Last in a series

In the 16th century famed Swiss physician Paracelsus theorized that salt in the urine caused diabetes.

With an epidemic of obesity looming in 2012, health care providers like Kaiser Permanente face the sad and intimidating prospect of a burgeoning caseload of patients diagnosed with diabetes, a debilitating disease that unless treated will mercilessly kill its victims, young and old.

A disease that baffled physicians until the early 20^th century, diabetes is reasonably well understood today, and research has tied its rising incidence to equivalent increases in overweight and obesity. Treatment is sophisticated and can allow for a normal and long life. But getting to this level has been a long road.

Scientists first identified diabetes about 3,000 years ago. In 1552 B.C. an Egyptian physician described it as “polyuria” or frequent urination. In the 1^st century, Greek physician Aretaeus dubbed it “the melting down of flesh and limbs into urine.” Until the 11^th century, the disease was diagnosed by “water tasters” who drank the urine of people thought to have diabetes to see if the excretion was sweet like honey. In Latin, diabetes is siphon and mellitus is honey or sweet, hence the disease name that endures to this day – Diabetes Mellitus.

In the 16^th century, famed Swiss-born physician and astrologist Paracelsus studied diabetes and theorized that salt in the urine caused the disease. (Wrong! It was that other white substance.) French pharmacist and hygienist Apollinaire Bouchardat was spurred to experimentation with diet after noticing diabetes symptoms disappeared when food was rationed in Paris during the Franco-Prussian War in the 1870s.

In the late 19^th century Italian diabetes specialist Catoni is said to have locked up his patients to get them to follow their special, low-carbohydrate diets. Before the 1920s, a diagnosis of diabetes was a death sentence for most patients. They usually faded away and died within about 18 months. But a grasp on the underlying medical condition remained elusive.

19^th century scientific discoveries confirmed the problem – a diabetic’s pancreas was not manufacturing the normal hormone, now known as insulin, needed to properly turn food into energy. Food converted to sugar (glucose) leaked into the urine because the body could not absorb it from the blood. Researchers began to experiment with dogs whose pancreases had been removed so scientists could better understand how the lack of insulin affected metabolism.

1920s development of insulin revolutionizes diabetes care

Unmanaged diabetes often leads to heart disease. Fotosearch image

Eventually researchers developed experimental pancreatic extracts that allowed diabetic dogs to properly digest food. In 1921, Frederick Banting, a young Canadian surgeon, and his assistant Charles Best, kept a diabetic dog alive for 70 days by injecting it with canine pancreatic extract. The same year, Dr. Banting and other physicians refined the experimental insulin and gave it to a young boy dying of diabetes. It seemed like a miracle when the boy’s blood sugar dropped to within normal limits in 24 hours.

At 13, Elizabeth Hughes, the daughter of the U.S. Secretary of State at the time, Charles Hughes, became one of the first children to be treated with insulin. Although she was fading away at only 45 pounds in 1922 when Dr. Banting began her treatment, she recovered and lived to age 74.

Propelled forward by the milestone discovery of insulin, researchers continued throughout the 20^th century to make advances in the quest to control high blood sugar and stave off complications such as heart disease, stroke, kidney disease, and eye problems.  In 1935, physician Roger Hinsworth identified two different types of diabetes, juvenile (Type 1), caused by a malfunctioning pancreas from birth, and adult onset (Type 2), a condition caused by the body’s cells becoming resistant to insulin.

Technical advances improve lives of diabetic patients

Also In the mid-1930s, pork/beef insulin and PZT insulin, a longer acting type, became available. In the 1950s, oral drugs called sulfonylureas for controlling blood sugar for Type 2 diabetes patients were introduced. In the early 1960s, urine test strips were developed to test blood sugar levels. This invention made self-care much simpler for diabetics who had been testing their urine by dissolving a chemical reagent in a test tube and making crude insulin dose calculations based on the chemical reaction. Patients had to wait a week for laboratory blood sugar test results.

In 1969, the first blood glucose meter – weighing three pounds and costing $650 – was developed. In 1979, blood sugar meters for home use became standard. Today, many diabetics wear pager-sized pumps that can be set to administer insulin as needed to control blood sugar.

Incidence of both types of diabetes on the rise

Lollipops are a child's delight but too much sugar can damage a young one's future health. Fotosearch image

The enhanced understanding of the disease and emergence of better treatment tools have happily coalesced to give providers more power to face the barrage of new cases in recent decades. Experts have sounded the alarm that we are in the midst of a diabetes epidemic that will likely get worse.

In 1900, the incidence of diabetes (mostly Type 1) was low; only one or two per 100,000 children in the U.S. were afflicted. Today, the number of diabetics, both Type 1 and Type 2, is growing steadily. Researchers are struggling to understand the increase in Type 1 (up to 14.3 per 100,000), a condition believed to be genetic. The hike in Type 2 diabetes is attributed mainly to an increase in the number of overweight and obese people.

In 2003, the Centers for Disease Control and Prevention researchers reported that the incidence of diabetes in America had increased by 40 percent between 1990 and 1999, from 4.9 percent to 6.9 percent. In the same article in the Journal of the American Medical Association, authors predicted that the number of diabetics would increase 165 percent between 2000 and 2050. In 2011, the American Journal of Managed Care reported the shocking statistic that 25.8 million Americans are suffering from diabetes. That is 8.3 percent of the U.S. population. High and going higher.

KP Care Management Institute addresses diabetes care

In 1998, the Kaiser Permanente Care Management Institute (CMI) developed the Integrated Diabetes Care Program (IDC) that incorporated the best practices already in use into a uniform, team approach to treating all KP patients with diabetes. New categories of staff were established to specialize in diabetes care; diabetic clinics were set up; and a registry was started to keep track of each patient’s needs and to follow up when necessary.

Diabetes wordcloud. Fotosearch image

More than 70 KP experts worked together to develop a comprehensive program that addressed all aspects of diabetes care. These include:  patient education and self-care, long-term control of blood glucose levels, screening for kidney disease, regular examination of the feet for peripheral vascular disease or nerve damage, screening for heart disease, and periodic checks for vision problems.

A tough prescription: Get active and forsake sugar

Research has for the most part verified that a lack of exercise, excessive consumption of sugary snacks and sodas and refined carbohydrates such as white bread, rice, and potatoes, are to blame for the rise in diabetes diagnoses. The challenge for society, medical science and individuals is to reverse this trend. How can we do that?

Kaiser Permanente has been promoting healthy eating and exercise – the prescription for weight loss and prevention of chronic disease such as diabetes – since World War II in the Kaiser Richmond Shipyards. In the late 1960s, a new emphasis was placed on wellness and prevention of chronic disease when KP Northern California opened the first health education center in Oakland. The idea soon caught on in all KP regions, and today a core curriculum is offered in most medical center service areas across the country.

KP’s core Healthy Living courses offered include: healthy lifestyle and weight management, a 10-session program that addresses good nutrition, stress management and physical activity; Weight Watchers ^TM, a balanced diet program that encourages exercise; Pilates; Personal Health Coach, a program that offers individual support for members to reach their health goals; Fitness for Women 40 and Over; and discounted memberships in community health clubs.

Specifically for members with diabetes or concerns of developing diabetes, KP health education core classes include:  diabetes basics; diabetes foot care; blood glucose meter training, diabetes nutrition, Type 2 diabetes support group, diabetes update, carbohydrate counting for diabetes; prediabetes; insulin pump support group and even a healthy grocery shopping tour for people with diabetes.

Home Box Office series premiers May 14

Kaiser Permanente also offers on-line Healthy Lifestyles programs that include: Care^TM for Diabetes, Balance^TM for weight loss; Relax^TM to reduce stress; Nourish^TM for healthy eating; Breathe^TM to stop smoking; Care for Your Health^TM for managing chronic conditions, including diabetes; and Care for Pain^TM for chronic pain management. Members can also access Succeed^TM a total health assessment that offers advice on how to achieve your health improvement goals. http://bit.ly/dmza66

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) documentary series the obesity epidemic and its consequences. The four-part series airs on May 14 and 15. For more about KP’s fight against obesity: http://bit.ly/IJHVhm

Fourth in a series

In 1772, Edward Jenner, an English physician, was the first to postulate that hardened coronary arteries in autopsies was a probable cause of heart disease. Photo courtesy of Jenner Museum in Berkeley, England.

In 1956, my grandfather died suddenly of a heart attack. He was 56.   I never got to know him.  Grandpa Barr, a life-long inhabitant of rural Iowa who had weathered the Great Depression and sent a son to war, didn’t know what hit him. He had no idea he had heart disease, and even if he had been diagnosed, his small town doctor had little in his black bag to prevent his early demise.

In the 1950s, physicians and researchers had no more than an inkling of how they could treat cardiovascular disease. In fact, physicians weren’t sure of the causes of heart attacks, and researchers were struggling to put together the heart disease puzzle.

Fifteen years later my mother told me she would probably die of a heart attack in her 50s like her father. Almost true to her prediction, she developed heart disease in her 60s. In her 70s she told me she was living on “borrowed time.” Maybe she was, but with lots of drugs, plenty of visits to the medical center and the installation of a pacemaker, she made it to the age of 87.

The difference between my mother’s fate and her dad’s is an amazing body of research and advances in technology that makes it routine in 2012 for doctors to be able to extend the lives of heart disease victims by decades.

