The Body Fat Setpoint, Part IV: Changing the Setpoint

Prevention is Easier than Cure

Experiments in animals have confirmed what common sense suggests: it's easier to prevent health problems than to reverse them. Still, many health conditions can be improved, and in some cases reversed, through lifestyle interventions. It's important to have realistic expectations and to be kind to oneself. Cultivating a drill sergeant mentality will not improve quality of life, and isn't likely to be sustainable.

Fat Loss: a New Approach

If there's one thing that's consistent in the medical literature, it's that telling people to eat fewer calories isn't a very effective fat loss strategy, despite the fact that it works if strictly adhered to. Many people who use this strategy see transient fat loss, followed by fat regain and a feeling of defeat. There's a simple reason for it: the body doesn't want to lose weight. It can be difficult to fight the fat mass setpoint, and the body will use every tool it has to maintain its preferred level of fat: hunger, increased interest in food, reduced body temperature, higher muscle efficiency (i.e., less energy is expended for the same movement), lethargy, lowered immune function, et cetera.

Therefore, what we need for sustainable fat loss is not starvation; we need a treatment that lowers the fat mass setpoint. There are several criteria that this treatment will have to meet to qualify:
  1. It must cause fat loss
  2. It must not involve deliberate calorie restriction
  3. It must maintain fat loss over a long period of time
  4. It must not be harmful to overall health
I also prefer strategies that make sense from the perspective of human evolution.

: Diet Pattern

One treatment that fits my criteria is low-carbohydrate dieting. Overweight people eating low-carbohydrate diets generally lose some fat and spontaneously reduce their calorie intake. In fact, in several diet studies, investigators compared an all-you-can-eat low-carbohydrate diet with a calorie-restricted low-fat diet. The low-carbohydrate dieters generally reduced their calorie intake and body fat to a similar or greater degree than the low-fat dieters, despite the fact that they ate all the calories they wanted (1). This may suggest that their fat mass setpoint had changed. At this point, I think moderate carbohydrate restriction may be preferable to strict carbohydrate restriction for some people, due to the increasing number of reports I've read of people doing poorly in the long run on extremely low-carbohydrate diets.  Furthermore, controlled trials of low-carb diets show that the long-term weight loss, despite being greater than low-fat diets, is not that impressive for the "average person".  Some people find it highly effective, while most people find it moderately effective or even ineffective.

Another strategy that appears preferable is the "paleolithic" diet. In Dr. Staffan Lindeberg's 2007 diet study, overweight volunteers with heart disease lost fat and reduced their calorie intake to a remarkable degree while eating a diet consistent with our hunter-gatherer heritage (3). This result is consistent with another diet trial of the paleolithic diet in diabetics (4). In post hoc analysis, Dr. Lindeberg's group showed that the reduction in weight was apparently independent of changes in carbohydrate intake*. This suggests that the paleolithic diet has health benefits that are independent of carbohydrate intake.

Strategies: Gastrointestinal Health

Since the gastrointestinal (GI) tract is so intimately involved in body fat metabolism and overall health (see the former post), the next strategy is to improve GI health. There are a number of ways to do this, but they all center around four things:
  1. Don't eat food that encourages the growth of harmful bacteria
  2. Eat food that encourages the growth of good bacteria
  3. Don't eat food that impairs gut barrier function
  4. Eat food that promotes gut barrier health
The first one is pretty easy in theory: avoid fermentable substances of which you're intolerant.  This can include lactose (milk) and certain polysaccharides, and a number of other FODMAPs.  For the second and fourth points, make sure to eat fermentable fiber. In one trial, oligofructose supplements led to sustained fat loss, without any other changes in diet (5). This is consistent with experiments in rodents showing improvements in gut bacteria profile, gut barrier health, glucose tolerance and body fat mass with oligofructose supplementation (6, 7, 8).  However, oligofructose is a FODMAP and therefore will be poorly tolerated by a subset of people.

The colon is packed with symbiotic bacteria, and is the site of most intestinal fermentation. The small intestine contains fewer bacteria, but gut barrier function there is critical as well. The small intestine is where the GI doctor will take a biopsy to look for celiac disease. Celiac disease is a degeneration of the small intestinal lining due to an autoimmune reaction caused by gluten (in wheat, barley and rye). This brings us to one of the most important elements of maintaining gut barrier health: avoiding food sensitivities. Gluten and casein (in dairy protein) are the two most common offenders. Gluten sensitivity is more common than most people realize; just under 1% of young adults and the prevalence increases with age.

Eating raw fermented foods such as sauerkraut, kimchi, yogurt and half-sour pickles also helps maintain the integrity of the upper GI tract. I doubt these have any effect on the colon, given the huge number of bacteria already present.

Strategies: Miscellaneous

Anecdotally, many people have had success using intermittent fasting (IF) for fat loss. There's some evidence in the scientific literature that IF and related approaches may be helpful (14). There are different approaches to IF, but a common and effective method is to do two complete 24-hour fasts per week. It's important to note that IF isn't about restricting calories, it's about resetting the fat mass setpoint. After a fast, allow yourself to eat quality food until you're no longer hungry.

Insufficient sleep has been strongly and repeatedly linked to obesity. Whether it's a cause or consequence of obesity I can't say for sure, but in any case it's important for health to sleep until you feel rested. If your sleep quality is poor due to psychological stress, meditating before bedtime may help. I find that meditation has a remarkable effect on my sleep quality. Due to the poor development of oral and nasal structures in industrial nations, many people do not breathe effectively and may suffer from conditions such as sleep apnea that reduce sleep quality. Overweight also contributes to these problems.

* Since reducing carbohydrate intake wasn't part of the intervention, this result is observational.

Rules - Do They Respect the Elderly?

I live in a building that is joined to a nursing home, but it is owned by a separate property owner. The building is nice and bright. It is also secure. For the most part, so is the nursing home.

However a disturbing trend seems to have been taking place over the last few years. Funding to the nursing home has been cut back and rules, set to make life easier for the employees, have been slowly creeping in. The thing is, I don't think they're stopping to think about what they are really saying. To me, it is not promoting an atmosphere of respect for the seniors who live in the home.

What does this have to do with accessibility you ask?

Well, in some ways it does not directly impact me. But in other ways it does. I say this because over the last several years cost savings measures has resulted in fewer answers to phone call enquiries, a requirement to self-serve more often, and a requirement for me, a wheelchair user, to free up time to meet the schedule of the supports I have to depend upon. In the last 3 or 4 years my life has become less and less of my own.

