The U.S. Presidential Fitness Test was established in 1956 by President Eisenhower. It was discontinued in 2013 but reestablished this year by President Trump. Based on Donald Trump’s history, we can expect some changes to the various components included in the renewed Presidential Fitness Test.
The original test consisted of 7 items: (1) pull-ups, (2) sit-ups, (3) shuttle run, (4) standing broad jump, (5) 50-yard dash, (6) softball throw, and (7) 600-yard run. Children who scored in the 85th percentile in all events received the Presidential Physical Fitness Award. Times and priorities have changed since the Eisenhower era, so we should expect that the components of the revived fitness test will reflect the values of President Trump. Here are some of the possible exercises that could be included:
The competitive eating challenge. President Trump’s fondness for fast food is well known. He famously served the national champion Clemson Tigers football team $5,500 of fast food from McDonald’s, Wendy’s, and Burger King. This exercise will be based on the annual Nathan’s Hot Dog Eating Contest but instead of hot dogs, children will eat as many Burger King Whoppers as possible in 10 minutes.
The 50-yard flat foot dash. Donald Trump was able to avoid the Viet Nam draft because his doctor reported that he had heel spurs. This podiatry condition was quite an accomplishment for an 18-year old since heel spurs typically occur in older people as a result of a lifetime of walking on flat feet. For this exercise, children will tie pieces of 2 x 4 lumber to the bottom of their feet and run for 50-yards.
The 280 character thumb texting test. President Trump has a penchant for social media tweeting, first on Twitter (X) and more recently on Truth. During his first term, he made more than 25,000 tweets. Indeed, he has often touted his “TBBT” (two big beautiful thumbs) resulting from exercising those thumbs on his nightly tweets. In honor of the President’s profound thumb strength, children will be timed on how fast they can create a 280-character tweet on an iPhone 16, using only their thumbs.
Competitive tanning event. The President is proud of his orange hair and spray tan. In recognition of this, children will perform five 15-minute tanning treatments in a standardized Ergoline LED tanning bed. Children with the greatest change in skin pigmentation will eligible for the fitness award. Black and brown-skinned children will have the option of instead performing the orange hair dye competition with those most closely able to dye their hair to the President’s orange hue in 15 minutes becoming eligible for the award.
The 600-yard golf cart race. During his first term, President Trump played 261 rounds of golf and spent 1 out of every 3 days of his presidency at one of his golf courses. For this event, children will race Club Car golf carts on a 200-meter figure eight go-kart track. Those with the fastest times will be eligible for the award.
Monopoly board game competition. The President became wealthy by buying and selling real estate after inheriting $413 million from his father. For this event, children will start the Monopoly game with $413 million and those ending the game with the most money will be declared the winners. Cheating is permitted. Extra points awarded to any child who buys Greenland.
Tax evasion challenge. Despite having a net wealth of $1.6 billion, Donald Trump only paid $750 in federal income tax in 2016 and 2017. This remarkable feat will be memorialized in the new Presidential Fitness Test with a tax evasion event. Children will be given an IRS 1040 form, a Schedule A form, and a Schedule C form. From a starting annual income of $600 million, those children will be judged by who can generate the largest amount of tax deductions in 15 minutes.
The vaccination dodge event. President Trump is particularly fond of vaccine skeptics and anti-vaxxers. For this event, a basketball court will be used to define in-bounds and out-of-bounds areas. Ten children at a time will each be given a 1 cc syringe with a 22-gauge needle and attempt to jab as many of the other children as possible. The child receiving the fewest jabs after 10 minutes of play wins.
The ketchup bottle shot put. During the January 6th insurrection of Congress, Donald Trump threw ketchup at the White House walls. In honor of this event, children will throw 32-ounce bottles of Heinz ketchup. The longest distance wins.
Bobbing for tariffs. President Trump said that “Tariffs is the most beautiful word in the dictionary“. For this event, apples will be labeled with tariffs from 10% to 400%. The apples will be floated in a 50-gallon gold-plated tropical fish aquarium. Children will remove apples using only their teeth. Those with the highest amounts of tariffs in 2 minutes win.
The paper towel roll toss. After Hurricane Maria devastated Puerto Rico in 2017, President Trump visited San Juan to survey the damage. At a church, he tossed rolls of paper towels to the newly homeless citizens. For this event, children will throw paper towel rolls at a line up of ten Puerto Ricans from 20 yards away. Children hitting the most Puerto Ricans with paper towel rolls in 30 seconds win.
The donkey piñata. One of President Trumps favorite pastimes is bashing Democrats. For this event, piñatas in the shape of the Democrat Party mascot donkey will be made out of papier-mâché. Children will be blindfolded and then strike the piñata with a golf putter. The child causing the piñata to burst wins. Instead of being filled with candy and toys, the piñata will be filled with McDonald’s french fries.
The wall building contest. Using Lego blocks, the child who builds the tallest wall in 2 minutes wins. Extra points are given to children who get another kid to pay for the Lego blocks.
Jumping Donalds. The President considers self-aggrandizement to be an art form. As such, “jumping Jacks” will be modified as “jumping Donalds”. However, he believes the human body is like a battery – energy used is energy lost. For this reason, he doesn’t like exercising too much. Children will stand with their feet spread apart and clap their hands overhead without jumping. The child doing the fewest jumping Donalds in 1 minute wins.
Journalism trap shooting. President Trump is a staunch gun rights advocate, despite the fact that as a felon, he cannot legally own a gun himself. He recently instructed the Attorney General to allow citizens to carry rifles and shotguns in public in Washington, D. C. The President also has a strong distain for all journalists who do not work at Fox News. For this event, clay pigeons will be embossed with the emblems of all major news networks and newspapers (Fox News will be excluded). A trap shooting range will be set up on the National Mall, in front of the Washington Monument. Each child will be given a 12-gauge shotgun and 10 shotgun shells. Children hitting the most clay pigeons win. Double points are awarded if the child hits the clay pigeon embossed with the NPR emblem.
During his first term as president, Donald Trump had a body mass index of 30.4, putting him officially in the “obese” range of BMI. Indeed, he was the most obese president since William Howard Taft (1909 – 1913) who weighed in at 340 pounds. Given this plus President Trump’s frequently stated abhorrence of exercise, we should expect that the new Presidential Fitness Test to look very different from that originally envisioned by Presidents Eisenhower and Kennedy.
Recently, there has been political talk suggesting that the United States should make Canada the 51st state and buy Greenland from Denmark. Acquiring Canada would improve the health of the U.S. But acquiring Greenland would worsen the health of the average citizen. The reason? Greenland has the highest prevalence of cigarette smoking in the world.
Greenlanders smoke… a lot
This morning, I was giving our first year medical students their lung cancer lecture as part of their pulmonary course. Each year, I review the demographics of lung cancer and the demographics of cigarette smoking, the greatest risk factor for lung cancer. In the U.S., the states with the highest prevalence of smoking are those in the Mississippi River Valley and the Ohio River Valley. Worldwide, the country with the highest prevalence of smoking is the tiny Micronesian island nation of Nauru where 48.3% of adults smoke. But Nauru holds its distinction only because Greenland is technically not an independent country, but instead is an autonomous region of the Kingdom of Denmark. With a smoking prevalence of 60% of adults in 2018, Greenland would have the highest smoking rate in the world if it were an independent nation. In contrast, the overall prevalence of cigarette smoking in the U.S. is 12% of adults. The smoking rate in Greenland is nearly 3 times higher than West Virginia, the state with the highest prevalence of smoking in the U.S. at 21%.
About 15% of smokers will develop lung cancer. A much higher percentage will die from other smoking-related diseases, such as COPD, cardiovascular disease, stroke, and cancers in other parts of the body. Based on the numbers, about 1 out of every 10 Greenlanders is going to develop lung cancer, a much higher number than anywhere in the U.S.
Greenland’s life expectancy
The life expectancy from birth in Greenland is 71.3 years but there is a significant gender disparity: the life expectancy for men is 69.6 years and the life expectancy for women is 73.2 years. In the U.S. the life expectancy from birth is 76.4 years (73.5 years for men and 79.3 years for women). But there is tremendous variation between the 50 states with a life expectancy of 79.9 years in Hawaii to low of 70.9 years in Mississippi and 71.0 years in West Virginia (the only two states with a shorter life expectancy than Greenland).
The U.S. already has the lowest life expectancy of all developed countries. Acquiring Greenland would not improve America’s average life expectancy.
Greenland’s personal income levels
The median personal income in Greenland is $34,000/year. In contrast, the median personal income in the U.S. is $48,000. However, the cost of living in Greenland is approximately 25% higher than in the United States, meaning that the personal income in Greenland of $34,00/year can purchase the same amount of goods and services as $27,000/year in the U.S. Furthermore, Greenland is heavily dependent on support from Denmark with about one-third of Greenland’s revenue coming from Danish government transfers (about $700 million per year). Without this financial support from Denmark, the average personal income would drop by about one-third, to $22,000/year or the U.S. equivalent buying power of about $18,000/year.
To put that in context, the U.S. poverty level is currently $15,000 for a single person or $31,000 for a family of four. An American can qualify for Medicaid if their income is less than $20,783 (in other words, 138% of the poverty level). As a result, if the U.S. acquired Greenland, the average Greenlander would have an income low enough to qualify for Medicaid, when income is adjusted for the high cost of living in Greenland.
The good news is that the population of Greenland is only 57,000, making it smaller in population than all 50 U.S. states as well as Washington DC, Puerto Rico, Guam, and the U.S. Virgin Islands. Many Americans view Greenland is similar to Alaska but with Alaska’s population of 740,000, it is 13-times more populous than Greenland. However, Greenland is larger in geographic size at 836,000 square miles than Alaska at 665,000 square miles.
