Tips from gaining health

NOTE #2: Wanna help out a good cause? Yay! The Minneapolis Heart Institute Foundation is asking CHG readers to fill out this Healthy Eating poll for research. They dont want any personal information – just a few answers to some very worthwhile questions. Head on over!

In my humble, meek, somewhat self-effacing (yes, I used the Thesaurus tool) opinion, one of the best recipes we’ve ever featured on CHG is the unfortunately named Cheesy Eggplant Bake. A tornado of vegetables and frommage, it’s most excellent for those days you just want to pack your face with large quantities of delectable healthiness.

Jeez, though. That name.

Today’s recipe has a similar problem. It’s a limey, fresh, summer-appropriate mixture of chicken and various guacamole-associated ingredients. And ideally, it goes in a wrap, on top of a few leaves of lettuce.

So, do we call our creations Deconstructed Guacamole Wraps? On one hand, the name sounds like the classy-like results of a Top Chef quickfire challenge. On the other hand, what everyday cook ever deconstructs anything? Besides his blender, I mean.

Or, do we go with Lime Chicken Salad with Avocado and Tomato? It lacks the upscale panache of the first name, but it IS much more picnic-ready. Like you can just throw it together and be off. Still, there’s the slight mayo-association that comes whenever you use the word “Salad.” And nobody wants that.

Sweet readers, what to call this thing? Would you go with either of the proposed titles? Would you call it something else entirely? How do we convey that it requires leftover chicken? Am I overthinking this?

(My answers: dunno, maybe, yes, beats me, yes.)

Before you get to brainstorming, though, know this: these wraps, while scrumptious, are much richer than our usual entries, due to a lot of avocado and a not-modest amount of olive oil. However, you can drop a significant amount of fat by reducing each ingredient by half. Not that you have to. This is all pretty healthy, fat-wise.

With that said, how about that name? Im stymied.

~~~

If you dig this recipe, these might also float your boat:

• Chipotle Pork Tenders
• Pasta with Turkey Sausage and Broccoli Rabe
• Skillet Chicken Fajitas

~~~

Deconstructed Guacamole Wraps
OR Lime Chicken Salad with Avocado and Tomato
Serves 4.


8 ounces grilled chicken, chopped into bite-sized pieces
1 avocado, diced
1 cup halved cherry tomatoes
1/4 cup red onion, minced
1/4 cup cilantro, chopped
3 tablespoons lime juice
2 tablespoons extra virgin olive oil
1/2 teaspoon kosher salt
Freshly ground black pepper
4 large leaves green lettuce
4 tortilla wraps

NOTE: I used grilled chicken thighs for this, due to their moistness and general tastiness. There were three of ‘em and I took each apart with my fingers.

1) In a medium bowl, combine chicken, avocado, cherry tomatoes, red onion, and cilantro. Stir, gently if you have very-ripe avocado.

2) In a small bowl, whisk together lime juice, olive oil, salt, and pepper to taste. Pour on to chicken mixture and stir to combine.

3) Place a few leaves of lettuce on each wrap. Split chicken evenly among wraps. Roll them up. Serve!

Approximate Calories, Fat, Fiber, Protein, and Price
368 calories, 23 g fat, 5.7 g fiber, 18 g protein, $1.30

NOTE: Your numbers will be slightly different depending on what cut of chicken and what kind of wraps you use. My calculations are for chicken thighs and Tropical brand tortillas.

Calculations
8 ounces grilled chicken, chopped into bite-sized pieces: 435 calories, 22.7 g fat, 0 g fiber, 54 g protein, $1.27
1 avocado, diced: 322 calories, 29.5 g fat, 13.5 g fiber, 4 g protein, $1.00
1 cup halved cherry tomatoes: 27 calories, 0.3 g fat, 1.8 g fiber, 1.3 g protein, $0.99
1/4 cup red onion, minced: 17 calories, 0 g fat, 0.6 g fiber, 0.4 g protein, $0.12
1/4 cup cilantro, chopped: 1 calories, 0 g fat, 0.1 g fiber, 0.1 g protein, $0.25
3 tablespoons lime juice: 12 calories, 0 g fat, 0.2 g fiber, 0.2 g protein, $0.50
2 tablespoons extra virgin olive oil: 239 calories, 27 g fat, 0 g fiber, 0 g protein, $0.24
1/2 teaspoon kosher salt: negligible calories, fat, fiber, protein, $0.01
Freshly ground black pepper: negligible calories, fat, fiber, protein, $0.01
4 large leaves green lettuce: 19 calories, 0.3 g fat, 2.4 g fiber, 1.4 g protein, $0.10
4 wraps: 400 calories, 12 g fat, 4 g fiber, 12 g protein, $0.72
TOTAL: 1472 calories, 91.8 g fat, 22.6 g fiber, 73.4 g protein, $5.21
PER SERVING (TOTAL/4): 368 calories, 23 g fat, 5.7 g fiber, 18 g protein, $1.30

The CDC (Centers for Disease Control and Prevention) recently posted a "New and Improved" website for diabetes statistics:

CDC - Diabetes Data and Trends

New features include:

• Separate gateways for national and state surveillance data
  
• Maps, easy-to-read graphs, and data tables illustrating state surveillance data
  
• Ability to view state-specific trends by age or sex
  
• Quicker access to data tables

________

We all know that exercise is good for you, but how good? While previous studies have shown the link between physical activity and a lower risk of premature mortality, the number of years of life expectancy gained among persons with different activity levels has been unclear—until now. In a new study from Brigham and Womens Hospital (BWH), in collaboration with the National Cancer Institute, researchers have quantified how many years of life are gained by being physically active at different levels, among all individuals as well as among various groups with different body mass index (BMI).