Gone are the social meeting places, gone is the sports club for the disabled, gone are the accessible taxis, and recently, gone are several Access Buses. The societal trend seems to be one of cutting funding to places where those who are least able to compensate for the loss of supports, are going to be the most impacted.

Our ability to enjoy all that Ontario has to offer, as per the Human Rights Act, and more recently, the AODA (Accessibility for Ontarian's With Disabilities Act), is actually less, not more.

To illustrate I took a picture of a sign that was posted in our elevator. It is one that seems to foster disrespect, rather than respect.

To be honest, I was so glad to see one of my neighbours write the letters UN in front of the word friendly. My gut reaction was to write, "do not feed the animals" because it reminded me of the signs you see in the zoo. Their toned-down method of getting the point across is a lot better.

For those using screen readers, the text has also been typed here.


Tower Residents may not
smoke in the Rideaucrest
smoking hut


Please do not give Rideaucrest
Residents matches and lighters.

Thank you.

Blackwall, Red Stone

At last I've been able to photograph one of my favourite London buildings. Countless times I have passed through this red sandstone portal, countless times I have said to myself "I really must get a shot of this". Last week I managed the task, albeit not the definitive photograph I'm looking for. But this is the southern entrance to the white glazed brick Blackwall Tunnel, the first of what became two tunnels taking vehicular traffic under the Thames. And now under The Dome, with a hugh hole in its roof that's one of the ventilation shafts. This is the 1897 Southern Tunnel House, designed by London County Council architect Thomas Blashill and perched on the north western tip of what is now euphemistically called the Greenwich Peninsular. I just love it, the pavilion roofs, the fanciful turrets. And the reminder it gives of the towers of Tower Bridge, completed just three years before. To stand here waiting for the sun (that never really came), is to feel like the proverbial fish out of water. It's only just possible to photograph it without the attendant huge control gantries, and to avoid being run over or splashed with pink mud by a continual succession of giant trucks sliding about ferrying material from supply depots, under the river to the Olympic site at Stratford.

Winter Rose

Winter Rose
Winter Rose

Parachutes & Corsets

Unmitigated England is full of buildings and bits of buildings that start life in one place and then wake up one morning in another, sometimes quite incongruous, location. Such is the fate of this bell tower that once looked out over the centre of Market Harborough from the top of the red brick six storey high Symington corset factory. Put up there in 1876, it housed a bell cast by the famous Taylor's in Loughborough. I'm not exactly sure when it was taken down and placed at the centre of flower beds in the town's Welland Park, but a plaque was put on it in 1977 to commemorate the Queen's Jubilee. Symington's were famous in the town for both corsets and soups, and examples of both trades can be found in the excellent museum that now resides in the cupola-less factory. But perhaps even more amazing is the fact that the Symington's of blush-inducing underwear went on to make over one million parachutes for the RAF in the Second World War. When I read this I have to confess that the thought did cross my mind as to whether they were shell pink with elasticated suspension. Only fleetingly of course.

Employment Supports - Not Helpful

Another lesson learned. This is meant as an education piece to illustrate the lack of understanding by the able-bodied.

I just discovered the ODSP employment supports worker, the one who was supposed to assist with job retention, has no understanding of barriers. As a result, her behaviour has led to the loss of my job.

Here is a summary of her actions:

In March, she joined me in a meeting with my employer about additional training opportunities. The employer wanted to train me separately from the other employees and I disagreed. My disability requires me to use a wheelchair but my level of comprehension is fully intact. The employment retention specialist agreed with the employer holding me back, so I was powerless to change anything.

In April the Access Bus went on strike for 60-days and when they came back, they had to take 6 buses off the road. My only way to get to and from work and arrive on time was to motor 1 hour to get there each day in my power chair.

In January the grocery store around the corner closed so, instead of it taking 30 minutes to buy groceries, it took 2.5 hours, because I had to factor in bus time.

In June, the department store that was also within wheeling distance closed. Now even more time had to be wasted on the bus.

In July the employer said they had to change the time of my shift because I was not trained on the new phone lines (the training that the employment retention specialist agreed my employer should train me on separately).

I panicked because I knew how inflexible my disability related services could be, so I emailed the employment specialist to ask for her help.

She obliged by calling a meeting with my employer and chose not to include me. I didn't even know the meeting took place until it was over. She wrote me to tell me she had the meeting and she would see me in 2 weeks to give me an update on what was discussed. In that email she assured me she was successful at negotiating a slightly better time for my shift.

The time she negotiated, of 10 am to 6 pm on Tuesday to Saturday, was not only impossible to accommodate with the bus, but according to the employer, it was one they never seriously agreed to offer.

Two days after the employment retention specialist met with my employer, the employer decided to call a meeting with me. In that meeting they said she was the specialist about my disability related supports, then insisted I had to accept the new shift time of 11:15 am to 7:15 pm. Since I had not been at the earlier meeting, I was powerless to say a word to counter the email report that was sent from the 'specialist'.

All I could do was, once again, try to describe the impact of the new community barriers to my employer and, when that failed, write a letter to the employment retention specialist to educate and hopefully get her support. Her response to my educational piece was to go to ODSP and, in an unprofessional manner, close my file. She then emailed me and told me I would have to start over again with ODSP; a process that can take several months.

And the upshot of all this? I broke down from the overabundance of stress and I eventually had to quit my job.

I don't know what else I can say except I wish I could get one able-bodied volunteer to take up the challenge of trying to live for a day in my shoes.

I would take away their car, the help of their spouse, kid, friend, or whoever, then tell them they would have to live with the bus as their only form of transportation. I would force them to get off the city bus every time a person with perfume got on, and I would deny them the opportunity to take a taxi or accept a ride with a friend (because a power wheelchair won't fit into a car), and then I would give them a list of items selected at random and tell them to go shopping when the stores are all closed.

I would also limit their choice of stores to the ones I can use. They would not be allowed to shop in a store that has steps or aisles that are too crowded for a wheelchair to pass through, because if it is not accessible, it is not a store I can shop in.

If they survive, I will pay them for lessons.