A kernel of evidence emerges in the 18^th Century

The earliest recognition of what might cause heart attacks was documented in 1772 when Edward Jenner, an English physician, noted hardening of the coronary arteries in the autopsy of a heart attack patient under his care.

“. . .after having examined the most remote parts of the heart, without finding any means for which I could account for his sudden death, or the symptoms preceding it, I was making a transverse section of the heart pretty near its base when my knife struck against something hard and gritty, as to notch it. I well remember looking up at the ceiling, which was old and crumbling, conceiving that some plaster had fallen down. But on further scrutiny the real cause appeared: The coronary arteries had become bony canals,” Jenner wrote to his colleague, Caleb Hillier Parry.

In 1938, O.F. Hedley, MD, a Philadelphia public health official, discussed Jenner’s letter in an article in the American Journal of Public Health (AJPH). “The opinion Jenner expressed concerning the progressive nature of the underlying changes was prognostically prophetic, for medical science still waits methods for preventing coronary artery disease or satisfactorily postponing its more serious consequences.”

Long journey to understanding heart disease

Many decades have gone by since Jenner first implicated atherosclerosis (hardening of the arteries) as a culprit in heart disease. In the intervening years, researchers have inched forward in their quest to bring down the heart disease death toll.

In 1921, heart disease became the leading cause of death in the United States, according to mortality data collected by the Census Bureau. New York's heart attack rate was soaring at the time.

In a 1927 AJPH article, William Munley, a New York physician, reported that between 1910 and 1925, New York City’s deaths from heart disease had increased by 50 percent – from 175 per 100,000 population to 266 per 100,000. He estimated that 2 million Americans were afflicted with heart disease at that time.  The statistics had shifted so that atherosclerotic heart disease accounted for 40 percent of the deaths while rheumatic heart conditions made up 25 percent. (Syphilitic heart disease made up 10 percent with the rest in the category of unknown cause.) Rheumatic heart disease, thought to be the main cause of heart attacks and failure until the 1920s, had been largely conquered through public health efforts to eradicate rheumatic fever, which often left a damaged heart.

Munley wrote: “We have no established facts concerning the prevention of the degenerative types of heart disease. It is true that much has been written of the physical stress and nervous strain of the present-day (1927) mode of living as a factor in the production of high blood pressure and hardening of the arteries.  .  . While no preventive methods are at present known for this type of disease, people can be taught the right way to live. Though we cannot cure this disease, we can hope to relieve some of the suffering produced by it and thus hope to prolong life.”

So that was medical researchers’ mission for the next six decades: find ways to treat coronary atherosclerosis and high blood pressure to prevent early death. Technical advances in the 1920s and 1930s gave birth to the first blood pressure monitor and the electrocardiogram (EKG), both useful diagnostic tools. Researchers also forged ahead to discover ways to prevent heart disease, and other chronic conditions, through exercise and dietary and lifestyle changes.

Federal government gets into the act

A wise advertiser suggested eating salad for good health as early as 1929.

In 1948, the federal government, recognizing heart disease as a growing threat to public health, sponsored the Framingham Heart Study, a compilation of the health data of thousands of ordinary people in Framingham, Massachusetts. Data collected initially from 6,000 residents was used to make the connection between the study group’s health, diet, medical history and lifestyle and the eventual development of heart disease. The now-legendary project has followed three generations and spawned over 1,200 research articles, shedding light on many aspects of heart disease.

In the early 1960s, the Framingham researchers published results that showed cigarette smoking, high cholesterol levels, high blood pressure and abnormalities in EKG results indicated increased risk for heart disease.  In 1967, they found that physical activity reduced the risk of heart problems while obesity increased the probability.

In 1970, they published studies that identified high blood pressure and atrial fibrillation (uncontrolled fast heart rate) as risk factors for stroke.  In 1976, they found menopause increased the risk of heart disease; in 1988, they learned that high levels of the “good” cholesterol HDL (from fats such as avocados, olive oil, fish oil and nuts) reduced the risk of heart disease.

KP researchers undertake key studies

Longshoremen queue up for their KP multiphasic health screening in 1961 on the San Francisco waterfront.

Meanwhile, other organizations, including Kaiser Permanente, were conducting studies of their own. In 1959, KP joined with the Public Health Institute and UC Berkeley for the Child Health and Development Studies (CHDS), a collection of data from 15,000 East Bay pregnant health plan members from 1959 to 1967. CHDS scientists continue to use the data collected 50 years ago to study biologic, behavioral, genetic and environmental factors in early family life and how they affect the health of the subjects as adults.

In 2010, these researchers published a study that established a connection between preeclampsia (high blood pressure and protein in the urine) in pregnancy and heart disease later in life. Of the women who participated in the early study, 481 developed preeclampsia and 266 of them died of cardiovascular disease many years later. This link gives physicians and patients knowledge of an increased risk that can be ameliorated with preventive measures. CHDS researchers are taking the longitudinal study to a new level today by following up with the adult children whose mothers participated in the initial study.

In 1971, researchers in the California Department of Public Health and the University of California at Berkeley published an 18-year follow-up study of 3,263 Oakland and San Francisco longshoremen who participated in the Kaiser Permanente  multiphasic (comprehensive health check-up) examinations in 1951. The study revealed that 350 of the participants – all male –  had died of heart disease and 93 of stroke by 1970.

Researchers separated out the high- and low-risk populations and identified four categories associated with cardiac death: already having heart disease and/or high blood pressure, smoking one or more packs of cigarettes a day and being overweight. The study also found that the heart attack rate was less for men who had physically demanding jobs.

Total Health Project focuses on prevention

Kaiser Permanente researcher Steve Sidney, MD, tests a CARDIA participant on a treadmill. KP Division of Research photo.

By 1981 the understanding of what causes heart disease had progressed far enough to spur KP founding physician Sidney Garfield to launch a study essentially to test patients’ willingness to change their lifestyle to prevent chronic disease. He invited new KP members to complete a health self-assessment and to have a comprehensive physical at the experimental Total Health Center in Oakland. The participants were encouraged to avail themselves of expanded groundbreaking health education services to learn more about how to preserve their good health.

The Total Health Project gave rise to enhanced health education services throughout the KP health system so physicians could refer their patients to programs that could help them prevent disease and to manage chronic disease when it struck.

In 1985 the Division of Research (DOR, Oakland, CA) collaborated on a study of young adult men and women, black and white, from Oakland, Chicago, Minneapolis and Birmingham, Alabama. The Coronary Artery Risk Development in Young Adults (CARDIA) followed 5,000 Americans who were 18 to 30 years of age in 1985-86 to middle age 20 years later.

The 20-year follow-up study showed that the participants gained an average of 30 to 35 pounds. Testing of the participants, now 38 to 50 years of age, showed that 18 percent had calcification of the coronary arteries (atherosclerosis, a precursor to cardiac disease).

In 1998, a KP Division of Research team worked with UC San Francisco to study the usage and effectiveness of beta-blocker drugs prescribed for patients after an acute myocardial infarction (heart attack). The research team focused on 396 patients who took beta-blockers and compared their experience with the rest of the 1,050 study group. They concluded the use of beta-blockers, even in a lower dose than initially recommended, resulted in 38 percent fewer heart attack deaths.

Kaiser Permanente South Sacramento Planning for Health newsletter graphic promoting a preventive medicine class, 1990.

Physicians associated with Kaiser Permanente’s Center for Health Research (Hawaii and Oregon) collaborated in studies in 1995, 1997 and 1999 to assess the success of the Dietary Approaches to Stop Hypertension (DASH) trial involving Americans with high blood pressure. Ethnically diverse study subjects followed one of three diets in the research carried out in four clinical centers across the country.

In the 1999 study, hypertensive participants who followed the DASH fruit and vegetable diet or the expanded combination diet, which also included whole grains, low-fat dairy, fish, poultry and nuts, experienced significant reductions in 24-hour blood pressure. The others who continued to eat a regular American diet of red meat, sweets and sugary soda saw no reduction in blood pressure.

KP’s aggressive approach to heart disease two-pronged

In the past decade, Kaiser Permanente has made great strides in attacking heart disease. On the research front, studies have been done to validate drug therapies (i.e. beta blockers, aspirin, etc.) that stave off heart attacks and keep heart disease patients alive. This research includes a major study between 1999 and 2008 that showed a marked decrease in the number of KP patients who died following a heart attack.

In 2010, KP’s Division of Research published “Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction,” in which they reported a 24 percent decrease in heart attacks among KP patients during the study period. They also reported a 62 percent decrease in serious heart attacks that do permanent damage in the same time frame. This decline in heart attacks contributed to the KP Northern California region’s status as an island where heart disease is no longer the number one cause of death, as it is in the rest of the country.

KP’s second approach is prevention with a capital “P.” In the literature it’s sometimes called “primordial prevention.” This is defined as the individual’s commitment to improve his or her lifestyle to maintain a healthy weight, exercise and avoid heart disease. Kaiser Permanente’s “Thrive” campaign, launched in 2004, was initiated to highlight the health education and prevention programs that help KP members to keep their risk of chronic disease low.

