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Healthy Eating (transcript)
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(Dr. Salgo)      
Welcome to Second Opinion, where each week our healthcare team solves a real medical mystery.  When we close this file in a half an hour from now you’ll not only know the outcome of this week’s case but you’ll be better able to take charge of your own healthcare and doctors will be able to listen to patients more effectively.  I’m your host, Dr. Peter Salgo, and you’ve already met our special guests.  So we’re joining our primary care physician, Dr. Lou Papa.  Lou, thanks for joining us again. 

(Dr. Papa)      
Good to see you again, Peter. 

(Dr. Salgo)
Now I’d also like to point out that Sue is here, who has a special relationship to Lou.  You’re his wife. 

(Sue)   
He’s my handsome husband, yes. 

(Dr. Salgo)      
Well he imposed upon you to join us and we’re grateful that he did.

(Sue)   
I’m very happy to be here.  Thank you.

(Dr. Salgo)      
Now no one, not Lou nor Sue or anyone else on this panel knows what’s in this case, so let’s get right to work.  Let me tell you a little bit about Ed.  Ed is in his primary care physician’s office.  And he’s in for a follow up on some lab work that he got during his annual visit.  Here’s what we know about Ed from the chart.  Ed is forty-five years old.  He’s six feet tall.  He weighs 213 pounds and does not consider himself overweight.  Blood pressure, 142/92.  He has a fasting blood sugar of 110 and normal for the lab that his doctor uses is 106.  Fasting triglycerides are 150, with a normal of less than 85.  Total cholesterol is 170 and his HDL is 45.  What kind of a picture are you getting about Ed?  How’s he doing? 

(Lou)  
I’m a little bit concerned at a couple of things.  One, his blood pressure is elevated.  Two, his fasting blood glucose, although it’s a little high, it’s also a little abnormal.  And that raises a concern in my mind.  And his HDL, or his good cholesterol, is lower than I’d like it to be with a correspondent increase in his triglycerides.  And that kind of paints a more worrisome picture to me down the road for him.

(Dr. Salgo)      
So what are you going to do for Ed?

(Lou)  
We’re going to give him an opportunity to improve his lifestyle.  Once we get an idea of what his lifestyle is like.

(Dr. Salgo)      
Now lifestyle.  Lifestyle.  Is that a code word here?  Is that because he weighs 213 and he’s 6 feet tall?

(Lou)  
It’s a whole package.  I mean your weight and your blood pressure, your cholesterol, your blood sugar, they all come.  They all travel in the same bus. 

(Dr. Salgo)      
I can tell you what his doctor told Ed to do.  His doctor says, Ed, take a Statin because your cholesterol is too high.  I’m going to put you on a blood pressure medication because your blood pressure is too high.  That doesn’t sound like what you were suggesting that you would do.

(Lou)  
 No.  I would say it depends.  It depends on a couple of things.  One, if this is his very first visit with the doctor we don’t have a history of multiple blood pressure readings.  We have a history of multiple blood pressure readings and there hasn’t been any attempt or there has been an attempt and it’s failed in improving this with lifestyle.  That may be appropriate. But at the first step I’m not sure.  I don’t think I would do that at the first step.

(Dr. Salgo)      
Well his doc thinks it a good idea.  He wants to give him drugs right away.  Would you have done that or would you say lose weight?

(John)
I think, it is like a lot of people where they’re in their late thirties, mid forties, and things are moving in the wrong direction.  So when to start a drug really depends on how much effort has been put into therapeutic lifestyle changes first.  And there is some risk in having somebody with a blood pressure of 140 to 150 as far as stroke, as far as heart attack.  So allowing someone a year or two years to change their lifestyle is probably too long because there is a risk of stroke that goes along with that.  But you certainly want to give him the opportunity to lose weight and to change his lifestyle.

(Dr. Salgo)      
Now Sue, you’ve had experience trying to lose weight.

(Sue)   
Yes.

(Dr. Salgo)      
Is it something that happens overnight, and do you think Ed can wait while he tries to lose weight if it’s going to take him a year or two?

(Sue)   
Well if I were Ed, I would say now wait a second.  Let’s try another avenue and try to figure out a way to rectify these problems whether it’s eating better, an exercise regime, and then really monitor it.  And I would not want to be thrown on the drugs right away.  I would absolutely not want to do that. 