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Lunch Anyone? A Dilemma for Wheelchair Users

Today there was a Provincial Government Finance Committee Conference at the Four Points Sheraton Hotel, and an acquaintance of mine from Ottawa, was in town to give them a presentation. During the break for lunch, I offered to go out to buy a Take-Out lunch. We both have mobility challenges. I use a power wheelchair and she uses a walker, so it made sense for me to head out to buy the lunch instead of making her walk too far to look for a sit-down restaurant.

I went up and down Ontario Street, King Street, Wellington Street and the lower part of Princess Street looking for a place to buy a take-out lunch, but I couldn't get into any of them. They had a step, or several steps, and this made it impossible for me to enter them. I thought I might be able to get the attention of an employee inside Subway on Ontario Street because I've done this before, but today I was not so lucky. I sat outside and waved, but it was too cold to stick around to do that for very long. I quickly gave up and moved on.

I was starting to think the best solution would be to wheel to my home on Rideau St, make us some sandwiches, and take them back, but then I remembered the Bookends Cafe in the library. Thankfully they were accessible and I was able to buy our lunch. Better yet, I was able to give my business to an employer who hires people with disabilities.

I wonder what the tourists would do?

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Get your free CD with Get Ready materials now

Planning a health fair or Get Ready Day or just want to spread the word about being prepared to your community or co-workers? APHA’s Get Ready campaign has a handy tip: For a limited time, we’re offering free CDs containing Get Ready preparedness materials.

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This free offer won’t last long, so order your Get Ready CDs today!

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Midway Bob... For You Who are TALL

(Click on images to enlarge.)
Source: Modern Beauty Shop, January 1943

Maine Public Health Update 01/28/10

Maine CDC/DHHS Public Health Update
January 28, 2010

Keep ME Well
Governor Baldacci, in his State of the State Speech and in a January 27th press conference, launched the Keep ME Well initiative. This novel tool helps people to assess their health risks, to obtain a report that helps them take action and find local resources and support in their own communities, and to find low-cost health care services. This will be a very useful web site for health care providers and their patients. Check it out at

2010 District Health Indicator Tables are posted!
In 2008, Maine CDC published tables comparing major health indicators for each of the 8 public health districts, Maine, and the U.S. These tables have just been updated and include additional indicators such as some on preventable hospitalizations by district and cost data associated with them. District data that are significantly different than the state data are yellow highlighted. Both the 2008 and 2010 tables along with the data resources used can be found under “Health Indicator Comparison Tables” on the upper left hand side of our homepage ( or directly at We hope you find these tables useful.

Group A Strep
Maine CDC issued a health advisory last week to health care providers on an increase in the number and severity of invasive Group A Streptococcal (GAS) infections seen in January in Maine. Since then, additional cases have been identified, bringing the total thus far this month to ten, with an age range of 15 – 90 years-old. Four of these have resulted in Streptococcal Toxic Shock Syndrome (STSS), of which three have died. Although GAS is a common bacteria in the throat and skin, often causing strep throat or impetigo, invasive GAS disease is rare, with the five-year median in Maine being 19 cases per year. More information, including recommendations, can be found in last week’s health advisory at: or visit this US CDC web site:

Earthquakes and Public Health
There are many public health concerns as a result from earthquakes, including those related to victims of the disaster and those related to people traveling to post earthquake zones such as Haiti to assist in recovery efforts. The US CDC’s earthquake website has helpful information for those who may be involved with the Haiti relief efforts or who are interested in improving their preparations here at home.

Influenza Activity in Maine and the US
There were no new confirmed cases of H1N1 influenza reported in Maine last week. However, 10 people in Maine have been hospitalized due to H1N1 since the beginning of this month, including four children. Of those hospitalized, three required admission to an intensive care unit, including one child and one young adult. Only one of those hospitalized was fully vaccinated and only two had received early antiviral medicines, despite risk factors for severe disease. These hospitalizations are reminders of the importance of health care providers offering H1N1 flu vaccine to every patient at every encounter. Vaccination against influenza and early detection with prompt treatment are still very important, especially for those at risk for complications. We expect to see the pandemic form of H1N1 to circulate for months to come. We have not yet detected any seasonal influenza virus in samples submitted for testing this winter, and there have been no outbreaks of seasonal flu reported in other parts of the country. Vaccine can still be found in a number of public clinics, including many that are offering it for free. These can be located by calling 211 or by visiting The free clinics are in bold font.

H1N1 Vaccine Supply
There is now plenty of H1N1 vaccine in Maine, with over 900,000 doses of H1N1 vaccine available statewide since October to about 500 health care providers. The Maine CDC is able to process orders with about a 4-day business day turnaround between order and receipt of vaccine. More than half of the doses of vaccine distributed have not been reported as administered. Vaccine administrators are required to report doses administered weekly. The weekly vaccine reporting form can be found at: Detailed instructions are also available at:

Messages to the Public
• Many people are still susceptible to this virus and would benefit from vaccination. Being vaccinated not only protects you, but it helps protect the people around you who are more likely to suffer serious complications from the flu.
• To find a vaccine, call your health care provider, or get the list of public vaccine clinics by calling 211 from 8 a.m. to 8 p.m. or visiting (all clinics posted in bold are free).
• If you think you have the flu, cannot reach your doctor, and/or your health plan does not have a nurse call line available, you may call 2-1-1 from 8 a.m. to 8 p.m. to be connected with a health professional who can assess your symptoms.

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Where's That Then? No 9

A bit of rugged coastline this morning. I love chalk cliffs. Something to do with the vertiginous nature of them, and the fact that they have a propensity to suddenly collapse on to the beach below. These are particularly spectacular, but I don't think I'll be tempted to try and get into those yawning caves without a guide and a very hard hat. Anyway, I expect there's a story behind that bloke on the edge.

Right For Each Other

(Click on the images to enlarge.)
Source: 1000 Hints Beauty #7, 1956

The Body Fat Setpoint, Part III: Dietary Causes of Obesity

[2013 update: I've edited this post to remove elements that I feel were poorly supported.  I now think that changes in the setpoint are at least partially secondary to passive overconsumption of calories, particularly low quality calories]

What Caused the Setpoint to Change?

We have two criteria to narrow our search for the cause of modern fat gain:
  1. It has to be new to the human environment
  2. At some point, it has to cause leptin resistance or otherwise disturb the setpoint
Although I believe that exercise is part of a healthy lifestyle, and can help prevent fat gain and to some degree treat overweight, it probably can't explain the recent increase in fat mass in modern nations. This is because exercise doesn't appear to have declined. There are various other possible explanations, such as industrial pollutants, a lack of sleep and psychological stress, which may play a role. But I feel that diet is likely to be the primary cause. When you're drinking 20 oz Cokes, bisphenol-A contamination is the least of your worries.