The study will be published on November 6, 2012 in PLOS Medicine.

"We found that adding low amounts of physical activity to ones daily routine, such as 75 minutes of brisk walking per week, was associated with increased longevity: a gain of 1.8 years of life expectancy after age 40, compared with doing no such activity," explained I-Min Lee, MD, associate epidemiologist in the Department of Preventive Medicine at BWH and senior author on this study. "Physical activity above this minimal level was associated with additional gains in longevity. For example, walking briskly for at least 450 minutes a week was associated with a gain of 4.5 years. Further, physical activity was associated with greater longevity among persons in all BMI groups: those normal weight, overweight, and obese."

In pooled data from six prospective cohort studies, the researchers examined associations of leisure-time physical activity of a moderate to vigorous intensity with mortality. They analyzed data from more than 650,000 subjects and followed subjects for an average of ten years- analyzing over 82,000 deaths. The large sample size allowed them to estimate years of life gained after the age of 40 among persons with different levels of physical activity and BMI.

The findings show that physical activity was associated with longer life expectancies across a range of activity levels and BMI groups. Participation in a low level of leisure time physical activity of moderate to vigorous intensity, comparable to up to 75 min of brisk walking per week, was associated with a 19 percent reduced risk of mortality compared to no such activity.

Assuming a causal relationship, which is not specifically demonstrated in this research, this level of activity would confer a 1.8 year gain in life expectancy after age 40, compared with no activity. For those who did the equivalent to 150 min of brisk walking per week--the basic amount of physical activity currently recommended by the federal government--the gain in life expectancy was 3.4 years. These benefits were seen in both men and women, and among white and black participants. Importantly, they were also observed among persons who were normal weight, overweight, and obese. Participants faring best were those who were both normal weight and active: among normal weight persons who were active at the level recommended by the federal government, researchers observed a gain in life expectancy of 7.2 years, compared to those with a BMI of 35 or more who did no leisure time physical activity (a 5 ft 5 in tall person with BMI of 35 weighs 210 lb).

"Our findings reinforce prevailing public health messages promoting both a physically active lifestyle and a normal body weight," explained Dr. Steven C. Moore, PhD, research fellow at the National Cancer Institute (NCI) and lead author of this study. This findings may also help convince currently inactive persons that even being modestly active is worth it for greater longevity, even if it may not result in weight control.

My previous post discussed the link between smoking and death from heart and lung diseases (and showed benefit for quitting). Heres a study, actually a study of studies or a meta-analysis, from 5 months ago that reasserted the often observed link between smoking and type 2 diabetes:

Active Smoking and the Risk of Type 2 Diabetes, JAMA, December, 2007

Of the 25 studies included in this analysis, 24 reported a positive association between smoking and diabetes, specifically:

"The pooled adjusted RR was 1.44."

An RR (Relative Risk) of 1.44 means that there was a 44% increased risk for developing diabetes among active smokers vs. non-smokers. Among heavy smokers, the risk increased to 61%:

"The risk of diabetes was greater for heavy smokers (≥20 cigarettes/day; RR 1.61) than for lighter smokers (RR 1.29) and lower for former smokers (RR 1.23) compared with active smokers, consistent with a dose-response phenomenon."

The link was so consistent that the authors stated there was "no need for further cohort studies to test this hypothesis." They recommended instead "that future studies focus on plausible causal mechanisms or mediating factors such as obesity, lack of physical activity, dietary habits, and stress levels."

One mechanism they noted which has appeared in previous studies is smokings link to insulin resistance or inadequate insulin secretion - a mechanism which should bear scrutiny in future investigations.
________

Researchers from The University of Texas MD Anderson Cancer Center found statins, the commonly used drug to lower cholesterol, improved progression-free survival in patients with inflammatory breast cancer (IBC).

The retrospective study was presented today in a poster discussion at the 2012 CTRC-AACR San Antonio Breast Cancer Symposium and follows a previously reported Danish study indicating there is some evidence to suggest the anti-inflammatory properties of statins could reduce the risk of breast cancer recurrence. Still, the overall effects of statins have not been examined in relation to IBC.

IBC is a rare type of breast cancer that develops quickly when malignant cells block lymph vessels in the skin and soft tissue. It accounts for only 1-5 percent of all invasive breast cancers, according to the American Cancer Society.

"We decided to take a different approach with the smaller population of inflammatory breast cancer patients and see if its truly an inflammatory disease, whether or not theres some substantial impact of statin use in this population," said Naoto T. Ueno, M.D., Ph.D., professor in MD Andersons Department of Breast Medical Oncology and executive director of the Morgan Welch Inflammatory Breast Cancer Research Program and Clinic.

Ueno, the corresponding author, and his colleagues reviewed 724 patients diagnosed and treated for stage III inflammatory breast cancer at MD Anderson between 1995 and 2011. Patients with records indicating statin use at the time of diagnosis were compared to those who were not taking statins. In total, the stage III group contained 74 statin users and 650 non-users.

The primary end-point was progression-free survival (PFS), while secondary end-points measured overall survival (OS) and disease-specific survival (DSS).

Additionally, researchers compared the clinical outcomes of those in the statin group based on the type of statin, lipophilic (fat-soluble) or hydrophilic (water-soluble), an important distinction as differences in survival emerged throughout the trial. The authors note patients who used both drug categories, or patients missing information on their specific statin type, were excluded from the survival estimates.

Outcomes Show Improvement

Patients with no record of statin use had 1.76 years DFS, while patients who took lipophilic statins saw improved survival rates of 2.47 years. The greatest improvement in survival was noted in patients with past hydrophilic statin use at 4.88 years.

