomach to make acid and your liver to make bile.
4. A ‘hiatal hernia’ occurs when part of your stomach is above the diaphragm.  This means that the diaphragm no longer helps keep acid and bile in the stomach, making G.E.R.D. much more likely.

If you are born with a hiatal hernia or develop it later in life there are surgical ways to deal with it, but that should be the your last alternative.  Most hiatal hernias can be dealt with by making certain lifestyle adjustments.    Here are a few adjustments that might help:

1. Do not be overweight.   Being heavy means that there is more fat in the abdomen.   Believe it or not, this causes an increase in pressure on the stomach and actually makes it more likely for stomach acid to be pushed up into the esophagus.
2. Do not lie down within two hours of eating. Once you eat, your stomach starts producing acid to digest the food you just ate.   Maximum acid production occurs an hour to two after a meal.  If you are like many people and either lie down on the sofa or go to bed after a meal, you are very likely to have symptoms of G.E.R.D.    After a meal is a great time to go for a short stroll or walk the dog.   Let gravity be your friend and help the meal and the acid go down through your intestine, not up to the esophagus.
3. Eat Small Meals.  The larger the meal, the more the stomach is stretched.   The more the stomach is stretched the more the L.E.S. is stretched.   The more the L.E.S. is stretched, the more likely stomach contents will reflux into the esophagus.  In this case less really is more.
4. Avoid foods that open the L.E.S. Certain substances cause the lower esophageal sphincter to open, thus making reflux more likely to occur.  Many of these substances are stimulants, like caffeine (that includes coffee, tea and sodas) and nicotine.   Fatty substances also affect the L.E.S;  for example, fatty meats, chocolate and fried food.   Some foods like peppermint and raw onions are notorious for causing reflux but how they do so is unknown.

Not all of these recommendations work for everyone, but most of them work for most people.   Try them out and see which ones work for you.   On my next blog I will get specific about which foods are the most notorious for causing G.E.R.D.   Stay tuned for HEARTBURN PART III:   You Mean I Have to Give  Up Tomatoes?

Heartburn, more technically known as gastroesophageal reflux disease (G.E.R.D.), occurs when the caustic fluids within the stomach come up into the esophagus where they do not belong.  These fluids, whether they are  acid or bile, can burn the esophogus (esophagitis) and cause an uncomfortable burning feeling under the breast bone.

There are many reasons people get heartburn.  One of them is being born with something called a “hiatal hernia”.   Simply put, a hiatal hernia is the stomach being above the diaphragm.   This is not good because along with the lower esophageal sphincter (LES) the diaphragm helps create a belt line that prevents the stomach juices from rolling up into the esophagus.   Without this extra barrier stomach contents can easily be pushed into the esophagus burning its very delicate lining.   Interestingly, approximately one out of three people have a hiatal hernia.

Besides a hiatal hernia, another cause of heartburn is overeating.  When one overeats, the stomach is stretched to the point where the LES is also stretched.   Think of the LES as the gate between the esophagus and the stomach.  Once stretched, this gate is open and the stomach contents can rise up and burn the esophagus.  Heartburn is caused not just by what you eat, but also by how much you eat.

In the case of those of us who ate at the Peruvian restaurant, our greatest sin was eating too much.  It wasn’t that the food was too spicy.  We just filled our stomachs with too much of it.

But are there certain foods that make heartburn more likely?   Find out in my next blog,  Heartburn Part II:  G.E.R.D  and LIFESTYLE

January 2, 2010
Many of you who saw me on either Campbell Brown or Anderson Cooper’s show on CNN know that during 2009 I passionately advocated in favor of health care reform.   Unfortunately, what has been structured in Congress is not health care reform…but health care DEFORM.   It will not solve the problems of our ailing health care system.  The process became all about politics instead of doing what is best for this country and its citizens.   In the homestretch, the politicians compromised any purpose they originally may have had, so that they could appeal both to their constituents and to their party.   Shame.  Shame.  Shame.   You and I suffer the consequences…again.

Here is how I would have tackle health care reform.   I would begin by clarifying the goal.   Is the objective to insure every citizen?   This narrowly defined statement does not tackle what I believe our main objective should be – to ensure that every American is able to live a longer healthier life.    Having insurance does not guarantee this, especially since most people use insurance only after they are sick, not to maintain good health.