(Lou)  
The key is here is you’re assuming that what we do with the drugs is harmless and drugs are not harmless. There’s a risk with them.

(Dr. Salgo)      
Let’s just take a look at this, alright, from a societal point of view.  Here’s Ed immersed in American society.  If you go to the supermarket what do you see?  You see diet food everywhere.  Low glycemic index food.  There’s sugar free food.  There’s eat this food high in fiber and lose weight.  Everywhere you look, everything on the shelf says eat me and lose weight.  That looks really easy.  If it was easy, and if it is easy, how come as a country we’re all overweight?

(Jessie)           
Well it is not easy.  And there are a lot of stressors that play into it including the availability of food.  And it certainly may not be healthful food for Ed. 

(Dr. Salgo)      
 Is the labeling on the food, on all these shelves, somewhat disingenuous.  You can have low fat food high in high fructose corn syrup.  You can have low calorie food high in fat.  I mean somehow or other how do you make sense of a label that’s designed to attract you and have you buy it and eat it. 

(Jennifer)        
Well I think that we do live in what’s been called the toxic environment for nutrition.  Food is plentiful to too many people.  And the types the foods that are out there are very confusing to everyone, nutritionists included.  And so, you know, it is a quagmire.

(Dr. Salgo)      
Sue, you’ve must have tried diets over years?

(Sue)   
Yes I have, Peter.  Yes, many.

(Dr. Salgo)      
And they failed?  Or they worked for awhile?

(Sue)   
Some were successful and then I can’t stick to a regiment of just pure protein, it drives me crazy.  And then the weight comes back on.  And certain stress factors will contribute to not really taking care of yourself.  I think it comes down to not really taking care of yourself.  I think it comes down to really taking care of yourself.  If you’ve got three kids and a dad that needs, you know, help all the time, you put yourself last, and that’s the hardest thing I think to overcome.

(Dr. Salgo)      
So you’re blaming Lou?

(Sue)   
I’m blaming Lou, of course.  But it’s just, there’s so many factors involved.  It’s just not are you eating the right things. 

(Dr. Salgo)      
Let me ask this in the broadest way possible.  Do diets work?

(Rick) 
I would like to sort of put in something that has been mentioned so far actually about diets.  And it helps in terms of lowering blood pressure, which is the Dash Diet.  And the Dash Diet is, you know, depending on what the patient’s already taking, I’d want to know what is the salt intake, how much protein, what fats the patient is taking in, how much fiber.  And the Dash Diet is readily available on the websites and that’s where I think not just assessing the diet but also finding out from the significant other, you know, what sort of foods are they eating at home.  Because this is not just an individual issue, it’s a family issue.

(Lou)  
I think diet’s a terrible term.  I don’t like the word diet because it suggests an acute intervention that’s going to pull away.  It really is healthy eating.  And there’s very good diets, the Dash Diet, the Lion’s Study, the nurse, the long term nurses study that show that healthy diets reduce your risk for disease.  That’s the, that one should be the primary thing that we’re looking at. And I think diets, as they call them, and watching the number of calories you’re taking in.  Watching the type of food you’re eating do work but it takes significant behavior change.

(Dr. Salgo)      
How obese are we, as a nation?

(Jessie)           
As a nation?

(Dr. Salgo)      
Yeah.

(Jessie)           
Well obesity, about a third of the adults are obese and overweight it’s sixty-six percent.  We are very obese.  And kids it’s sixteen percent of our children are now obese.

(Dr. Salgo)      
And this despite the fact that there’s always a diet book on the best seller list. 

(Jessie)           
But it is a.  As Lou said, it’s a diet book.  It’s a quick fix.  It is not a healthful eating pattern for life. 

(John) 
There’s no question that these dietary interventions will help.  The key question is how do you keep people on them for long periods of time.  How do you persuade them to eat something that they simply don’t like at the moment? 

(Sue)   
I agree.

(John) 
I think it’s underestimated how.

(Rick) 
Oh no, I agree with that.

(John) 
Unhappy people are when they change their diet. 

(Jennifer)        
And I think you need to look at the term diet.  It’s really derived from Greek and Latin and it means lifestyle.  Way of life.  And I think particularly we, in the United States, tend to narrow it down to just food selections.  You need to broaden it out.  You need to think it in long terms.