Acquiring Greenland would not be a good public health deal for the U.S.
There are several reasons why the U.S. would like to acquire Greenland – most notably for Greenland’s untapped mineral wealth and its strategic military location in the Arctic. But from a health standpoint, the U.S. would be acquiring a lot of future lung cancer if it were to buy Greenland. It would also be acquiring a population that would largely be dependent on Medicaid.
To buy Greenland means that you are buying the people who live there. And those people come with a lower life expectancy, higher smoking rate, and lower income than the rest of the U.S. With acquisition comes responsibility and that responsibility extends to healthcare.
Since the 2024 election, removal of fluoride from public drinking water has been proposed because of concerns that fluoride causes cancer. In this post, I will review the actual data about fluoride and cancer and will argue that fluoride should not be removed from public water supplies. The campaign for fluoridation was led by dentists and not physicians. Oral health is something that most physicians know very little about. Since dentists are generally not a presence in American hospitals, most physicians are unfamiliar with the reasons for or risks of fluoridation. But because physicians, and not dentists, are the experts in non-oral cancers, we need to be familiar with the fluoridation literature in order to knowledgeably participate in public health debates.
Fluoride is the anionic version of the element fluorine that is found in natural water sources. It is a common component of rocks and is the 13th most abundant element on the surface of the Earth. The amount of fluoride in natural water sources varies, depending on geographic location and the amount of mineral fluoride in local rocks and soils. For example, seawater averages 1.1 mg/L of fluoride and freshwater fluoride levels can range from 0.05 to 8 mg/L.
In the early 1900’s, dentists noticed that children in communities with high levels of naturally-occurring fluoride in the city water system had fewer dental caries than children in communities with low city water fluoride levels. Based on these observations, in 1945, the City Commission of Grand Rapids in Michigan voted to add fluoride to the city’s public water system. The rate of cavities in children born after fluoridation dropped by 60%. Shortly after, other U.S. cities as well as foreign countries added fluoride to drinking water and found similar reductions in the rate of childhood cavities. Overall, fluoridation reduces dental caries by about 25%. In 1951, fluoridation became an official policy of the U.S. Public Health Service. In 1962, the Federal government updated its drinking water standards to state that the optimal level of fluoride should be 0.7 to 1.2 mg/L. Fluoridation became a recommendation but not a requirement, allowing individual communities to decide for themselves whether or not to add fluoride to city water supplies. In some cities, the fluoride levels were naturally above 0.7 mg/L in water sources and it was unnecessary to add additional fluoride. However, the natural water sources for most U.S. cities have levels of fluoride below 0.7 mg/L and the majority of these cities add additional fluoride to achieve levels above 0.7 mg/L. The fluoride level in domestic water wells depends on geographic location, the depth of the well, and the geology of the rocks containing groundwater. About 15% of U.S. wells have fluoride levels above 0.7 mg/L. Currently, 77% of Americans have tap water that has the recommended 0.7 mg/L or more of fluoride, either because their water naturally contains enough fluoride or because fluoride is added to the municipal water supply.
Here in Ohio, a state law was passed in 1969 requiring fluoridation of city water supplies. However, individual cities could vote to opt out of fluoridation by a referendum. Lancaster, Ohio was one of the cities that voted to not add fluoride to the city water supplies. Lancaster is only about 30 miles from Columbus, so I had a lot of patients from Lancaster. For my patients younger than 60-years-old, I could tell if they grew up in Lancaster because when I would do physical exams, those from Lancaster always had teeth full of fillings or had lots of teeth removed. Those from other Central Ohio communities generally had pretty good teeth.
So, it is pretty clear that fluoridation reduces dental caries. And getting cavities in your teeth is not an entirely benign thing. Dental caries can affect quality of life by resulting in mouth pain, bad breath, difficulty chewing, and loss of teeth. They can also affect a person’s health by causing dental abscesses and chronic inflammation that in turn can affect children’s growth. They are financially costly, too – a dental filling to repair a cavity costs around $200 for silver amalgam and about $1,200 for a porcelain filling. If the cavity results in infection of the pulp of the tooth, the cost of a root canal is about $1,000. Since adults have 32 teeth, dental expenses can really ramp up in communities like Lancaster.
The reason the residents of Lancaster, Ohio voted to not put fluoride in the water supply was concern that fluoride causes cancer. This concern is also the reason why public figures such as Robert F. Kennedy, Jr. have advocated to ban fluoridation of water supplies. Most people would rather have a few cavities than have cancer, so what is the real story about fluoride and cancer.
Does fluoride cause cancer?
Fluoride is mainly taken up in the teeth and bones. Consequently, the cancers that have been suspected to be related to fluoride are bone cancers, particularly osteosarcoma. This is a relatively rare cancer, with a total of only about 1,000 cases per year in the U.S. The incidence of osteosarcoma has two peaks – one peak between the ages of 10-14 and a second peak in adults older than 65-years-old. Boys and men are affected with osteosarcoma more frequently than girls or women. Because of its rarity, studies about whether osteosarcoma is related to fluoride levels in water inevitably only involve very small numbers of subjects, making statistical significance difficult to achieve. Moreover, it is exceedingly difficult to be sure of the actual fluoride consumption by subjects in these studies since there can be significant variations in the amount of tap water a person consumes (as opposed to bottled water or other liquids), whether a subject’s tap water had a home filtering system, whether subjects had lived in multiple communities over the course of their lives with different levels of fluoride in the different communities, and the level of naturally-occurring fluoride in water systems that do not have fluoride chemically added.
Carcinogenicity studies generally start with animal studies and there have been several studies examining the effect of fluoride in drinking water in rats and mice. In one study, rats were given drinking water containing 175 mg/L of fluoride (250 times greater than the concentration that the Federal government has recommended for municipal water supplies). Four of the male rats in the fluoride groups developed osteosarcomas but none of the control rats developed osteosarcomas; female rats did not have an increase in osteosarcoma. With only 4 rats developing cancer, it is not really possible to establish a link between fluoride and osteosarcoma in rodents. A second study in rats two years later compared rats consuming drinking water with 250 mg/L fluoride (350 times greater than the recommended levels in municipal water supplies) and found no increase in osteosarcoma compared to control rats. Two additional studies in 1990 and 1993 fed rats and mice 25 mg/kg body weight and found no increase in the rate of cancer. Another study of mice fed high doses of fluoride found no increase in cancers. The bottom line is that there is no good evidence that even very high doses of fluoride causes cancer in rats.
Last month, a review of all of the scientific literature regarding fluoride and cancer in humans was published in the journal Bone. There have been 14 studies published – 12 of these found that fluoridation was not associated with bone cancer and 2 showed an increased risk of osteosarcoma in boys. Both of these latter two studies had significant flaws.
One human study had very small numbers of subjects – 12 boys under age 19-years-old developed osteosarcoma from communities with fluoridated tap water versus 8 boys developing osteosarcoma from communities without tap water fluoridation. These numbers are too low to make any confident conclusions about fluoride and cancer.
The other human study looked at 9 communities (3 states and 6 large cities) in the United States and determined the percentage of the population in each of those communities who had fluoridated water; for example, in Iowa (one of the states in the study), 70% of the population had access to fluoridated tap water whereas in Utah (also one of the nine areas in the study), only 2% of the population had access to fluoridated tap water. The study authors then looked at the incidence of various cancers in each of those 9 communities and did linear regression comparing the incidence of cancer to the percentage of the population with fluoridated tap water. They found a statistically significant relationship with osteosarcoma in boys – there was a higher incidence of osteosarcoma in communities with a higher percentage of the population having access to fluoridated public drinking water. This study has been cited by those opposed to fluoridation but what is usually not mentioned is that this same study found that prostate cancer, melanoma, lip cancer, and thyroid cancer were all less common in communities with a high percentage of population having access to fluoridated drinking water. So, if you use this study to conclude that fluoridation causes osteosarcoma, then you also have to conclude that fluoridation prevents prostate cancer. Furthermore, there are a lot of other differences between people who live in Utah versus those in Iowa – smoking prevalence, alcohol consumption, racial demographics, obesity, etc. and any of these other variables could just have easily been responsible. Another major flaw of this study is that it was based on the 1985 Fluoridation Census that reported the percentage of municipalities that added fluoride to public water supplies. Many public water supplies (particularly in the western U.S.) naturally contain high levels of fluoride and therefore do not add additional fluoride. So, in Utah, for example, 2% of the population were in communities where fluoride was added to the public water supply but we have no way of knowing how many of the other 98% of the population were in communities that naturally had enough fluoride in the water so that fluoridation was unnecessary. In other words, there is absolutely no way to know how much fluoride people in the different communities actually ingested.
Taken together, there is no convincing evidence that fluoride causes bone cancer in either rodents or humans. Since osteosarcoma is such a rare cancer, it remains possible that there is an effect on the incidence of fluoridation on osteosarcoma that is too small to detect in epidemiological studies. But given that existing negative studies have involved thousands of people, if there is a link between fluoride and cancer, it is incredibly minimal.
On the other hand, a recent meta-analysis found that tooth loss due to periodontal disease and inflammation doubles the risk of oral cancer. So, poor dental health may actually be a greater risk of getting cancer than fluoridation, especially since oral cancer is far more common than osteosarcoma.
Other sources of fluoride
The recommended daily consumption of fluoride to prevent tooth decay is 1 mg for young children and 3 mg for teenagers and adults. Foods naturally contain fluoride but only in very small amounts. For example, shrimp is one of the most fluoride-rich foods but only contains 0.17 mg of fluoride per 3 ounces. In order to get enough fluoride to prevent cavities, an adult would need to eat 3.3 pounds of shrimp every day.
