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Archive for the ‘Laws’ Category

BY MICHAEL F. JACOBSON

I love black beans generally and black bean soup in particular. Filling and inexpensive, beans are high in dietary fiber, low in unhealthful fats, and hospitable to garlic, onion, red pepper, and spices. If you were having lunch at a restaurant, black bean soup could be the healthiest thing on the menu.

Or, it could be a bowl of stroke du jour.

If you’re at all skeptical of whether the federal government should regulate the amount of sodium in processed or restaurant food, consider Chili’s. A bowl of black bean soup at Chili’s contains 1,480 milligrams of sodium. For fully 70 percent of the adult population– including those of us over 40, African-Americans, and people with high blood pressure–that’s basically all the sodium they should eat in an entire day.

Chili’s Jalapeno Smokehouse Burger, with Jalapeno Ranch dressing and a side of fries, certainly doesn’t have the same kind of healthy halo that black bean soup has. Everyone knows that plate will have too many calories and too much saturated fat. But seriously: Would anyone expect a burger and fries to have 6,460 mg of sodium, or more than four days’ worth?

A weekly meal of that sort at Chili’s–plus similar horror stories at restaurants or at home– is likely to set even healthy people on the path to hypertension. And for an elderly person, a meal with thousands of milligrams of sodium could be enough to trigger congestive heart failure.

Chains like Chili’s are basically vandalizing the food supply.

Happily, a long-awaited report from the Institute of Medicine has alighted on the desks of top officials at the Food and Drug Administration and the U.S. Department of Agriculture. Ordered up by Congress at the behest of Senator Tom Harkin (D-IA) and Representative Rosa DeLauro (D-CT), the report confirmed what many in the medical community have been saying for years: Americans are eating too much salt, which raises blood pressure and promotes heart disease, stroke, and other ailments. And the first recommendation made by the IOM is that the FDA “expeditiously initiate a process to set mandatory standards”–in other words, limits–“for the sodium content of foods.”

Limiting salt in packaged and restaurant foods is perhaps the single most important dietary improvement that the Food and Drug Administration could bring about. Cutting sodium levels in packaged and restaurant foods in half is predicted to save 100,000 lives and tens of billions of dollars in health-care expenses each year.

The IOM recommends that reductions be phased in stepwise, giving Americans’ palates, now accustomed to overly salty foods, a chance to readjust to safely seasoned foods. Though an unnamed FDA source speculated that such a transition could take 10 years, some foods have two or three times as much as competing products, suggesting that there’s a lot of low-hanging fruit that should permit faster action.

In anticipation of the IOM report, companies such as Kraft, Campbell’s, General Mills, and PepsiCo have all issued press releases in recent months indicating that they will take steps to reduce the sodium in their products by various percentages. I’m glad they’re doing that. And I hope more companies follow suit, particularly restaurant chains. But it won’t be enough. As the IOM report unambiguously points out, 40 years of voluntary action by manufacturers and restaurants to reduce salt intake has been a dismal failure.

As if on cue, the Salt Institute, the industry trade association, said that reductions would be “immoral,” based on poor science, and that high-sodium diets actually benefit some people. And the Tea Party crowd huffed that the prospect of limits on salt is “the nanny state gone wild.” But those of us who really care about culinary liberty know that limits on salt actually restore power to consumers, who could be set free to add as much or as little salt to their black bean soup as they want.

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The Food and Drug Administration on Tuesday announced a gradual but potentially far-reaching effort to reduce the amount of salt Americans consume in a bid to combat high blood pressure, heart disease, strokes and other health problems that have soared to near-epidemic proportions.

The FDA’s efforts will begin by seeking voluntary cutbacks by the food industry. But ultimately, the agency may resort to regulating acceptable levels of sodium in food and beverages.

“Nothing is off the table,” said FDA spokeswoman Meghan Scott. “Everyone’s in agreement that something needs to be done….We just don’t know what it’s going to look like.”

The FDA’s decision was applauded by public health advocacy groups and scientists, who have long pointed up the link between high salt intake and a host of serious – and costly – medical problems.