(Dr. Salgo)      
We know weight loss is calories in and calories out.  It’s a simple equation, right?  You eat less, fewer calories than you use, your weight will go down.  But you seem to be saying that if you eat healthy that’s more important than eating fewer calories than you expend.  Is it better to eat a healthy diet or simply to eat less food? 

(Jessie)           
And I think it depends.

(Dr. Salgo)      
Oh thanks.

(Jessie)           
Because.

(Dr. Salgo)      
That’s really…

(Jessie)           
But if you have.

(Dr. Salgo)      
Have you considered running for office?

(Jessie)           
If you have risk factors for diabetes, hypertension, and changing the food choices doesn’t change those risk factors and weight will.  We know that statistically that if you lose weight your blood pressure will go down.  Your diabetes will be better managed or your risk for diabetes will be lessened.  And so it does depend. 

(Rick) 
It really is if they can reduce the calorie intake and they can really control the weight.  I mean there’s plenty of evidence out there showing what you eat may not be as important as we think.  I mean there is the issue of, you know, having fruits and vegetables.  I agree with that.  But if you look at the composition of protein, fat, and carbohydrates the mix of, diets in terms of weight reduction don’t make too much difference.  It’s reducing your total calorie intake.  So if it comes down to that, it might be better actually for people just to reduce their calorie intake and keep their weight under control. 

(John) 
That is so much.

(Dr. Salgo)      
That would cost even less.

(John) 
Well so much of this has to do with, I think, simply with weight.  I mean we’re dancing around this a little bit because we’re lamenting at one point that the average Americans heavier.  More adolescents are heavier.  And then trying, at some point, to say that’s okay as long as they’re eating the right food.  I mean clearly the message we’re giving, and the underlying message here, is a lower weight will suggest less blood pressure, less diabetes. 

(Rick) 
Right, exactly.

(John) 
Yeah, so I don’t think we want to steer people into thinking that if you eat the right things that’s going to solve a lot of the problems. 

(Dr. Salgo)      
Now Sue, what kind of a diet do you eat today?  Are you eating a healthy diet?  In your view?

(Sue)   
That is what we try to do as a family. We do have a lot of fruits and vegetables at the house.  My husband is, well as you can see, he’s in very good shape.  He exercises a lot and he eats very healthy.  But we have like nuts in the house, which is very important for him.

(Dr. Salgo)      
Are those the kids or the food?

(Sue)   
(laugh) Oh, Peter. 

(Lou)  
Leave him all week. 

(Sue)   
We do have a lot of very healthy options sitting in our house right now.  And then of course, you know, Captain Crunch may come into the house now and then.  You know, depending on.  The kids can only take so much.  We really do try to focus on healthy eating.  And I know, I mean looking at me you wouldn’t think that and I’m not.  I don’t know what my problem is exactly.  I think it’s, again, putting myself last.  Not exercising enough, which of course I’ve tried to turn the tide with that right now.  But I do try to eat the healthy foods.  I do try to be conscious of what I’m putting in my mouth, even if it’s not the best.

(Dr. Salgo)      
What happened to your food bill when you started transforming your shopping into healthy foods?

(Sue)   
I think it definitely went up.  Because your fruits and vegetables are.

(Dr. Salgo)      
Which is important.

(Sue)   
Are going to be expensive.

(Dr. Salgo)      
I mean let’s be clear about this, right. You can slide into the drive through window at a given take out place, order food for six people and drive out again and some of them for ten bucks, fifteen bucks. 

(Sue)   
Right.

(Dr. Salgo)      
You can’t do that if you go to the health food store or even shop in the high end foods in the supermarket.

(Sue)   
That’s right.

(Dr. Salgo)      
Is it cheaper to eat fast food now and then worry about paying for meds later or is it cheaper to buy the good food now and avoid medical problems later in life?

(Jessie)           
No doubt about it.  It’s cheaper to spend it up front than all of the medical costs that happen from our chronic diseases of obesity, diabetes, and hypertension.

(Dr. Salgo)      
I’m not even talking dollars and cents.  There’s a human cost too. 

(Lou)  
Yeah.

(Dr. Salgo)      
But there are people who succeed at losing weight.  I mean.

(John) 
Absolutely.

(Dr. Salgo)      
I mean clearly it can be done.  So what.  What do we learn from people who actually succeed at losing weight?  What are the lessons you can take away from them?