Most toothpaste contains fluoride but since most people spit toothpaste out of their mouth after brushing, adults only get about 0.1 mg of fluoride per brushing. In order to get enough fluoride to prevent cavities from toothpaste, an adult would need to brush their teeth 30 times a day.
In the 1960’s, before our Columbus, Ohio municipal water supply was fluoridated, our dentist would administer fluoride gels directly to my teeth twice a year as a form of fluoride supplementation. However, the amount of fluoride absorbed is between 1 and 30 mg, meaning that a person would need to have fluoride gel treatments somewhere between three times a day and very 10 days, depending on absorption.
Fluoride is not usually included in most multivitamin and mineral supplements. However, fluoride supplements are commercially available and are an option for people living in communities that lack municipal fluoridation and for people dependent on well water when their water supply does not naturally have sufficient fluoride. Over-the-counter supplements containing 3 mg/tablet of fluoride are commercially available as are supplements available by prescription.
Arguments against fluoridation
Those opposed to drinking water fluoridation have posed a number of reasons why they believe that fluoride should be removed from municipal water supplies. The main argument has been the risk of osteosarcoma and as described above, this argument has largely been debunked. Fluoride opponents have also claimed that fluoride causes a plethora of other diseases including cognitive decline, arthritis, thyroid disease, brain damage, pineal gland damage, kidney disease, fluorosis, and impotence. These claims are dubious at best. For example, the studies suggesting fluoride reduces IQ all come from non-U.S. countries, such as India, where water supplies contain much higher levels of fluoride than in the U.S. (averaging 2.37 mg/L). No studies in the U.S. have shown that fluoride affects IQ.
The one argument made by fluoride opponents that does have merit is that fluoride ingestion can cause fluorosis. This is a condition where the enamel of the teeth can develop lacy white opacities (photo below) and in severe cases, the teeth can develop pits on their surface. Less than 1% of children ingesting fluoride develop severe fluorosis; however, a high percentage of children can develop mild or vert mild fluorosis. In the vast majority of cases, fluorosis is only a mild cosmetic concern but in very severe cases, it can require dental fillings when pits develop. However, the risk of getting a cavity requiring a dental filling by drinking non-fluoridated water is much greater than the risk of developing fluorosis severe enough to require a dental filling by drinking fluoridated water.
Dental fluorosis with white opacities at the tip of the teeth
Opponents also argue that fluoridation is unethical because individuals cannot opt-out of fluoridation – in other words, individuals do not have the freedom to choose whether or not to fluoridate their drinking water. Although communities (such as Lancaster, Ohio) are legally able to vote to not fluoridate water, the argument is that if a referendum fails at the voting booth, the minority who opposed fluoridation are being discriminated against by being forced to drink fluoridated water. Opponents also argue that fluoridation discriminates against low-income families because high income families who do not want their children to ingest fluoride can afford to buy fluoride-free bottled water whereas low income families are too poor to buy fluoride-free bottled water. Another option is to buy charcoal filters for drinking water. Household charcoal filters remove about 50% of fluoride from tap water. I have 3 charcoal water filters that range in price from about $1 for the charcoal filter in my coffee maker to $10 for the in-line charcoal filter in my refrigerator’s water dispenser to $15 for a charcoal-filtered water pitcher that I bought last year.
What would happen if fluoride was banned from municipal water supplies?
If fluoridation goes away, many Americans who are concerned about dental health, and in particular the dental health of their children, will likely purchase fluoride supplements. This will open up a whole new market for supplement makers and we will likely see multivitamins with fluoride on the store shelves.
But the majority of Americans will likely not purchase fluoride supplements. Because it is not possible to get sufficient fluoride from food sources or from toothpaste, these people will have about a 25% increase in cavities. Those cavities will either need to get costly dental fillings or the teeth will ultimately need to be removed. Because 88% of Americans have dental insurance, this will result in a considerable rise in dental insurance premiums. Because Medicaid covers dental care, the Centers for Medicare and Medicaid Services (CMS) expenses will rise, resulting in greater costs to taxpayers. Currently, 38% of American children get dental care through taxpayer-funded Medicaid or CHIP. Taxpayers would have to pay for a lot of fillings in these kids. Most of the 12% of Americans without dental insurance will need to have decayed teeth removed in the future unless they pay out of pocket to get dental fillings. The increase in dental caries in the U.S. will result in an increased demand for dentist services; the law of supply and demand dictates that this will result in increased costs for dental care until the supply of dentists can be increased.
The drinking water in many communities naturally contains more than 0.7 mg/L of fluoride. This is particularly common in the western United States. For example, there are hundreds of communities in Texas where drinking water naturally contains more than 1.0 mg/L of fluoride and several communities with natural fluoride levels exceeding 5.0 mg/L – these communities do not add additional fluoride to their municipal water supply. As noted above, about 15% of U.S. domestic wells have well water naturally containing > 0.7 mg/L of fluoride. Americans living in these communities would not be affected by a ban on supplementing fluoride in municipal water supplies. Similarly, anyone who gets their drinking water from well water would be unaffected.
So, should doctors care about fluoridation?
The American Dental Association and the American Academy of Pediatrics both recommend fluoridation of public water supplies in communities where the naturally occurring fluoride levels are < 0.7 mg/L. The pediatricians make this recommendation because dental caries disproportionately affect the health of children. The dentists make this recommendation in part because there are not enough dentists to fill the tens of millions of new cavities and perform the increased numbers of root canals resulting from fluoride removal.
There are several reasons why (non-pediatric) physicians should be concerned about banning fluoride from public water supplies. First, it will increase Medicaid costs as well as dental insurance costs to all Americans. Second, we’re supposed to be the nation’s experts in cancer and the medical literature has shown that there is no convincing evidence that fluoridation causes cancer or any medical conditions other than dental fluorosis (and having fluorosis is not nearly as bad as having cavities). Third, just because oral health is not taught in medical schools does not mean that oral health is any less important than the health of other parts of the body.
Back in the 1960’s, before public water fluoridation, Crest toothpaste ran TV ads featuring kids that proudly told their fathers after their dental check-ups: “Daddy, Daddy, I only had 1 cavity!” Today, most children’s dentist visits result in no cavities. The CDC reports that the average American child develops only 2 cavities in their permanent teeth during their entire childhood. Personally, I don’t want to go back to a time where having only one cavity at each dental visit was a reason to rejoice.
America’s rural hospitals are in peril and are closing at an alarming rate. The result is a widening in the divide between rural and urban health care. It results in patients having to travel farther for hospital services and forces doctors who perform those services to relocate to communities that still have a hospital. For physicians just completing their training and entering the medical workforce, joining a practice at a rural hospital can be a risky career move.
What is a rural hospital?
Rural hospitals tend to be smaller than urban hospitals. 48% of rural hospitals have fewer than 25 beds and an additional 18% have only 26-50 beds. Most rural hospitals are non-profit (56%) and 34% are owned by state or local governments. Critical access hospitals are a category of rural hospitals that have fewer than 25 beds and are at least 35 miles from the next nearest hospital. One way of improving the viability of a rural hospital is to affiliate with a larger health system. Currently, 56% of rural hospitals are affiliated and this number is growing every year.
On average, rural residents are older, poorer, and have more chronic conditions than urban residents. In addition, rural populations have a higher prevalence of cigarette smoking, obesity, and teen pregnancies. Rural hospitals tend to serve a population with a higher percentage of Medicare and Medicaid than urban hospitals. This payer mix gives rural hospitals an inherent disadvantage compared to their urban peers since hospitals lose money on Medicaid patients and at best break-even on Medicare patients. In states that do not participate in Medicaid expansion, rural hospitals generally have a much higher percentage of uninsured patients, leading to even greater financial stress.
Rural areas have fewer physicians per population than urban areas. For example, rural communities have 46 primary care physicians per 100,000 population versus urban communities that have 62 primary care physicians per 100,000 population. For medical specialty physicians, the difference is even more striking – 5 physicians per 100,000 in rural areas versus 30 physicians per 100,000 population in urban areas. The result of this is that rural primary care physicians often have to work outside of their comfort zone and treat complex medical conditions that would normally be managed by specialists in urban areas.
Together, these factors can make recruitment of physicians by rural hospitals difficult. The high percentage of Medicaid and uninsured patients can result in lower physician income. The lower density of physicians results in more frequent night call and difficulties arranging coverage for vacations and medical education conferences. The relative paucity of medical and surgical specialists results in primary care physicians frequently having to manage medical conditions that they are not comfortable with or trained to manage.
Rural hospitals are closing
The Sheps Center at the University of North Carolina monitors the health of our nation’s rural hospital system. Since 2005, there have been 192 rural hospitals in the U.S. that have either closed completely (105) or converted to only providing limited outpatient services (87). States with the most hospital closures in the past 20 years include Texas (25), Tennessee (15), North Carolina (12), Kansas (10), Missouri (10), California (9), Florida (8), Oklahoma (8), Alabama (7), and Georgia (7).
The Center for Healthcare Quality and Payment Reform reports that 700 more rural hospitals are in danger of closing due to financial pressures. This represents 30% of all U.S. rural hospitals. Leading the nation is Texas with 80 hospitals at closure risk, representing 50% of the rural hospitals in Texas. Of the rural hospitals at risk, half are at immediate risk of closure due to the severity of their financial problems.
