As a physician who had been in practice for many years, I remember the hardships suffered by many of my elderly patients prior to the initiation of Medicare in 1965. During that time, I was forced to sit painfully by as many unfortunate sufferers lamented that, even though they desperately needed to be hospitalized or needed expensive tests and additional services, they had only received small monthly social security payments with or without a small pension that barely kept them at a subsistence level. In short, that situation afforded not only insufficient medical care, but threatened their financial security during their so-called “golden years.” Then, in 1965, something abruptly and miraculously changed the landscape—the advent of Medicare. Suddenly our elderly could receive a standard level of medical care, which included, among others, diagnostic tests and hospitalizations. Simultaneously, the financial burden was lifted from both the patients and physicians, because we were no longer confronted with agonizing daily decisions about how we could provide decent medical care on a shoestring budget without threatening our patients’ health or survival.  Although Medicare is not an ideal solution, it has persisted for many years, and its success is supported by the huge numbers of senior citizens that cry out against any threats to this form of insurance that periodically arise in the political arena.

Now history seems to be repeating itself, for our focus has been sharpened by recent editorials written by two physicians, appearing in the well-respected New England Journal of Medicine (November 20, 2014). One of these, entitled “Civil Disobedience and Physicians—Protesting the Blockade of Medicaid,” was written by C. van der Horst, MD. In his communication, he stated that, with the anticipated passage of the Affordable Care Act, he would no longer need to worry about, among other issues, patients’ affording necessary medications, preventive care services and hospitalizations; moreover, “providing contraceptives free of charge would decrease the number of unwanted pregnancies that shackle teen mothers to unrelenting poverty.” He went on to quote reliable data that demonstrated that, up to the present date, 23 to 28 million Americans have gained access to health insurance through insurance exchanges, Medicaid expansions, and allowing children to remain on their parents policies until the age of 26, and no longer excluding those with pre-existing conditions. And these changes have resulted in a well-documented reduction of mortality.   But then his hopes were dashed by a law passed in North Carolina, his home State, blocking Medicaid expansion. In addition, many other states, including Indiana, have decided not to expand Medicaid, even though the federal government is bearing 100% of the costs for the first 3 years and never less than 90% thereafter. Those decisions have left 5 million Americans—most of them the working poor, with incomes below the federal poverty level—in the “Medicaid gap,” i.e. bereft of decent medical care. This is the same type of disadvantaged patients that I had seen so many years ago. Vigorously opposing the state’s decision not to expand Medicaid, Dr. van der Horst interestingly quoted his guiding philosophy taken from Moses Maimonides, the ancient Jewish physician and philosopher, who stated “The eternal providence has appointed me to watch over the life and health of Thy creatures and Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend.”

Thus, over the protests of health care workers, teachers, union workers, immigrants, environmentalists, and people of all races and religions, North Carolina has remained steadfast in this—arguably callous—opposition to such expansion of care.

By contrast, a second editorial in the same journal was written by Michael Stillman, MD, from the state of Kentucky, entitled “The Affordable Care Act, 1 Year Later.” Contrary to expectations and despite objections to the Affordable Care Act by both its senators, Kentucky approved Medicaid expansion and this, as stated by Dr Stillmen, “fundamentally altered our medical practice, allowing us to provide data-driven and thorough care without first considering our patients’ ability to pay.” The decision by Governor Steve Beshear allowed 650,000 Kentuckians to gain access to decent and comprehensive medical care. They had previously lacked health insurance, or at best, were receiving “disjointed and disastrous” care. Previously they could be seen only in subsidized facilities and be charged for visits on a sliding scale, but they were asked to pay in advance for most diagnostic tests and consultations. Many of them had avoided routine and preventive care—and worried that a medical emergency would leave them bankrupt. Not only did this legislation lighten the financial and emotional burden on the group, but it even provided better student physician education, for those doctors in training had previously been forced, against their better judgment, to offer and become accustomed to offering substandard and incomplete care. Now they could provide guideline and evidence-based care. While 23 states have thus far not expanded Medicaid eligibility, Kentucky has moved in the right direction, but Dr. Stillman points out that there remains a need for policy-makers and insurers to provide benefits that are both adequate and fair, which is not always the case. Perhaps he is lobbying for a single payer system?

This country will eventually—and inevitably—support decent medical care for all its constituents. Perhaps the process would be enhanced if our politicians were forced to spend time on the “front lines” of medical care in our clinics and hospitals and actually have dialog with those patients who are most vulnerable and under served.




For the past several years, we have known that the so-called “trans fats” are deleterious to health, but most people have little knowledge about these “little devils,” how they threaten us, and how we can avoid them. I am prompted now by a recent study that has shown that, in this country at least, consumption continues at an excessively high rate.

    The study to which I refer is entitled Trans fats still weighing Americans down, published by the American Heart Association, 10/28/14. The report began with “good news, bad news” that is, the amount of trans fats we eat has declined over the last 30 years, but we’re still consuming more than recommended. In a study of over 12,000 adults 25-74 years of age, the results showed the following:

  • Trans fat intake dropped by about one–third in men (32 percent) and women (35 percent).
  • Average intake of the good omega–3 fatty acids  (such as that derived from fish) was steady, but current intake was still very low.
  • Intake of saturated (bad) fats dropped, but still account for about 11.4 percent of daily calories for men and women. The American Heart Association recommends limiting saturated fat to 5–6 percent of total calories.