In the last post, I described two mechanisms that may contribute to elevating the body fat set point by causing leptin resistance: inflammation in the hypothalamus, and impaired leptin transport into the brain due to elevated triglycerides. After more reading and discussing it with my mentor, I've decided that the triglyceride hypothesis is on shaky ground*. Nevertheless, it is consistent with certain observations:
  • Fibrate drugs that lower triglycerides can lower fat mass in rodents and humans
  • Low-carbohydrate diets are somewhat effective for fat loss and lower triglycerides
  • Fructose can cause leptin resistance in rodents and it elevates triglycerides (1)
  • Fish oil reduces triglycerides. Some but not all studies have shown that fish oil aids fat loss (2)
Inflammation in the hypothalamus, with accompanying resistance to leptin signaling, has been reported in a number of animal studies of diet-induced obesity. I feel it's likely to occur in humans as well, although the dietary causes are probably different for humans. The hypothalamus is the primary site where leptin acts to regulate fat mass (3). Importantly, preventing inflammation in the brain prevents leptin resistance and obesity in diet-induced obese mice (3.1). The hypothalamus is likely to be the most important site of action. Research is underway on this.

The Role of Digestive Health

What causes inflammation in the hypothalamus? One of the most interesting hypotheses is that increased intestinal permeability allows inflammatory substances to cross into the circulation from the gut, irritating a number of tissues including the hypothalamus.

Dr. Remy Burcelin and his group have spearheaded this research. They've shown that high-fat diets cause obesity in mice, and that they also increase the level of an inflammatory substance called lipopolysaccharide (LPS) in the blood. LPS is produced by gram-negative bacteria in the gut and is one of the main factors that activates the immune system during an infection. Antibiotics that kill gram-negative bacteria in the gut prevent the negative consequences of high-fat feeding in mice.

Burcelin's group showed that infusing LPS into mice on a low-fat chow diet causes them to become obese and insulin resistant just like high-fat fed mice (4). Furthermore, adding 10% of the soluble fiber oligofructose to the high-fat diet prevented the increase in intestinal permeability and also largely prevented the body fat gain and insulin resistance from high-fat feeding (5). Oligofructose is food for friendly gut bacteria and ends up being converted to butyrate and other short-chain fatty acids in the colon. This results in lower intestinal permeability to toxins such as LPS. This is particularly interesting because oligofructose supplements cause fat loss in humans (6).

A recent study showed that blood LPS levels are correlated with body fat, elevated cholesterol and triglycerides, and insulin resistance in humans (7). However, a separate study didn't come to the same conclusion (8). The discrepancy may be due to the fact that LPS isn't the only inflammatory substance to cross the gut lining-- other substances may also be involved. Anything in the blood that shouldn't be there is potentially inflammatory.

Overall, I think gut dysfunction could play a role in obesity and other modern metabolic problems.
Exiting the Niche

I believe that we have strayed too far from our species' ecological niche, and our health is suffering. One manifestation of that is body fat gain. Many factors probably contribute, but I believe that diet is the most important. A diet heavy in nutrient-poor refined carbohydrates and industrial omega-6 oils, high in gut irritating substances such as gluten and sugar, and a lack of direct sunlight, have caused us to lose the robust digestion and good micronutrient status that characterized our distant ancestors. I believe that one consequence has been the dysregulation of the system that maintains the fat mass "setpoint". This has resulted in an increase in body fat in 20th century affluent nations, and other cultures eating our industrial food products.

In the next post, I'll discuss my thoughts on how to reset the body fat setpoint.

The ratio of leptin in the serum to leptin in the brain is diminished in obesity, but given that serum leptin is very high in the obese, the absolute level of leptin in the brain is typically not lower than a lean person. Leptin is transported into the brain by a transport mechanism that saturates when serum leptin is not that much higher than the normal level for a lean person. Therefore, the fact that the ratio of serum to brain leptin is higher in the obese does not necessarily reflect a defect in transport, but rather the fact that the mechanism that transports leptin is already at full capacity.

Winter Tale

Get Ready Mailbag: Do I need a flu shot if I have had H1N1?

Welcome to another installment of the Get Ready Mailbag, when we take time to answer questions sent our way by readers like you. Have a question you want answered? Send an e-mail to

I think I already had H1N1 flu, aka swine flu. Should I still get the vaccine? How do I know for sure that I’ve had H1N1?

Unless you know 100 percent for sure that you had H1N1 flu — by way of a lab-confirmed test — you should still get vaccinated, according to federal flu experts. Most people who have had flu-like illnesses since March 2009 (when H1N1 was first recognized) don’t know for sure that it was the flu, or whether it was H1N1.

If you absolutely positively want to know whether you’ve had H1N1 or any other specific flu strain, you’d need a special test, called the "RT-PCR" to confirm it. Such tests are often used in clinical settings such as hospitals to help health workers decide how to treat really sick patients. However, they aren’t generally recommended for people who’ve had regular flu symptoms and don’t need special care, so your doctor will probably tell you that you don’t need the test.

And even if it does turn out that you’ve had H1N1 — and possibly developed full or partial immunity to the virus — getting the vaccination won’t harm you. Talk to your doctor about whether you should get the vaccination, as certain people are at higher risk of getting sick from H1N1. The bottom line? It’s always better to be safe than sorry.

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Winter Cold

Winter Fairy Tale

Winter Fairy Tale

Weekly update on H1N1 in Maine 1/21/10

Maine CDC/DHHS Public Health Update
January 21, 2010

Flu Activity in Maine and the US
We continue to see H1N1 circulate in Maine, though at declining levels from a month ago. This last week there were two new hospitalizations, one of whom required intensive care. Since the beginning of January, 10 Mainers have been hospitalized for H1N1, including four children. Of those hospitalized, three required admission to an intensive care unit, including one child and one young adult. We are finding an increasing number of hospitalized patients who have neither been vaccinated nor received early treatment with antiviral medicines. Vaccination against influenza and early detection of infection with prompt treatment are still important, especially for people at risk of complications. These cases are also a reminder that we expect to see the pandemic form of H1N1 influenza virus to continue to circulate for months to come, so it is important to keep H1N1 in the differential for people presenting with symptoms.