To address the large number of rural hospitals that are closing, CMS began providing grants to vulnerable hospitals to shut down their inpatient units while preserving their emergency departments. In the past year and a half, 29 rural hospitals have converted to rural emergency hospital status. 6 of these are located in Mississippi, 5 in Texas, and 4 in Arkansas. This preserves emergency room care to rural areas but patients requiring inpatient admission must be transferred to a full-service hospital.
There are several reasons why rural hospitals are at higher risk of closure than urban hospitals.
Lower reimbursement from commercial insurance. This is the most important obstacle that rural hospitals face. Each hospital gets paid a standard amount from Medicare but independently negotiates rates from commercial insurance companies. A large urban hospital can afford to dedicate several staff members to contract negotiation whereas small rural hospitals generally cannot afford to maintain a payer contract department to research and effectively negotiate with the dozens of different insurance companies. Furthermore, large hospitals can leverage specialized services such as trauma center designation, cancer care, critical care services, and surgical specialties in order to get higher payment rates than small rural hospitals offering only general medical and surgical care. The net result of these factors is that rural hospitals get paid less than urban hospitals to manage similar patients.
Medicare Advantage Plans. The mantra of Medicare Advantage Plans (Medicare Part C) is “Just say no“. Medicare Advantage is a privatized version of Medicare where commercial insurance companies administrate Medicare benefits. One of the main ways that these companies are able to make a profit margin is by denying services and procedures. These can be prospective denials, for example, when a doctor asks the insurance company permission to obtain an outpatient CT scan. Or, they can be retrospective denials, for example, when a patient is admitted for a COPD exacerbation and the insurance company denies payment for the admission after the fact. Large urban hospitals (such as the Ohio State University Medical Center where I practiced) have entire teams of staff dedicated to appealing denials but small rural hospitals often lack the staff to do these appeals. As a result, small rural hospitals often do not get paid for medically necessary services that they perform.
Higher costs to deliver care. When it comes to delivering health care, there is an economy of scale. For example, a large urban hospital can run its CT machine constantly all day long whereas a small rural hospital may only use its CT machine for 2 or 3 patients per day. Considering the cost of equipment and personnel to run the equipment, this increases overhead cost.
Inability to bill for the highest paying DRGs. Hospitals are paid by Medicare and commercial insurance companies based on a patient’s diagnosis (DRG), not the actual hospital costs incurred during a hospital stay. The DRGs that pay the most to hospitals are typically specialized inpatient surgeries such as spine surgeries, organ transplants, and joint replacements. These are surgical specialties that most rural hospitals cannot provide since there are generally insufficient numbers of patients in their geographic area to fill a specialty surgeon’s clinical practice. As a consequence, rural hospitals are left with the lowest paying DRGs and end up transferring the patients with the highest paying DRGs to secondary and tertiary care hospitals in urban areas.
Rural hospitals are losing maternity care
Fewer and fewer rural hospitals have labor and delivery units. The result is that pregnant women in rural areas have to travel much further for their pre-natal visits and for the actual delivery of their babies. At urban hospitals, more than 70% of women live within 20 minutes of the hospital that they will deliver at. However at rural hospitals, more than 95% of pregnant women have to drive more than 20 minutes to reach their delivery hospital and 40% have to drive more than 40 minutes to reach the hospital.
Leading the nation in rural hospitals that no longer provide maternity care is Florida where 91% of rural hospitals do not provide maternity care, followed by North Dakota (79%) and Louisiana (75%). As with hospital closures, there are several reasons why rural hospitals are abandoning maternity care:
Lower reimbursement from commercial insurance. Once again, rural hospitals do not have the resources or leverage to negotiate as high of rates as larger urban hospitals. Furthermore, the higher percentage of patients with Medicaid in rural areas translates to poor overall reimbursement for maternity services.
Higher costs to deliver care. Maternity units also benefit by an economy of scale. A rural hospital that only does 100 deliveries per year still has to employ several full-time obstetric nurses and has to provide call pay for an anesthesiologist and pediatrician in addition to the obstetrician, family physician, or midwife who will perform the actual delivery. When the labor and delivery unit is empty, these staff still must be paid.
The need for a critical mass of obstetricians at any given hospital. Babies come at all hours of the day and night and someone has to be on-call to deliver them. In urban areas, obstetricians are usually member of large group practices and thus only have to take call one night a week or even less often. Small rural hospitals usually cannot support having multiple obstetricians on staff and consequently, rural obstetricians are on-call far more frequently than urban obstetricians. Even if a midwife or family physician takes call for the normal vaginal deliveries, there must be an obstetrician on back- up call to perform emergency C-sections when necessary. For these reasons, rural hospital practice is unattractive to many obstetricians.
Malpractice insurance. Obstetricians pay some of the highest premiums for medical malpractice insurance, especially in states such as Florida where premiums for obstetricians can be more than $200,000 per year. Whereas the statute of limitations for malpractice events is 1 to 5 years from the discovery of injury, for obstetricians, injury may not become apparent until later in the child’s life, resulting in malpractice suits that can be filed many years after delivery. Family physicians in rural areas often deliver babies but when they do, their malpractice insurance premiums can skyrocket, making it cost-prohibitive to obtain malpractice insurance just to perform 5 or 10 deliveries per year.
The U.S. has one of the highest infant and maternal mortality rates of all developed countries. The crisis in maternity care at our country’s rural hospitals contributes to these high rates. The CDC reports that the infant mortality rate is higher in rural counties (6.55 infant deaths per 1,000 live births) than urban counties (5.44 infant deaths per 1,000 live births). A recent study found that in 2019, maternal mortality is nearly twice as high in rural areas (82 deaths per 100,000 live births) than in urban areas (42 deaths per 100,000 live births).
What can a rural physician do?
The thing is that despite all of the doom and gloom about rural hospitals, we really, really need rural physicians. There are already significant health disparities between rural populations and urban populations. The elimination of maternity care at rural hospitals and the closures of rural hospitals will only exacerbate these disparities. Our nation’s rural physicians, and in particular rural primary care physicians, are the last defense against further worsening of health disparities experienced by rural populations. For physicians considering taking a job with a rural hospital, there are certain considerations that do not necessarily apply for jobs at urban hospitals.
Ask to see the hospital’s financial statements. Given the large number of rural hospitals that are closing because of financial reasons, you do not want to take a job at a hospital only to have that hospital announce it is closing 6 months later because it cannot meet payroll. If you don’t know how to analyze a financial statement, hire an accountant to decipher it for you.
Who manages prior authorizations and denials? If the hospital expects that you (the physician) will be responsible for doing all of your own prior authorizations and will have to appeal denials, then this is going to add considerably to your paperwork burden and uncompensated time.
Have a full understanding of what services and procedures you will be expected to do. Are you going to have to intubate patients? place chest tubes? place central venous catheters? If so, get training before you start the job.
Know what the back-up plans are. If there is a snowstorm and the medical evacuation helicopter can’t fly, what is the plan for managing a patient with a myocardial infarction? a stroke? a woman in labor with a breech baby? Telemedicine contracts with tertiary care hospitals can help provide specialized care when patient transportation services are not possible.
Get the call schedule details. If you are a general internist and the hospital tells you that you’ll be on call every 6th night, that may sound pretty good but if the other people sharing call with you are 3 nurse practitioners and 2 family physicians and you are the only one who knows how to do a thoracentesis, do a lumbar puncture, or manage a ventilator, then you are really on call every night. If you are the only pediatrician in the county, who is going to cover your patients when you are on vacation?
Does the state participate in Medicaid expansion? It is bad enough that rural populations have a higher percentage of Medicaid patients than urban populations but if you are being recruited by a rural hospital in a state that did not agree to Medicaid expansion, then you will be facing a potentially financially unsustainable uninsured patient population. States that do not participate in Medicaid expansion include Wisconsin, Wyoming, Kansas, Texas, Tennessee, Mississippi, Alabama, Georgia, South Carolina, and Florida. Not surprisingly, these are the states that have some of the largest numbers of rural hospital closures.
The crisis in rural hospitals is a symptom
Quick, what does the United States have in common with South Africa, Iran, Egypt, Nigeria, Pakistan, Afghanistan, Yemen, and Syria? The answer is that the U.S. is one of a small number of countries that does not offer universal health care. In fact, the U.S. is the largest country to not have universal health care and the only developed country to lack it. For sure, there are problems with universal health care but our system of dozens of different private health insurance companies that each independently negotiate rates with every hospital and every physician group in the country results in health care disparities and enormous administrative overhead costs.
These disparities and overhead expenses are glaringly obvious when it comes to our rural hospitals. These hospitals and the physicians who practice at them are facing an uphill battle that many of them will ultimately lose. It will take new and innovative health care funding systems to stop the bleeding of rural hospitals.
Yesterday, Ohioans voted fairly convincingly to keep abortion legal. The reason for most abortions in the United States is because of an unwanted pregnancy. The reason for most unwanted pregnancies is unintended conception. We keep wasting divisive emotional energy, political energy, and money on the end-result of unintended conception when we should be working together to fix the root causes of unintended conception. So, what can we do in Ohio (and in the rest of the country)?
Who gets abortions in the U.S.?
Abortion is common in the United States – nearly 1 out of every 4 (23.7%) American women will have an abortion before age 45. Data from the Guttmacher Institute shows that currently in the U.S., 46% of all pregnancies are unintended and of those, 34% end in abortion. The most recent data from the CDC shows that in 2020, there were 620,327 abortions in the United States. This is an underestimate of the true number because California, Maryland, and New Hampshire did not report abortion numbers to the CDC. The Guttmacher Institute includes data from all 50 states and thus its estimate of annual abortions is higher than the CDC’s. The Guttmacher Institute reported that in 2020, there were 930,160 abortions in the U.S. Every year. Overall, there were 198 abortions for every 1,000 live births – this works out to mean that 16.5% of all pregnancies end in abortion. Although the highest number of abortions occur in women in their 20’s, the highest rate of abortion occurs in adolescents. 1.5% of all women of childbearing age have an abortion. The majority of abortions (59%) are performed in women who already have children. In addition, 85% of abortions are performed in women who are unmarried and 49% are in women living below the poverty level.