Home Box Office series premiers May 14

Farmers’ Markets sponsored in every KP region, Community Benefit programs to reach out to underserved populations living in healthy food “deserts,” online Healthy Lifestyle programs, “Everybody Walks,” “Safe Routes to School,” and other exercise campaigns, as well as participating in community health promotion events, all contribute to KP’s Community Health Initiative.

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) documentary on obesity in America that premiers on May 14 and 15. For more information about KP’s part in fighting this epidemic: http://bit.ly/IJHVhm

Next time: Diabetes mystified researchers and doctors for 3,000 years.

Third in a series

The Kaiser company sponsored a women's basketball team during the Richmond Shipyard days. Bancroft Library photo.

Getting regular exercise plays a key role in staying physically and mentally healthy. A given in 2012, the relationship between physical activity and good health has only been well understood for the past few decades.

While work once involved physical labor for a majority of Americans, early 20^th century technological advances changed most jobs into something requiring much less exertion. Henry Ford introduced the assembly line into his Detroit factory to produce cars more rapidly, and mechanization spread to other industries, including farming.

Getting workers into ship-shape

The man behind California’s Richmond Kaiser Shipyards understood the value of good health. Industrialist Henry J. Kaiser knew that keeping workers and their families healthy and happy was vital for the success of his business. Competition among Kaiser teams to produce the most ships at the fastest pace was intense.

To keep workers fit, and to boost morale, the Kaiser Shipyard management provided many opportunities for employees to be active. Softball and basketball games were scheduled so that day, swing, and graveyard workers could participate. And bowling, skating, swimming, tennis and horseshoes were available any time.

Most able-bodied American men were away fighting on the war front, so women workers (who became collectively known as “Rosie the Riveter” and “Wendy the Welder”) took on jobs that in peaceful times would have been considered men’s work. The work was demanding – and early on women found their jobs requiring more strength and stamina than they could muster.

Richmond Shipyards shopfitters baseball team during World War II. Bancroft Library photo.

When shipyard gynecologist Hannah Peters recognized many of the women were resigning because the work was too hard, the yard began providing them with strength training.  The women learned how to climb ladders, lift loads, and how to combine the two skills to climb with loads.

A mid-century check-up

By the early 1950s, the effect of industrialization began to show, and Americans were judged to be less physically fit than previous generations. “Muscular Fitness and Health,” a 1953 article published in the Journal of the American Association for Health, Physical Education, and Recreation, asserted that the sedentary 20^th century American lifestyle had led to a loss of muscle tone in this country’s citizens.

Co-authors Hans Kraus, MD, and Bonnie Prudden cautioned that Americans needed to adopt physical fitness regimens to regain the level of fitness of earlier generations who used their feet to get around and sweated through their work day.

Kraus and Prudden’s message gained traction when mainstream publications such as Newsweek, U.S. News & World Report and Sports Illustrated picked up on a study Kraus had done that showed American youth to be significantly less fit than their European counterparts.

In the early 1950s Kraus studied students between the ages of 6 and 16 and measured their strength and flexibility as they performed sit-ups, leg lifts and toe touches.

A startling 56 percent of the 4,400 American students tested by Kraus and his colleague Sonja Weber, MD, failed at least one of the fitness components. In contrast, only 8 percent of the 3,000 European students (who hailed from Switzerland, Italy or Austria) failed even one part of the test.

Kraus blamed the American students’ poor showing on their pampered lifestyles: Their parents typically drove them to school, and they did only light chores and played within their own neighborhoods. Their European peers, on the other hand, typically walked miles to school, rode bicycles and performed strenuous chores such as chopping wood.

John and Jackie Kennedy on the cover of Sports Illustrated, Dec. 26, 1960

When President Dwight D. Eisenhower suffered a heart attack in 1954, America received a lesson in preventive care from Dr. Paul Dudley White, the president’s physician. Dr. White used television – 65 percent of Americans had a TV at home by 1955 – to tell Americans they could stave off heart attacks by exercising more, giving up cigarettes, and by eating healthier food, and less of it. President Eisenhower followed his doctor’s advice and went on to establish the President’s Council on Youth Fitness in 1956.

Sowing the seeds of a fitness revolution

In December 1960, then President-elect John F. Kennedy spearheaded a public awareness campaign promoting physical fitness. In “The Soft American,” an article he wrote that appeared in Sports Illustrated, Kennedy cited the results of the Kraus-Weber Test as well as an annual physical fitness exam at Yale University: 51% of the class passed in 1951, 43 percent passed in 1956 and 38 percent passed in 1960. http://sportsillustrated.cnn.com/vault/article/magazine/MAG1134750/index.htm

“Physical fitness is not only one of the most important keys to a healthy body; it is the basis of dynamic and creative intellectual activity,” wrote Kennedy. “The relationship between the soundness of the body and the activities of the mind is subtle and complex. Much is not yet understood. But we do know what the Greeks knew: that intelligence and skill can only function at the peak of their capacity when the body is healthy and strong; that hardy spirits and tough minds usually inhabit sound bodies.”

Once he took office, President Kennedy’s message reached an even wider audience via a public awareness campaign, President’s Council-sponsored pilot projects to test children’s fitness levels, clinics and educational films and booklets.

Outdoor aerobics class led by registered nurses in Hawaii, 1982

When Kaiser Permanente (KP) opened the doors of its Health Education Research Center in Oakland in 1969, its overarching educational theme was, “You have only one life to live – live it in good health.” The experimental center featured a patient health library and health exhibits. “Story of Life,” one of the most popular displays about human reproduction and family planning, used life-size, three-dimensional models and color slides.

Another area of the center presented information about health hazards: weight problems, smoking, venereal disease, cancer, and alcohol and drug abuse. The “Pathway to Positive Health” exhibit focused on how visitors could stay well by paying attention to nutrition, dental hygiene and the physical, mental, emotional and social aspects of good health.

The Health Education Research Center was an outgrowth of a pilot project that explored education’s role in increasing the effectiveness of preventive care. This was a new approach to prevention; it spread through the Kaiser Permanente system and beyond. By 1987, 85 percent of all U.S. hospitals offered health education programs.

From aerobics to yoga – 1970s ushered in fitness craze

Unofficial estimates in the early 1980s suggested that more than half of all Americans pursued some sort of recreational exercise, such as bicycling, swimming, tennis or running.  This new dedication to physical activity signaled a change.

“Until recently, modern generations of Americans by and large failed to act on a compelling accumulation of knowledge linking individual lifestyle with individual health. As a nation, our eating habits violated accepted standards of nutrition. We shunned devoting our leisure time to regular physical exercise,” declared the writers of Kaiser Permanente’s 1984 annual report.

Fitness guru Richard Simmons leads a class in aerobics.

During the 1970s and 1980s many Americans got swept up in the fitness craze. Wearing leotards, neon spandex and leg warmers, they headed to health clubs and performed leg lifts and side bends and hoisted dumbbells to upbeat music. Or they popped Jane Fonda’s Workout in the video cassette recorder (VCR) and worked up a sweat at home. Others jogged their way to good health after reading Jim Fixx’s 1977 bestseller The Complete Book of Running.

Americans had different motivations to exercise, according to a 1978 Harris poll. Twenty-four percent of regular exercisers cited their reason was to strengthen their heart and/or lungs, 41 percent sought to lose weight, 24 percent wanted to become healthier, and 45 percent hoped to stay healthy.

A 1976 Centers for Disease Control and Prevention study of the 10 leading causes of death in the United States looked at the importance of four factors. Lifestyle, including exercise and diet, figured most prominently at 51 percent, followed by heredity (20 percent), environment (19 percent) and inadequate access to health care (10 percent).

Garfield’s Prescient Total Health Care Project

KP founding physician Sidney Garfield’s crowning achievement, the Total Health Care Project, came towards the end of his life in 1984. Among the Total Health Care Project’s goals was “to provide comprehensive primary care services for both wellness and illness and to provide incentives to professional staff to keep members well rather than just treating them when they are sick.”

An aggressive outreach plan to new members encouraged them to schedule a health evaluation appointment to review their current health and to develop a personalized Health Improvement Plan (HIP).

Colorado KP employees and members participate in an aerobics class. Kaiser Permanente 1984 Annual Report photo.

Members received a mailing with the instructions: “If you are feeling fine, we also want to see you to make sure you are in good health and assist you in preventing future problems. We really think the BEST time for you to get acquainted with us is when you’re feeling good, without the pressure of illness.”

Members who visited the Total Health Care Center for initial and periodic examinations assessed their own health via a questionnaire. They were asked about their eating habits, their lifestyle and how frequently and intensely they exercised. Part of the assessment was a treadmill endurance test to determine cardiovascular fitness.

Through the Total Health program, the center staff guided members in their quest for good health. Handouts offered tips such as how to select an activity that you will stick with as well as how to take your own pulse.

In the 1980s, popular health books included Pritikin Program for Diet & Exercise, Better Homes & Gardens’ Good Food & Fitness and Covert Bailey’s Fit or Fat? Fitness programs and initiatives began to take root throughout Kaiser Permanente’s regions. For instance, in 1984, the Ohio Region launched its “Annual Frost Belt Classic,” a series of five-, 10-, and 15-kilometer cross-country ski races. The race drew 500 skiers in 1987.

In the early 1980s, every KP region sponsored or supported a race or fun run. As part of its Dr. Wizardwise health education program, the Hawaii region sponsored a run for children.