Therefore, the ten things that I would include in “Dr. Jorge’s Health Care Reform Bill” are:

1. Every American should have health insurance.  There should be a competitive government option along with private insurers, thus providing multiple tiers of service.  There should be a basic coverage for everyone, along with the option for different tiers that provide greater expediency and less hassle, but not greater coverage.  If you have worked hard all your life  and want to pay for a private clinic as opposed to using the basic coverage, why not?     Everyone has the right to a basic education, but not everyone goes to college.  Everyone should be able to drive a drive a car; but not everyone has or wants leather seats.  Choice is the American way.  Competition is the American way.  Let the best plans win.  Let people choose the level of coverage they want or can afford.
2. Deny no one health insurance because of a pre- existing condition.  What is the point of health care insurance otherwise?
3. Incent Americans to become or stay healthy.   In the long run, healthy Americans are less expensive to the health care system.    Anyone who has ”registered” with a family physician can qualify.   The physician must verify that this person has been under their care for at least a year and has had their yearly physical examination.   Apply a federal tax rebate toward health care insurance costs for every American who…
   1. is of a good, healthy weight (BMI less than 25)
   2. has a normal blood pressure, with or without medication.
   3. has normal cholesterol, with or without medication.
   4. Has a normal diabetes test ( HgbA1C), with or without medication.
   5. performs the recommended cancer screening when appropriate (mammograms, colonoscopies etc.)  This way we can help control the risk factors for heart disease, cancer and diabetes.   Together these diseases account for approximately one million deaths a year and hundreds of billions of health care dollars.)  Prevent, prevent, prevent.
4. Find a way to outlaw or decrease the use of cigarettes.   (We don’t make drinking cyanide legal do we?)
5. Decrease the amount that plaintiff lawyers can receive from a malpractice lawsuit.   When this was done in Texas the number of malpractice suits decreased by approximately 50% in the first year. Makes you wonder how many of the previous lawsuits were frivolous, doesn’t it?  The following year 18% more doctors moved to Texas to practice medicine     Of course, we must continue to make sure that doctors that are truly committing malpractice can be sued and have their licenses revoked; but remove the sword from above doctors’ heads.
6. Invest in the future of American physicians.  There are too few college students going to medical school who want to become primary care physicians.   We need more Marcus Welby M.D.s and less Dr. McDreamys.   This can be done by mandating that any medical school that receives federal research funds must have 25% of their medical school class agree to become primary care physicians once they graduate.   Most importantly, the government will pay for those students’ medical school career in exchange for the same number of years of service as primary care physicians in underserved areas.   This would be like a “Medical Peace Corps”.   Once they have fulfilled their obligation they may return to become specialists if they wish.
7. Create medical center based clinics where those “Medical Peace Corp” doctors can practice medicine.
8. Do not decrease the compensation of physicians.   As distasteful as talking about physician reimbursement is, Medicare and insurance companies have decreased physician reimbursement by at least 30% over the past decade.  This is causing future doctors to seek out other professions and practicing doctors to retire at the highest rates ever.   Who is going to take care of us if this trend continues?
9. Invest in the future health of America’s children by providing billions of dollars of financial incentives to states that have mandatory physical education and health education in their school system.   Current trends in childhood obesity will cause heart disease, diabetes and cancer to sky-rocket in the future.   Make sure that the future generations are healthier than the current generations.   Healthy people leads to more productive people and a decrease burden in the overall cost of healthcare.
10. Increase the number of generic medications available to the general population.

Sure, there are a lot of other issues that need to be addressed.   These ten may appear simplistic, but they keep focus on making Americans healthier, not JUST making sure they can get into the hospital when they are sick and dying.  That is important too…but by then; it is too late to make much of a difference either in their overall health or in the cost of health care.

Many of you know that during 2009 I passionately advocated on CNN’s Campbell Brown Show in favor of health care reform.   Unfortunately, what has been structured in Congress is not health care reform…but health care DEFORM.   It will not solve the problems of our ailing health care system.  The process became all about politics instead of doing what is best for this country and its citizens.   In the homestretch, the politicians compromised any purpose they originally may have had, so that they could appeal both to their constituents and to their party.   Shame.  Shame.  Shame.   You and I suffer the consequences…again.

Here is how I would have tackle health care reform.   I would begin by clarifying the goal.   Is the objective to insure every citizen?   This narrowly defined statement does not tackle what I believe our main objective should be -  ensure that every American is able to live a longer healthier life.    Having insurance does not guarantee this, especially since most people use insurance only after they are sick, not to maintain good health. 