Why do women get abortions?
A study in the journal BMC Women’s Health reported the most common reasons cited by women who underwent abortions in the United States. Most women (64%) reported more than one reason for undergoing abortion. The most common reasons were financial (40%), timing (36%), absence of a supportive partner (31%), and need to focus on their other children (29%). A study in the journal Contraception found that half of all women undergoing abortion were using some form of contraception during the month that they became pregnant with condoms being the most frequent method, followed by birth control pills.
So, how do we reduce the number of abortions without making them illegal?
In medicine, the key to curing a disease is to first determine the root cause of that disease and then treat the root cause, so that the disease never occurs in the first place. The same applies to hospital quality initiatives – you determine the root cause of a medical error and then correct that root cause so that the error can be prevented in the future. The problem with abortion in the U.S. is that we have focused most of our attention on the end result (abortions) instead of the root cause (unintended conception). Rather than contentiously facing off against each other over abortion, those who are in the “right to life” camp and those who are in the “right to choose” camp should unite on the common ground of reducing unintended conception. Here are some tactics that can reduce the number of unintended conceptions and thus reduce the number of abortions.
Improve insurance coverage for effective contraception. The most effective methods of birth control are sterilization, hormone implants, and IUDs. These methods are required to be covered by federal law, however, there is a legal exemption for churches, religious-affiliated schools, and religious-affiliated universities who can opt out of health insurance coverage of contraception for their employees. The opt-out initiative was led by the Catholic Church that still decrees that the use of contraception is a sin. Although this decree is largely ignored by U.S. Catholic women (99% of who use some method of contraception), it may contribute to Catholic women having a higher rate of abortion than mainline Protestant women and nearly twice as high of a rate as evangelical Protestant women and women of other religions. Ideally, all health insurance should cover tubal ligation, IUDs, vasectomy, and hormone implants. If health insurance provided by religious organizations does not cover contraception, then women (and men) should have access to alternative health insurance plans.
Improve over-the-counter contraception options. Condoms were cited as the most common method of contraception used by women undergoing abortion. Why were they used? – because they are immediately available to anyone over-the-counter. The problem with condoms is that they just don’t work very well – nearly 20% of women who rely on condoms are pregnant within a year. Fortunately, there is a new over-the-counter oral contraceptive pill (Opill) that will be available in early 2024. Hopefully, this will be followed by other over-the-counter oral contraceptives. The most effective contraceptive methods (sterilization, IUDs, and implants) are not amenable to over-the-counter sales since these methods require a procedure performed by a physician (or NP/PA).
Improve sex education in middle schools and high schools. In the United States, by age 15, 21% of American girls have had sexual intercourse. By age 18, 65% of females have had sexual intercourse. Sex education requirements vary by state and only 39 states require schools to teach sex education. The CDC recommends 20 specific topics be covered in school sex education classes, however fewer than half of high schools and fewer than one-fifth of middle schools provide instruction on all 20 of these topics. The majority of teens reported that they had not had any sex education prior to their first sexual intercourse. In public schools, sex education curricula are usually set by elected school boards and recently, those school board elections have become heavily politicized, especially by ultra conservative groups. In many home-schooled and religious-affiliated schools, abstinence is the only contraceptive method that is taught (if anything is taught at all). But here is the thing: ABSTINENCE AS A PUBLIC POLICY JUST DOES NOT WORK. Parents, if you have 3 kids then statistically, 2 of them are going to have intercourse before they graduate from high school. You may not be very happy about it but that is reality. Clearly, our schools can do better.
Fund organizations that provide sex education and contraception. Many abortion opponents advocate for defunding Planned Parenthood. This makes about as much sense to me as defunding the IRS in order to improve the federal deficit. Teenagers and adults in their 20’s need someplace to go to learn about contraception if they aren’t learning about it in their schools or in their homes. Furthermore, they need someplace to go if they don’t have health insurance, don’t have a regular healthcare provider, or don’t feel comfortable asking their doctor for contraception. If you really want to reduce the number of abortions in the U.S., then fund Planned Parenthood and similar organizations specifically to help prevent unwanted conception in the first place.
Promote the use of “morning after” pills. These are levonorgestrel-based medications that can be taken up to 5 days after intercourse in order to prevent pregnancy. They range in price from about $12 (My Choice Emergency Contraception) to about $50 (Plan B One-Step). Most are available over-the-counter and you can even have them delivered to your door within 30 minutes using DoorDash. We need greater public awareness of these products and greater societal normalization of their use.
Reduce fetal abnormalities. Although fetal abnormalities account for a minority of abortions, they are often sensationalized in the press. There are tangible measures that we as physicians can take to reduce fetal abnormalities and thus reduce the attendant abortions: ensure adequate folic acid supplementation, stop teratogenic medications (preferably before pregnancy), smoking cessation, and promotion of alcohol abstinence.
Optimize the health of the mothers. A minority of abortions are performed because the mother’s life is in danger. Although these conditions are sometimes unanticipated and unavoidable, they are often preventable with good maternal care. Ensure that hypertension is treated. Screen and treat gestational diabetes. Provide regular prenatal office visits. Focus on achieving a healthy weight, a healthy diet, and a regular exercise regimen (preferably before pregnancy). Counsel women of childbearing potential who have chronic diseases about the risks of pregnancy and the timing of pregnancy in the anticipated course of their underlying disease. Support community educational programs for mothers-to-be.
So, where do we go after Ohio Issue 1?
For those who voted against Issue 1, don’t despair, there is still much that you can do to reduce the number of abortions in Ohio by reducing unintended pregnancies. For those who voted for Issue 1, your work is just starting since legalization of abortion means that you now need to focus your advocacy efforts on availability of contraception and sex education. Abortions should not be felonies but they should be fewer. Reducing unintended conception is the way to do it.
The United States is leading the international pandemic of obesity. Once a child becomes obese, it is incredibly difficult to sustainably return to a normal weight as an adult. Is obesity due to genetics or overeating? There is increasing evidence that obesity changes our genes making both us and our children more susceptible to obesity. The explanation is in the science of epigenetics.
What is epigenetics?
The concept that our environment can change our genes is “epigenetics”. Each person’s genes are composed of a fixed sequence of the four nucleotide bases: adenine, cytosine, guanine, and thymine in our DNA. These genes are “read” in the nucleus of cells and the reading of the genes determines how and when to make various proteins. These proteins determine everything from our bodily appearance to how our organs function. But environmental factors can affect the structure of genes and how these genes turn on and off. There are three main mechanisms by which our environment can change our genes:
DNA methylation. A methyl group is a chemical structure that can be attached to our DNA. Adding a methyl group to a cytosine nucleotide is “methylation” which can turn on a gene. Removing a methyl group is “demethylation” which can turn off a gene. Our genes can become methylated or demethylated by various environmental factors such as chemicals, drugs, diet, and aging. Importantly, when a parent’s genes become methylated, their baby can inherit those methylated genes. In other words, our environment can change our offsprings’ DNA.
Image: NIH Common File
Histone modification. Histones are proteins that wrap around DNA. When histones are packed tightly together on DNA, they can cover up genes, making them unreadable. By adding or removing chemical groups from histones, genes can be turned on or turned off.
Non-coding RNA. The genes located in DNA tell our cells what kinds of proteins to make by creating mRNA (messenger RNA) molecules that function as the signal or template for ribosomes located in the cytoplasm of the cells to make those proteins. Some non-coding RNAs can inactivate mRNA thus short-circuiting the messages generated by our genes. In other words, the DNA sends out a signal to make a protein but the ribosomes never receive that signal.
Many different environmental factors can cause epigenetic effects resulting in disease. For example, smoking causes demethylation of the AHRR gene. Tuberculosis can cause increased histone aggregation that can turn off the IL-12B gene. DNA methylation of the BRCA1 gene can increase the risk of breast cancer.
One of the most famous examples of how epigenetics affects both people and their offspring was the Dutch famine of the winter of 1944-45. At the end of World War II, the Nazis blocked food to the Netherlands beginning in November 1944 until Allied liberation in May 1945. This resulted in a precipitous 6-month serious food shortage in the Netherlands and as a result, the typical caloric intake of Dutch citizens fell to 400-500 calories per day; 22,000 people died of hunger. The children of women who were pregnant during this famine had life-long health problems including a high rate of schizophrenia, heart disease, and type II diabetes compared to their siblings who were not in utero during the famine. Research 60 years after the famine found that these children (now older adults) had increased methylation of some genes and decreased methylation of other genes, indicating that when mothers were starved during pregnancy, their fetuses’ genes underwent methylation changes and these changes lasted the entire lifetime of the sons and daughters.
Epigenetics and obesity
Since 1975, the number of obese humans worldwide has tripled. Genetics alone does not explain why some people become obese and others do not. Studies have shown that genes linked to obesity such as the leptin, adiponectin, PGC1A, and insulin genes are regulated by methylation. There is growing evidence that obesity can cause DNA methylation. For example, researchers at the Medical College of Georgia reported in 2019 that in 1,485 subjects, obesity caused changes in DNA methylation that persisted over a 6.2 year period. It follows, therefore, that if a pregnant woman is obese, her child’s genes that regulate obesity can be altered and that alteration can persist for the child’s entire life.