Increased survival rates also extended to the DSS end-point. Patients with no statin use measured a DSS of 4.52 years, while hydrophilic patients measured 5.10 years.

The authors note there is a trend in overall survival, however the OS end-point did not reach statistical significance.

"The previous Danish study looking at statins examined a much larger group of participants, around 10,000 and more. So were talking about a much smaller set of inflammatory breast cancer patients and to see the significant improvement in survival gives us a new perspective on the use of statins," said Ueno.

While Ueno added the findings are encouraging, the study does have limitations. First, no data was available describing how long patients had been taking statins, or for what indication. Those who did use statins may represent a population with better access to health care, a more health-conscious lifestyle and a higher education level, according to the researchers.

"This is an existing drug that was not developed for cancer and while developing new agents is important, statins are currently in the market and may have a significant role in the treatment we provide," he said.

Heard of "down-jobbing?"

Your PCT will see you now.....

The Disease Management Care Blog first became aware of the term years ago when it was pointed out that primary care docs can take on some specialty care responsibilities, while nurses can take on primary care roles, while office assistants can take on nursing roles. A parallel phenomenon is the movement of surgeries and other medical procedures from the inpatient to the outpatient surgi-center to the physicians office.

Naturally, the ultimate down-jobbing target is the patient. Examples include the reasonable innovation of self-service kiosks as well as emergency or wacky "self surgery."

Which naturally prompts the DMCB to offer its own definition of down-jobbing: the historical movement of medical treatment from higher to lower levels or locations of health care services.

Of course, the major driver of down-jobbing is economics. DMCB readers are well aware of our national obsession with transitioning from "fee-for-service" (FFS) to more "value-based" reimbursement arrangements. These include pay-for-performance as well as shared-risk, global or other capitated approaches.

Since traditional FFS is notoriously linked to medical necessity as well as provider credentialing (examples are not hard to find), physicians have had little incentive to go along with down-jobbing. As FFS allegedly goes the way of the dinosaurs (a perspective likewise not hard to find), health care providers in these new value-based payment systems are looking for cost-effective ways to service their patients within a fixed budget or fixed payment system. One way to do that is to down-job.

So it was only a matter of time until someone thought of the option of "primary care technicians" ("PCTs") as a value-based and down-jobbed solution to the nations physician shortage. As Kellermann et al point out in the November 2013 issue of Health Affairs, the pipeline for primary care docs, physician assistants, nurse practitioners is not only expensive, its unlikely to meet future demand.  They argue that PCTs can be to primary care providers like emergency medical technicians (EMTs) are to emergency care rooms.  Like EMTs, PCT training to handle preventive care, treatment of minor illnesses and monitoring chronic conditions neednt be extensive. Thats especially true if PCTs are armed with a health IT safety net that provides tablet-based decision-support algorithms that are ultimately tethered to (or teamed with?) a primary care physician.

So there you go: a few questions, a cursory exam and a recommended treatment plan for millions of healthcare hungry Americans is well within reach.  All it takes is some additional down-jobbing.

The DMCB thinks that, on paper, its not a bad idea and no accident that it would appear in the academic health policy literature.  Whether this could gain any traction in the real world of patients remains to be seen.  Perhaps the next step is a randomized controlled clinical trial comparing the outcomes of patients seeing newly minted PCTs to those receiving usual care.

The DMCB has two additional concerns:

1. The promise of the expansion of access to health insurance under the current iteration of health reform was that patients would be able to access the current health care system, including doctors and hospitals.  Even if this system of primary care meet outcome expectations, this will hardly burnish Americans ambivalent views of Obamacare.

2. Liability concerns are significant. Allegations of malpractice are inevitable with PCTs and their supervising docs will naturally worry about being ensnared in even more lawsuits by a very nimble plaintiffs bar.

Image from Wikipedia

Here they come....

Like manna from heaven, the Congressional Budget Office (CBO) has given the nations physicians and their medical organizations an opening against Medicares reviled sustainable growth rate (SGR).

Regular Disease Management Care Blog readers already know that the SGR is part of a 1997 law that was designed to battle rising health care costs. It relies on the blunt force of a "conversion factor" that unilaterally adjusts physicians Medicare fee schedules to match the growth in the U.S. gross domestic product. Despite the good intentions, physicians costs have blown past the GDP faster than high income earners fleeing California. Not wanting to disappoint a grumpy constituency, Congress has repeatedly approved temporary patches to undo the conversion factor.

Unfortunately, the original 1997 law was never repealed and the Feds bookkeepers have kept track of the growing gap between the GDP and the physician fees.  Without another patch, Medicare will deploy the conversion factor and reduce payments by approximately 25% beginning in 2014. 

As the DMCB understands it, the problem with the SGR is the projected costs of cancelling it. According to a recent article in AMA News, the price tag of repealing the SGR would increase the projected 10 year cost to $244 billion.  That calculated deficit has complicated Washington DCs efforts to balance the federal budget, find common ground on the sequester and fix the debt ceiling.

Enter the CBOs updated and just-released Budget and Economic Outlook for 2013 to 2023 . This telling sentence is buried on page 31:

"... holding payment rates through 2023 at the levels they are now would raise outlays for Medicare (net of premiums paid by beneficiaries) by $14 billion in 2014 and about $138 billion (or about 2 percent) between 2014 and 2023."

Whether you believe the projected slowdown in physician costs from $244 to $138 billion is the result of a moribund economy (the Republicans) or the enlightened interventions of Obamacare (the Democrats), the implications for the U.S. budget deficit are enormous.  Knowing a fiscal opening when they see it, politicians have responded faster than the DMCBs misanthropy to a crowded Amtrak train. 

