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We Are Too Fat and It’s Killing Us. Obesity — America’s Number One Health Threat.


evolution of obesityBy Bob Aronson

Obesity may well be the greatest threat to public health ever, at least that’s the conclusion of a good many national and international health agencies ranging from the American Centers For Disease Control and Prevention (CDC) to the World Health Organization (WHO).

Too many people see obesity as a cosmetic problem and dismiss it as such.  It isn’t.  bad haircutA bad haircut is a cosmetic problem but a bad haircut never killed anyone.  Obesity can and does with great regularity.  Obesity is not about how you look, it is about slow suicide.

Before we get into the details it is important to define obesity.  According to the medical profession men are obese if fat makes up more than 25% of their body weight. Women are obese at more than 30% body fat.  In order to measure the percentage of body fat health professionals use a formula called the Body Mass Index (BMI).  It is based on height and weight (there is some controversy about the accuracy of BMI in some professional circles but that determination is best made by experts in the field and not by this author.  This link will give you more information http://healthland.time.com/2013/08/26/why-bmi-isnt-the-best-measure-for-weight-or-health/

The obesity epidemic is a fact, though, and will continue to be a problem regardless of how the BMI debate is settled).

  • A BMI of 18.5 to 24.9 is normal weight.bmi index
  • 25,0 ti 29.9 is overweight
  • 30.0 to 39.9 is obese
  • 40.0 and above is extremely obese

You can determine your BMI in private just by clicking on either of the two links below.

  1. If you want a simple BMI calculator click here. http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
  2. If you want a BMI that measures more and is more accurate, click here. http://www.healthstatus.com/calculate/body-fat-percentage-calculator

Studies indicate that nearly one in five US deaths is associated with obesity, which is nearly three times higher than previous estimates.  It is now thought that 34% of American adults are obese. Another 34% are overweight.

The preceding information is disturbing enough but even more upsetting is that fact that 17 percent of American children are obese. Another 15% are overweight.  That means that a third of our children have weight problems and you can bet that they will carry those problems into adulthood.

So – why worry about all of this, why is it important?  It is important because obesity kills. It kills just as sure as a 45 caliber bullet can kill, only it usually takes longer and the death can be painful and far more costly.  Bullets are usually mercifully quick.  Death by obesity is slower, much slower.  It creeps up on you, destroys your organs, debilitates, disables, depresses and costs far more than you can afford and then kills you anyway.  It is a long, hard and painful existence, but it can be avoided.  It’s not easy, but it can be avoided.

I am writing about obesity because it is a clear and present danger to everyone.  According to the National Institutes of Health (NIH) we run the risk of contracting any or all of the following when we ignore warnings about overweight and obesity..

Health Risks of Overweight and Obesity?

http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks

Being overweight or obese isn’t a cosmetic problem. These conditions greatly raise your risk for other health problems (this list has been edited.  To read all of it in detail click on the link above).

Coronary Heart Disease

As your body mass index rises, so does your risk for coronary heart disease (CHD). CHD is a condition in which a waxy substance called plaque (plak) builds up inside the coronary arteries and reduces blood flow to the heart thereby causing a heart attack or heart failure.

High Blood Pressureblood pressure cuff

Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps blood. If this pressure rises and stays high over time, it can damage the body in many ways.  Your chances of having high blood pressure are greater if you’re overweight or obese.

Stroke

Earlier we talked about a buildup of plaque in your arteries. Well, it can rupture, causing a blood clot to form and if that clot is close to the brain it can cause a stroke. The risk of having a stroke rises as BMI increases.

Type 2 Diabetes

Diabetes is a disease in which the body’s blood sugar, level is too high. In type 2 diabetes, the body’s cells don’t use insulin properly. Diabetes is a leading cause of early death, CHD, stroke, kidney disease, and blindness. Most people who have type 2 diabetes are overweight.

Metabolic Syndrome

Metabolic syndrome is the name for a group of risk factors that raises your risk for heart disease and other health problems, such as diabetes and stroke.