For years, physicians’ recommendations for weight loss was straightforward: just take in fewer calories than you burn up. This led to a perception that obesity was simply due to the chosen behavior of the obese person – if they could just eat less and exercise more, they wouldn’t weigh so much. But many of my patients have told me that no matter how much they diet, they cannot lose weight. And those who do lose weight soon gain it back after a year or two. Epigenetics suggest that obesity is not simply due to a person making a conscious choice to eat too many calories and not exercise enough. Instead, it is due to changes in their genetic make-up.
The change to the majority of Americans now being overweight has resulted in a cultural normalization of obesity. But obesity comes with many health consequences that can reduce quality of life and reduce life expectancy. Obesity-related arthritis contributes to disability. Obesity-related diabetes contributes to heart disease. During the pandemic, COVID preferentially killed obese people. Just because everyone else is overweight doesn’t make being overweight right from a public health standpoint.
Epigenetic implications for reducing obesity
Another implication of the epigenetic basis of obesity is that we cannot just treat obese adults and we cannot just treat obese children who will later become obese adults. We need to think of obesity as a consequence of maternal conditions. If a woman is obese during pregnancy, then that woman’s child may be destined to become obese, regardless of the child’s diet after birth. In other words, the best predictor of whether a person will be obese as an adult may be whether or not that person’s mother was obese when she was pregnant.
Of even greater concern is that there is animal evidence that methylation of sperm and ova DNA can be passed on for multiple generations. If this is true with obesity, then it suggests that if your grandfather was obese because his DNA was methylated, then you are also more likely to be obese because you now carry that methylated DNA. If this is true, then the U.S. may be entering a vicious cycle of each generation getting more and more obese.
If our DNA can be methylated by environmental and nutritional factors, then it is likely that our DNA can also be demethylated with targeted therapeutic medications. By changing the direction of research into obesity treatments to focus on how we can pharmacologically manipulate DNA methylation of obesity-related genes, we may be able to develop more effective and more lasting treatments for obesity. The emerging field of genetic engineering could perhaps better be termed epigenetic engineering when applied to obesity treatment.
We should place a high priority for ensuring optimal maternal nutrition. The Dutch famine of 1944-45 shows us that maternal starvation is bad and recent research implies that maternal obesity is also bad. Both better nutritional education of women before pregnancy and better access to high quality nutrition before and during pregnancy are needed.
Because methylation of obesity genes early in childhood may persist throughout a person’s entire life, avoidance of excessive caloric intake by children is also critically important. The methylation research implies that once a person becomes obese, they are likely to remain obese. Prevention of obesity in childhood is likely to be more effective than treatment of obesity in adulthood.
What is the solution?
The new theoretic paradigm of obesity is that it is caused by (1) the amount of calories consumed, (2) the amount of calories burned, and (3) the modification of genes that regulate metabolism. Until we have effective ways of pharmacologically modifying methylation of obesity genes, we are left with the following tactics to reduce obesity in the U.S.:
Increase caloric expenditure. Our country has an epidemic of exercise deficiency. There are many social and technologic reasons for this: a shift from a physical labor workforce to a skilled labor workforce, increased reliance on automobiles and mass transportation, and increased sedentary television and computer screen time. Judicious exercise during childhood and even during pregnancy is warranted.
Decrease caloric consumption. During the past 75 years, the U.S. diet has shifted from home-prepared foods to highly processed foods. We have become increasingly reliant on fast food restaurants for a regular part of our diet. These are foods that are not only calorically dense, but they are also specifically taste engineered to make you want to eat more of them. Moreover, serving sizes have increased substantially in the past few decades. A major obstacle to weaning Americans off of fast food and highly processed food is that they are tasty, cheap, and convenient.
Treat obesity earlier in life. Given that DNA methylation can last a lifetime, we need to aggressively treat obesity early – in childhood and perhaps even in parents prior to conception. In this sense, adult obesity is really a childhood disease and needs to be treated as such. This means more aggressive pharmacologic and bariatric surgery treatments of obese children.
What can hospitals do?
Our nation’s hospitals cannot cure the obesity epidemic by themselves but they can set the right examples. Our hospital cafeterias can serve food with correct serving sizes. We can eliminate high-calorie soft drinks containing sugar in our hospital vending machines. We can avoid leasing space to fast food restaurants with calorically dense menu items on our hospital campuses. We can provide and promote comprehensive weight management clinics.
As physicians, we need to be more proactive discussing obesity with our patients in a non-judgmental way. We need to identify children whose growth curves show weight percentiles that significantly exceed height percentiles. We can become more comfortable prescribing medications to lose weight, not only for our adult patients but also our pediatric patients. And we can become community educators and advocates for better nutrition and obesity prevention.
It turns out that obesity is a lot more complicated than we thought it was just a few years ago. The prevention and treatment of obesity is also a lot more complicated. But just because a problem is complicated does not mean we should just give up and accept it as the new normal. We have to take a more multi-faceted approach to obesity treatment and start that treatment earlier in life. We need to take back control of our own genes.
Last month, I was giving the annual lung cancer lecture to our first year medical students. As part of that lecture, I discussed the demographics of cigarette smoking. American Indians have by far the highest rate of smoking and in 25 years, that will translate into the highest rate of lung cancer in the United States. As the medical director of an urban community hospital, I saw the results of racial healthcare disparities first hand. Our hospital’s demographic has a high percentage of Black and immigrant patients. These populations have a low rate of cancer screening, high infant mortality rate, and high rate of insufficiently treated chronic diseases. But the health disparities between Black and White Americans often get more public attention than the disparities between Indian and other Americans. We need to broaden the discussion on health disparities to include what is in many ways our greatest national health disparity.
Summary Points:
The greatest health disparities in the U.S. currently exist among American Indians
The prevalence of cigarette smoking is twice as high among American Indians compared to other racial/ethnic groups
Higher rates of cigarette smoking today will amplify health disparities in the future
We have the opportunity to reduce health disparities in the future by reducing cigarette smoking among American Indians today
When we talk about health disparities, we usually are talking about differences between the big 4 racial/ethnic groups in the United States: White, Black, Hispanic, and Asian. The group that gets less public attention is American Indian. For the purposes of this post, I will use “Indian” as a term of simplicity for Native American, Alaskan Native, and American Indian peoples. This demographic group is often lost in our discussions of American health disparities. A minority among minorities, American Indians comprise 1.3% of the U.S. population versus White (59.3%), Hispanic (18.9%), Black (13.6%), and Asian (6.1%) Americans (Native Hawaiian/Pacific Islanders comprise 0.3%). What disparities exist between American Indian and these other racial/ethnic groups?
Life expectancy
The United States has a relatively poor life expectancy compared to other developed countries. The OECD reports that in 2021 the average American life expectancy from birth was 77.0 years – slightly better than Mexico but slightly worse than China.
Within the U.S., there is considerable variation in life expectancy by race/ethnicity. The National Institutes of Health reports that the U.S. Asian population has the longest life expectancy at 85.7 years, followed by the Latino population (82.2 years), White population (78.9 years), and Black population (75.3 years). The lowest life expectancy is in the American Indian population at 73.1 years.
Chronic health conditions
The National Health Interview Survey has been conducted by the Centers for Disease Control annually since 1957. The most recent data is through 2021 and consists of interviews with 30,000 adults and 9,000 children. The Survey is one of the most comprehensive assessments of the current health status of Americans. Once again, we find that health and healthcare disparities disproportionately affect American Indians in the United States.
American Indians are much more likely to report having chronic medical conditions and chronic psychologic conditions than any other racial/ethnic group in the U.S. In addition, American Indians are more likely to report that they have overall poor health and to have some form of disability. They are more likely to have had at least one emergency department visit in the past year and are a close second to Hispanics in high percentages lacking health insurance. Suicide rates are also higher among American Indians than any other racial/ethnic group in the U.S.
COVID has uncovered preventative care disparities affecting American Indians. The vaccination rate (receipt of at least 1 dose of a COVID vaccine) is lowest among American Indians (77%) compared to White (87%), Hispanic (88%), Black (89%), and Asian (98%) Americans. Not surprisingly, the COVID death rate among American Indians (yellow curve in the graph below) is also higher than other American racial/ethnic groups:
Not only were American Indians more likely to die of COVID during the pandemic, but they were also more likely to be diagnosed with COVID and more likely to be hospitalized with COVID, according to a report from the CDC:
Smoking as a forecast of future health problems
As a pulmonologist, one of the public health metrics that concerns me the most is the prevalence of cigarette smoking. The health effects of smoking can be divided into those that affect people now and those that affect people 25 years from now. If a person starts smoking today, the main short-term health effects that they will experience are cough, bronchitis, and wheezing. For most smokers, these are minor problems and are consequently ignored so they continue to smoke. The greater health problems are those that occur decades later, namely lung cancer, COPD, and heart disease. The best reflection of this can be seen in the graph below that compares per-capita cigarette consumption to the death rate from lung cancer in the United States. Annual cigarette consumption peaked in 1965 at about 4,300 cigarettes per person in the U.S. The lung cancer death rate peaked 25 years later in 1990.
Smoking can kill people in a lot of ways other than lung cancer: heart disease, COPD, stroke, esophageal cancer, kidney cancer, and other cancers. Overall, about 1 out of every 5 deaths in the U.S. is related to smoking. Because of this, a woman who smokes a pack of cigarettes a day can expect to live 11 years less than a woman who does not smoke. Men who smoke a pack a day will live 12 years less than men who do not smoke. Overall, this works out to about 14 minutes of life lost for every cigarette smoked.