The U.S. House Republicans have released their outline of an SGR reform proposal, while Pennsylvania Rep Allyson Schwartz (D-PA) (see below) has introduced a House bill dubbed the "Medicare Physician Payment Innovation Act of 2013."

Both are remarkable for their two similarities than differences:

1) Strangling the SGR by repealing the looming 25 percent across-the-board rate cut in 2014 along with any future rate cuts. Congress will establish a temporary five-year period of "predictable payment rates."

2) Finishing off fee-for-service (FFS) by soliciting organized medical society and "other relevant stakeholder" input to create multiple scientifically based payment models that use a variety of quality and efficiency metrics that will be periodically updated by Medicare.

These models will include registries, risk adjustment approaches, physician rankings, performance feedback, shared decision-making tools and pay-for-performance. Should a doc disagree that the registry-based risk adjusted ranking of how the shared decision making improved performance, he or she will be given opportunity to make an "appeal."

Ms. Schwartzs bill has more detail. She would lock-in the current payment rates until the end of 2014 and transition in the reforms described above over 5 years. During this time, she would also annually increase primary care physician payment rates by 2.5%. An interim report on the pace and success of the reforms would need to be submitted by the General Accounting Office to Congress in 2017. For docs that are struggling with the demise of fee-for-service, thered be a payment track that retains FFS "for providers who are incapable of transitioning."

The DMCBs take:

1. Given the degree of Democratic and Republican agreement and the relatively low cost of "only" $138 billion, the likelihood of repeal of the SGR is better than it has been for years. Maybe it will really happen this year.

2. There is a remarkable bipartisan consensus that Medicares FFS system needs to go away, despite an astonishing lack of evidence that we can really achieve an payment approach that is truly a better payment mousetrap.  The DMCB remembers the perils of exquisitely engineered global payment systems that were designed to reimburse for value and not volume.  It was called "capitation" and it failed miserably.

Maybe a 2019 target date is warranted. Itll take that long to not repeat history.

3. Also buried in the CBO report is this caveat:

.....spending per enrollee for Medicare and Medicaid—which generally has grown faster than GDP—is very difficult to predict. If per capita costs in those programs rose 1 percentage point faster or slower per year than CBO has projected for the next decade, total outlays for Medicare (net of receipts from premiums) and Medicaid would be about $650 billion higher or lower for that period."

While the DMCB understands the fiscal and political logic behind the timing of the SGR appeal, lets be honest: this is a budget decision built on assumptions based on guesses that are ultimately propped up by wishful political decision-making.

4. As a member of several professional medical organizations, the DMCB appreciates the proposed role of these entities in this next phase of health reform.  If you are a doctor and you are not paying dues to one organization or not participating in meetings and emailing its leadership, you stand to lose. 

Docs: Join. A. Professional. Society. Or. Association. Now. 

Thats especially true if, as an employed physician, you think your Health System CEO has your interests at heart.  This might be a good start.

First study:

Fatal And Nonfatal Outcomes, Incidence Of Hypertension, And Blood Pressure Changes In Relation To Urinary Sodium Excretion, JAMA, May 2011

While an increase in sodium (as measured by sodium excretion) was associated with an increase in systolic blood pressure (but not diastolic blood pressure), "this association did not translate into a higher risk of hypertension or CVD complications."

Also, from news@JAMA which summarized the study:

"In the study, the researchers categorized the 3681 study participants according to sodium intake, using a procedure that measures sodium in the urine over a 24-hour period, considered the gold standard for such assessment. At a median of nearly 8 years later, participants in the group with the lowest sodium intake at the beginning of the trial were significantly more likely than the other 2 groups to die of cardiovascular disease."
- Author Insights: Questioning The Benefits Of Salt Restriction, JAMA News, May 3, 2011

Second study:

Reduced Dietary Salt For The Prevention of Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials (Cochrane Review), American Journal of Hypertension, July 2011

Results:

“Relative risks (RRs) for all-cause mortality in normotensives and hypertensives showed no strong evidence of any effect of salt reduction CVD morbidity in people with normal BP.

Raised BP at baseline also showed no strong evidence of benefit.

Salt restriction increased the risk of all-cause mortality in those with heart failure.”

Neither of these studies lend strong support for the recommendation to restrict sodium ... for cardiovascular disease. However, other conditions may benefit from sodium restriction. High sodium intake has been associated with greater calcium losses and osteoporosis.¹ Also, the efficient renal mechanism that excretes excess sodium may not be fully effective if the kidney is compromised - as it is with diabetes, hypertension, or existing kidney and vascular disease.
________
¹ Salt Intake, Hypertension, And Osteoporosis, Journal of Endocrinological Investigation, 2009

Poor physical performance on activities including walking was associated with increased odds of dementia in a study of individuals 90 years and older, according to a report published Online First by Archives of Neurology, a JAMA Network publication.

Individuals 90 years and older are a unique segment of society that has not been well studied. Previous studies have suggested a relationship between poor physical performance and cognitive impairment in the younger elderly populations, according to the study background.

The study conducted by Szofia S. Bullain, M.D., and colleagues from the University of California, Irvine, involved 629 participants from the 90+ Study on aging and dementia performed at the university from January 2003 through November 2009. The average age of participants was 94 years, and most (72.5 percent) were women.

"Our cross-sectional study found a strong dose-dependent association between poor physical performance and dementia in the oldest old, with higher odds of dementia associated with poorer physical performance," the authors note. "The results reveal that even modest declines in physical performance are associated with increased odds of dementia. The strongest association is seen with gait slowing, followed by five chair stands, grip strength and standing balance."