(Jennifer)        
Well there’s a weight control registry that has shown people who have taken off weight and kept it off weigh themselves regularly, which is against some of the common knowledge that we were trained with.

(Dr. Salgo)      
And I’ve heard that you’re not supposed to do that.

(Jennifer)        
Well you need to keep track of where you are.

(Lou)  
Right. 

(Jennifer)        
Okay.  Now you don’t want it to get problematic where you’re lamenting every last little fluctuation but, you know, again looking at it over the long term.  They changed.  They’ve made a change in their diet.  Whatever it is, you know, hopefully healthy.  They exercise regularly.  Okay.  And so, you know these sorts of things they’ve learned from people who have taken it off and successfully kept it off. 

(Dr. Salgo)      
So those are some basic tips.  Let me tell you a little bit more about Ed.  Ed was surprised when his doctor told him that he needed drugs and then he decided I don’t want those drugs.  I’m going to lose weight instead.  To which, I guess, you would say good choice Ed.  He went on the Atkins Diet.  He said because he likes food I don’t want to starve is what he said. Is the Atkins Diet going to work for him?

(John) 
I think the Atkins Diet will succeed in having him lose weight, if you look at him six months or twelve months from now, because it’s a diet that for many people will allow them to be on a low calorie intake that they could sustain for a while.  If we compare it to other diets the outcome, even as far as looking at some measurements of blood pressure and cholesterol abnormalities are comparable.  But the question is, is the Atkins Diet something that he can stay on as a lifestyle change that he can maintain for years?  Or will he just bounce back up in weight like many people?

(Jennifer)        
You know, one of the most important things is that it’s something that the person believes in, that they can do, and that it won’t require a major, major change on their part.  That it needs to be doable.  It needs to be sustainable.  Anything that just steps it up a little bit or takes the food intake down. Matching that with the individual is incredibly important. 

(Dr. Salgo)      
Alright, let me stop for just a minute and sum up what we’ve been discussing.  And then we can go forward from this point forward.  Fad diets fail because they’re fad diets.  They have an end point and then what do you do.  Weight loss can only be achieved and maintained by a change in the way you’re eating and living permanently, including the way you eat, how much you eat, how much exercise.  And I guess what I take from you is that it’s somewhat personal, it’s got to be what works for you not what’s in the latest best seller.  Is that fair?

(Group)          
Aha.

(Dr. Salgo)      
Alright, let’s go further here.  Alright, let me tell you about Ed.  Ed did what he said he was going to do.  He went on the Atkins Diet.  It’s now nine months later.  He’s also exercising every day.  He’s lost twenty-four pounds.  And he comes back and it says here in the chart doc, it doesn’t really say doc but I’m assuming he says doc I love this diet because I don’t have to worry about fat.  I can eat all the meat that I want.  It’s been about nine months.  He’s lost twenty-four pounds.  Order of magnitude about a pound a week, a little less than that.  Is that a good rate to lose?

(Jennifer)        
Yes. 

(Jessie)           
It’s one of those rates that you’re probably going to keep it off.  If you lose it too fast, you aren’t.  He’s lost ten percent of his weight.  Statistically that will show he’s reduced his risk for diabetes and heart disease, probably had a significant change in his lipid panel and his blood pressure.  We don’t know that yet, but probably.  That’s usually statistically enough.
Dr.  Salgo:      
I want to go back for a minute, though. Ed, remember, is hypertensive.  And I have more family history that the chart was hiding from all of us until just now.  It turns out he’s got a family history of heart disease.  It’s not specified exactly what.  He’s on the Atkins Diet.  He’s eating red meat and that’s all over the media.  That’s bad stuff.  Cholesterol.  Are you happy with that?

(John) 
I’m not.  I’m not completely happy with that but the last thing we want to do when Ed comes in after nine months, having found a way to lose twenty-four pounds, which very few people do, is to bring Ed in and say we don’t like what you’re doing.  Ed has accomplished something that most people cannot accomplish.  He’s found a diet that matches his lifestyle. 

(Lou)  
And one thing.

(John) 
He’s found something that’s worked for him.

(Lou)  
Right.

(John) 
And I would encourage him through that rather than give him another burden.

(Lou)  
I would say that I would like to somehow transition him out of that diet.

(John) 
Why?