Also in the 1980s, Kaiser Permanente’s Northern California Region established partnerships with about 15 local health clubs, enabling its members to join for a low or no initiation fee and a reduced monthly rate.

The current picture of health

Members of the Kaiser Permanente Dragon Boat Team, the KP Dragons. KP 2007 Annual Report photo.

Today medical assistants in Kaiser Permanente’s Southern California, Northern California, Colorado and Northwest regions ask patients about their exercise habits as a matter of course. Exercise as a Vital Sign was launched in Kaiser Permanente’s Southern California region first in 2009 to capture information about members’ physical activity.

Medical assistants routinely ask two questions: 1) On average, how many days a week do you engage in moderate or greater physical activity (like a brisk walk)? 2) On those days, how many minutes do you engage in activity at that level? Those answers are entered into the KP member’s computerized health record, and his or her physician can view that information along with the rest of the patient’s vital signs.

Kaiser Permanente also promotes healthy living through its Every Body Walk!, Thrive Across America, Healthy Eating Active Living and KP Healthworks programs and by sponsoring walks, runs and cycling events and offering an array of fitness classes at its medical centers.

Home Box Office series premiers May 14

With Exercise as a Vital sign in the exam room and a broad array of healthy living initiatives, Kaiser Permanente’s longtime fitness message endures: regular exercise is one of the cornerstones of preventive care and ultimate good health.

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) upcoming documentary series “Weight of the Nation,” which covers the issue of obesity in America. The four-part series will be aired May 14 and 15. For more information about KP’s involvement in the fight against obesity: http://bit.ly/kptwotn

"Fear of Fat" in the March 1984 KP Reporter newsletter warned of going too far with weight consciousness.

Second in a series
Efforts to combat obesity, childhood obesity in particular, are making news. Examples include First Lady Michelle Obama’s signature public health campaign “Let’s Move!” the Home Box Office (HBO) documentary series “The Weight of the Nation,” and the popular charge to incite health providers, schools and communities to join the fight to stop the spread of obesity.

But the current attention devoted to this issue in a culture obsessed with fad diets and alarmist health news raises the question: Is this really a significant problem?

To begin with, medical experts do not universally acknowledge “obesity” as a disease, like AIDS or lung cancer. There have always been overweight people, and for many the driving concern for weight loss has been more about the aesthetics of body image than physical health.

But two significant and disturbing facts have changed over the past two decades. First, for reasons not fully understood, there has been a measurable increase in the numbers and demographic distribution of obese people. And second, there has been an accumulation of research linking excess body weight to bad health.

The obesity epidemic

Data reveal our population’s progressive ponderosity over time. Medical concern over weight and obesity show up in the mid-1960s. A 1965 UC Berkeley student paper by a physician noted “Estimates run as high as 25 million overweight Americans (based on desirable weights taken from actuarial tables). Some epidemiologists might consider that we have an epidemic of obesity in America. . . A tremendous amount of time, effort, and money is being devoted to the understanding of the problem of obesity and its significance and solution. Diet foods are a multimillion dollar industry. The military attempts to legislate weight and physical fitness with compulsory standards.”¹

A 1984 article in Kaiser Permanente’s KP Reporter noted that the Metropolitan Life Insurance Tables showed that a “surprising” 40% of American men and 55% of American women were overweight, currently defined as those having a Body Mass Index (BMI) between 25 and 29.9. The more serious condition is obesity, with a BMI over 30. (BMI is computed by dividing a person’s weight by the square of his or her height.)

A 1987 Planning for Health Kaiser Permanente (KP) member newsletter article stated that “Obesity is our nation’s number one nutritional problem.”  Last year the Centers for Disease Control and Prevention reported that between 1980 and 2008, obesity rates had doubled for adults and tripled for children. During the past several decades, obesity rates for all population groups — regardless of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region — increased markedly. More than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are considered obese.

KP promotional brochure for its Oakland weight control program in 1973

The main reasons proposed for this alarming phenomenon include a more sedentary lifestyle, unhealthy diet, a proliferation in the use of sweeteners (first the “white death” sugar, eclipsed now by high-fructose corn syrup) in food products, and lack of exercise.

Even greater use of worksite microwave ovens during the 1980s was described as adversely affecting healthy eating habits. But other, more complex, causes have been proposed as well, and Kaiser Permanente has embraced a range of treatment modalities and education techniques to help keep members healthy.

Nutrition and health

Doctors advise patients to eat right and in moderation, with increasing medical evidence supporting the case that excess weight contributes to life-shortening conditions such as diabetes, heart trouble, and high blood pressure. Kaiser Permanente early on recognized that the changing dietary behaviors of its members were having a negative effect on waistlines.

Fast food chains, offering cheap high-fat, high-sugar, and high-salt meals, grew enormously during the 1960s and 1970s. Soon KP challenged this trend as an unhealthy one.  A 1987 Planning for Health newsletter posed the question, “Burger King, McDonald’s, Wendy’s, Jack-In-The-Box. Everyone is familiar with the names of these fast food restaurants. But how many of us are aware of the ingredients found in their food? Take a few moments to complete our Fast Food Facts quiz.”²

Mary Wheeler, PhD, with young Ohio patient enrolled in the Optimal Growth Center weight management program. KP 1979 Annual Report photo.

Influencing young people to eat a healthy diet and control their weight is crucial. In 1975, developmental psychologist Mary Wheeler, PhD, and pediatrician Karl Hess, MD, in KP’s Ohio Region started the Optimal Growth Center to help overweight children learn new eating habits. They addressed the social stigma of being overweight, with the long-term view that if they didn’t change their condition they would face significant risks of hypertension, heart disease, and diabetes as adults. ³

Education and outreach

As early as 1956, the Oakland Kaiser Permanente staff realized that peer groups could help people lose weight, and they instituted a group treatment program for overweight patients. In small, informal, round-table support groups of eight to 10 participants, physicians offered information and the group discussed mutual problems.

How much should you weigh? An illustration from "The Importance of Diet" in Planning for Health KP member newsletter, Spring 1965.

In the late 1980s, Kaiser Permanente Nutrition Services Departments hosted workshops for members on subjects such as “The Right Way to Good Nutrition.” One Health Plan member who benefitted from the program commented, “When I had a physical last fall, my physician said I was showing signs of arteriosclerosis (hardening of the arteries). After taking three nutrition workshops, I recently had another physical. My cholesterol count was down 20 points and I’ve lost 11 pounds.”⁴

One successful medium for reaching youth is KP’s Educational Theatre Project. For 25 years the troupe has used live performances at public schools to engage youth audiences on a range of health subjects, including childhood obesity in “1½” and “Give Peas a Chance.” In 2007 KP partnered with educational publisher Scholastic, Inc., to launch an online game based on another play, “The Amazing Food Detective,” teaching children about healthy eating and maintaining an active lifestyle. The game automatically shut off after 20 minutes and encouraged players to get up and exercise or perform some activity away from the computer screen.

Kaiser Permanente was also quick to acknowledge the role that gender and social (rather than medical) standards played in defining “desirable” weight.  Second-wave feminism of the 1970s challenged the standard guidelines, noting that women were particularly susceptible to exaggerated concerns about weight that could have negative health consequences of their own.

A 1984 KP Reporter article “Fear of Fat” asked: “Why have we saddled ourselves with an ideal of beauty which torments most women over the age of 20, not to mention many teenagers? One reason is purely commercial. Fifth Avenue has chosen human clothes-hangers who can model any style of clothing.” It goes on to say: “Kaiser-Permanente offers weight-loss programs that do not make a fetish about fat but rather stress good nutrition, exercise, and behavior modification.”

Obesity as a shield against attention

Another connection between self image and weight came out of research conducted by the Southern California Permanente Medical Group. In 1982 Vincent J. Felitti, MD, then a San Diego Kaiser Permanente internist, developed a program to help obese people lose weight, which matured into the Positive Choice Weight Loss Program in 1985. He was confounded by the observation that many of those who experienced success began to drop out. After studying hundreds of patients he learned that many were unconsciously using their obesity as a shield against unwanted sexual attention, a behavior based on experiencing physical or sexual abuse as children.

Subsequent research resulted in a comprehensive assessment protocol, Adverse Childhood Experiences (ACE), that examines the hidden legacy of childhood trauma and helps identify patients for whom conventional weight reduction programs don’t work. More than 17,000 San Diego KP members have been diagnosed using ACE and the study has produced 72 scientific publications thus far.

Home Box Office series premiers May 14

As Dr. Felitti describes it, “The program involves the essential linkage of two disparate elements: prolonged absolute fasting using the supplement “Optifast” to preserve health in the absence of food intake, and a psychodynamic approach whose function is to help each person discover the unconscious forces underlying their use of eating for its psychoactive benefits and the possible advantages of obesity in their life. Using this approach it is possible to reduce a person’s weight about 300 pounds in a year and help them tolerate that emotionally.”⁵

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) upcoming documentary series “Weight of the Nation,” which covers the issue of obesity in America. For more information about KP’s involvement in the fight against obesity: http://bit.ly/kptwotn

¹ “Obesity and its Measurements as it Relates to a Multiphasic Screening Program,” by Clarence F. Watson, MD; student paper from UC Berkeley public health class PH274A, Fall, 1965. Dr. Watson’s essay makes the case that “skinfold measurement” using calipers rather than BMI is a more accurate indicator of obesity.