We have not yet detected any seasonal influenza virus in samples submitted for testing this winter, and there have been no reported outbreaks of seasonal influenza in other parts of the country as well.

H1N1 Vaccine Supply
There is now plenty of vaccine in Maine, with about 800,000 doses of H1N1 vaccine distributed statewide since October. Maine CDC is now processing orders for H1N1 vaccine the same day the request comes in from a health care provider, with about a four-day turnaround between order and receipt of vaccine.

About 500 health care providers in the state have received H1N1 vaccine. We strongly urge health care providers to offer the H1N1 flu vaccine to every patient at every encounter.

Public clinics can be located by calling 211 or visiting There are many clinics that are offering free vaccine, identified by the bold font on the website.

December 2009 National Survey of H1N1 and Seasonal Flu Vaccine Coverage
US CDC has released data from a national survey conducted through much of December on H1N1 and seasonal flu vaccine coverage. Maine stood out as having an H1N1 vaccine rate among children that is more than twice the national average – 60% versus 28%. Although we do not know our formal ranking, we know only 4 states had pediatric coverage rates of over 40%.

Maine also had higher rates of H1N1 vaccine in health care personnel working with high-risk patients (46% vs. 27% nationally) and of seasonal flu vaccine coverage among children (52% vs. 34% nationally).

Additional information on vaccine coverage can be found in this MMWR:

Main Messages to the Public
Many people are still susceptible to this virus and would benefit from vaccination. Being vaccinated not only protects you, but it helps protect the people around you who are more likely to suffer serious complications from the flu.
To find a vaccine, call your health care provider, or get the list of public vaccine clinics by calling 211 from 8 a.m. to 8 p.m. or visiting (all clinics posted in bold are free).
If you think you have the flu, cannot reach your doctor, and/or your health plan does not have a nurse call line available, you may call 2-1-1 from 8 a.m. to 8 p.m. to be connected with a health professional who can assess your symptoms.

To view the full update:

Chocolate Epilogue

So, farewell then Cadbury's as we knew it. Or as we like to remember it, as I went on about here last November. It's a great shame, to see something so decidedly English become just another name in Kraft's brand fortfolio. (They come over here, chat up our girls and eat our chocolate.) But the writing was very clearly marked on the wrapper. You've only got to look at what happened to good old Rowntrees, snaffled up by Nestles. Smarties were sent off to Germany, with the loss of 646 jobs, but they did build a new factory in York, saying the old Haxby Road factory was difficult to make chocolate in because of keeping the temperature consistent. Funny how Rowntrees managed to do it for over a 100 years without it melting. Of course that's not the point. It's only about the consistency of making money, not chocolate. But I still eat an Aero every other day; they're still made in York and I couldn't tell you it tastes any different. Although I heard a rumour that the current Terry's Chocolate Orange, another Krafty deal that moved production out of York to Slovenia or somewhere, now tastes more like Bert's Chocolate Mothball. It might still be alright down at blossom-filled Bournville, but I doubt it. Whatever their bleating protestations last November, Cadbury's were always going to sell to the highest bidder whatever, even if it was to a producer of tasteless processed cheese.

Sweet January

Save Time Without Sacrificing the Quality of Your Permanents

(Click on the images to read the text.)
American Hairdresser, November 1942

Krauss's New Article on Saturated Fat Intervention Trials

Dr. Ronald Krauss's group just published another article in the American Journal of Clinical Nutrition, this time on the intervention trials examining the effectiveness of reducing saturated fat and/or replacing it with other nutrients, particularly carbohydrate or polyunsaturated seed oils. I don't agree with everything in this article. For example, they cite the Finnish Mental Hospital trial. They openly acknowledge some contradictory data, although they left out the Sydney diet-heart study and the Rose et al. corn oil study, both of which suggested increased mortality from replacing animal fats with polyunsaturated seed oils. Nevertheless, here is the conclusion:
Particularly given the differential effects of dietary saturated fats and carbohydrates on concentrations of larger and smaller LDL particles, respectively, dietary efforts to improve the increasing burden of CVD risk associated with atherogenic dyslipidemia should primarily emphasize the limitation of refined carbohydrate intakes and a reduction in excess adiposity.

Dr. Martin Luther King, Jr. and Health Care

Below is a wonderful tribute to Dr. Martin Luther King, Jr., written 10 years ago by the then head of US DHHS' AHRQ. About a year after this was published, Dr. John Eisenberg was diagnosed with an aggressive brain cancer, and died in 2002. I think this piece is a wonderful tribute to both men we were so fortunate to have on this planet, though for too short a time. Dora

Birthday Observance of Dr. Martin Luther King, Jr.
Remember! Celebrate! Act! A Day On, Not a Day Off!
John M. Eisenberg, MD, Director, Agency for Healthcare Research and Quality, January 14, 2000


When I was invited to welcome you to the Department of Health and Human Service's 26th observance of Martin Luther King, Jr.'s birthday, my first thought was about how honored I was to be asked. My second thought was about what Martin Luther King's birth could mean to a rebirth of health care in this country. Few have had as much impact upon the American consciousness.

But what did Martin Luther King, Jr. think about health care?

My colleagues and I searched through his writings and his speeches, and realized that he didn't give speeches about health care. Martin Luther King, Jr. was confronting the basic nature of American society. He had mountains to move—and mountaintops to climb—for this country so that today we can address the issues of high quality health care for all Americans.

If Dr. King were alive today he'd be 71 years old. He'd be eligible for Medicare. Like many 71-year-olds, he might be dealing with a chronic medical condition—maybe arthritis, or hypertension, or diabetes. What would he think of the health care system we have today? What would he think of the medical care he might receive? And what advice would he be giving the Department of Health and Human Services?

No, Dr. King didn't give many speeches about health care. But like the rest of society, health care had to change too.

When I was a teenager in Memphis, before the Medicare program was passed, the Baptist Hospital was the biggest in town, and the proudest of the care it gave. But if you were African-American in Memphis and you went to the Baptist Hospital, you'd go in through a back entrance. And you'd go to a segregated ward, where you would be in a big room with about 15 or 20 other people. And your doctor, if he was black, would not have privileges on staff. And the same would have been true for Dr. King in Montgomery or in Atlanta.