What this means is that people who smoke today will be dying from lung cancer, COPD, and heart disease 25 years from now. So, we can use today’s smoking demographics to predict the future’s health disparities. Today’s smokers are more likely to have a lower income and lower education level than non-smokers. Americans who have the lowest income are nearly 4-times more likely to smoke than those who make over $100,000 per year. Those whose education is limited to a GED are 10-times more likely to smoke than those who have a graduate degree:
The good news is that we have made great headway in reducing the percentage of cigarette smokers in the United States. Because 90% of smokers start smoking before age 18, much of the reduction in smoking prevalence can be attributed to preventing adolescents from starting to smoke in the first place. Currently, 14.1% of U.S. men smoke and 11.0% of U.S women smoke. This is a vast improvement from the 1960’s when approximately half of all American adults smoked.
However, smoking cessation and prevention efforts have not been uniform across all racial and ethnic groups. Here is where one of the most glaring health disparities exist with American Indians. The CDC reports that they are twice as likely to smoke as Black Americans and White Americans. They are three and a half times more like to smoke the Hispanic Americans and Asian Americans:
The implication of this is that 25 years from now, there will be even greater health disparities among American Indians, with much higher rates of lung cancer, COPD, stroke, heart disease, and other cancers compared to all other U.S. racial/ethnic groups. Furthermore, the life expectancy for Indian Americans (which is already considerably shorter than for White, Black, Hispanic, and Asian Americans) will be even shorter.
Why have we failed American Indian populations?
For many years, we’ve known that American Indian populations have a higher incidence of cirrhosis than other racial/ethnic groups and this has been attributed to a higher rate of alcohol abuse among American Indians. We now must face that the rate of other chronic health problems will also be higher in American Indians in the near future. How did these disparities come to exist?
As the first European immigrants arrived at our Eastern shores, they brought with them European diseases, such as smallpox and measles. An estimated 90% of Native Americans subsequently died of these diseases. Those who survived were pushed westward. As a consequence, most tribal reservations are located west of the Mississippi River and in the northern part of Alaska. These are largely remote, rural areas that distant from large cities. This also means being distant from higher paying urban jobs, distant from tertiary care hospitals, and distant from institutions of higher learning. Data from the 2021 U.S. census shows that the median annual household income for all Americans was $69,717. American Indians had a median annual household income of only $53,148. In contrast, Asian Americans had the highest median income at $100, 572. The U.S. Department of Eduction reports that American Indians also have the lowest college enrollment rate of all U.S. racial/ethnic groups at 19%. Asians had the highest college enrollment rate at 58%, followed by White (42%), Hispanic (39%), and Black (36%) Americans.
Health disparities in the U.S. are usually a consequence of discrimination. Discrimination against Blacks has its roots in slavery. Discrimination against Indians has its roots in geographic displacement. Discrimination against Asians backfired as I outlined in a previous post – the restriction of immigration to only Asian merchants and teachers in the 19th and early 20th century in the U.S. had the unintended consequence of an Asian American demographic that had a higher education level and higher income than other Americans (the intention of the Chinese Exclusion Act of 1882 was to prevent unskilled Chinese workers from competing with American-born U.S. citizens for labor jobs). The Indian Health Service is an attempt to overcome healthcare disparities but this has by necessity resulted in a “separate but equal” healthcare delivery system. Separate but equal did not work in the education of Black Americans in the 1950’s and it wasn’t working in 1913 when my grandmother became the first non-white child to attend Atlanta public schools.
So, what can we do?
Last month, at the end of my lecture to the medical students on lung cancer, I challenged them to address disparities in lung cancer. Specifically, I challenged them to address the high prevalence of cigarette smoking in the American Indian population. If we can reduce smoking now, we can reduce health disparities in the future.
On December 20, 2019, the United States Congress passed legislation amending the Family Smoking Prevention and Tobacco Control Act of 2009. This amendment raised the age that anyone can buy cigarettes to 21 years old in all U.S. states and on all tribal lands. This will help reduce the number of American Indians who start to smoke as teenagers. But cigarette smoking is often a symptom of employment and educational disparities so another way of reducing health disparities in the future is by improving employment and education today.
Historically, tribal lands were geographically distant from high-paying urban jobs. A silver lining of the COVID pandemic has been the normalization of working remotely and so we need to promote remote-working jobs to those living on tribal lands. An implication of this is that we need to prioritize high-speed internet access to these areas. Because many of the jobs that are amenable to remote work require education beyond a high school level, we need to eliminate barriers to higher education. Educational debt forgiveness is fiercely debated in political circles but if there is any one group that could really benefit by reducing the cost to attend 2-year community colleges and 4-year universities, it is those living on tribal lands. An 18-year old growing up in a U.S. city can live with his/her parents and commute across town to attend a public university at minimal cost but a 100-mile commute from a family home on tribal lands to an urban university is unrealistic. In addition, sustainable change has to come from within and effective reduction in smoking prevalence also requires engagement and advocation by tribal leaders.
All too often, public health is reactive, we wait until there is a health problem and then we react to that problem. We have a rare opportunity to make public health proactive… by reducing American Indian smoking rates today we can reduce health disparities in the future. When the ocean waters recede from the beach just before a tsunami, there are two kinds of people: those who walk around picking up newly uncovered seashells and those who run to high ground. There is a public health tsunami coming for American Indians, let’s not act like people on the beach picking up seashells.
Recently, there have been health concerns raised about gas ranges. This has led some cities to prohibit their installation in new homes, including Los Angeles, New York and San Francisco. I am interested in these health concerns for two reasons. First, as a pulmonologist, I want to be sure that the people in our community are safe from health risks. Second, I am getting ready to buy a new range for myself. So, what are the health risks of gas ranges and should you be worried about them?
The basics of cooking ranges
First, some definitions. Many people use the terms “range”, “stove”, and “oven” interchangeably. Technically, an oven is the enclosed box that you bake in. A stove is the surface heating area that you heat pots on. A range is when a stove and an oven are combined into a single appliance. Sometimes the term “cooktop” is used when the stove is separate from the oven. For the purpose of this post, I will use the term “range” for the appliance that combines an oven with a stove.
In the United States, there are essentially four types of ranges: electric, gas, duel fuel, and induction. Electric ranges work by passing an electric current through a metal coil that heats up as it creates resistance to that current. These electric coils (“burners”) can be exposed on the top of the stove or covered underneath a flat sheet of glass. Electric ranges also use electric heating elements inside the ovens. Gas ranges work by igniting a jet of natural gas. The resultant flame is used to heat pots and pans on the stove. Gas ranges also use gas flames inside the oven for baking purposes. Duel fuel ranges use gas flames for the stove to heat pots and pans but use electric heating elements in the oven for baking purposes. Induction ranges work by using electricity to create a magnetic field on the stove that then heats up any pot or pan placed on the stove that contains iron or steel. Induction ranges generally use a standard electric heating element in the oven for baking purposes.
For many years, electric ranges dominated the U.S. appliance market. However, gas ranges are preferred by many cooks because of the better control over the amount of heat generated, for example, allowing the cooking surface to instantly increase or decrease in temperature. Duel fuel ranges combine the advantages of the gas stove for surface cooking with the more even heating of an electric oven for baking. Induction ranges offer the advantages of using electricity, thus avoiding an open flame, while also offering the advantage of being able to instantly control the temperature applied to the pot or pan. Consumer Reports found that induction ranges out-performed electric and gas ranges in cooking tests.
As a general rule, when things burn, the resultant products of combustion are bad for our lungs. Whether that be burning cigarettes, military burn pits, house fires, or indoor wood/charcoal cooking. Natural gas is often called “clean-burning” because it does not produce visible smoke, unlike a wood fire or charcoal fire. However, just because we cannot see or smell the products of combustion from natural gas does not mean that those products of combustion cannot hurt us.
What is natural gas?
Natural gas is a type of fossil fuel produced by the decay of long-dead plants. It accumulates in large gas pockets deep underground and then can be removed by drilling gas wells into those pockets. The main component of natural gas is methane which in pure form, creates water and carbon dioxide when it burns. However, natural gas is not pure methane and instead contains small amounts of other gases and chemicals. The typical components of natural gas include:
Methane
Ethane
Butane
Propane
Hydrogen sulfide
Carbon dioxide
Oxygen
Nitrogen
Trace elements: helium, hydrogen, Xenon, and Neon
When natural gas is burned, these components produce new gases, including carbon dioxide, nitrous oxide, methane, carbon monoxide, formaldehyde, nitrogen dioxide, and particulate matter. Many of these gases can cause lung disease.
Carbon dioxide
It is estimated that a typical U.S. family cooking with a gas stove produces slightly less than a pound of carbon dioxide each day from the combustion of natural gas. This is about the same amount of carbon dioxide produced by coal or gas power plants to generate the amount of electricity required to cook using an electric range or an induction range. So, we don’t really produce more carbon dioxide by using a gas range but we do concentrate that carbon dioxide inside our homes. To illustrate this, I measured the concentration of carbon dioxide in my kitchen before and during the use of my gas range. At baseline, the carbon dioxide level in my kitchen was 646 parts per million.
After turning on 4 burners on the gas stove for five minutes, the carbon dioxide level increased to 1609 parts per million.
I then turned on the overhead exhaust fan for five minutes and the carbon dioxide level fell to 821 parts per million.