² “Fast Food Facts,” Planning for Health newsletter (Richmond edition), Winter 1987-1988

³ “Helping Overweight Children,” KP Annual Report 1979

⁴ “The Path to Good Nutrition,” Planning for Health newsletter (Vallejo/Napa/Fairfield edition), Summer 1988

⁵ Email correspondence from Dr. Felitti 3/22/2012. For more about Dr. Felitti’s California Institutes for Preventive Medicine: http://www.caipm.org/about/index.html

But despite the heavily publicized advice of these powerful men – and God knows the urgings of our doctors – we find ourselves in 2012 with a startlingly high rate of obesity, overweight and resultant chronic illness, including heart disease and diabetes.

Understanding the connection between healthy living and good health didn’t come easy. Over the last 100 years, physicians and researchers have been studying chronic disease and looking for ways of saving and lengthening lives. They’ve made a lot of progress.

This “History of Total Health” series spotlights the milestones in the journey of scientists and physicians, including Kaiser Permanente practitioners, to help patients achieve Total Health, a concept KP has embraced since World War II in the Kaiser Shipyards. In five parts, we describe the evolution of knowledge of the causes of chronic disease and how it can best be prevented and managed. Below is the first part in the series.

– Ginny McPartland

Childhood artery changes may signal heart disease in later life

By Bryan Culp
Director of Heritage Resources

First in a series
In 1965, Martin Reisman, MD, a Kaiser Permanente pediatric cardiologist and clinical professor at UCLA School of Medicine, warned of the danger of a fatty diet in childhood leading to early onset of coronary heart disease. His supposition that this disease may begin in the young and that pediatric intervention is called for was not the prevailing view.

“The present standard American diet is a major contributing factor in the etiology of atherosclerosis [the fatty deposits of plaque that accumulate in arterial walls]. “The larger part of the ‘incubation period’ of this disease may very well be the first two decades of life, and a modest change in diet, instituted early and sustained through life, might be clinically significant.”

In the future, Reisman said, “our pediatric nutritionists will have to concern themselves . . . with the long term consequences of prevailing childhood diets.”  Studies of the disease “should begin to appear in the table of contents of our pediatric journals and on the agenda of our meetings and conferences.  It is time for us to join intellectually with our colleagues in adult medicine, and concern ourselves with a disease that is probably a mutual responsibility.”

The doctor confessed that his speculations though shared by a few pediatric cardiologists were a “personal groping in a yet incompletely charted field of possible pediatric responsibility.” ¹

Kaiser Permanente pediatric cardiologist Martin Reisman, MD, published in the Journal of Pediatrics in 1965.

Reisman’s warnings seem prescient today

If Reisman’s recommendations 50 years ago were “speculative,” they seem prescient today.  The alarm sounds on the incontrovertible evidence that empty calories and sedentary lifestyles have dramatically increased the incidence of overweight and obesity, a known driver in heart disease. One third of the nation’s young, ages 2 to 19, and two-thirds of the adults 20 years and older are overweight or obese.

The impact of overweight or obesity on the quality of life for both the young and older is real.  The afflicted often suffer from high blood pressure; higher rates of joint, kidney, and gall bladder disease; from issues in infertility; and higher rates of psychological depression.  Worse, overweight and obesity factor into five of the 10 leading causes of death in this country, including coronary heart disease, Type 2 diabetes, cancer, stroke and kidney disease.

“Obesity has become one of the most serious threats to the health of the American people,” says Harvey Feinberg, MD, President of the Institute of Medicine.  And Francis Collins, MD, director of the National Institutes of Health, has said that we must face this or “face, for the first time in our history, a situation where our children are going to live shorter lives than we do.”

Debate on nutritional intervention

In 1959, R.L. Holman, MD, titled his address to the Ninth International Congress of Pediatrics provocatively: “Atherosclerosis – A Pediatric Nutrition Problem?” He said any disease that is responsible for 54 percent of the deaths in the U.S. “is a pediatric problem, but whether it is a nutritional problem, I am not too certain.”

Citing autopsy studies, Holman traced the progress of the disease in a four-stage development starting in infancy with the presence of fatty streaks in the aorta; the development of fibrous plaque in the second decade of life; lesions and ulceration follow in the coronary arteries; then as early as the fourth decade of life, atherosclerosis and the onset of clinical manifestations like heart attack and stroke.

Absent in his concluding remarks are the words so familiar in today’s lexicon on coronary heart disease – mention of the preponderance of empty calories, and worrisome lipids and cholesterols in the blood.  Holman concludes saying fatty streaks in the aorta occur in infancy, are universal the world over, appear to be independent of ethnicity, and accelerate down the path to aggravation and illness beginning in puberty.  He offered no dietary recommendations in pediatric
care. ²

Isidore Snapper, MD, (1889 --1973) discovered benefits of a diet low in harmful cholesterols and rich in polyunsaturated fats. Photo courtesy of the Mount Sinai Hospital Archives.

Snapper compared Eastern and Western diets

There were others at the time who joined the debate citing evidence of the role of diet in the progression of coronary heart disease, prominent among them the irrepressible Isadore Snapper, MD, Chief of Medicine at Mount Sinai Hospital in New York City.  Snapper is remembered for throwing clinical light on the benefits of a diet low in harmful cholesterols and rich in polyunsaturated fats.

A physician of international reputation in service to royalty in his native Holland, Snapper was recruited by the Rockefeller Foundation in the 1930s to become chief of medicine at the University of Beijing where he did research and published on the  causes of cardiovascular disease.

In popular work, Chinese Lessons to Western Medicine (1941), Snapper contrasted the rates of heart disease among Chinese and Westerners, their different levels of blood cholesterols and attributed the cardiovascular health in the Chinese population to diets rich in plant foods.

In 1963 Snapper weighed in on the debate on the prevention of the disease in children in the American Journal of Cardiology.  If Holman were reticent on the effects of diet and nutrition in the onset of the disease, Snapper was anything but.  He said the disease could only be prevented early if a diet high in a ratio of polyunsaturated to saturated fat (P/S ratio) is “introduced in early childhood immediately or soon after the child is weaned, as is the custom in the Orient.

“The difficulties of the implementation of this proposal may well be insurmountable.  The myth that a daily intake of 800 cc of milk rich in saturated fats is mandatory for normal calcium metabolism can probably never be destroyed.  This, despite the fact that most clinicians today recognize that it is dangerous to encourage children to stuff themselves with milkshakes, ice cream and other foods with unsatisfactory P/S ratios.” ³

Debate among pediatric cardiologists continued in the 1960s

The debate among experts in pediatric cardiology on the role of diet and nutrition continued through the 1960s, and discussions continued on the pediatrician’s responsibility in preventing heart disease.

The American Academy of Pediatrics’ Committee on Nutrition took up for consideration the newly released “Report of the Inter-Society Commission for Heart Disease Resources: Primary Prevention of the Atherosclerotic Diseases” (1970) and issued its recommendations on it in 1972.

In its report “Childhood Diet and Coronary Heart Disease,” the academy concluded that dietary intervention was experimental at the time and recommended against sweeping changes in children’s diet.

“Unproven preventive measures should be tested first in a group at exceptionally high risk of disease,” the committee reported.  Though children at excess risk should receive preventive therapies, “a nationwide alteration in diet may well impair the sense of well-being of the general public.” ⁴

The academy’s caution surfaced a view within the pediatric community that early screening for heart disease risk may do more psychological harm than medical good.

Also in 1972, others were reporting research studies and looking up the road. “The technologic revolution has provided a surfeit of food at the same time that physical activity has been curtailed.  Eating habits, indolence and sedentary living habits, propensity to obesity, and possibly the cigarette habit” require pediatric intervention, wrote the authors of one study.

With food choices conditioned in childhood, they argued, “It would seem reasonable for pediatricians to counsel mothers on the feeding of a diet emphasizing skim milk, cottage cheese . . . legumes, fruits, starches, lean meats, poultry and fish.”

Citing evidence that atherosclerosis has its origins in childhood, the authors concluded that the prevention of obesity, early screening for lipid abnormalities, nutrition and diet intervention, the promotion of exercise, and the discouragement of cigarette smoking should involve the intervention of the pediatrician. ⁵

Bogalusa Heart Study confirms childhood diet and disease connection

Also in 1972, researchers at Tulane University School of Medicine launched what has become a definitive long-term study of the early natural history and development of coronary artery disease.  The Bogalusa Heart Study (1972 – present) has tracked vital data on children’s heart health in Bogalusa, Louisiana, a black/white rural community on the Louisiana/Mississippi border. More than sixteen thousand individuals have been tracked over three decades from infancy into adulthood. From the study emerges a clear picture of the beginnings of cardiovascular disease in the young.

Among the study’s key findings:

• Heart disease may begin in childhood and there is a clear relationship between diet and cardiovascular health;
• Autopsies of young participants who were killed in accidents provide clear evidence that fatty buildup forms in the aorta in the first decade of life with documented anatomic changes occurring by 5 to 8 years of age;
• Cholesterol levels are predictors of arterial plaque;
• Children who are overweight have a high risk of becoming overweight adults – excess weight tracks from childhood to adulthood;
• Obesity in children and adolescents is related to elevated cholesterol and elevated blood pressure and these track from childhood to adulthood. ⁶

Home Box Office series premiers May 14

The Bogalusa Heart Study confirmed pediatric responsibility in the prevention of coronary heart disease.  Though atherosclerosis is “a silent disease” with clinical manifestations occurring later in life, the pediatrician, as Dr. Reisman understood, should intervene with clinical guidance in sound nutrition, the control of overweight and obesity and recommendations for regular physical activity.