But it was also criticized by some industry groups, and some conservative political leaders denounced it as another government assault on personal freedom.

The deliberate pace sketched by the FDA, and the absence of any immediate plans to issue regulations, were in contrast to a strongly worded report concurrently released Tuesday by the Institute of Medicine, the health arm of the National Academy of Sciences.

The institute declared that expeditious “regulatory action is necessary” because efforts to educate the public about the perils of excessive dietary salt and voluntary sodium-cutting efforts by industry have failed, although the institute called for such regulations to take effect gradually.

On a daily basis, Americans consume almost 50% more than the roughly one teaspoon of salt recommended as a maximum by the federal government’s 2005 Dietary Guidelines for Americans, according to the institute’s report.

Sodium intake is “simply too high to be safe,” said Dr. Jane E. Henney, former commissioner of the Food and Drug Administration and chairwoman of the institute committee that produced the report. “Clearly, salt is essential.… We need it. But the level we’re taking in right now is far beyond the maximal levels we need.”

The 14-member panel’s findings, more than a year in the making, come on the heels of a welter of studies tallying the health and economic costs of excessive salt intake.

Researchers from the Harvard School of Public Health predicted that, if dietary sodium consumption declined to the levels recommended in the 2005 federal guidelines, some 90,000 deaths could be averted yearly.

A Rand Corp. study published in September estimated that reducing American sodium intake to recommended levels could save $18 billion yearly in treatment for hypertension, stroke, renal disease and heart failure associated with excessive salt consumption.

“There is now overwhelming evidence that we must treat sodium reduction as a critical public health priority,” said Dr. Walter Willett, chairman of the Harvard School of Public Health’s department of nutrition.

Willett, who was a key figure in the recent federal initiative to drive trans fats from the U.S. food supply, noted how quickly the U.S. food industry adapted to those new rules, and called for that industry’s “best creative minds to bring similar leadership” to the bid to reduce sodium.

But the head of the salt lobby blasted efforts to curb salt consumption as unwarranted and overly broad.

“It’s not scientifically sound,” said Lori Roman, president of the Salt Institute. “They’re talking about some very drastic reductions. They could be harming people.”

Another key industry trade association, the Grocery Manufacturers Assn., took a more measured approach.

It said in a statement that food makers already offer low- or no-sodium versions of many items. “We look forward to working with the U.S. Food and Drug Administration to develop a national sodium reduction strategy that will help the consumer,” the group said.

The FDA’s decision to press food makers to reduce salt caps a 30-year campaign by the Center for Science in the Public Interest. The center sued the FDA in 2005 to try to force the agency to reclassify salt as a food additive subject to regulation.

Salt currently is categorized as a substance “generally recognized as safe,” hence not regulated in food products.

Center director Michael Jacobson urged the FDA to adopt mandatory limits on salt swiftly, and then phase them in slowly. A gradual phase-in is considered crucial so that consumers do not notice a taste difference in foods with diminished amounts of salt.

While public health advocates like Jacobson hailed the clampdown, libertarian skeptics of government viewed it as another sign of a nanny state run amok.

“It’s another encroachment on people’s personal freedom,” said Gary Howard, spokesman for Campaign for Liberty, a libertarian advocacy group formed in the wake of Texas Rep. Ron Paul’s 2008 presidential campaign.

“They’ve already gotten into people’s medical care,” Howard said. “Where will they go next? Will they mandate exercise?”

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BY ELLIE KRIEGER

I paid nearly a dollar for an organic apple the other day, and I couldn’t help but think: that’s the entire food budget for a child’s school lunch! With the Child Nutrition Act up for reauthorization, Michelle Obama making child wellness a priority, and tremendous public awareness of food issues, we are seeing great momentum for change in school food now. There is a refocusing on fresh, local produce and whole grains, support for community school gardens and a desperately needed updating of the national standards for school food.

On Wednesday I will have the opportunity to visit with thought leaders and members of Congress to discuss this important subject. On behalf of Food Network, I will testify before the House Committee on Agriculture about nutrition, healthy eating and the growing epidemic of childhood obesity.