Carbon dioxide is a by-product of living animals. Our bodies normally produce carbon dioxide that we exhale with every breath. If the levels of carbon dioxide in our bloodstream builds up, it can be toxic to the human body. Similarly, if the level of carbon dioxide in the air increases and then we breath that air, we can suffer ill health. NIOSH considers breathing air containing over 5,000 parts per million over the course of a 10-hour day to be toxic and over 30,000 parts per million for a 15-minute period to be toxic. It would require cooking for a long period of time in a poorly ventilated kitchen to reach these levels using a gas range.
Carbon monoxide
Like carbon dioxide, carbon monoxide is produced when things burn. However, carbon monoxide is much more toxic to humans than carbon dioxide. It is an invisible, odorless gas. When inhaled, it tightly binds to the hemoglobin molecules in our red blood cells thus preventing oxygen from binding to those hemoglobin molecules. Without oxygen, the cells in our bodies suffocate. We all inhale small amounts of carbon monoxide from our environments so there are always low levels of carbon monoxide in our blood stream. Cigarette smokers have higher levels of blood carbon monoxide than non-smokers. Very high levels of carbon monoxide are fatal. This is how most people die in house fires or die by suicide from running their car in a closed garage. Lower levels of carbon monoxide can cause headaches, ringing in the ears, and confusion. Every house with a gas range should have a carbon monoxide detector installed.
Nitrogen dioxide
The air we breathe is mostly made up of nitrogen – it constitutes about 80% of the gases in air. Nitrogen gas is considered inert – it does not cause any direct harm to the body except when nitrogen dissolved in the bloodstream “boils” and creates nitrogen gas bubbles in the tissues when SCUBA divers ascend too rapidly and get the bends. But when gases are burned, pure nitrogen can be converted into nitrogen oxides. One of these is nitrogen dioxide, which can be very toxic and poses the greatest health risks to our lungs from gas ranges.
Nitrogen dioxide can also build up from decay of certain types of plant materials. In pulmonary medicine, an important result of nitrogen dioxide toxicity is in “silo-filler’s disease”. This occurs when nitrogen dioxide builds up inside of poorly ventilated silos storing silage. If a farm worker enters that silo and inhales high concentrations of nitrogen dioxide, the lungs can become injured. In the short-term this can result in ARDS (acute respiratory distress syndrome), where the lungs are damaged and fill up with inflammation and fluid, thus blocking air from getting into the lung’s alveoli (air sacks) where oxygen normally transfers into the bloodstream. In the long-term, small airways in lungs exposed to high concentrations of nitrogen dioxide can fill up with scar tissue, resulting in permanent blockage of air getting to the alveoli. This is called “bronchiolitis obliterans“. A famous event resulting in pulmonary nitrogen dioxide toxicity occurred in Cleveland in 1929. At that time, a fire arose in the Cleveland Clinic in a room where large amount of old x-rays films that were made of nitrocellulose were stored. The resultant nitrogen dioxide gas produced by the burning x-ray films resulted in 129 deaths, including one of the Clinic’s founders, Dr. John Philips.
In lower concentrations, nitrogen dioxide can irritate small airways causing asthma. This can be particularly insidious because nitrogen dioxide does not cause allergic reactions, unlike many allergic triggers of asthma such as cats dander or pollens. For this reason, most people with asthma worsened by nitrogen dioxide do not realize that it is their gas cooking range that is making them sick. A 2013 meta-analysis of 41 studies found that indoor gas stove use increases the incidence of asthma in children. A recent study estimated that 12.7% of childhood asthma is due to nitrogen dioxide and other by gases produced by gas ranges. Adults with asthma may be less affected by gas ranges than children based on a 2003 study of 445 subjects.
Formaldehyde
Every middle school student who accidentally opened the jar of preserved frogs in biology class knows how noxious inhaling formaldehyde is. It is another toxic by-product of natural gas combustion. Formaldehyde is also produced by burning cigarettes and can be released by wood adhesives in newly constructed houses. It is often one of the suspected culprits in patients with “sick building syndrome”. When inhaled, formaldehyde can cause eye irritation, nose irritation, throat irritation, and cough. Meta-analyses in 2010 and 2018 showed that environmental formaldehyde in homes is associated with asthma in children. Formaldehyde is also considered a carcinogen. A 2018 study found that using even 1 gas burner turned on low increased air formaldehyde levels above safe thresholds.
Particulate matter
Natural gas is often called “clean-burning” but that is not exactly true. Tiny particles (< 10 μm) of soot are produced when gas is burned, even if those particles cannot be easily seen with the naked eye. Breathing particulate matter can cause cough and worsened asthma. It is one of the main causes of respiratory symptoms when outdoor air quality is poor, due to air pollution. Some particulate matter is produced from food as it is cooked, however, gas ranges produce particulate matter even if there is no food being cooked.
Fire
Accidental house fires are another harmful consequence of gas ranges. It surprises me that there are not more of these. Spilled cooking oil or a dishtowel accidentally dropped onto an open flame can quickly develop into a kitchen fire. The National Fire Protection Association estimates that there are 179,500 fires due to cooking in the United States, accounting for 49% of all house fires. Ranges account for 61% of cooking-related house fires and 87% of cooking-related fire deaths. Interestingly, electric ranges are more likely to cause house fires than gas ranges. There is very little research in fire risk from induction ranges compared to electric or gas ranges but given that induction cooktops produce no heat if a pan is removed, it would seem that there would be less risk of fire if the induction range was accidentally left on after cooking. Grease fires may also be less frequent given the absence of a flame (gas ranges) or hot electric coil (electric ranges).
Fire is a particular risk for people with lung disease who require supplemental oxygen. As pulmonologists, we caution our patients to never use their oxygen in the kitchen when using a gas range. However, there is no risk of fire when using supplemental oxygen around an induction range.
Thermal injuries
Both electric ranges and gas ranges produce high heat. Small children who don’t know any better can get severe hand and finger burns from reaching up to an electric or gas burner. Even experienced cooks often burn their hands from accidentally touching a hot burner. Induction ranges substantially reduce the risk of burns. Only the bottom of a pot or pan gets hot; the surface of the range does not heat up. So unless a toddler touches the bottom of a pan, there is no danger of thermal injury with an induction range.
So, what are the downsides of induction ranges?
The main problem with induction ranges is that they are expensive. The cheapest electric or gas range is several hundred dollars less than the cheapest induction range. However, a provision of the Inflation Reduction Act to discourage gas ranges provides a tax credit of up to $840 to replace gas ranges with electric or induction ranges. This only applies to Americans with lower incomes. Those with middle incomes can qualify for a reduced amount of the tax credit while those with higher incomes are not eligible for any tax credit. Although induction ranges can be expensive, it is anticipated that prices will come down in the future as the market for induction ranges increases. Consumer Reports recently rated ranges and found that the top rated induction ranges cost about the same as the top rated gas or electric ranges. The least expensive of the top four rated induction ranges costs $1,200.
A second problem with induction ranges is that the bottom of pots and pans must contain iron or steel. Copper, purely ceramic, aluminum, and glass cookware will not work with an induction range. If you have to buy all new steel/iron plated cookware, it can considerably add to the cost of a new induction range. An easy way to determine if a given pot or pan will work is to see if a refrigerator magnet sticks to the bottom.
A final problem with induction ranges is that you cannot generate extremely high heat. This is especially a problem for restaurants using very high heat output gas flames for wok cooking. These high heat levels are generally not achievable with an induction cooktop. However, there are now “induction woks” being marketed that surround the wok bowl with an induction element, thus permitting cooking temperatures similar as can be produced using high-output gas burners.
“I have a gas stove. What can I do to reduce the risk of harm?”
If you have a gas range, the most important step you can take is to ventilate the kitchen. This can mean opening kitchen windows when the weather outside permits. If you have a fan that you can put in that window, even better. If you have an exhaust hood above your range, then turn it on when cooking. An exhaust hood that blows air outside is optimal. If a child in the house has asthma, then try to keep that child out of the kitchen when cooking. If you are unsure of how effective your kitchen ventilation is, you can buy a home CO2 monitor for about $80. If the CO2 level increases significantly when you are cooking, then your ventilation is likely inadequate.
A second way of minimizing harm from a gas range is to use other kitchen appliances for cooking instead of the range whenever possible. For example, an electric kettle can be used to heat water rather than boiling water in a pot on the gas stove. An air fryer can replace the use of a gas oven for many foods. And a slow cooker can be used instead of the range range for chili, stews, and soups.
“Should I switch out my gas range for an induction range?”
The short answer is that most people do not need to ditch their gas ranges if they already have one. However, if your kitchen is poorly ventilated or lacks an exhaust fan over the range, then replacing your gas range with an electric or an induction range may make sense. Also, if there are children in the house, the health risks of a gas range increase significantly, especially if one of the children has asthma or another lung disease. If someone in the home uses supplemental oxygen, then getting rid of the gas range can reduce the risk of a house fire, particularly if the oxygen-user does the cooking.
For climate-conscious people, changing gas to electric or induction ranges can appear on the surface to be the more responsible choice. However, if your local electricity producer uses fossil fuel power plants, then there really is not much advantage in electric or induction ranges since the overall CO2 production is similar. Here in Ohio, we can choose our electricity provider and for several years, I have purchased electricity from providers that only produce electricity from wind and solar sources. So for me, an induction range will result in less overall CO2 production than a gas range. People in other parts of the country where the electrical grid sources electricity from hydroelectric power-plants can also reduce their CO2 footprint by switching from gas to electric or induction ranges.
For me, I don’t have any lung disease and no longer have children in the house. I like breathing clean air in the home and I like to minimize my personal CO2 footprint. However, I also like the ability to easily regulate the cooking temperature that in the past was only achievable with a gas stove but is now achievable with induction stoves. We are building a new house and had to decide what kind of appliances to install. So, I just ordered my new induction range.
