Healthy Food & Healthy Living by Dr. Ayala

Immunity boosting foods? Really?

I'll be taking a a few weeks off to spend time with my family and travel. Meantime, I'll be reposting some of the more popular and relevant posts I’ve written over the past years so that new readers have a chance to catch up.

The connection between diet and health was proposed some 24 centuries ago by Hippocrates, and I can imagine he first heard of it from his mom, who heard it from her ancestors.

Today, grandmas, moms and physicians have piles of scientific evidence supporting their observations and advice. It’s true: Diet does play an important role in health. We’re learning more each day and the discovery is fascinating.

Unfortunately, scientific discoveries are being overly-interpreted to promote the sale of foods, and scientific jargon appears all too often as buzzwords on packaged goods.

Every Flu season and especially the recent spread of the new H1N1 virus have given rise to a new barrage of immunity claims shouting at us from every supermarket shelf and commercial. It’s a perfect time to look at the diet/health connection and these claims.

A short introduction to food label claims

There are several types of claims allowed by the FDA on foods.

A health claim describes a relationship between a food or food component and a disease, and it must:

• Be pre-approved by the FDA. There are currently slightly more than a dozen of these approved claims.

• Be phrased in the specific language the FDA requires. The claim must indicate that the disease may be caused by a variety of causes, and must state that the food should be consumed as part of a healthy diet.

• Appear on food that meets certain nutritional requirements.

A structure/function claim is quite a different animal.

Structure/function claims describe a role of a nutrient, a substance in food or a food supplement in affecting the normal structure or function in the body. Unlike a health claim, it doesn’t relate to a disease or a health-related condition. The verbs “support”, “improve”, “boost” and “maintain” are often a telltale sign of a structure/function claim.

A Structure/function claim:

• Requires no FDA pre-certification.

• Can be attached to any food, including junk food (there are no overarching nutritional requirements).

• Can be phrased in many ways.

• Is the manufacturer’s responsibility. While the claim “must be truthful and not misleading”, there’s no specification about how much evidence is needed to make the claim.

A few quick examples:

“Calcium reduces the risk of osteoporosis” is a health claim; “calcium builds strong bones” is a structure/function claim.

“Fiber may reduce the risk of some cancers” is a health claim; "fiber maintains bowel regularity," is a structure/function claim.

Confused? You’re in good company. Most consumers can’t tell the difference.

Even the pros in the food industry can’t necessarily make sense of structure/function claims. They consult expert lawyers whose entire practices are devoted to advising companies on the language of the label. Creative marketing devises the claim and legal counsel makes sure it’s defensible and at least somewhat based on reality.

What’s clear is that the structure/function claim has been a boon to food manufacturers. Since there are so few limitations on its use and the trusting public can’t distinguish between a health claim and a structure/function one, why not be creative, develop a claim that meets your goals and slap it on the package? Market research shows these structure/function claims really help with sales.

What's the evidence backing these “immunity” claims?

There are, in fact, no approved health claims related to immunity.

What does that mean? It means that no one has presented to the FDA enough evidence of a relationship between a food, a food ingredient or a dietary supplement and reduced risk of contracting or of treating an immune mediated or infectious disease such as the flu to warrant a health claim.

That means the immunity claims you see everywhere are all structure/function claims.

What are the claims based on? The immune system is very complicated, and its integrity depends, among other things, on good nutrition. States of vitamin, mineral or protein deficiency lead to reduced immunity and correcting the deficiency does improve immunity.

But while it’s true that if you had a vitamin C or zinc deficiency you could improve your health and immunity by eating a vitamin-fortified cereal or a vitamin supplement, it’s clear that shouting “Immunity!” from the cereal box is misleading. Vitamin deficiencies are rare, and therefore the cereal might be yummy, but it’s not doing much for your immune system.

Most food contributes to one’s health, so by that token we can add a structure/function claim to pretty much anything:

• Sleep, for example, is very important to immunity; should we advertise mattresses as immunity boosters? All mattresses or only some brands?