A diagnosis of metabolic syndrome is made if you have at least three of the following risk factors:

  • A large waistline. This is called “having an apple shape.” Having extra fat in the waist area is a greater risk factor for CHD than having extra fat in other parts of the body, such as on the hips.
  • A higher than normal triglyceride level (or you’re on medicine to treat high triglycerides).
  • A lower than normal HDL cholesterol level (or you’re on medicine to treat low HDL cholesterol).
  • Higher than normal blood pressure (or you’re on medicine to treat high blood pressure).
  • Higher than normal fasting blood sugar (or you’re on medicine to treat diabetes).Being overweight or obese raises your risk for colon, breast, endometrial, and gallbladder cancers.Osteoarthritis is a common joint problem of the knees, hips, and lower back. The condition occurs if the tissue that protects the joints wears away. Extra weight can put more pressure and wear on joints, causing pain or broken bones.Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.Reproductive Problems
  • A person who has sleep apnea may have more fat stored around the neck. This can narrow the airway, making it hard to breathe.
  • Sleep Apneasleep apnea
  • Osteoarthritis
  • Cancer
  • Obesity can cause menstrual issues and infertility in women.

Dementia

  • Recent studies show that obesity is linked with brain atrophy. This increases the risk of dementia as people get older.

I think we have pretty well established that obesity can cause irreparable physical harm, but it can cause mental and emotional problems that is just as painful.  For example:

  • Obesity makes life more difficult. It is harder to tie your shoes, fit in an airplane seat, or find a mate.
  • Obese people are stigmatized by society. Many normal weight people look down on obese people.
  • Employers discriminate against obese people in hiring, pay increases, and promotions.
  • Obesity is a cause of depression in women.
  • Obese children rate their quality of life as being even lower than do children who have cancer.

Space does not allow for us to delve farther into adolescent or child obesity but it is a significant problem and we will tackle it in another separate blog.

So now we know about obesity and its effects.  Now let’s look into how we get that way and what can be done about it.

The problem and the solution to it seem simple.  All you have to do to maintain a healthy weight is to burn up as many calories as you take in. That’s not easy because some people burn calories at a different rate than others. The problem is that few pay any attention to the number or nature of the calories they consume.  Furthermore, even fewer people pay any attention to the trade-off of burning them up.

The secret to maintaining a healthy BMI is to be calorie conscious.  You should know what you are consuming and how much exercise or activity it takes to burn it off.  For example, if you go to a professional football game and eat just one of their hotdogs you will consume about 250 calories.  In order to get rid of 250 calories you would need to walk for about an hour (see calorie/exercise ing caloriescalculator and other calculators here  https://www.fitwatch.com  If this particular link does not satisfy you just Google calorie calculators and you’ll find dozens of free apps for your phone, tablet, PC or Mac).

Obesity does not come on overnight.  No one goes to bed fit and in good shape and awakens as a morbidly obese person.  The process is gradual and can be stopped at any point along the way if you do two things; 1) Eat right and 2)exercise.  That’s all, eat right and exercise.

Most of us live very busy lives and feel as though we don’t have time to cook so “Fast food” becomes a way of life, but there are faster healthy foods that you can prepare for yourself that won’t add inches to your waistline.  Try some of these or google “Healthy nutritious and fast food recipes” and you are bound to find something that appeals to you.  This site, for example, is very helpful. http://www.eatingwell.com/recipes_menus/collections/quick_healthy_dinner_recipes

Nearly everyone I know has some kind of a sweet tooth. Some have it more than others but almost everyone likes a little “Sweet” now and then and a little might be fine but we just don’t seem to be able to handle just a little.  Well, you’d better learn how.sugar

In September 2013, a bombshell report from Credit Suisse’s Research Institute brought into sharp focus the staggering health consequences of sugar on the health of Americans. The group revealed that approximately “30%–40% of healthcare expenditures in the USA go to help address issues that are closely tied to the excess consumption of sugar.”  The figures suggest that our national addiction to sugar runs us an incredible $1 trillion in healthcare costs each year. The Credit Suisse report highlighted several health conditions including coronary heart diseases, type II diabetes and metabolic syndrome, which numerous studies have linked to excessive sugar intake.