Therefore, the ten things that I would include in “Dr. Jorge’s Health Care Reform Bill” are:

1. Every American should have health insurance.  There should be a competitive government option along with private insurers providing multiple tiers of service.  There should be a basic coverage for everyone, but with different tiers that provide greater expediency and less hassle, but not greater coverage.  If you have worked hard all your life  and want to pay for a private clinic as opposed to using the basic coverage, why not?   Choice is the American way.  Competition is the American way.   Everyone should be able to drive a drive a car; but not everyone has or wants leather seats.    Let the best plans win.  Let people choose the level of coverage they want or can afford.
2. Deny no one health insurance because of a pre- existing condition.  What is the point of health care insurance otherwise?
3. Incent Americans to become or stay healthy.   In the long run, healthy Americans are less expensive to the health care system.    Anyone who has ”registered” with a family physician can qualify.   The physician must verify that this person has been under their care for at least a year and has had their yearly physical examination.   Apply a federal tax rebate toward health care insurance costs for every American who…
   1. is of a good, healthy weight (BMI less than 25)
   2. has a normal blood pressure, with or without medication.
   3. has normal cholesterol, with or without medication.
   4. Has a normal diabetes test ( HgbA1C), with or without medication.
   5. performs the recommended cancer screening when appropriate (mammograms, colonoscopies etc.)  This way we can help control the risk factors for heart disease, cancer and diabetes.   Together these diseases account for approximately one million deaths a year and hundreds of billions of health care dollars.)  Prevent, prevent, prevent.
4. Find a way to outlaw or decrease the use of cigarettes.   (We don’t make drinking cyanide legal do we?)
5. Decrease the amount that plaintiff lawyers can receive from a malpractice lawsuit.   When this was done in Texas the number of malpractice suits decreased by approximately 50% in the first year. Makes you wonder how many of the previous lawsuits were frivolous, doesn’t it?  The following year 18% more doctors moved to Texas to practice medicine     Of course, we must continue to make sure that doctors that are truly committing malpractice can be sued and have their licenses revoked.  
6. Invest in the future of American physicians.  There are too few college students going to medical school who want to become primary care physicians.   We need more Marcus Welby M.D.s and less Dr. McDreamys.   This can be done by mandating that any medical school that receives federal research funds must have 25% of their medical school class agree to become primary care physicians once they graduate.   Most importantly, the government will pay for those students’ medical school career in exchange for the same number of years of service as primary care physicians in underserved areas.   This would be like a “Medical Peace Corps”.   Once they have fulfilled their obligation they may return to become specialists if they wish.
7. Create medical center based clinics where those “Medical Peace Corp” doctors can treat people.
8. Do not decrease the compensation of physicians.   As distasteful as talking about physician reimbursement is, Medicare and insurance companies have decreased physician reimbursement by at least 30% over the past decade.  This is causing future doctors to seek out other professions and practicing doctors to retire at the highest rates ever.   Who is going to take care of us if this trend continues?
9. Invest in the future health of America’s children by providing billions of dollars of financial incentives to states that have mandatory physical education and health education in their school system.   Current trends in childhood obesity will cause heart disease, diabetes and cancer to sky-rocket in the future.   Make sure that the future generations are healthier than the current generations.   Healthy people leads to more productive people and a decrease burden in the overall cost of healthcare.
10. Increase the number of generic medications available to the general population.

Sure, there are a lot of other issues that need to be addressed.   These ten may appear simplistic, but they keep focus on making Americans healthier, not JUST making sure they can get into the hospital when they are sick and dying.  That is important too…but by then; it is too late to make much of a difference either in their overall health or in the cost of health care.

So in 2010 think about and take action towards getting and staying healthier.

Thanks Sally….we really, really do like you.

a. Most women in their 40’s do not need screening mammograms, and mammograms should be reduced to just one every other year after a woman reaches fifty years of age.

b. The need and efficacy of manual breast examinations was also questioned.

c. These recommendations can change based on a person’s family history.

I don’t think that anyone expected the storm of public opinion that this would create.   After the recommendations were made public everyone from politicians to physicians to cancer societies weighed in.   Now it’s my turn.

Should Science or Emotion Dictate Policy?
In defense of the USPSTF their recommendations are scientifically sound.  It has correctly concluded that screening mammograms for women between the ages of 40 and 49 are not as effective as they are in diagnosing breast cancer in women between the ages of 50 and older.  Before the age of 50 years, mammograms are diagnostically correct 1 out of every 1900 mammograms.  After the age of fifty, mammography finds breast cancer 1 in every 1300 mammograms.  Using statistics, these changes show that there is a marked and important difference depending on when in a women’s life a mammogram is done.   When looking at “cost effectiveness” the recommendations are correct…but are they the right thing to do?

Recommendations Do Affect Policy
Within a few hours of the release of the recommendations, so many politicians were back- peddling that it almost created a tsunami on the shores of the Chesapeake Bay.   Make no mistake about the importance of the USPSTF recommendations.  They will affect policy.   The new healthcare reform bill states quite clearly that only preventive recommendations made by the USPSTF ranked an “A” or a “B” would be covered by the new healthcare program.   Since these recommendations were classified a “C”, these recommendations will eventually become policy for ALL insurances, not just for government based health programs.   That is the pattern that rules the day.   Once Medicare changes its screening recommendations or physician payment schedules, within two years all private insurances do the same thing.  All of them. When a politician states that keeping the healthcare program privatized would eliminate these recommendations becoming policy, history has in no way shown this to be true.