Dr. Vanessa Gamble, who is the new director of minority affairs at the Association of American Medical Colleges here in Washington, has documented the incredibly important role that Medicare and Medicaid played in helping to desegregate hospitals. Medicare was a lever that lifted equity and equality in hospitals. In 1965, our Department issued regulations mandating that hospitals had to be in compliance with Civil Rights Act—which had been passed just the year before—in order to be eligible for Federal assistance or to participate in any federally assisted program. The passage of Medicare and Medicaid legislation that year made every hospital a potential recipient of federal funds, and therefore obligated every hospital to comply with civil rights legislation if they wanted to get paid.

The law changed, but practice was slower.

When I was a medical student in St. Louis, at Barnes Hospital around 1970, researchers asked why the hospital still seemed to be segregated. Why? Because clerks in the admissions office—both black and white—were so accustomed to the old ways that they continued to admit the races to their old units. The law had changed, but racial stereotypes had remained. Racist practices were illegal, but racism was institutionalized, and the seeds of racism grew into practices that amounted to discrimination.

I ask you, is it any different today, 31 years after Dr. King was shot in my hometown, and we grieved over the loss of a great American? Is it different 31 years after I was ashamed of the symbol that my hometown had become, when all that Dr. King wanted was to put into practice the placards that the Memphis sanitation workers wore, that read, "I am a man"?

Today, research shows that African-Americans are one-third less likely to have coronary bypass surgery than whites with the same conditions. Why? And today, African-Americans with HIV are less likely to receive antiviral treatment. Why do these disparities occur?

The easy answer is that it is because African-Americans are more often uninsured. And that is true. But even with the same insurance, African-Americans don't have the same access to primary care doctors, specialists and hospitals. And most distressing, even with the same insurance and being cared for at the same hospitals, African-Americans get different care. In one study I did, if you were a black woman you were much less likely to get referred for cardiac catheterization.

The reason—I fear—is that, despite Dr. King's advances, and despite civil rights laws, and despite Medicare, racism is a part of the institution of American life, and the seeds of racism still grow into discriminatory practices.

So, now 31 years after Dr. King's death and 35 years after Medicare broke down segregated wards in the nation's hospitals, the question for us is: What can we do today in our Department to eliminate these disparities, whether they grow out of lack of insurance, lack of access, or lack of quality care for those who get access?

No matter where we work in this Department—

At the Health Care Financing Administration, where care is funded.

At the Health Resources and Services Administration, where programs are supported to help access.

At the Food and Drug Administration, where safe drugs are assured.

At the National Institutes of Health, where research can identify the causes of disease.

At the Agency for Healthcare Research and Quality, where we find out why the quality of care isn't what it can be, and where our name itself speaks of an arc, of closing gaps.

In every operating and staff division—

We can use the levers that we are so lucky to have, and so privileged to use, to eliminate the barriers to high quality health care.

Because we shall overcome.

We shall overcome the disparities in health care, whether they are due to economic barriers, or institutionalized racism, or even unconscious discrimination. We—as public servants—can build on Dr. King's contribution to the moral health of our country to make our own contributions to the physical and mental health of all of its people.

Let's make that commitment today.

Current as of January 2000


Internet Citation:

Birthday Observance of Dr. Martin Luther King, Jr.: Remember! Celebrate! Act! A Day On, Not a Day Off! Opening Remarks by John M. Eisenberg, M.D., Director, Agency for Healthcare Research and Quality, January 14, 2000. Agency for Healthcare Research and Quality, Rockville, MD.


Haiti Earthquake

This US CDC website is very useful for earthquake preparedness. Believe it or not, we have them in Maine on occasion, and certainly many Mainers frequently travel to zones of higher earthquake activity. It also has good information for those who may be traveling to Haiti to assist in the recovery efforts there, including which vaccines to obtain and what other health issues to be concerned about.

Where's That Then? No 8

A fairly easy one this week, I should think. Another classic English view, but I'll give a slight hint. That building on the right with the big blank gable end is a pub. And in many Britain In Colour-style photographs it sports the name and slogan of a particularly good local brewer. So a fried egg on your bacon sandwich this morning if you can get that too. And black pepper on it all if you can give the nickname of the church tower.

The Body Fat Setpoint, Part II: Mechanisms of Fat Gain

The Timeline of Fat Gain

Modern humans are unusual mammals in that fat mass varies greatly between individuals. Some animals carry a large amount of fat for a specific purpose, such as hibernation or migration. But all individuals of the same sex and social position will carry approximately the same amount of fat at any given time of year. Likewise, in hunter-gatherer societies worldwide, there isn't much variation in body weight-- nearly everyone is lean. Not necessarily lean like Usain Bolt, but not overweight.

Although overweight and obesity occurred forty years ago in the U.S. and U.K., they were much less common than today, particularly in children. Here are data from the U.S. Centers for Disease Control NHANES surveys (from this post):

Together, this shows that a) leanness is the most natural condition for the human body, and b) something about our changing environment, not our genes, has caused our body fat to grow.

Fat Mass is Regulated by a Feedback Circuit Between Fat Tissue and the Brain

In the last post, I described how the body regulates fat mass, attempting to keep it within a narrow window or "setpoint". Body fat produces a hormone called leptin, which signals to the brain and other organs to decrease appetite, increase the metabolic rate and increase physical activity. More fat means more leptin, which then causes the extra fat to be burned. The little glitch is that some people become resistant to leptin, so that their brain doesn't hear the fat tissue screaming that it's already full. Leptin resistance nearly always accompanies obesity, because it's a precondition of significant fat gain. If a person weren't leptin resistant, he wouldn't have the ability to gain more than a few pounds of fat without heroic overeating (which is very very unpleasant when your brain is telling you to stop). Animal models of leptin resistance develop something that resembles human metabolic syndrome (abdominal obesity, blood lipid abnormalities, insulin resistance, high blood pressure).

The Role of the Hypothalamus

The hypothalamus is on the underside of the brain connected to the pituitary gland. It's the main site of leptin action in the brain, and it controls the majority of leptin's effects on appetite, energy expenditure and insulin sensitivity. Most of the known gene variations that are associated with overweight in humans influence the function of the hypothalamus in some way (1). Not surprisingly, leptin resistance in the hypothalamus has been proposed as a cause of obesity. It's been shown in rats and mice that hypothalamic leptin resistance occurs in diet-induced obesity, and it's almost certainly the case in humans as well. What's causing leptin resistance in the hypothalamus?