In order to implement needed changes, schools need more than just guidelines and calls to action. The fact is, it’s cheaper and easier to buy, store and prepare overly processed, sodium-laden, artificially-flavored food than the fresh, additive-free, unprocessed food our children deserve. Not only do we need more money to purchase better quality food, we need the facilities to store and prepare it and the staff training to do so healthfully.

My daughter’s public school is a perfect case in point. The passionate and hardworking kitchen staff there works miracles daily, producing two meals a day for more than 700 children in a kitchen not much larger than a suburban walk-in closet. They have just two burners and two ancient ovens, one of which was not working last time I was there. There is neither funding nor space for a steamer. Infrastructural and equipment improvements as well as staff education are essential for supporting the use of more fresh produce, more from-scratch cooking and other healthful changes.

Food Network is trying to make a difference too, working in close partnership with Share Our Strength. In addition to delivering educational television programming and information on the Web about fresh foods and healthy eating, Food Network and Share Our Strength are educating children and families on the importance of fruits and vegetables by establishing Good Food Gardens at inner-city schools and family centers across the country. Their Good Food Gardens program teaches children hands-on gardening experiences that inspire healthy eating habits for life – a key to ending childhood obesity and hunger. This year the two organizations will also develop new initiatives around nutrition education in daycares and healthy school lunches and breakfasts.

And while much attention is paid to school meals, recent research reveals that 27 percent percent of children’s calories actually come from snacks. To truly impact children’s behavior, schools need to take a 360-degree approach to health, extending healthy guidelines in all foods distributed there, including vending machines and daily snacks. Celebrations and fundraisers should not necessarily disallow cupcakes (please, homemade should be encouraged, not banned in favor of packaged chips). Rather these events are a perfect opportunity to set an example of balance, moderation and creative healthy cooking. Perhaps a rainbow-colored fresh fruit salad at the party, too? Or a morning mango smoothie bar as a fundraiser?

We have a tremendous opportunity to redefine school food and shape our children’s lives, and thus the future of our country, for the better. Let’s make sure we take a truly holistic approach, looking at all the steps and facilities necessary for implementing the changes and creating a consistent environment of balanced eating of real food throughout the school.

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BY LESLEY ALDERMAN

A primary goal of the health care overhaul was to provide insurance for more people, namely those who could not afford coverage and those with pre-existing conditions for whom insurance was too costly.

But the new law also aims eventually to improve health insurance for everyone. By now you have probably read or heard about big changes like the rules that will require insurers to cover everyone who applies, regardless of health status, and forbid them from dropping people when they get sick.

You may not yet be aware, though, of another notable improvement to insurance, a change that could save a consumer or family hundreds of dollars a year. Under the new law, insurers must offer preventive services — like immunizations, cancer screenings and checkups — to consumers as part of the insurance policy, at no additional out-of-pocket charge.

The idea is that healthy Americans will be less costly Americans.

“This is transformative,” says Helen Darling, president of the National Business Group on Health, a nonprofit organization for large employers. “We’re moving from an insurance model that was based on treating illness and injury, to a model that’s focused on improving an individual’s health and identifying risk factors.”

The trend toward offering free preventive care has been gaining steam for a decade among large companies that provide employee health benefits. “Employers recognize that if they want to control costs, they have to persuade their workers to be healthier, including their children,” Ms. Darling said.

Three out of four large companies now offer free preventive health services to their workers, according to a 2009 survey by Mercer, a benefits consulting firm. Smaller employers, though, and individual health plans have been less likely to offer free care of any type.

But under the new law, more generous “wellness” benefits should eventually be available to almost all Americans with insurance.

“Eventually” is the operable word, though. Although this feature of the law goes into effect at the end of September, it will apply to new insurance policies only. That means if you switch to a different policy, or buy a new one, the preventive services will be offered.

But if you are already in a plan, your benefits probably will not be upgraded until the plan makes a significant change, like modifying its cost structure. Simply signing up again during next fall’s annual enrollment for the same coverage you now have may not necessarily cause the new preventive-care requirement to begin. Until the Department of Health and Human Services actually writes the new regulations for this and many other parts of the law, though, no one can say for certain what will count as a event that sets the preventive care requirement in motion.