Sponsors of the series include Kaiser Permanente, The Michael and Susan Dell Foundation, the Institute of Medicine, the National Institutes of Health, and the Centers for Disease Control. For more about the “Weight of the Nation” series: http://bit.ly/kptwotn

Next time: Obesity: a runaway trend predicted to sabotage health of the nation

¹ Reisman M, Atherosclerosis and Pediatrics, Journal of Pediatrics, 66, no. 1, 1965.
² Holman RL, Atherosclerosis – A Pediatric Nutrition Problem? American Journal of Clinical Nutrition, 9, 1961.
³ Snapper I, Diet and Atherosclerosis: Truth and Fiction, The American Journal of Cardiology, 11, no. 3, 1963. See also Snapper I, Chinese Lessons to Western Medicine, Grune & Stratton, New York and London, 1941 and 1965.
⁴ Childhood Diet and Coronary Heart Disease, Committee on Nutrition, American Academy of Pediatrics, 49, no. 2, 1972.
⁵ Kannel, WB, et al., Atherosclerosis as a Pediatric Problem, Journal of Pediatrics, 80, no. 4, 1972. See also Voller RD, Pediatric Aspects of Atherosclerosis, American Heart Journal, June 1981.
⁶ Berenson, GS, et al., Atherosclerosis: A Nutritional Disease of Childhood, American Journal of Cardiology, 82 (10B), 1998. See also Tulane University Center for Cardiovascular Health, “History of the Bogalusa Heart Study, 1972-2005,” at www.tulane.edu/som/cardiohealth.

Oil House tourists enjoy the ambiance.

By Ginny McPartland
Heritage writer

It’s not quite ready yet, but a group of proud fans of Richmond, California, got an early tour of the resurrected Ford Company Oil House on the Richmond waterfront Saturday. The industrial brick building that once powered the Ford motor vehicle plant has been morphed into what promises to be a gorgeous visitors’ center for Rosie the Riveter national park. The center is scheduled to open to the public next month.

Evidence that construction crews planned to return after the party to finish their work was everywhere in the three-level renovated space, but no one seemed to care. Partygoers sipped sparkling wine and relished the fulfillment of a decade-old dream.

Cheers to the new visitors' center!

The Rosie the Riveter/World War II Home Front National Historical Park was established by an act of Congress in 2000. The National Park Service (NPS), the Rosie the Riveter Trust and many community groups have been working toward the opening of the visitors’ center since that time.

The park encompasses the Kaiser Richmond Shipyards and other World War II sites in the area. The restored Red Oak Victory ship, which houses a museum and gift shop, can be seen across the water from the old Ford plant.

Modern design for historical structure

The Oil House was constructed in 1931 as part of the Ford Motor Company Assembly Plant Complex (where tanks were manufactured during World War II). Although not shown in the complex original plans, the style of the building indicates it was designed by Albert Kahn Associates. “The construction, brickwork, industrial metal sash windows and detailing of the building clearly indicate that it was designed by the same architect,” explained the Rosie the Riveter Park Chief of Interpretation Morgan Smith.

“The function of the building was essential to the assembly line operation, housing multiple large oil tanks that fueled the boilers that, in turn, ran the steam powered conveyer system and equipment of the plant.” The lower level of the Oil House was only accessible through a tunnel from the main plant building and from a narrow enclosed ladder from the upper levels.

The Visitor Education Center to open in the refurbished Oil House will feature a theater, classroom and traveling exhibits. The park service’s goal was to create a modern facility yet retain the historical integrity of the original construction.

The reception at the Oil House was a preliminary to the annual Rosie the Riveter Trust Annual Dinner, a fundraiser for the national park. A number of Kaiser Shipyard workers attended the dinner and were recognized from the podium by Diane Hedler of Kaiser Permanente, vice president of the Rosie Trust board. John August, executive director of the Coalition of Kaiser Permanente Unions, was the keynote speaker. Jane Bartke, president of the Rosie Trust board, was chair of the event.

The dinner was staged in the Craneway Pavilion, formerly the Ford Assembly Plant, which was converted into an event space in 2008. Developer Eddie Orton and architect Marcy Wong won an American Institute of Architects national award in 2011 for the restoration of the 40,000-square foot Craneway, which also houses the Boiler House Restaurant.

Photos by Joe Paolazzi

The Craneway Pavilion was once the Ford Assembly Plant.

Mosaic artist Tina Amidon is a long-time Kaiser Permanente nurse who works at Oakland Medical Center in Oakland, California. Photo by Ginny McPartland

Most of us who grew up in the Bay Area were affected in some fashion by Henry Kaiser’s legacy: our parents or grandparents came here to work in his wartime shipyards, or we were influenced by the growth and change the massive migration brought. Untold numbers of us received medical care in the health plan that bloomed in the wake of it all.

Oakland Kaiser Permanente medical-surgical nurse and artist Tina Amidon is a product of the Bay Area and draws inspiration for her art from its diverse and dynamic culture and history. Her childhood in North Berkeley was influenced by artistic and outdoors-loving parents. That influence drew her to a nursing career that allowed her the freedom to pursue those pleasures while nurturing the resilience and intuitive powers she uses to create her art.

Recently she found herself immersed in a particular aspect of Richmond history that ties back to Henry Kaiser’s shipyards and Bay Area culture.

Her years of working in mosaics, producing large sculptural installations, culminated in October with the public unveiling of a commission for the Richmond Museum of History. From ceramic shards she collected along the shoreline that had been dumped by TEPCO, an El Cerrito dinnerware factory, she built a large diner coffee cup as a tribute to the East Bay’s working class tradition.

Fashioned as a love seat, the cup replicates one of the many styles produced by TEPCO in one of its more popular colors, Sunglow. Along with dozens of broken bits from cups and plates used at various eateries and clubs, the chair features photos of TEPCO workers at the old plant, framed by snaps from discarded pottery molds Amidon also found on the shore; and dinner plates from the Red Oak Victory, the Kaiser-built ship converted to a museum and docked at the former Richmond Shipyard No. 3.

Tina Amidon takes a seat in her mosaic coffee mug in the courtyard of the Richmond Museum of History. Photo by Fina Lloyd.

To Amidon, it forms a quilted narrative of the city, the shipyards and the lives of workers who enjoyed their time off in “the local restaurants and cafes where they spent their hand-earned money after work,” she said.

“This piece honors the men and women who not only worked at the TEPCO factory but built the ships and got their health care at Kaiser Permanente… They sipped their coffee at diners all over the Bay Area and at places like Trader Vic’s and Tad’s Steakhouse.”

And so did the rest of us who were around in the past five decades.

Sandi Genser-Maack and husband Lynn Maack, of Richmond, are TEPCO china collectors and can cite more spots that used Tepco: Mel’s Drive-In, Doggy Diner, Rod’s Hickory Pit, the old Villa De La Paix in Oakland; the Milk Farm on I-80 near Dixon, The Broiler in Sacramento, the Lau Yee Chee Restaurant in Honolulu, Louie’s Club in El Cerrito and the Cerrito City Club. Mama’s Royal Café in Albany still does and there are probably others.

Hundreds of commercial and fraternal establishments ordered dishes with customized logos in a selection of TEPCO colors and designs. The old West was a major theme for many eating places in the mid-20^th century and the U.S. Navy was a big customer, according to Genser-Maack. During World War II, she said, “all the Liberty and Victory ships that went to sea left with TEPCO.”

The Technical Porcelain and China Ware Co. – TEPCO’s official name – was founded by Italian immigrant John Pagliero and run by the family from 1918 to 1967. It was the largest dinnerware factory in the West and El Cerrito’s largest business to date.

Trash turned into treasure

Throughout the years, imperfect pieces were unceremoniously dumped, like much garbage at the time, along the bay shoreline where Amidon discovered them a decade ago while walking her dog near Point Isabel. It became her favorite collection spot for mosaic pieces, but it wasn’t until she attended a 2007 exhibition of the Maack collection that she saw her first intact TEPCO plate. She was surprised when she learned about the factory and its place in local history.

“I was able to piece together the whole story,” she said. Literally.

Fascinated by how cast-off items can create a narrative, Amidon says everything she creates tells some sort of story. A 2008 piece, “Allegorical Reliquary,” is a 12-foot-high, 8-by-10 foot roofless room that resembles an abandoned Irish chapel. It resides at Annie’s Annuals in Richmond where customers can amble through it as they shop for flower seedlings. The interior, which has water flowing down the walls inspired by the weeping walls of Zion National Park, features a lively pictorial of mosaics from found objects to tell simply of the joys and struggle of everyday life.

Nursing feeds artistic instinct

During her 22 years as a Kaiser Permanente nurse, Amidon has spent a lot of time listening, and what she’s heard has provided the fodder for the metaphorical tales told in her pieces. Currently she works part time in both Peri-op, giving pre-surgery patients vital instructions, and in the Ambulatory Surgery Unit, where she preps them on the day they arrive for the operation.