(Lou)  
Because there’s.  Because part of it gets back to what Rick was saying was, very often you have to look at the way they’re eating.  There’s not many studies that show eating that kind of diet is good for you. There’s many studies that show that eating a diet that’s not like that reduces your risk for vascular disease.

(John) 
So you’re going to risk putting him on something that may be a failure.

(Lou)  
The end point is to improve his health.  You know he’s losing weight.  The key is I’m not going to.  I don’t want to dampen his enthusiasm for this but I got to figure out a way to transition out of this.  One, because it has questionable benefit to his long term health. And two, you said it, it’s not sustainable. 

(Dr. Salgo)      
John, can I rat you out here.

(John) 
Yes.

(Dr. Salgo)      
Somebody told me a secret about you.

(John) 
Alright.

(Dr. Salgo)      
You gained weight.  Substantially while you were a house officer. 

(John) 
That’s right. 

(Dr. Salgo)      
So what did you do?  You obviously lost it. 

(John) 
Yeah.  So I did try many, many different of the standard healthy diets, which for my particular lifestyle did not work.  I was hungry all the time.  And for this reason I think it’s underestimated how difficult it is for somebody who is heavy to lose weight.  You’re irritable.  You’re always hungry.  You always have that feeling that many people with normal weight have right before they eat.  People around you tell you that you’re irritable.  You’re spending your whole day looking for food.  And ultimate diets, like a lower carbohydrate diet, Atkins, Zone, South Beach Diet, gives someone the ability to transition.  Now most people who are heavy they know that they’re heavy and they’ve tried to modify their diet using the standard approaches and have failed that.  And they need something different in many cases.

(Dr. Salgo)      
You went on a diet, lost weight. 

(John) 
Yep.

(Dr. Salgo)      
And you kept it off.

(John) 
And I have more.  And I should lose more so.

(Dr. Salgo)      
Sue, you’ve been on diets.  You’ve lost weight and you didn’t. 

(Sue)   
Aha.

(Dr. Salgo)      
Are you genes differently than Sue’s genes, is her genetics likely to be different than yours?

(John) 
I think it’s possible but I think it’s really an unknown.  We liked to be able to say that but I’m not sure that, it is just pure speculation whether there is such a, such a gene.

(Dr. Salgo)      
Now do you consider yourself healthy, Sue?

(Sue)   
I would say no, probably not.  My blood work has been good, knock on wood.  And I’ve been pretty lucky and I think that is definitely genetic where I’m protected whether I’m a woman.  But I know I can’t play that roulette game forever and I’ve got to, now, make changes.  And I am trying to do that, and I am exercising, and I feel so much.  Feeling better, just being more flexible, having more energy, is so.  That’s my motivator.  I’m feeling better. 

(Dr. Salgo)      
But once you’ve lost weight or you ascertain that you are where you want to be, should you at that time diversify your diet?  Search for a more healthy diet, if you will, then the diet that got you down to the weight?  Do you need to reset the thermostat to a maintenance diet? 

(John) 
I think optimally if there’s, if one can transition successfully to a more healthy diet that is a sure thing.

(Dr. Salgo)      
Well let me ask the sixty, forty, I guess in this era, the trillion dollar question.  What’s a healthy diet?  You use the term to find it.

(John) 
Yeah, I think it’s.  Well it’s a diet that we, as healthcare people, feel is healthy, which is high in fruits and vegetables, similar to the Dash Diet that was mentioned fairly low in sodium that we feel has the best outcome for people in the long run.

(Lou)
I mean a lot of diet studies are very difficult to do because of a lot of bias that’s built into them.  But a lot of the studies are very repetitive.  The Dash Diet, the Lions Diet, the nurse’s long term study, these studies show these diets that are high in fruits and vegetables, nuts, lean protein, fish. 

(Jennifer)        
Whole grains.

(Lou)  
Low in saturated fats.  Lots of grains.  It’s.  There’s a lot.  There’s a lot of.  There’s a ton of data on that. 

(Rick) 
There’s a ton of data but I want to come back to John’s point about diet.  Rod is saying what the.  It should be self referenced.  What’s healthy for you? 

(Dr. Salgo)      
I want to understand that I’m hearing you correctly.  That there is no objective good diet.  That is what’s good for you is Twinkies that’s good? 