• Exercise improves immunity. Maybe “immunity now!” should be painted on sidewalks?

• Stress reduction improves immunity; how about an “immunity massage”?

• Why, even breathing air supports immunity.

These immunity claims are all without much substance I’m afraid, but it’s especially outrageous to see them on junk food. Cocoa Krispies is 40 percent sugar, but hey, don’t you need to maintain normal sugar levels for good immunity? Correcting potential hypoglycemia is critical for good immunity, isn't it?

Thankfully, after receiving a letter from San Francisco’s city attorney last November, Kellogg announced it would phase out the immunity claims on Cocoa Krispies.

Will misleading claims ever end?

Two scenarios I can imagine:

• Consumers will start rejecting these claims, viewing them as a hyped and misleading insult to their intelligence, and move toward products that are marketed in a more sensible and honest way.

The only reason these claims abound is because we’re buying them.

And here comes my question: Do people really believe that they can buy immunity in box? Or are they buying it knowing that an easy fix is a fantasy, but it still feels good to dream?

• The second option is the litigious route: A few really big class action suits, representing misled consumers who saw no health benefits from investing their hard-earned money in products that failed to deliver can change everything. In that respect, the recent FDA warning letters to manufacturers who post misleading or false claims could act as important evidence and actually make a difference.

I prefer the first scenario.

There’s actually a third possibility.

The FDA can overhaul the whole health-claim structure/function scene, crackdown on false and misleading claims and help consumers understand that good health (and building a strong immune system) has nothing to do with buying products that make health claims. People need to just eat well by consuming healthy, real foods over a long period of time.

Sorry, but that’s the truth—eating well is about good habits and good food, not about sprinkling vitamins, anti-oxidants and omega 3 on processed food. The Center for Science and Public Interest (CSPI) is urging the FDA to do just that in a report it recently sent. (It’s 158 pages, but well worth a read, and it includes lots of pictures.)

So, what to make of these medicinalized foods?

I think it’s best to simply leave them on the shelves and opt for good, healthy choices. As Hippocrates said, “To do nothing is sometimes a good remedy.”

Happy healthy new year!
Dr. Ayala

Kitchen remedies for the common cold

I'll be taking a a few weeks off to spend time with my family and travel. Meantime, I'll be reposting some of the more popular and relevant posts I’ve written over the past years so that new readers have a chance to catch up.

Medical science has no cure for the common cold; symptomatic relief is the best we can offer as we wait for our body to overcome the viral illness.

Although the common cold is generally a mild disease and poses no real threat to overall healthy people it can be quite unpleasant. As a mom and a physician I really like having some helpful, natural, inexpensive common sense therapies to prescribe.

A good number of the methods used today haven’t changed much since my grandma’s time: Her advice was drink lots of liquids, get plenty of rest and eat chicken soup, but every grandma’s different and home remedies change from culture to culture.

Most of these home remedies pose no harm, and are well worth a try, even if there’s only an anecdotal notion of benefit. But I wanted to see if any of the remedies have attained enough scientific support through rigorous research so that we can now firmly say these kitchen-based medicines work better than a placebo, and there’s more than suggestion in their mechanism of action.

So, I headed to the online Cochrane library looking for reports on some of these natural remedies.

Before I get into the details of what I found, I’m sure you’ve been wondering how we make sense of study results when one study shows one finding while another study refutes those results. The experience can leave everyone quite confused, not knowing what to believe. But this is how the scientific method works. It’s only through refining and repeating studies that we can arrive at a tentative conclusion. The Cochrane reviews aim to do just that—take into account only the best of studies, and see if there’s enough evidence to prove efficacy.

The global Cochrane Collaboration is an independent network of volunteers that doesn't accept conflicted funding, and whose mission is to gather the best available evidence, summarize and interpret the results and make them readily available as a resource for evidence-based medicine on which to base scientifically grounded health-care decisions. (The full reports require a subscription, but the abstracts and summaries are free.)