A clear exception is Medicare. Starting next year, all enrollees — even if they do not change insurance plans — will be entitled to a free annual checkup and free screenings, like colonoscopies and mammograms.

For people of all ages, many details of the new prevention benefits will remain sketchy until Health and Human Services writes the rules.

“Here, as with many other places in the legislation, much will depend on how H.H.S. writes the implementation regulations,” says Timothy S. Jost, a professor of law at Washington and Lee University School of Law and an expert on health reform.

Generally, though, here is how preventive services will be integrated into health insurance plans, beginning this fall.

NO OUT-OF-POCKET FEES New group and individual health plans must provide preventive health services at no additional charge to consumers — the services will not be subject to a co-payment or to a deductible.

BASED ON FEDERAL GUIDELINES The preventive services will include those that the United States Preventive Services Task Force, a panel of outside experts under the Health and Human Services Department, has given their top A or B rating, like screenings for H.I.V., depression, osteoporosis in postmenopausal women, as well as breast, colorectal and cervical cancer. Children will receive free screenings for conditions including iron deficiency, sickle cell diseases and hypothyroidism. A government Web site has a handy calculator that lets you enter a person’s age and gender to see what those screening recommendations would be. (We have also posted the task force’s entire list of recommendations with the online version of this column.)

In addition, immunizations recommended by the Centers for Disease Control and Prevention will be covered, including vaccines for Hepatitis A & B, tetanusdiphtheria, seasonal flu vaccines and human papilloma virus for girls 9 to 26 years old.

WHEN IT TAKES EFFECT The parts of the law governing preventive care go into effect on Sept. 23 (six months after it was signed by the president). At that point, new plans, and plans that make changes, must start to offer free preventive care. If you are covered by Medicare, the upgrades will go into effect on Jan. 1.

If these changes sound too far off, or you have resigned yourself to not seeing any benefit because you will not be changing insurance plans any time soon, take note: if you have group coverage, you may already be entitled to some free preventive benefits. Check what your plan offers, either by calling the toll-free customer service number on your membership card, looking at your insurer’s Web site, or reading the plan’s summary plan description booklet (free services are usually listed up front).

“Employees tend not to read their benefits information,” Ms. Darling said.

One of your best health habits should be to make good use of the services that will not cost you a cent.

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BY JESSIE MCKINLEY

Tuesday was a good day for vegetables — and San Franciscans who love them — as the city’s Board of Supervisors passed a nonbinding resolution declaring every Monday as “meat-free.” The resolution, sponsored by Supervisor Sophie Maxell, a vegetarian, urges restaurants, stores and schools to offer “plant-based options” every Monday to improve the general civic health. Ms. Maxwell tied the measure to the fight against global warning and said it would “encourage citizens to choose vegetarian foods as a way to protect the planet and their health.” The board also passed a nonbinding resolution commending businesses that use only cage-free eggs. Ms. Maxwell invited the entire board to her office “for a vegetarian treat.”

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BY ROBERT PEAR

WASHINGTON — Amid all the rancor leading up to passage of the new health care law, Congress with little fanfare approved a set of wide-ranging public initiatives to prevent disease and encourage healthy behavior.

The initiatives provide a big dose of prevention in an effort to counter the powerful forces that encourage people to engage in sedentary lifestyles, to smoke and to eat fatty, high-calorie foods.

The emphasis on disease prevention comes nine months after President Obama signed a law that gave sweeping authority to the Food and Drug Administration to regulate tobacco products. It reflects a sea change in federal health programs and policy, said Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee.

Republicans supported many of the health promotion initiatives and objected to a few, but had much bigger concerns about the overall law. The proposals largely escaped public notice as lawmakers fought over abortion, taxes and a government-run “public option.”

Under the law, chain restaurants will have to provide nutrition information on their menus. Employers must provide “reasonable break time” for nursing mothers.

Health insurance companies will soon have to cover all recommended screenings, preventive care and vaccines, without charging co-payments or deductibles.