(Rick)
No, no, no.  I’m not saying that at all.  I’m saying there are elements.  You can say what the ideal diet could be or range of diets because I don’t think you’re going to get any one single authority saying this is the diet.  There is a range of options as Lou nicely illustrated there.  Amongst those options, which ones do you think you can incorporate into your lifestyle in such a way that you can live with it over the long term. 

(Dr. Salgo)      
So you’re just talking.  You’re going to pick from an acceptable pallet.

(Rick) 
Yeah.

(Dr. Salgo)      
But the mix of that pallet is up to you.  Is that what you’re saying?

(Rick) 
Yeah.  And that, is something you’d spend time negotiating, see what you can do for that person.

(Jessie)           
And you have to spend that time because once people lose the weight what you see is congratulations you’ve lost the weight.  And we’re not spending that time talking to them about how to maintain it and how to transition from that weight loss.

(Dr. Salgo)      
Alright, let’s pause for just a moment here and sum up what we’ve been talking about.  We’ve really covered a lot of topics.  Once you’ve gotten down to your ideal weight, the quality of the food you eat becomes a little more important than the quantity.  Specific nutritional needs will have to be based on your medical history.  There’s an acceptable pallet of food you can choose from and that mix seems to be pretty much up to you as long as you work this out with your doctor.  Now I’ve got some more information for you about Ed.  Ed stayed on his diet.  Ed stayed on his exercise program.  And a year later he was still at the weight that he was at.  The twenty-four pound weight loss that he was at when he talked to his doctor.  However, it also says here that his lipid panel did not change, so he was put on Statins and they did that.  His blood pressure, however, did come down, and so he didn’t need a blood pressure medication.  So now he’s eating his new diet, his new lifestyle diet.  He’s exercising and he’s on a little medication, which seems to be what I think all you guys were talking about.   But I want to go back before we close to the grocery store here.  And about the confusion that people see because if you’re going to pick from a pallet of acceptable foods you got to know what’s acceptable.  And we hear these names that you see on packages, organic, whole, local, seasonal, vegetarian, free range.  I wrote them all down.  A grass fed.  What is a consumer to think?  Is it all bunk? 

(Rick) 
It’s a lot of marketing hype, unfortunately.

(Dr. Salgo)      
Bunk.

(Rick)
It’s predominantly bunk.  There’s.  There might be a little truth in it.  But I wouldn’t weight them.  You really have to look at the labels and see what’s really in it.  You have to do some research to find out. 

(Dr. Salgo)      
If you want to put a button on it, what’s a healthy diet?

(Jennifer)        
In my mind, it’s fresh, whole, plant based.  Okay.  Less processed, lean, low fat. 

(Dr. Salgo)      
And would you agree?

(Jessie)           
Yes. 

(Dr. Salgo)      
How are you doing?

(Sue)   
I’m good.  I’m good. 

(Dr. Salgo)      
Is your goal to lose more weight or to stay on this diet that you’ve got now?

(Sue)   
Absolutely.  Absolutely.   I realize it’s a long term effort.  I didn’t gain weight overnight.  Mostly, once I had my kids that’s when it really made it more difficult.  But, yeah, it’s the long term goal.  We’re going to, you know, keep eating healthy and definitely exercise.  My husband wants me to get out on that bike and ride on the paths with him. 

(Dr. Salgo)      
One last question.  Have you forgiven Lou for dragging you over here today?

(Sue)   
No. 

(Dr. Salgo)      
No, she has not.  You know, I really want to thank you for coming. 

(Sue)    Oh, it was my pleasure. 

(Dr. Salgo)      
And we really like Lou.  He’s great.

(Sue)   
I like him too.  We’ll keep him.

(Dr. Salgo)      
Again, thank you, all of you for being here.  It’s been a terrific show.  Let’s sum up what we’ve been talking about.  Diets fail, fad diets fail because they are diets.  Weight loss can only be achieved and maintained by lifestyle change and a change in the overall way you look at the diet that you eat.  Now once you’ve gotten to your ideal weight, the quality of the food that you eat becomes more important that the quantity.  Specific nutritional needs will be based on your medical history.  There’s an acceptable pallet of foods that you can mix and match to make you happy.  Our final message is this, taking charge of your health means being informed, and having honest communication with your doctor.  I’m Dr. Peter Salgo and I’ll see you next time on another Second Opinion.

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Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent locally operated and community based Blue Cross and Blue Shield plans supporting solutions that make quality affordable healthcare available to all Americans. 

Additional funding provided by...