There are three leading explanations at this point that are not mutually exclusive. One is cellular stress in the endoplasmic reticulum, a structure inside the cell that's used for protein synthesis and folding. I've read the most recent paper on this in detail, and I found it unconvincing (2). I'm open to the idea, but it needs more rigorous support.

A second explanation is inflammation in the hypothalamus. Inflammation inhibits leptin and insulin signaling in a variety of cell types. At least two studies have shown that diet-induced obesity in rodents leads to inflammation in the hypothalamus (3, 4)*. [2013 update: several studies have shown that preventing hypothalamic inflammation attenuates fat gain in obesity models].  If leptin is getting to the hypothalamus, but the hypothalamus is insensitive to it, it will require more leptin to get the same signal, and fat mass will creep up until it reaches a higher setpoint.

The other possibility is that leptin simply isn't reaching the hypothalamus. The brain is a unique organ. It's enclosed by the blood-brain barrier (BBB), which greatly restricts what can enter and leave it. Both insulin and leptin are actively transported across the BBB. It's been known for a decade that obesity in rodents is associated with a lower rate of leptin transport across the BBB (5, 6).

What causes a decrease in leptin transport across the BBB? Triglycerides are a major factor. These are circulating fats going from the liver and the digestive tract to other tissues. They're one of the blood lipid measurements the doctor makes when he draws your blood. Several studies in rodents have shown that high triglycerides cause a reduction in leptin transport across the BBB, and reducing triglycerides allows greater leptin transport and fat loss (7, 8). In support of this theory, the triglyceride-reducing drug gemfibrozil also causes weight loss in humans (9)**. Low-carbohydrate diets, and avoiding sugar and refined carbohydrates in particular, reduce triglycerides and produce weight loss, although that doesn't necessarily mean one causes the other.

In the next post, I'll get more specific about what factors could be causing hypothalamic inflammation and/or reduced leptin transport across the BBB. I'll also discuss some ideas on how to reduce leptin resistance sustainably through diet and exercise.

* This is accomplished by feeding them sad little pellets that look like raw cookie dough. They're made up mostly of lard, soybean oil, casein, maltodextrin or cornstarch, sugar, vitamins and minerals (this is a link to the the most commonly used diet for inducing obesity in rodents). Food doesn't get any more refined than this stuff, and adding just about anything to it, from fiber to fruit extracts, makes it less damaging.

** Fibrates are PPAR agonists, so the weight loss could also be due to something besides the reduction in triglycerides.

The "Crazy, Mixed-up Skin"

"Nearly every teen-ager faces the embarrassment of acne at some stage of growth. New discoveries are speeding skin health."

(Click on the images to enlarge.)
Source: 1000 Hints Beauty #7, 1956

Ancient plagues share similarities with H1N1, other modern diseases

The emergence of the new H1N1 influenza virus last year grabbed the attention of health authorities and many of the world’s people. This never-before-seen disease spread quickly across the globe, causing illness and death and triggering a major public health response. But while the virus itself is new and unique, some researchers say it is just the latest in a long line of infectious diseases that share common ancestry in the way that they spread.

Infectious diseases are responsible for more than a quarter of deaths annually in the world. Dating back to the earliest days, viruses have had a huge toll on human health. Yellow fever, for instance, claimed 3.5 million lives, and the plague, ominously referred to as the Black Death, killed 50 million people across Europe and Asia in the 14th century,.

Disease experts and medical historians have traced outbreaks of disease through history. In a study last year, (PDF) researchers found similarities in what caused their spread.

The most significant cause found was the movement of humans. For example, disease spread along trade routes. As more and more trade routes popped up, more and more groups of people became connected, enabling disease to spread farther faster. (Just think about the impact of modern air travel.) Poverty and social inequality, and war and famine have similarly affected patterns of movement and the sharing of viruses.

Another common contributor to disease spread was the emergence of new technology and industries. The re-emergence of dengue fever, for instance, was sped in part by the preference of the disease-carrying mosquito to lay its eggs in discarded tires and metal cans.

As our world becomes more complex, opportunities for diseases to emerge are greater. New threats like H1N1 will continue to arise, and infectious disease, as it has throughout recorded history, will remain a challenge to human survival. Lessons learned from both ancient and modern plagues can help us better understand how diseases spread and reduce their impact in the future.

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That London

I haven't been down in that London for oh, nearly a year. How I've missed it. I'm a country boy at heart I suppose, but the Big City always draws me in and I have fond memories of my three year sojourn in Bedford Park. The early doors sessions around District Line pubs, the playing football in my flat at two in the morning to Led Zeppelin (the neighbours waved me goodbye with alacrity) and yelling hello to Richard Briers and his dog every morning as I ran to the Underground. Yesterday, as I sat in traffic, red stop lights reflecting on the rainy streets, it all came back. The art nouveau Blackfriars pub, The Seven Stars in Carey Street, the Inner Temple, black cabs, girls scurrying with umbrellas and the wondering if I had time for a quick Sercial in Gordon's or a slow Harvey's in The Ship & Shovel. I didn't, but as I moved up below the pigeon haunted turrets of the Holloway Road I realised I hadn't photographed anything. As the traffic came to a halt I snapped this without getting out of the car. I know, I could be anywhere, but I wasn't. I love stuff spilling out of shops onto the pavement, and this was very North London. Except for the Gourock Ferry sign in the window, which brought back the memory of sharing the journey over the Clyde to Dunoon in the 1960s with my family and an occupied coffin, put down on the deck in front of my brother's Ford Anglia. I rang the shop up about the sign. It's £85, but this is that London.

Weekly update on H1N1 in Maine 1/14/10

Flu Activity in Maine and the US
We continue to see H1N1 in Maine, including three new hospitalizations this week – one in a child younger than 5, another child younger than 18, and an adult in the 50-64 age range. There was also an outbreak of H1N1 at a long term care facility. Although H1N1 flu activity has decreased in Maine in recent weeks, there have been increases in H1N1 illness in other areas of the U.S.

Many people are still susceptible to this virus and would benefit from vaccination. Being vaccinated not only protects you, but it helps protect the people around you who are more likely to suffer serious complications from the flu.