Medicare beneficiaries will get free annual physicals. Medicaid will cover drugs and counseling to help pregnant women stop smoking. And a new federal trust fund will pay for more bicycle paths, playgrounds, sidewalks and hiking trails.

Those are some of the provisions Congress tucked into the legislation in an effort to reduce the huge toll of preventable diseases — regardless of whether the initiatives also save money for the government, as some lawmakers expect.

John R. Seffrin, chief executive of the American Cancer Society, said the new law would unquestionably save lives by increasing the number of people screened for colon cancer and breast cancer.

“When people have insurance,” Dr. Seffrin said, “they are much more likely to receive screenings and treatment. And they are more likely to seek screenings when they do not have to pay co-payments or deductibles.” As a result of such screenings, he added, cancers are more likely to be detected at an early stage, when they are treatable.

Under the law, insurers must provide coverage for all services recommended by an independent panel of experts, the United States Preventive Services Task Force, and cannot impose “any cost-sharing requirements.”

In addition, each Medicare beneficiary will be entitled to an “annual wellness visit,” in which a doctor can assess the patient’s condition, check for signs of Alzheimer’s disease and draw up a “personalized prevention plan” with a screening schedule for the next five or 10 years.

Senator Tom Harkin, Democrat of Iowa and chairman of the Senate health committee, said: “We don’t have a health care system in America. We have a sick care system. If you get sick, you get care. But precious little is spent to keep people healthy in the first place.”

Kathleen Sebelius, the secretary of health and human services, said the measures, taken together, had immense potential to “save lives and to save money.”

Under the health care law, chain restaurants with 20 or more locations will have to provide a calorie count for each standard menu item. The data must be displayed on the menu “in a clear and conspicuous manner.” Salad bars and buffets can satisfy the requirement by placing signs next to food items.

To customers who request more information, chain restaurants must provide brochures listing the amount of fat, cholesterol, sodium, carbohydrates and protein in menu items.

Margo G. Wootan, director of nutrition policy at the Center for Science in the Public Interest, a research and advocacy group, said consumers appeared to be choosing lower-calorie foods as a result of calorie-posting laws and regulations adopted in New York City and several other places. Equally important, she said, some restaurants have changed their menu offerings, shrinking portion sizes, reducing the fat in pastries or substituting low-fat milk for cream.

Cathy Nonas, director of physical activity and nutrition at the New York City Health Department, said consumers experienced “tremendous sticker shock” when they saw how many calories were in the food they were eating. “About 15 percent of people who come in to chain restaurants say the calorie information makes a difference in their purchasing decisions,” Ms. Nonas said.

The new law also allows employers to give stronger incentives to employees who participate in programs to lose weight, stop smoking or improve their health in other ways.

Employers can offer rewards equal to 30 percent of the cost of coverage — up from 20 percent under prior law — to employees who participate in such programs.

“This is exciting,” said Helen Darling, president of the National Business Group on Health, which represents 300 large employers. “It puts the emphasis on health improvement, not just paying for illness and injuries.”

Senator Jeff Merkley, Democrat of Oregon, championed the provision that requires employers with 50 or more employees to provide time for new mothers to express, or pump, breast milk.

Research shows that “children who are breastfed are less likely to be susceptible to a host of illnesses like asthma, diabetes and obesity,” Mr. Merkley said.

Many of the public health initiatives — but not all — had bipartisan support.

The law provides $5 billion over five years for a “prevention and public health fund,” which will provide money to state and local governments and community organizations.

Senator Harkin said the money could be used to create “healthier communities,” where people would have safe places to engage in physical activities.

But Republicans derided the money as pork barrel spending for jungle gyms.

Senator Tom Coburn, Republican of Oklahoma, said he agreed with parts of the law that would help prevent chronic diseases. But, he complained, the law also creates “a slush fund to build sidewalks, jungle gyms, farmers’ markets and other pork barrel projects.”

Supporters of the law said the emphasis on fitness, physical activity, improved nutrition and disease prevention would keep people out of hospitals and cut health costs.

But the Congressional Budget Office has reviewed the evidence and is skeptical of such claims.