According to Medicine Net http://www.medicinenet.com/script/main/art.asp?articlekey=56589         Each American consumes one hundred and fifty-six pounds of added sugar.  That’s 31 five pound bags of sugar according to the U.S. Department of Agriculture (USDA). Imagine it: 31 five-pound bags for each of us.

In the U.S. diet, the major source of “added sugar” — not including naturally occurring sugars, like the fructose in fruit — is soft drinks. They account for 33% of all added sugars consumed, says Kristine Clark, PhD, RD, a spokeswoman for the Sugar Association. Clark is also director of sports nutrition in the athletic department of Penn State University.

Anne Alexander, editorial director of Prevention and author of The Sugar Smart Diet provided this explanation of what sugars can do to your body.

 Glucose

  • It seeps through the walls of your small intestine, triggering your pancreas to secrete insulin, a hormone that grabs glucose from your blood and delivers it to your cells to be used as energy.
  • But many sweet treats are loaded with so much glucose that it floods your body, lending you a quick and dirty high. Your brain counters by shooting out serotonin, a sleep-regulating hormone. Cue: sugar crash.
  • Insulin also blocks production of leptin, the “hunger hormone” that tells your brain that you’re full. The higher your insulin levels, the hungrier you will feel (even if you’ve just eaten a lot). Now in a simulated starvation mode, your brain directs your body to start storing glucose as belly fat.
  • Busy-beaver insulin is also surging in your brain, a phenomenon that could eventually lead to Alzheimer’s disease. Out of whack, your brain produces less dopamine, opening the door for cravings and addiction-like neurochemistry.
  • Still munching? Your pancreas has pumped out so much insulin that your cells have become resistant to the stuff; all that glucose is left floating in your bloodstream, causing prediabetes or, eventually, full-force diabetes.

Fructose

  • It, too, seeps through your small intestine into the bloodstream, which delivers fructose straight to your liver.
  • Your liver works to metabolize fructosei.e., turn it into something your body can use. But the organ is easily overwhelmed, especially if you have a raging sweet tooth. Over time, excess fructose can prompt globules of fat to grow throughout the liver, a process called lipogenesis, the precursor to nonalcoholic fatty liver disease.
  • Too much fructose also lowers HDL, or good cholesterol, and spurs the production of triglycerides, a type of fat that can migrate from the liver to the arteries, raising your risk for heart attack or stroke.
  • Your liver sends an S.O.S. for extra insulin (yep, the multi-tasker also aids liver function). Overwhelmed, your pancreas is now in overdrive, which can result in total-body inflammation that, in turn, puts you at even higher risk for obesity and diabetes Robert Lustig, an endocrinologist from California gained national attention after a lecture he gave titled “Sugar: The Bitter Truth” went viral in 2009.  www.youtube.com/watch?v=dBnniua6-oM

Fruit and Sugar substitutes

There are two questions associated with sugar that must be addressed, one has to do with the safety of sugar substitutes and the 2nd with fruit.

Stay away from sugar but eat more fruit! Huh?  Fruit is loaded with sugar so how can it possible be good for you?  Here is the definitive answer. EAT FRUIT! And here’s why.  While fruit does contain sugar it is digested and burned farfiber filled fruit differently than is the sweetener used in soft drinks, donuts, candy bars and cakes.  I could provide you with thousands of words on why fruit is good for you but you don’t need that.  What you need to know is this: it is almost impossible to over eat fructose by eating fruit.  If you need more details and the research behind the facts click on this link http://well.blogs.nytimes.com/2013/07/31/making-the-case-for-eating-fruit/?_r=0 Fruit can also help keep us from overeating according to Dr. David Ludwig, the director of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital.  He says, “Unlike processed foods, which are usually digested in the first few feet of our intestines, fiber-rich fruit breaks down more slowly so it travels far longer through the digestive tract, triggering the satiety hormones that tend to cluster further down the small intestines.”