In my opinion, the USPSTF conclusions are not significant enough to stop recommending mammograms between the ages of 40 and 49.  Thousands of lives are saved by early detection.   So pink ladies, please don’t picket me.   I’m on your side AND the USPSTF’s side.  But must we look closely at the hypocrisy of this issue.   In April of this year the USPSTF made similar recommendations concerning the efficacy of the PSA test to prevent deaths of men from prostate cancer.  There are currently limitations on how often a man can get a PSA (prostate cancer screening test) and debate as to whether this test is even valid.    As a point of information there are approximately 40,000 deaths from breast cancer every year compared to 27,000 deaths from prostate cancer.

Why This is Our Fault
America needs to wake up and realize that if we are going to fix our health care program many difficult and unpopular decisions need to be made…including how often mammograms and PSAs should be done.  How come there is no uproar about the number of African-American or Latino deaths due to obesity and their ability to receive access to blood pressure control?  How come there is not an uproar that the healthcare program does not including a way for Americans to lose weight and control their blood pressure and cholesterol so that we can save a great percentage of the 600,000 people who die every year from heart disease?

This is a complicated debate.  I believe that women should get yearly mammograms and men yearly PSAs and rectal examinations.   I believe it is cost efficient and saves lives.   However, there is a price for this; a price than can be offset if Americans stop smoking, control their weight, cholesterol and blood pressure.   Make no mistake about it; the USTPST is making decisions that might eventually cost people their lives.  We don’t like to talk about it, but unfortunately that is a daily occurrence in medical care.  As a doctor I make those decisions…but as a patient YOU make those decisions too.   The person that is overweight and is smoking while ordering their burger at the “drive-through” is not only making a decision about their health, but by eventually taxing the resources of the health care system they will one day affect someone else’s ability to get health care…maybe you.  Let’s debate that!

Over 200,000 women every year are newly diagnosed with some form of breast cancer.   If you are over 40 years of age a yearly mammogram is definitely recommended.   If you are younger than that, the value of monthly self examinations is under question, but in my opinion Breast Self Examination (BSE) is still very valuable and should be conducted by every woman on a monthly basis.

The key to early detection of breast cancer is to know your body and know your family history.   If you notice a change in your breast consistency (if it becomes too hard or if a lump arises) then immediately contact your physician.   If there is a very positive history of breast cancer in your family, then you may choose to have your physician perform genetic testing on you to see if you are at greater risk of developing breast cancer.  Depending on those results you may then need more frequent examinations, or you may choose to take preventive measures; but in either case,  forewarned is forearmed.  The take home message is this:  know your body; know your “people”.

Along with regular examinations, there are some simple but important changes that can be done in your daily life that will decrease your chance of getting diagnosed with breast cancer.   For example:

Among the easiest things to control are what you eat and drink and how active you are. Here are some strategies that may help you decrease your risk of breast cancer:

• Limit alcohol.
  A link exists between alcohol consumption and breast cancer. How strong a link remains to be determined. The type of alcohol consumed — wine, beer or mixed drinks — seems to make no difference. To protect you from breast cancer, consider limiting alcohol to less than one drink a day or avoid alcohol completely.
• Maintain a healthy weight.
  There’s a clear link between obesity — weighing more than is appropriate for your age and height — and breast cancer. This is especially true if you gain the weight later in life, particularly after menopause. Experts speculate that estrogen production in fatty tissue may be the link between obesity and breast cancer risk.
• Stay physically active.
  Regular exercise can help you maintain a healthy weight and, as a consequence, may aid in breast cancer prevention. Aim for at least 30 minutes of exercise on most days of the week. If you haven’t been particularly active in the past, start your exercise program slowly and gradually work up to a greater intensity. Try to include weight-bearing exercises such as walking, jogging or aerobics. These have the added benefit of keeping your bones strong.
• Consider limiting fat in your diet.
  Results from the most definitive study of dietary fat and breast cancer risk to date suggest a slight decrease in risk of invasive breast cancer for women who eat a low-fat diet. But the effect is modest at best. However, by reducing the amount of fat in your diet, you may decrease your risk of other diseases, such as diabetes, cardiovascular disease and stroke. And a low-fat diet may protect against breast cancer in another way if it helps you maintain a healthy weight — another factor in breast cancer risk. For a protective benefit, limit fat intake to less than 35 percent of your daily calories and restrict foods high in saturated fat.