The study found that men consumed about 1.9 percent of their daily calories from trans fats and women about 1.7 percent. The American Heart Association recommends limiting trans fats to no more than 1 percent of total calories consumed, but ideally zero.

So let’s take a closer look at this problem and see what we can do about it.

Trans fat is considered by most of the medical profession to be the worst type of fat consumed. Unlike other dietary fats, trans fat — also called trans-fatty acids — both raises your LDL (“bad”) cholesterol and lowers your HDL (“good”) cholesterol, and that spells “double trouble,” because this combination poses a special risk of developing hardening of all the major arteries, increasing your risk of heart disease, which is the leading killer of both men and women. So here’s some information about trans fats and how to avoid them.

Most trans fats are formed through an industrial process that adds hydrogen to vegetable oil, causing the oil to become solid at room temperature. This manufactured form of trans fat bears the common name partially hydrogenated oil. This partially hydrogenated product is convenient to use in margarine spreads and less likely to spoil, allowing foods made with it have a longer shelf life. Some restaurants even use this product in their deep fryers, because it doesn’t have to be changed as often as do other oils. Although some meat and dairy products contain small amounts of naturally occurring trans fat, most of the latter are formed in this manufactured form, found in the products noted below::

  • Baked goods. Most cakes, cookies, pie crusts and crackers contain shortening, which is usually made from partially hydrogenated vegetable oil. Ready-made frosting is another source of trans fat.
  • Snacks. Potato, corn and tortilla chips often contain trans fat. And while popcorn can be a healthy snack, many types of packaged or microwave popcorn use trans fat to help cook or flavor the popcorn.
  • Fried food. Foods that require deep frying — french fries, doughnuts and fried chicken — can contain trans fat from the oil used in the cooking process.
  • Refrigerator dough. Products such as canned biscuits and cinnamon rolls often contain trans fat, as do frozen pizza crusts.
  • Creamer and margarine. Nondairy coffee creamer and stick margarines also may contain partially hydrogenated vegetable oils.

So we are inundated by these devils, and this requires much diligence to reduce our intake. The American Heart Association recommends maximum reduction of foods containing trans fats. Reading and understanding the food labels is critical, because, in the United States, if a food has less than 0.5 grams of trans fat in a serving, its label can read 0 grams trans fat. This hidden trans fat can add up quickly, especially if you eat several servings of multiple foods containing less than 0.5 grams a serving. Therefore, when you check the label for trans fat, also check the food’s ingredient list for partially hydrogenated vegetable oil — which indicates that the food contains some trans fat, even if the amount is below 0.5 grams. Even if a food is clearly free of trans fat, it is not automatically healthy. Food manufacturers have begun substituting other ingredients for trans fat. Some of these ingredients, such as tropical oils — coconut and palm oils — contain much saturated fat, which also raises your LDL cholesterol.

In a healthy diet, up to 25 to 35 percent of your total daily calories can come from fat — but saturated fat should account for less than 10 percent of your total daily calories. This usually involves preparing lean meats and poultry without added saturated and trans fats

Monounsaturated fat — found in olive, peanut and canola oils — is a healthier option than is saturated or trans fat (see my post of Aug 20, 2014). Nuts, fish and other foods containing unsaturated omega-3 fatty acids are other good choices of foods with monounsaturated fats.

After you study the labels carefully, adequate reduction of your trans fat intake will probably result in your cutting back all those snack food goodies that you desperately desire, even if you waistline doesn’t!

But limiting these fats requires more than individual effort, since we are still at the mercy of restaurants and other public food sources, and this generally requires legislative action. Until recently, retail food establishments were exempt from federal nutrition labeling requirements, so consumers had no consistent way of determining which restaurant foods contain high levels of artificial trans fat, and thus no practical means of avoiding them.  Interestingly, the much maligned Affordable Care Act, passed in 2010, is helping to change that situation.  This law includes a menu labeling law which requires retail food establishments to disclose calorie information on their menus, and to make other nutritional information, including trans fat content, available in written form to consumers upon request, and prior to purchase.  The Food & Drug Administration is in the process of finalizing the regulations to implement the law.

Additional efforts to eliminate artificial trans fat from foods have gained momentum. In 2012, the USDA issued final rules for the national school breakfast and lunch programs, which added a requirement that food products and ingredients used to make these meals contain less  than  .5 g added trans fat per serving. A number of states and localities also have considered legislative proposals to limit or eliminate artificial trans fat use in food service establishments. To date, trans fat bans have passed in roughly a dozen localities including New York City, and one state— California—has imposed a statewide ban on artificial trans fat in restaurants. Legislation banning the use of artificial trans fats in restaurants has gained currency across the United States. This battle, however, is far from over since legal challenges are likely to arise from near and far!

Currently, Indiana has neither passed nor proposed legislation addressing trans fats in restaurants. The only current legislation that even mentions trans fats is an Indiana Code that requires that at least 50 percent of food items sold in schools qualify as “better food choices” and, among other definitions, specifies that better food choices are those in which (A) Not more than thirty percent (30%) of their total calories are from fat. (B) Not more than ten percent (10%) of their total calories are from saturated and trans fat.  Despite public resistance to public health regulations, Indiana should take the bold leap and enact such a ban, possibly modeled after those of New York City or California, in order to improve the health and welfare of Indiana citizens. Removing trans fats is not the cure-all remedy to our health problems, but at least a starting point.