That brings us to the issue of artificial sweeteners.  There’s still a lot we don’t know about them and research is still being done but the scientific community generally believes that they are not harmful.  TStevia and other sweetenershey urge caution, though, and say that if you must have something sweet, go with the artificial variety preferably Stevia.  But, the jury is still out and its best to avoid all sweeteners if possible.  You can find more details in the report from CNN’s Dr. Sanjay Gupta.  http://www.everydayhealth.com/sanjay-gupta/myths-and-facts-about-sugar-substitutes.aspx

While there’s no medical evidence these sugar substitutes are dangerous, a recent study suggests they don’t guarantee weight loss either. Researchers from the Yale University School of Medicine found that eating foods with artificial sweeteners when we’re hungry or tired increases the likelihood of choosing higher-calorie foods later on.

“We still don’t fully understand the long-term effects of artificial sweeteners,” says Alexandra Kaplan Corwin, a registered dietician in the division of pediatric endocrinology and diabetes at The Children’s Hospital at Montefiore Medical Center in New York City. “Though the [U.S. Food and Drug Administration] has said they’re safe and the National Cancer Institute says they don’t cause cancer, we still don’t really know if there are long-term health consequences.”

Conclusion

 We’ve discussed obesity, it’s causes, the dangers of sugar and the advantages of eating more fruit.  Now the ultimate question, if you are obese, how do you lose that excess weight? Most experts will tell you that almost any program will help you lose weight.  The real trick, though, is losing it and keeping it off. It would be quite easy to list a number of diets and let you choose, but that would not be helpful because everyone’s condition is different.  We suggest that your very first step is to talk to your primary care physicians about the options he or she believes best suit you. Your physician knows your medical history and is far better able to make wise recommendations that the writer of a blog.  What I can say without fear of contradiction is that before you take on any weight loss program you must first assess your total medical condition. If you do not you could be headed for trouble. Your doctor will either make diet recommendations or direct you to someone who can.

Chances are that if you read this blog you are have more than a passing acquaintance with the Internet and will continue to do some research on your own on how to get rid of those excess pounds.  Well, we anticipated that and found one link in particular that might offer significant help. http://www.cdc.gov/healthyweight/index.html  Clicking here will lead you to scores of sites that can help you achieve the weight loss goals you seek. 

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New heart, new life, new man

Feeling better than ever at age 76

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s over 4,000 member Organ Transplant Initiative (OTI) and the author of most of these donation/transplantation blogs. You may comment in the space provided or email your thoughts to me at bob@baronson.org.  And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.  You can register to be a donor at http://www.donatelife.net.  It only takes a few minutes.

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Prison’s Deadliest Inmate, Hepatitis C, Escaping


In our continuing series on Hepatitic C we offer this story from NBC and the Associated Press  3/14/2007

Public-health workers warn of looming epidemic of ‘silent killer’

Marcio Jose Sanchez  /  AP

VACAVILLE, Calif.  — The most dangerous thing coming out of prison these days may be something most convicts don’t even know they have: hepatitis C.

Nobody knows how many inmates have the disease; by some estimates, around 40 percent of the 2.2 million in jail and prison are infected, compared with just 2 percent of the general population.

Eventually, when they are released, medical experts predict they will be a crushing burden on the health care system, perhaps killing as many people as AIDS in years to come. At the same time, they will be carriers, spreading the disease.

Hepatitis C can be treated, but many prisons do not test for it. Among the reasons: Budgets are tight, and treatment is expensive. So prison officials close their eyes to the gathering emergency and pass it along to the outside world.

“Right now there’s a golden opportunity to bring solutions to this problem before it hits,” said Dr. John Ward, director of viral hepatitis at the National Center for HIV/AIDS at the Centers for Disease Control and Prevention in Atlanta.