The odds ratios for every unit decrease in a physical performance score were 2.1 for a four-meter walk, 2.1 for chair stands, 1.9 for standing balance and 1.7 for grip strength, according to the study results.

Participants who were unable to walk (score of 0) "were almost 30 times more likely to have dementia than people with the fastest walking time," the study results indicate. Even minimal slowing in the walking speed (less than or equal to 1.5 seconds, from score 4 to score 3) was associated with four times greater odds of dementia, according to the results.

"In summary, similar to younger elderly populations, our study found that poor physical performance is associated with increased odds of dementia in the oldest old. The establishment of this association may serve as a major stepping stone to further investigate whether poor physical performance is in the causal pathway and a potentially modifiable risk factor for late-age dementia," the authors conclude.

Today on Serious Eats: White Bean and Mushroom Ragout. Plus, a new cookbook find. Rawk.

Masterpiece Blog Theater proudly presents another installation of CHGs ongoing one-act plays.

CHARACTERS
KRIS: an alarmingly freckled 32-year-old food and frugality blogger.
MOTHER NATURE: a faceless, otherworldly entity with omnipotent control over the weather.

SCENE
The back deck of a 110-year-old Brooklyn brownstone that, by all rights, should have been condemned 109 years ago. Kris alofts, and turns her attention toward the sky.

KRIS: Mother Nature! Hi there! It’s Kris!

MOTHER NATURE: Who?

KRIS: Kris? Kinda tall. A little busty. Very near sighted.

MOTHER NATURE: Oh! You! The one with no sense of direction. What up, girl?

KRIS: We have 12 people coming for a potluck dinner today!

MOTHER NATURE: Oooo. Potlucks are the proverbial bomb. What are you making?

KRIS: Italian Turkey Sliders and Potato Salad with Green & White Beans.

MOTHER NATURE: Sweet. Mama likes. What about everybody else?

KRIS: Well, as far as I know:

• R & J: Banana Lemonade and Kettle Corn
• S: Black Bean Dip and Fresh Salsa
• A & A: Berry Trifle and Veggie Skewers
• M & S: Barbecue Pulled Chicken
• L: Hummus
• Leigh & B: Recipe(s) coming Thursday

MOTHER NATURE: Excellent. Send some my way, will you?

KRIS: Uh … but you don’t … have a mouth. Or organs. You’re a foodie?

MOTHER NATURE: Foodie, shmoodie. I’m gonna drop this stuff on washed cars.

KRIS: Oh.

MOTHER NATURE: That Black Bean Dip has a date with my neighbor’s Humvee. Steal MY lawnmower, will you, bud?

KRIS: Makes sense. I guess. But Ma Nature, I have a favor to ask.

MOTHER NATURE: They always do. *sigh* What is it, Magoo?

KRIS: Well here’s the thing: if it rains, we can’t use the backyard. And consequently, we have to stuff everybody – including two toddlers - into an apartment living room the size of a cookie sheet. So, um, can you hold the storms off for like, two or three hours?

MOTHER NATURE: Sure thing!

KRIS: Really?

MOTHER NATURE: No.

KRIS: Oh.

MOTHER NATURE: Ha! Father Time always falls for that, too. Don’t worry kid.

KRIS: So you will stop it from raining?

MOTHER NATURE: No.

KRIS: Um.

MOTHER NATURE: But I’ll tell you what I’ll do: If you give me the recipe for those Italian Turkey Sliders, I’ll make it rain just enough so that you THINK you can stay outside, but after ten minutes, you have to haul everyone and all their food upstairs.

KRIS: That doesn’t sound like a very good deal.

MOTHER NATURE: Wait – I’m not done. Then, I’ll cut it down to a misty drizzle, so everyone moves back outside again.

KRIS: And then you’ll stop the rain altogether?

MOTHER NATURE: Sure.

KRIS: Really?

MOTHER NATURE: No.

KRIS: I don’t like you.

MOTHER NATURE: Then itll rain for the rest of the afternoon. But you know what they say: False hope is better than no hope at all.

KRIS: I don’t think anyone says that.

MOTHER NATURE: I’m sure someone said it. Anyway, that recipe?

KRIS: Uh. Okay. Here you go.

MOTHER NATURE: Excellent. Hey, hold this lightning for me, will ya?

KRIS: Sure th******** (Kris is electrocuted.)

MOTHER NATURE: Heh. Father Time fell for that one, too.

~~~

If you like this recipe, you might also be stoked by:

• Maque Choux with Chicken and Turkey Sausage
• Turkey Breakfast Sausauge
• Turkey Burgers

~~~

Italian Turkey Sliders
Makes 24 mini-burgers.


1 20-ounce package sweet Italian turkey sausage links (I use Shady Brook. – Kris)
1 20-ounce package 93/7 ground turkey (Shady Brook again. – Kris)
24 slider rolls/mini-hamburger rolls (I use Martin’s Party Potato Rolls. – Kris)
24 small slices part-skim mozzarella cheese (optional)
1/2 cup your favorite tomato sauce (optional)

1) Preheat your grill.

2) Using a knife, make a long slit along each link of the turkey sausage. Remove sausage from casings. Discard casings.

3) Combine turkey sausage in a large bowl with ground turkey. Using your hands, mix/squish until meats are thoroughly combined.

4) Make your slider patties. They should each be approximately 2 to 3 inches across and 3/4-inch thick, with a light thumb indentation in the middle. Store on wax paper until ready to cook. (Note: If you’re refrigerating the patties for later, bring them down to near-room temperature before you slap them on a grill.)