“Expanded government support for preventive medical care would probably improve people’s health, but would not generally reduce total spending on health care,” said Douglas W. Elmendorf, director of the budget office. “The evidence suggests that for most preventive services, increased utilization leads to higher, not lower, medical spending.”

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BY SANDEEP JAUHAR

“I’m tired of paying for everyone else’s stupidity,” is a comment I read on the Internet last week after the health care bill was passed. It summed up the views of many Americans worried about shelling out higher premiums and taxes to cover the uninsured. Why should we pick up the tab when so much disease in our country stems from unhealthy behavior like smoking and overeating?

In fact, the majority of Americans say it is fair to ask people with unhealthy lifestyles to pay more for health insurance. We believe in the concept of personal responsibility. You hear it in doctors’ lounges and in coffee shops, among the white collar and blue collar alike. Even President Obama has said, “We’ve got to have the American people doing something about their own care.”

But personal responsibility is a complex notion, especially when it comes to health. Individual choices always take place within a broader, messy context. When people advocate the need for personal accountability, they presuppose more control over health and sickness than really exists.

Unhealthy habits are one factor in disease, but so are social status, income, family dynamics, education and genetics. Patient noncompliance with medical recommendations undoubtedly contributes to poor health, but it is as much a function of poor communication, medication costs and side effects, cultural barriers and inadequate resources as it is of willful disregard of a doctor’s advice.

A few years ago surgeons in Melbourne, Australia, were refusing to provide heart and lung surgeries to smokers, even those who needed the operations to stay alive. “Why should taxpayers pay for it?” said one surgeon quoted in media reports at the time. “It is consuming resources for someone who is contributing to their own demise.”

Though some were outraged by this stance — the Australian Medical Association called it “unconscionable” to ration services based on personal habits — many doctors agreed with it. Like the majority of Americans, they saw nothing wrong with patients paying for the consequences of their actions.

The problem is that punitive measures to force healthy behavior do not usually work. In 2006, West Virginia started rewarding Medicaid patients who signed a pledge to enroll in a wellness plan and to follow their doctors’ orders with special benefits, including unlimited prescription-drug coverage, programs to help them quit smoking and nutrition counseling. Those who did not sign up were enrolled in a more restrictive plan that, among other things, limited drug coverage to only four prescriptions a month.

The program, by many accounts, is failing. As of August 2009, only 15 percent of 160,000 eligible patients had signed up. Patients with limited transportation options were having a hard time committing to regular office visits. And experts say there is no evidence that restricting benefits for noncompliant patients has promoted healthy behaviors.

As a cardiology fellow, I once took care of a young man with severe congestive heart failure. We were supposed to start him on a blood thinner early in his hospitalization, but it got overlooked. Fed up with the delays in getting his blood sufficiently thinned, he left the hospital against medical advice. He said he had to go home to care for his toddler.

He came to the clinic a week later looking very embarrassed. He had left without prescriptions, so he had been taking no medications since he left, leaving him short of breath. To compound the problem, he had been eating cold cuts, cheap and readily available, which made his condition even worse. But the attending physician refused to give him prescriptions. She said that he had to go to a walk-in clinic. She said he had to learn personal responsibility.

Healthy living should be encouraged, but punishing patients who make poor health choices clearly oversimplifies a very complex issue. We should be focusing on public health campaigns: encouraging exercise, smoking cessation and so on. Of course, this will require a change in how we live, how we plan our communities.

“It’s the context of people’s lives that determines their health,” said a World Health Organization report on health disparities. “So blaming individuals for poor health or crediting them for good health is inappropriate.”

I must admit I often feel like my colleagues who grouse about spending all day treating patients who do not seem to care about their health and then demand a quick fix. I do not relish paying more taxes to treat patients who engage in unhealthy habits. But then I remind myself that we all engage in socially irresponsible behavior that others pay for. I try to eat right and get enough exercise. But then I also sometimes send text messages when I drive.

The whole point of insurance is to reduce risk. When people inveigh against the lack of personal responsibility in health care, they are really demanding a different model, one based on actual risk, not just on spreading costs evenly through society. Sick people, they are really saying, should pay more. Which model we eventually adopt in this country will say a lot about the kind of society we want to live in.

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