Hepatitis C is already the most common disease of its sort in the United States — a chronic, life-threatening, blood-borne infection. It is most commonly linked to infected needles used for drugs, though prison tattoos and body piercing with non-sterile equipment are also risky.

‘Silent killer’
What makes this virus particularly insidious is that as many as half of the people who have hepatitis C don’t even know they have it. The “silent killer,” already considered epidemic by the World Health Organization, often remains dormant for decades.

Some of the infected are lucky: One in five people who get hepatitis C will clear it out of their system naturally. But without treatment, one in four will suffer liver failure or develop liver cancer. Last year liver cancer was the only one of the top 10 fatal cancers in this country to increase, in large part because of hepatitis C.

More than $1 billion is already spent each year on this country on hepatitis C, and those costs are expected to soar unless prevention and treatment are expanded.

Without those changes, researchers project that liver-related deaths will triple from around 13,000 in 2000 to 39,000 by 2030. It’s also estimated that 375,000 Americans with hepatitis C will develop cirrhosis by the year 2015.

Anita Taylor, 48, is already there, in end-stage liver disease. Taylor speaks very slowly and moves with care. She often finds that she can’t say the words she wants to — they just won’t come out. Her body hurts most of the time. Her nose bleeds a lot.

‘Doctor gave me a death sentence’
A mother of two and former heroin addict, Taylor said she learned she had hepatitis C when she was jailed in Nevada in 1991 for being under the influence of drugs.

“They tested me and told me I had hepatitis C. They didn’t tell me there was a treatment and a cure,” she said. “And I didn’t know to ask.”

Taylor’s experience is not unusual.

“The doctor gave me a death sentence, recalls Leslie Czirr, a 36-year-old parolee. “He told me, ’There’s no cure for this and you will die from it unless you are hit by a truck first,”’

Czirr learned she had hepatitis C during a prenatal examination in 1996, at a time when she wasn’t in prison. Czirr has been arrested 10 times for drug possession and served almost eight years in prison on various drug possession and dealing charges.

She has started to suffer exhaustion, brain fog and aches. She recently enrolled in a county program to be treated — treatment, she said, she was denied at California’s Norco State Prison.

“I asked and asked, but they barely want to give you a Motrin,” she said. “I really want to get well, not just for myself, but so I’m not putting anyone else at risk.”

Limited studies indicate that fewer than 10 percent of prisoners who have contracted hepatitis C are treated. The reason vary. Medical staff have other priorities, and not all are well-informed about the disease. Prisoners with short sentences are often excluded because they won’t be able to complete treatment, and drug addicts who are inclined to return to risky behavior are often turned away because it is assumed they will simply reinfect themselves.

No funding for treatment
Usually, though, it comes down to money. Prison officials say that even if they wanted to provide the treatment, it is extremely expensive — about $9,500 per patient per year — and no federal funds have been earmarked to pay for it.

“It’s a hard sell to convince taxpayers why additional resources should be spent on the health care of the incarcerated when there are a lot of people who aren’t incarcerated who don’t have adequate health care,” said Dr. Joseph Bick, chief medical officer at the California Medical Facility at Vacaville.

Many of the inmates in Vacaville’s hospice unit — reserved for those given six months or less to live — are dying from hepatitis C-related ailments. Bick said half of the prison’s 3,200 inmates have a history of having been infected with hepatitis C, and at any given time about 40 of those men are receiving the intensive drug treatment to cure it.

“I’m pretty sure this is how I got it,” said Anthony Harris, an inmate at Vacaville. He rubbed his forearm hard, as if trying to remove the prison tattoo bearing his children’s names.

Harris, 51, is a former barber serving a life sentence for second-degree murder. In 2003, a doctor at another prison told him he had Hepatitis C; he researched the disease in the prison library and has sought treatment ever since.

“They gave me shots for Hep A and B, got rid of them. I’d like to get rid of the C too,” he said. “I’m entitled to that. But some docs will give you the treatment and others won’t. I keep making appointments. I keep asking.”