5) Place patties over direct heat and grill 4-6 minutes on each side, until outside is a bit browned and inside is cooked through. When finished, let sit for a few minutes.

6) Place patties on buns. Add mozzarella if you like (you can also do this on the grill), along with a few dabs of your favorite spaghetti sauce. Enjoy.

Approximate Calories, Fat, Fiber, Protein, and Price Per Serving
Due warning: I tried to use pretty generic calculations, but these numbers may differ slightly based on the brands you use.
Patty only: 73 calories, 3.9 g fat, 0 g fiber, 8.8 g protein, $0.29
Patty and bun: 117 calories, 4.4 g fat, 1 g fiber, 9.1 g protein, $0.42
Patty, bun, cheese, and sauce: 139 calories, 5.7 g fat, 1 g fiber, 10.9 g protein $0.52

Calculations
1 20-ounce package sweet Italian turkey sausage links: 960 calories, 54 g fat, 0 g fiber, 102 g protein, $2.99:
1 20-ounce package 93/7 ground turkey: 800 calories, 40 g fat, 0 g fiber, 110 g protein, $3.99
24 slider rolls/mini-hamburger rolls: 1040 calories, 12 g fat, 24 g fiber, 6 g protein, $3.19
24 small slices part-skim mozzarella cheese: 432 calories, 27 g fat, 0 g fiber, 41.3 g protein, $1.86
1/2 cup your favorite tomato sauce: 93 calories, 3 g fat, 0.5 g fiber, 2.4 g protein, $0.33
TOTALS: 3325 calories, 136 g fat, 24.5 g fiber, 261.7 g protein, $12.36
PER SERVING (no cheese, sauce, or bun): 73 calories, 3.9 g fat, 0 g fiber, 8.8 g protein, $0.29
PER SERVING (with bun, no cheese or sauce): 117 calories, 4.4 g fat, 1 g fiber, 9.1 g protein, $0.42
PER SERVING (with 1/4 oz cheese and ½ teaspoon tomato sauce): 139 calories, 5.7 g fat,1 g fiber, 10.9 g protein $0.52

Causes of Colon Cancer | The main causes of colon cancer is not known for sure. But there are several factors that can increase the risk of colon cancer. Risk factors include:

1. Contact with certain chemicals such as heavy metals, toxins, and ototoksin and electromagnetic waves.
2. Poor diet, such as too much meat and fat that is not matched fresh fruits and vegetables that contain lots of fiber.
3. Obesity.
4. Working while sitting all day, such as executives, administrators, or public vehicle drivers.
5. Such as excessive iron pigment found in bile, beef and lamb as well as blood transfusion.
6. Saturated fats and omega-6 (linol acid).
7. Alcoholic beverages, especially beer. Asetilaldehida convert alcohol into the intestine that increase the risk of colon cancer.

To reduce risk of colon cancer, we certainly need to avoid such risk factors. There was also some colon cancer prevention tips you can do:

1. Exercising and moving so much more easily and regularly for defecation.
2. Life relax and reduce stress.
3. Get plenty of fiber. To facilitate bowel movement and decrease the degree of acidity, concentration of fatty acids, bile acids, and iron in the colon.
4. Omega-3 fatty acids, which are widely found in certain fish.
5. Concentration of calcium, vitamin A, C, D, and E and betakarotin.
6. Milk containing Lactobacillus acidophilus.

There are a assortment of discipline loss products that offer that pdq weight loss results, however, are these really guaranteed? Could these produce forceful developing to their postulation of a fit body?

In US, there is an estimated 50 million people who try to lose weigh, unfortunately, only 5 per cent are successful. solitary thing's for sure, beware of invented claims further extreme high cost due to there is no magic to losing weight.

Samples of weight loss products in the hawk nowadays:

� Diet Patch � this was present-day removed for 1990's by FDA since they were proven ineffective.
� Magnetic Diet Pills � allegedly flushes out fat, but not.
� Guar Gum � causes maid obstruction.
� Electrical impact Stimulators � no proven effect.
� Eyeglasses that Suppress Appetite � These claims that the projected image on the retina decreases appetite. No proven fact.
� Weight loss earrings � through acupuncture, suppresses appetite.

There are also examples of limitation loss products:

Diet drinks that are complicated with beverages or moveable feast are used now meal substitutes. A downside of this is that once a friend stopped taking the drinks, they would eventually recover the lost predomination after a brief period of time becoming to feeling of emptiness in the tummy. Another is diet supplements and medicines that further don't work long-term. Over-the-counter pills that invest of phenylpropanolamine hydrochloride may prefer rust fear and palpitation. Ephedra on the mismatched cooperation can cause precarious side effects such as heart problems, seizure, stroke, and even passing. E.g.:

� Herbalife Nutritional mechanism � good as two meals, dieters may rely on shakes and ensue artificial dieting methods and apt don't want refreshment to action into their lives.
� Mega-Thin 100 rote � Its approach contains an anti-fat weapon, however, diet is not emphasized that's why it's concluded that rightful has an appetite suppressant.
� Nestl�'s Sweet vegetation � recommended to bring three times a day and it does not move ahead healthy eating habits. qualification loss is difficult to maintain once intake is stopped.
� Ultra Slim Fast � this plan requires regular exercise but does not elucidate good eating habits.
� Diet pills with Ephedra further PPA � many of these presume true enclosed diet plans. Slimming can come from the edible alacrity and not the pellet intake also there are risks of adverse side effects.
� Chitosan wares � contains fibers which were taken from shellfish that may cause diarrhea, bloatedness, and hysterical. This will only work if a low husky menu is practiced.
� Chromium Supplements �claim that commodities will lesser blood sugar, frame fat and cholesterol but causes anemia and calm memory loss. Studies show only minimal or no beneficial effect at all.
� Green Tea Extract Products � recognized since strong anti-oxidants that help secondary cholesterol and triglycerides, and promote weight loss, however, the caffeine content could cause insomnia and restlessness.
� Algae Tablets - Spirulina contains significant nutrients that can be an fair food when used as precedent of a varied diet but are very expensive.
� St. John's Wort adjunct - Claims that it leave suppress appetite and stay weight loss but certain could lead to gastrointestinal discomfort, tiredness, sleeplessness, and inspire loath reactions.
� Glucomannan Products � claim that two capsules before each meal decrease muckamuck relaxation. close as food thickeners but not in consummation proven safe or effective. Weight annihilation will only transpire if good diet plan is followed.

Even if you plan on using over-the-counter weight supplements or even participate in a domination loss activity, the verdict is that you still reckon on to eat fewer calories than you kindle to lose weight. When choosing a restraint curtains product or program, ensue as supremely information as viable.

Nowadays most of the people who are dieting only focused on weight loss alone. Whereas in the reduction program a healthy weight is important things is the weight of fat to get off.

Total weight loss is best if the weight of the fat should be dominant down, it is called a program of healthy weight loss. Fat weight that should be targeted or trimmed.

If just lose weight in one week then one can go down to 5 pounds by following a weight loss program pinned under a tree.

But given the drug in the body that makes the water out so the weight down. People that go in a sauna or a run in the daytime wear jackets can also make weight loss.

And if someone wants to lose weight in a healthy weight then the fat must be reduced, and it is no less important are the muscles in the body also be formed.

For that if you really want to lose weight, in addition to regular weigh scales suggested measure fat content in the body with a special tool once a month, to know whether there was a reduced fat or not.

Losing weight is really not just healthy but also your body shape. The way the diet is set in this case inevitably reduced portions and arranged so that the composition or species can not be arbitrary.

But if you want to lose weight the ideal self in 1 week down 0.5 to 1 kg in 1 month and approximately 2-4 kg, it is safe to do alone. Of course, still have to diet and exercise.
There are dangers that arise when losing weight too quickly as metabolic changes, namely triglycerides and uric acid soared so high.

This is due to the reduced fat, so fat cells break off and enter the blood, so if high triglyceride fat levels checked and if there is a clogged arteries then this could be dangerous.

Whereas in the case of uric acid will increase. This is because when there is a rapid decrease in the muscle or torn or burned, and the main content of muscle is protein. So if the protein is broken down causing high uric acid.

For that if you really want to lose weight in a healthy weight is fat look down, and this should be done gradually and not get in quick time.

Durian Better then Papaya and Watermelon - What do you think about durian? Durian not all-time bad for us. In certain cases Durian is more benefit then papaya and watermelon. Durian fruit most lots contain carbohydrates, fats and proteins. Not only that, other substances such as fiber, calcium, folic acid, magnesium, zinc and iron are also present in it.

But what do you know? it turns out, the durian has a lower glycemic index than watermelon and papaya. Durian is the most lower index glycemic then papaya, watermelon, pineapple.

Glycemic index (GI) is the scale or number given to certain foods based on how big these foods increase blood sugar levels, the scale used is 0-100. Called low-glycemic index when theyre on a scale of less than 50, medium glycemic index if its value is 50-70 and high glycemic index if the number is above 70.

But despite its low GI, durian is a fruit that has a high calorie so as not suitable for people with certain conditions or diseases.

Quoted from Healthmad, here are some diseases that can be overcome by eating durian fruit which is not too much.

1. Overcoming constipation, because many contain fiber
2. Overcoming anemia, because it contains folate or vitamin B9 is needed to produce red blood cells
3. Maintain healthy skin, because it contains Vitamin C that act as antioxidants and antiaging
4. Contains lots of potassium or calcium, so good for healthy bones and joints
5. Origin does not eat too much, the content of manganese in the durian can keep blood sugar levels remain stable
6. Contain copper compounds that can maintain the health of the thyroid gland
7. Keeping your appetite, because many contain thiamine or Vitamin B1
8. Overcoming migraine, because it contains the compound riboflavin or vitamin B2

Relieves stress and overcome depression, because it contains Vitamin B6 or pyridoxine Maintaining oral health because they contain posphor.

But, if you get any bad at body when you eat durian, try check how many have you ate durian, and what other food that you combine to durian.

The star fruit or carambola is a tropical fruit that is gaining popularity in the United States. This fruit acquired its name from the five pointed star shape when cut across the middle of the fruit. It has a waxy, golden yellow to green color skin with a complicated flavor combination that includes plums, pineapples, and lemons.

Originally from Sri Lanka and the Moluccas, and cultivated in Southeast Asia and Malaysia for several hundred years, this fruit also goes by many other names including: bilimbi, belimbing, Chinese star fruit, five-angled fruit and the star apple. Today, star fruit flourishes in south Florida and Hawaii because the fruit thrives on growing in a warm environment. Two types of star fruit are grown, tart and sweet. Tart varieties typically have narrowly spaced ribs, while sweet varieties tend to have thick, fleshy ribs. The tastes between the two are hardly distinguishable, as the tart variety still has some sweetness. This tropical fruit is readily available July through February.

Star fruits are an excellent source of vitamin C, is low fat, and naturally sodium and cholesterol free. A small whole star fruit will provide approximately 2/3 cup sliced.