“There are all these stories you encounter as a health care person,” she said. “We see a lot of life that other people don’t see.”

Amidon grew up going to art fairs with her mother, a rakú clay artist, and spending a lot of time outdoors (her father was an economist for the U.S. Forest Service). “I would make little clay animals and sell them and that’s how I earned my play money. My mom worked very hard to prepare for all the fairs and I got an early look at the art life.”

In Berkeley High School, she started respiratory therapy training but later realized becoming a nurse would give her both a living and the autonomy to travel for the art education she sought. Over the years the quest for art knowledge has taken her to international museums and sights that inspire her imagery. Before focusing on mosaics in the early 1990s, Amidon worked on drawings and watercolors, lithographs, photography and making floor cloths.

Ideas come from everywhere

“I have tons of ideas. I take classes and figure out how to do things. That how my art always is. I just do it,” she says.

Amidon also relies on the expertise and support of her husband Jim, a mechanical technician at Lawrence Berkeley Laboratory. Married almost 30 years, the couple traveled around the world some 20 years ago and continue to travel, camp, and explore the outdoors. They are known for their travelogue slide presentations given at REI in Berkeley over the years.

Amidon’s first show in 1995 featured wall pieces made from broken china, called “Grandma’s Dishes.” She has since created larger work and has exhibited nationally. The TEPCO chair has been accepted into the Mosaic Arts International 2012, a juried show of the Society of American Mosaic Artists in Kentucky.

Her 2005 sculpture “Passion,” a stylized chair with a heart-shaped back, depicts all forms of strong feeling and is on view at the Stained Glass Garden on Fourth Street in Berkeley. Two wall pieces: “Don’t Smoke in the Garden,” an ashtray the shape of a flower, and “Live Long and Prosper,” a couple sitting inside a hand imitating the split hand sign from Star Trek, are at Snapshot Mosaics on LaSalle Avenue in Oakland.

Bringing art to the people

Not satisfied merely with creating art, Amidon said she is “always trying to draw an audience” and wants to involve more people, particularly the youth in Richmond, where she lives. Amidon enlisted the help of modern dance teacher Jacqueline Burgess and her class at El Cerrito High to choreograph performances that were big hits at both the unveilings of her reliquary (a container for relics) piece and the TEPCO chair.

With Arty Cordisco, the owner of Douglas and Sturgess, an art supply store in Richmond, she is working on a community art space and sculpture garden. Her goal is to pull the large numbers of artists who live in Richmond into a “Bohemian art network” of like-minded folks who can help energize the creative spirit in town.

Amidon encourages everyone to visit her coffee cup in the courtyard of the charming and informative Richmond Museum of History at 400 Nevin Ave. just down the street from the Kaiser Permanente Richmond Medical Center.

Medical Center employees and patients really have no excuse not to pay a visit, she says. Housed in the former Carnegie Library, the museum “is a gorgeous building in itself. You can see the history of Richmond from the native American Indians all the way to farm lands to the Kaiser shipyards,” she said.

“You just go out the back door (of the medical center). It’s two blocks…there’s a park. It’s a great place to bring your bag lunch and have a picnic. You can have your sandwich in my chair. I don’t care.”

YouTube film by Fina Lloyd, Heritage associate

Last in a series

Sam Sapin, MD, Southern California Permanente Medical Group quality pioneer

The story of Kaiser Permanente in Southern California could not be told better than through the life and career of Sam Sapin, a pediatric cardiologist who joined the medical group in Los Angeles in 1955. Sapin, a New York City transplant with a slight accent reminiscent of his roots, could have had a lucrative career taking care of wealthy patients in his native city. He had a thriving practice on Park Avenue before choosing to migrate to California.

He was lured to Los Angeles after hearing from friends about an innovative, albeit fledgling, group of doctors with a philosophy quite different from his fee-for-service colleagues in New York. Rendering proper and compassionate care to patients without having to consider their ability to pay sounded good to Sapin. So good, in fact, that after one brief visit to the West Coast, he and his wife, Jean, with their two small children, picked up and moved.

In the course of six decades associated with KP, Sapin has seen unimaginable changes, played many roles and helped to nurture the health plan’s phenomenal growth in membership, reputation, and influence in Southern California and in all its regions.

He’s had his hand in establishing and expanding programs in physician and patient education and research; he’s been influential in the creation and refining of quality assessment and improvement systems; and he’s been a trailblazer in KP efforts to ensure appropriate use of medical technology.

LA Center for Medical Education honors Sapin

Sapin received an Excellence in Medical Education Award in 2011 from the Thomas F. Godfrey Center for Medical Education. He was honored for his lifetime achievements, especially in promoting physician education.¹  In presenting the award, retired director of the center and fellow pediatrician KP Rudy Brody said: “Over the years no one has done more for Kaiser Permanente to advance medical education, research and quality than Sam.

“He was co-founder in 1955 and a long-standing member of the Southern California Permanente Medical Group’s (SCPMG) Pediatric Symposium Committee (which celebrated its 50^th symposium in 2008). Most importantly, Sam was a member of the Center for Medical Education’s Advisory Committee (1999 to present) that guided the center through its initial years.”

These accomplishments are really just frosting on the cake for Sapin whose main career focus has been to take care of newborns and older children with heart problems. His decades-long efforts in this realm have entailed finding groundbreaking ways to repair congenital problems so his often tiny patients could live healthier and sometimes completely normal lives.

In 1981, Sapin was the KP Southern California medical group's director of Research and Education.

As KP physicians have always been encouraged to do, Sapin quickly associated himself with academia and conducted and published research throughout his career, as recently as 2005.

“Shortly after I joined the group I applied for a teaching appointment at Children’s Hospital, just across the street, but I was never accepted, nor rejected, because I was one of those ‘Kaiser’ doctors,” Sapin said recently. “I then drove across town to UCLA, where I was welcomed, became an assistant professor of pediatrics in the Division of Cardiology, and eventually, a clinical professor.

Setting up pediatric cardiac ‘cath’ lab

“I was able to take our pediatric patients to UCLA, perform cardiac catheterizations, and have their cardiac surgery done there. In 1957, Pete Mahrer, Mt. Sinai trained (as Sapin was), joined our group. ²  The two of us set up a small cath (cardiac catheterization) lab at Sunset (KP Los Angeles Medical Center). The equipment was kept in a closet and rolled out into an X-ray room when available.

“We put on our red glasses half-hour before the procedure, to be able to see the fluoroscope in the dark. Pete helped me with the pediatric cases, and I helped him with the adults,” he said. In 1960, a diagnostic cardiac catheterization laboratory for pediatric and adult patients was opened at Panorama City, and Sapin served as director until 1982.

Sapin took on administrative duties when he became the chief of pediatrics at Panorama City in 1959. But he didn’t give up his practice, a decision he never regretted. “Fortunately, for me, I was able to practice until I was fully retired in 2000.”

As chief of pediatrics, Sapin founded the first Kaiser Permanente nurse practitioner program in 1964 and at one point oversaw the training of nurse practitioners. He held the chief position until 1972 when SCPMG Medical Director T. Hart Baker appointed him regional director of the Department of Education and Research, a department created to manage the growing education and research programs funded by the Community Services Fund.

In accepting his lifetime achievement award last year, Sapin recalled: “Seeing patients was very gratifying. On the other hand, my administrative career could sometimes be frustrating. Physicians, who’ve been trained to be problem-solvers and independent operators, can be resistant to change.

“Let me read to you, from a brief memo, which Dr. T. Hart Baker, our medical director at the time, sent out to doctors in May 1972:

“ ‘Dr. Sam Sapin has been appointed director of Research and Education. . . The location of his office and his telephone number will be forwarded to you as soon as a suitable location is found.’

“What I’d like to read to you now is the comment of some anonymous person – presumably a physician – who sent the memo back to me with the following suggestion scribbled on the back of it, in red ink, about a suitable location for my office, it read: ‘On Edgemont, behind garage at 1226 apartment house – go thru back yard, but beware of German Shepherd dog. (Go) up to second story – above chicken coops – and past the old EKG labs.

“Turn left, then right, knock twice and say Marshal. If a short fellow scratching his cheeks answers, turn back, you’re in Fontana! P.S. Dress at this office is casual – jeans and old shirt – since only orange crates and dirty Zolotone boxes are available for desks. Boots are a must, until the exterminators are through. Bring your own Xerox machine, since our last one fell through the loose floorboard. Also, a cheerleader’s megaphone will come in handy for long distance calls.”

Growth of research and education spawns new department

In 1982, Sapin was appointed SCPMG's associate medical director of Clinical Services.

In 1982, newly appointed SCPMG Medical Director Frank Murray founded another new department – the Department of Clinical Services – which subsumed Sapin’s responsibilities concerning research, education and quality. Murray appointed Sapin associate medical director of Clinical Services, which soon included divisions of research, staff training and medical manpower, quality of care, quality of service and appropriate use of technology.

In 1983, Sapin beefed up KP Southern California’s preventive medicine program by requiring each medical center to offer a core health education curriculum addressing chronic conditions and healthy lifestyle issues. Also as Clinical Services leader, Sapin formalized the Inter-Area Chiefs of Service Groups and required chiefs in all specialties to convene four to six times a year. “I thought this structure was essential to assure the delivery of a comparable quality of care throughout the region.”