The course of treatment can take a year, and involves taking pills twice a day and weekly injections. Side effects are like those associated with chemotherapy — nausea, exhaustion, depression, debilitating aches and pains — and the cure only works about half the time.

But Bick said the high cost of treating prisoners for hepatitis C is a bargain compared to the bill that would come due if these cases are left untreated. “It’s a tremendous opportunity for us to have an impact on the larger health of the community,” he said.

Dr. Lynn Taylor, an assistant professor of medicine at Brown University’s medical school, agrees that prison is “perhaps one of the best setting for treatment of high-risk individuals.”

‘Window of opportunity’ for public-health efforts
“Prison can be a window of opportunity to reduce the reservoir of infection,” she said.

But there are no federal rules about testing and treating hepatitis C. Federal guidelines, issued by the CDC in 2003, said correctional facilities should “become part of prevention and control efforts in the broader community.” But they don’t recommend screening for all inmates.

Instead, the CDC urged medical staff to ask new inmates about their risk factors, and only those prisoners who seem likely to be exposed should undergo screening, which costs $5 to $10.

The CDC guidelines fell short, said Dr. Josiah Rich, a professor at Brown who directs the university’s Center for Prisoner and Human Rights. Rich’s studies confirm that convicted criminals are almost always willing to be tested for hepatitis C, but will often lie to prison authorities about their past drug use.

“We already know that more than one in three people coming through corrections has Hep C, so by definition everyone coming in is high risk. It’s absurd that they’re not testing everyone,” he said.

Rich concedes that testing every inmate will “jack up costs” for prisons.

“An individual is going to say, ’Hey, you tested me, you said I was positive, and now I want to be treated, and I’m going to sue you if I don’t get treated,”’ he said.

Lawsuits on the rise
Lawsuits are, indeed, on the rise.

The first significant case came in 1999, when officials at the Luther Luckett Correctional Complex in La Grange, Ky., refused to allow inmate Michael Paulley access to free hepatitis C treatment. Paulley, who was serving a 25-year sentence for rape and burglary, sued and won.

But the treatment came late and he died in 2004, the year he would have been eligible for parole. The litigation prompted broader testing and treatment in Kentucky, but Paulley’s physician, Dr. Bennet Cecil, a Louisville, Ky.-based hepatitis C specialist, said prisoners still die “all the time” for untreated hepatitis C.

“I think it’s immoral if a country, a state a society is going to incarcerate somebody and then deny them necessary medical care. I think that’s an outrage,” he said.

Prisons in at least a dozen states — Alabama, California, Delaware, Florida, Georgia, Idaho, Michigan, Mississippi, Nebraska, New York, Oklahoma and Virginia — are being sued over failure to treat hepatitis C.

But it’s tough going, said Oregon civil rights attorney Michelle Burroughs. Although she’s won a settlement that mandated testing for at risk inmates and treatment for those who are eligible, five of the 10 inmates she’s representing in a class-action lawsuit have died while the litigation proceeds.

5-year wait
“It’s appalling, horrendous, horrifying. Prisoners wait five years just to be evaluated,” she said.

Rep. Barbara Lee, D-Calif., recently reintroduced legislation that would mandate prison testing and treatment of hepatitis C. Earlier similar proposals in recent years have failed.

“The plain fact is that prisoners do not stay in prison. With more than 90 percent of incarcerated persons returning to their communities, it is clear that when a prisoner is infected, we are all affected,” Lee said.

In North Dakota, it didn’t take legislation, court orders or new regulations to prompt medical services director Kathleen Bachmeier to begin screening every inmate for hepatitis C after a methamphetamine epidemic tripled her state’s prison population in about a decade. As the intravenous drug addicts arrived, so did the hepatitis C.

“It became obvious to me that these people are going to cost the state a lot of money if we don’t do something about it,” she said.

North Dakota now treats anyone who meets certain medical criteria, whose sentence is long enough to complete the course of treatment and who is willing to try to quit using drugs.

“We look at this as a huge public health initiative,” she said.

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to bob@baronson.org and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

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