Selection
Select firm, shiny skinned, even colored fruit. Star fruits will ripen at room temperature and have lightly brown edges on the ribs when it’s ripe. Avoid purchasing star fruit with brown, shriveled ribs. This delicious fruit is also available dried.

Storage
Non-ripe star fruit should be turned often, until they are yellow in color and ripe with light brown ribs. Store ripe star fruits at room temperature for two to three days or unwashed, and refrigerated, in a plastic bag for up to one week.

Preparation
Star fruits are great to eat out of hand as these tropical delights do not need to be peeled or seeded before eating. Simply wash the fruit, remove any blemished areas, cut crosswise to get the star shape, and eat!

Star Fruit Serving size 1/2 cup sliced, raw (54g)

Amounts Per Serving	% Daily Value
Calories 20
Calories from Fat 0
Total Fat 0g	0%
Saturated Fat 0g	0%
Cholesterol 0mg	0%
Sodium 0mg	0%
Total Carbohydrate 4g	1%
Dietary Fiber 1g	4%
Sugars 3g
Protein 0g
Vitamin A	0%
Vitamin C	20%
Calcium	0%
Iron	0%

* Percent Daily Values are based on a 2,000 calorie diet.

We love spending time in the sun, whether it is soaking up the deliciously warm rays on the beach or enjoying a bright afternoon on the front porch. However, sun damage can harm the skin, accelerating the aging process and even contributing to the risk of some types of cancer. We must take steps to protect ourselves from excess sun exposure, and there are many options for doing so. This article will offer tips for avoiding unnecessary sun damage and recommendations for sun protection products that will keep your vulnerable skin safe and damage-free.

Minimize Exposure The first step in protecting your skin from the sun is to minimize the amount of exposure you receive on a daily basis. During the heat of summer, the body is much more susceptible to those damaging rays between the hours of 10 a.m. and 2 p.m. If possible, stay out of the sun during this peak time, or seek shade or adequate sun protection if you must be out during these hours. Watch the Clouds Sun damage occurs even on cloudy days because the suns rays can penetrate cloud cover to harm your skin. During the winter months, sun protection continues to be important, since the sun reflects off snow and becomes even more dangerous.

It is important to protect your skin year-round, not just during the summer months. Know Your Vulnerabilities Some medications and skin care products make you even more vulnerable to the damaging effects of the sun. Ask your doctor if the medication he is prescribing will make your skin more likely to burn. Look at the label on your skin care products to see if a warning about sun exposure is included. If so, you must be extra vigilant about your sun protections, applying sunscreen daily without fail before leaving your house. Best Sun Protection There are many sunscreen products to choose from, but some brands offer better protection than others.

Look for a high SPF, particularly if you have fair skin. Yonka offers a sunscreen with an SPF 40 specifically designed for those more vulnerable to the suns rays. It is also important to inspect the ingredients used to provide protection. One of the best is zinc oxide, which is the key ingredient found in Fenix sun care products. Both Yonka and Fenix products also provide ingredients that slow the effects of aging and reduce the risk of skin cancer due to sun exposure. Some people with oily skin do not like to use a sunscreen because it clogs pores and leads to breakouts.

However, G.M. Collin offers a sunscreen especially for those with oily skin that adequately protects the skin from sun damage without contributing to breakouts. G.M. Collin also offers a wide line of other sun protection products designed for every need and skin type. Sun protection is absolutely necessary today, and there are a wide variety of products to choose from. With the right SPF and the best ingredients, your skin will be safe from the damaging effects of the sun any time of year.

Authors Resource Box

Improve the youthful glow of your skin by learning more about suncare at DrSkinSpa.com, where all suncare products assessed based upon their scientific ingredients.

by : Dr. Farid Mostamand
Article Source :5 Beauty Tips for Protecting Yourself from the Sun

This is Oral Bacteria Cause Heart Disease | There are many bacteria that live in our mouths, one of which is Streptococcus Gordonii. A recent study found that, the bacteria Streptococcus Gordonii into the blood stream can cause blood clots and lead to endocarditis (inflammation of the lining of the heart).

Thus the results of the presented research by scientists from the Royal College of Surgeons in the Society for General Microbiologys Spring Conference, Dublin Ireland this week.

Streptococcus Gordonii is a type of bacteria in the mouth and has contributed in the formation of plaque on tooth surfaces. If the bacteria enter the bloodstream through the gums are bleeding, they will wreak havoc by posing as a human protein.

Researchers from the Royal College of Surgeons, Ireland (RCSI) and University of Bristol have found that S. Gordonii is able to produce molecules that mimic human proteins fibrinogen, and cause clots in the blood vessels. Platelet clumping can cause endocarditis, or inflammation of blood vessels that can block the blood supply to the heart and brain.

Dr Helen Petersen, said, with a better understanding of the relationship between bacteria and the risk of blood clots, it can help especially in the treatment of infective endocarditis do. Infective endocarditis is an infection of the heart valves, which are usually caused by bacteria.

"About 30 percent of people with infective endocarditis will die and most require heart valve replacement surgery who have been infected, with valves made ​​of metal or animals," says Dr. Petersen.

"Our team has now identified the components of S. Gordonii molecules that mimic fibrinogen, so we are getting closer to be able to design new compounds to block it. This will prevent the stimulation of unwanted blood clots," continued Dr Steve Kerrigan from the RCSI.

In addition, researchers were also more extensively studied other bacteria in dental plaque that may have an effect similar to S. Gordonii. "We also try to study the properties of other bacteria that have a relationship with S. Gordonii. Our findings clearly show how important it is to maintain oral hygiene and dental hygiene by brushing teeth regularly," said Dr. Petersen.