By 1990, Sapin had served on the SCPMG board of directors for 16 years, as an elected representative from 1957 to 1966 and as a regional associate medical director from 1982 to 1990. He had won the respect of his physician colleagues and the adoration of his patients. In his last years before retirement from the medical group administration, Sapin had several invitations to size up his career and the changes he’d seen. One such opportunity was to speak before the annual meeting of the American Group Practice Association in Minneapolis in 1989.

What makes a successful prepaid group practice?

Rather than speaking just from his perspective, Sapin surveyed his SCPMG colleagues and presented the results in his talk titled “Managed Care – What Works in Groups.”

The survey identified six KP success factors: 1) integrated care design with doctors making medical decisions and KP owning its own hospitals; 2) people with a social purpose and ethics, commitment to high quality and peer review; 3) innovation, long-term planning, nonprofit financing plan, comprehensive care and affordable rates.

Sapin’s list continues: 4) ability to control costs due to ownership of facilities, purchasing power and physician extenders (nurse practitioners, etc.); 5) support from labor, business, academia and government; 6) reputation as a strong organization that is always there to provide care for significant illness. ³

Sapin, a tireless KP defender and passionate believer, summed it all up for his audience: “The right people with a good idea at the right time.”

In 1992 when health care reform was hugely topical and Sapin was retired and consulting for Clinical Services, KP quality leader Sharon Conrow asked him to draft what he thought Kaiser Permanente’s reform position should be. Sapin didn’t hesitate.

“I said, one, I think it should be a single-payer system . . . eliminating the fee-for-service idea. That it would be essentially the model that we have now, but with (ways to address) some of the things we had problems with. For example, when it comes to new technology, what should we invest in?” Sapin recounted recently.

“Now (2012), my recommendation for reform is to duplicate the Kaiser Permanente model. That’s what I’ve been saying. The more I’ve been looking and thinking about this, and all these intrinsic, built-in things that make us have to provide better care based on all the evidence, and so on, (the best structure for effective reform) is the model that we’ve built.”

KP sticks to original HMO model

Kaiser Permanente is the one and only health maintenance organization (HMO), the only managed care organization that fits the original and the current HMO definition, Sapin says. As conceived in 1971 by Paul M. Ellwood, Jr., famed health policy expert, an HMO consists of a multi-specialty group practice whose doctors contract with a nonprofit health plan to take care of patients on a prepaid basis.

Ellwood, who has influenced national health policy over the decades, is frustrated by the lack of progress on the health reform front. He said he originally intended HMOs to be nonprofit entities and to include structure to ensure accountability for quality of care as well as to contain costs, the main objective in the early 1970s as well as today.

“What went wrong?” Ellwood asks rhetorically in his 2011 oral history. His answer: “Political expediency in the initial plan designed to promote HMO growth led to the inclusion of three mistakes: for-profit plans, independent practice associations, and the failure to include outcome accountability.”

Ellwood’s sad assessment gives credence to Sapin’s argument that KP stands out as the model. Ellwood says of Kaiser Permanente and its pioneering physician Sidney Garfield: “Sid Garfield’s plan is 80 years old but it is still the gold standard.” ⁴

¹ The Center for Medical Education was founded at the KP Los Angeles Medical Center in October 1999. The center offers continuing education, residency and fellowship programs and rotations for residents and fellows from nearby medical schools. Its advisory committee draws members from the community as well as SCPMG.

² Sapin earned his MD from the New York University College of Medicine and completed a rotating internship at Mt. Sinai Hospital and his residency in internal medicine at the U.S. Veterans’ Hospital, both New York institutions. He took his internship in pediatrics at Bellevue Hospital in New York and his residency in pediatric cardiology at Mt. Sinai Hospital in New York City.

³ “Managed Care – What works in groups 1989 – A case study of successful HMOs,” Samuel O. Sapin, MD, presented at the Annual Meeting of the American Group Practice Association, Minneapolis, Sept. 15, 1989

⁴ “Paul M. Ellwood, Jr., MD, In First Person: An Oral History,” American Hospital Association, Center for Hospital and Healthcare Administration History and Health Research & Educational Trust, 2011

Kaiser Permanente's first stab at formal quality assessment, low-tech paper and typewriter hospital reviews by first woman hospital administrator Dorothea Daniels in 1962

Seventh in a series
In 1989, Southern California quality guy Sam Sapin, MD, made a prescient plea to KP leadership: invest in information technology to improve quality of care. Having worked on quality issues for decades, Sapin saw the need for a KP database to be shared among all regions.

“This would allow us to compare ourselves to each other,” Sapin told a gathering of KP quality professionals. He continued: “The data must be accurate, otherwise one loses credibility and effectiveness. The data must be timely, not two to three years old, because the environment changes quickly these days. . .We need to develop data that will show the outside world – the public, employers and legislators – how good we are.”

Twenty-two years later, KP is positioned to capture detailed patient data across all KP regions and to analyze it in many different ways to learn what’s working and what isn’t. With an abundance of data, KP can not only record adherence to best clinical practices, but also potentially figure out more precisely how treatment affects outcomes.

In 2002 when George Halvorson took over Kaiser Permanente as president and CEO, the Care Management Institute was well on its way to performing the essential function of developing and sharing best practices among all KP physicians. But Halvorson, acutely interested and knowledgeable about medical information systems, was not satisfied that KP was on the path to develop a patient data system that would support his vision for quality improvement.

Telling the story of how rich data helps to achieve quality improvement. KP experts contributed to this book edited by Louise Liang, HealthConnect leader. See below*

He brought in Louise Liang, a physician, medical director and quality professional who had worked closely with Total Quality Management expert Donald Berwick at the Institute for Healthcare Improvement (IHI). She led the program-wide monumental task of finding an appropriate vendor, figuring out the best software and driving the implementation of KP HealthConnect, ultimately the data collection and interpretation system that would transform Kaiser Permanente’s ability to assess and improve quality.

In 2005, KP reorganized its quality management structure, creating the KP National Quality Committee (KPNQC), which took the place of the Medical Directors’ Quality Committee. The NPNQC oversees all quality activities for hospitals, outpatient clinics, and outside care for all KP regions.

Value of data to quality measurement

Fully implemented in 2010, KP HealthConnect has the capacity to generate comparable data across all KP regions, thus enabling physicians and other quality analysts to measure and compare quality results from all of KP’s facilities. KP HealthConnect also can use data to perform a much broader range of research to feed the CMI’s search for data to validate and refine Permanente best practices.

KP's current CEO George Halvorson

“Having data is extremely important,” Halvorson told the editors of the NCQA 20^th anniversary report. “Whenever you have data you can reach conclusions and you can change process, you can re-engineer, you can make things better. But if you don’t have data, you don’t have any particular direction to go.”

He adds, “There is an evolution from process to outcomes, and measuring the mortality rate for different conditions is a wonderful measurement, sort of the ultimate definition of outcome. Measuring process is good, and a far better thing than not measuring quality at all, but organizations really need to focus on what happens to each person. How many people have failing kidneys is a great measurement.”

NCQA president validates KP success in quality improvement

In her 20-year assessment of NCQA’s success in improving quality of care, President Margaret E. O’Kane concludes: “Our hard work has led to many gratifying and exciting results. In Northern California, for example, Kaiser Permanente has demonstrated that aggressive management of patients with coronary artery disease (CAD) pays off in the most important ways: fewer deaths.

“CAD is the leading cause of death in every other county across the U.S., but for Kaiser (Permanente) patients in Northern California it is second. This confirms that when quality measurement and science meet, patients benefit,” she wrote.

KP’s electronic medical record system also makes it possible for physicians to access a patient’s full medical history anytime in any KP facility.

“You never ever have to make a clinical decision about a patient without information,” Andy Weisenthal, KP pediatrician and quality expert, told Charles Kenney, author of Best Practices: How the new quality movement is transforming medicine.” He adds, “I cannot tell you what that means to me as a doctor.”

Has Kaiser Permanente been successful in demonstrating its high quality of care? The abundance of accolades showered onto the KP medical care program over the past decade speaks for itself.

In the fall of 2011, KP received the highest rating in 11 effectiveness measures – more than any other health plan in the nation – in the 2011 NCQA’s Quality Compass results.

KP also won J.D. Power & Associates first place awards, as well as the prestigious Davies Award for KP HealthConnect, the patient data system.

KP also distinguished itself by garnering Medicare five-star awards in five regions, outstripping other health plans in California, Hawaii, Colorado and parts of the Northwest. Only nine Medicare plans in the country earned five stars for the overall 2012 Medicare star quality rating.

Next time: Sam Sapin: Southern California pediatrician’s career parallels KP’s quest for best quality

To learn more about KP current quality honors:

 http://xnet.kp.org/newscenter/pressreleases/nat/2011/091311himmsdaviesaward.html

http://xnet.kp.org/newscenter/pressreleases/nat/2011/101011ncqacaremeasures.html

http://xnet.kp.org/newscenter/pressreleases/nat/2011/101211medicarestarqualityratings.html

http://xnet.kp.org/newscenter/pressreleases/nat/2011/032311jdpower.html

*Louise Liang’s book is discussed in the Permanente Journal and is available on Amazon.com.