Flu is unpredictable, but it often comes in waves. There was a mild surge in the spring of 1957, followed by a large surge in the fall, another large one in the winter of 1958, and others following that with the virus circulating for several years. All pandemics are different, but most have multiple waves of illness and death.

H1N1 Vaccine Supply
There is now plenty of vaccine in Maine, so it’s an excellent time for people who have not been vaccinated against H1N1 and seasonal flu to do so before the next wave of disease. Nearly 800,000 doses of H1N1 vaccine have been distributed statewide since October. Close to 500 health care providers in the state have received H1N1 vaccine. Call your health care provider, or get the list of public vaccine clinics by calling 211 from 8 a.m. to 8 p.m. or visiting (all clinics posted in bold are free).

Maine CDC recommends that health care providers offer H1N1 vaccine to every patient at every visit, every hospitalization, or other health care encounter, assuming contraindications do not exist.

Treatment Recommendations
Maine CDC issued a health alert on Jan. 11 to reinforce recommendations for early treatment of patients with increased risk of complications from influenza. Early treatment for influenza may prevent secondary bacterial infections. This alert can be viewed here:

If you think you have the flu, cannot reach your doctor, and your health plan does not have a nurse call line available, you may call 2-1-1 from 8 a.m. to 8 p.m. to be connected with a health professional who can assess your symptoms.

Information for People with Chronic Underlying Health Conditions
Pneumonia, bronchitis, acute respiratory distress syndrome, sinus infections and ear infections are examples of flu-related complications. The flu can also make chronic health problems worse. H1N1 has caused more deaths among adults with chronic medical conditions than in any other group. All 18 H1N1-related deaths in Maine have been in adults with chronic underlying conditions.

If you have a high-risk condition, getting vaccinated is the single best action you can take to protect yourself from the flu. Still, most adults with high-risk conditions have not been vaccinated yet. Many people in these groups do not realize that their medical conditions increase their risk. The following conditions put people are risk for flu-related complications:
· asthma;
· heart disease
· chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis);
· diabetes and other endocrine disorders;
· neurological or neurodevelopmental disorders, and especially those that affect lung capacity (muscular dystrophy, cerebral palsy, strokes, etc);
· blood disorders, such as sickle cell disease;
· kidney and liver disorders;
· weakened immune system due to disease or medication, such HIV/AIDS, cancer, or steroids;
· long-term aspirin therapy in people younger than 19.

If you have a chronic health condition and have not yet received your vaccine against H1N1, get one now. Contact your health care provider, specialist, call 2-1-1 from 8 a.m. to 8 p.m. for a list of public clinics, or check (clinics listed in bold are free).

If you have an underlying health condition and experience flu-like symptoms, contact your health care provider immediately to receive a prescription for antiviral medications (such as Tamiflu®).

To read the full update:

New Saturated Fat Review Article by Dr. Ronald Krauss

Dr. Ronald Krauss's group has published a review article titled "Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease". As anyone who's familiar with the literature could have predicted (including myself), they found no association whatsoever between saturated fat intake and heart disease or stroke:
A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.

People with chronic health conditions should be vaccinated against the flu

It’s National Influenza Vaccination Week, and although H1N1 flu activity has decreased in recent weeks, people in Maine and across the country are still being hospitalized and dying from influenza.

All 18 deaths due to H1N1 flu in Maine since August have been among people with underlying health conditions. If you have a high-risk condition, getting vaccinated is the single best action you can take to protect yourself from the flu.

Flu is unpredictable, but it often comes in waves. Now is an excellent time for people who have not been vaccinated against H1N1 and seasonal flu to do so before the next wave of disease. Vaccine is widely available in Maine now. Call your health care provider, or get the list of public clinics by calling 211 from 8 a.m. to 8 p.m. or visiting (all clinics posted in bold are free).

If you have an underlying health condition and experience flu-like symptoms, contact your health care provider immediately to receive a prescription for antiviral medications (such as Tamiflu®).

A schedule of events for National Influenza Vaccination Week is available on US CDC’s web site at:

Where's That Then? No 7

One of the things I like about Karl Gullers' photographs are the viewpoints. There somehow appears to be a spot welded to the ground in various locations in England where photographers must stand with their cameras, obligatory points of view. You can always see why- Durham Cathedral looks far more spectacular across the River Wear than it does across a car park, Lower Slaughter in the Cotswolds just has to have the white painted footbridge in the foreground and we never see Anne Hathaway's cottage from the back. I always feel obliged to take the standard shot myself, just one to add to the collective national album, as it were. Being from the Land of The Volvo, none of this seems to have permeated through into Mr.Gullers' consciousness, and as a result we've witnessed some great pictures in this series. He must be the only photographer who's resisted shooting Clovelly through the conveniently placed archway. Talking of Sweden, I have to say I'm thoroughly enjoying Wallander on a Sunday night. Kenneth Branagh's eponymous detective with his spooky mobile ringtone, the locations, the brilliant but understated photography, all comes together to make very watchable television, for once. All this and Sarah Smart. Sorry, I've been distracted. I don't suppose this week's picture will take too long, particularly in some corners of Unmitigated England.

Puzzle Corner

This is Uppingham churchyard. Or to be more precise the Victorian extension. Which made me wonder about this little gazebo tucked away in one corner. I've come across little shelters put up in the age of bodysnatchers for those protecting the newly-buried from the Resurrection Men, but this is from a calmer age and would appear to be for another purpose. There's no door on it, so that rules out a store for sexton's tools, and it's a little cramped and sepulchrally dark for more than one person to take cover from a shower. Or snowstorm. Perhaps it's more likely to be a shelter for the parson waiting for a funeral party, but whatever the reason I've just noticed that it's another one for the collection of buildings with faces. A yawning one at that- 'so tired, tired of waiting'.

Paleo is Going Mainstream

There was an article on the modern "Paleolithic" lifestyle in the New York Times today. I thought it was a pretty fair treatment of the subject, although it did paint it as more macho and carnivorous than it needs to be. It features three attractive NY cave people. It appeared in the styles section here. Paleo is going mainstream. I expect media health authorities to start getting defensive about it any minute now.

[2013 update.  Did I call it or what??]


Winter Time
Winter Time

Exercise is a Ball

If you love dancing you'll enjoy exhilarating exercises which can make you lovelier.

For those of you with a new years resolution to lose weight, you can try some old-fashioned exercises

(Click on the images to enlarge.)
Source: 1000 Hints Beauty #7, 1956