Now, here are some interesting findings from the library:

Garlic

Garlic’s is a common-cold remedy handed down for generations in my husband’s family, and while I love garlic in cooking and use plenty of it, the result of a spouse consuming half a head of raw garlic is offensive to my nose. I just hate it! I admit I’m biased here; I really wanted this one to be proven ineffective.

The Cochrane report authors looked for randomized controlled trials of common-cold prevention and treatment comparing garlic with placebo, no treatment or standard treatment, and found five such studies with only one fulfilling their criteria. The study included 146 people and found that people who took garlic (in supplement form) every day for three months had fewer colds and fewer days of illness with a cold than people who took a placebo. They found no information from randomized, controlled trials about whether taking garlic at the time of a cold reduces either symptom severity or the number of days of illness.

They conclude:

“While this one study was positive, there is a need for large, high-quality randomised controlled trials to support these findings. Possible side effects in this small trial included odour and a skin rash. More information is needed about the possible side effects of garlic.”

Honey

Honey has been used from ancient times for many medical purposes, from wound healing to respiratory relief. Mixing honey into warm milk, tea or juice is a time-honored sore throat soother and cough suppressant.

The Cochrane reviewers looked for randomized, controlled studies comparing honey to placebos for the treatment of chronic cough, and found none that were applicable for review. In other words, there are no good studies out there, therefore no proof for or against honey for a four- week-old cough.

Honey for acute cough has shown promise in some studies, in which it outperformed both no treatment and cough syrup, and this treatment modality is currently evaluated by the Cochrane group.

A word of caution: Honey should not be given to kids younger than one year due to the risk of infant botulism.

Plenty of fluids

Drinking plenty of liquids makes sense: the water replaces losses due to rapid breathing, reduces the viscosity of mucus (therefore reducing congestion) and prevents dehydration. Alas, the reviewers found no evidence for or against increasing fluid intake during the illness—no randomized controlled studies have been conducted.

Vitamin C

Vitamin C was popularized by Nobel Laureate Linus Pauling in the 1960s and has been used widely as both a preventive and therapeutic agent for the common cold for decades. It’s still very controversial.

The Cochrane review was restricted to placebo-controlled trials testing at least 0.2 grams per day of vitamin C. Thirty studies involving more than 11,000 participants were analyzed and they showed:

• Regular ingestion of vitamin C has no effect on preventing the common cold in the ordinary population.

• Vitamin C reduced the duration and severity of common cold symptoms very slightly, and the magnitude of the effect was so small its clinical usefulness was doubtful.

• Six trials included participants exposed to short periods of extreme physical or cold stress or both (including marathon runners and skiers). In these people vitamin C reduced the common cold risk by half.

• Trials of high doses of vitamin C administered to treat the common cold showed no consistent effect on either duration or severity of symptoms. The authors call for more therapeutic trials (especially ones including kids who weren’t studied in trials) to settle the question.

Echinacea

Echinacea is a plant widely used for the common cold, but preparations vary greatly (there are many Echinacea species, and different parts of the plant are utilized in different ways). The Cochrane review found 16 clinical trials investigating the effectiveness of several Echinacea preparations for common-cold prevention or treatment.

Two trials using Echinacea for 8 to 10 weeks for common-cold prevention showed no clear effect.

Most of the trials investigated Echinacea for treatment of common-cold symptoms, and it seems that some preparations may be effective in adults, but the results were inconsistent. There’s no evidence of efficacy in kids. Side effects were rare, and included rashes in one trial in kids.

Zinc

Seven trials of variable quality were included in the review, and no strong evidence was found to show that zinc lozenges reduce the duration of the common cold. Side effects included mouth irritation, unpleasant taste and diarrhea.

As for chicken soup, I couldn’t find it in the Cochrane reviews. A study in CHEST (the cardiopulmonary and critical-care journal) looked at mucus velocity and airflow through the nose of 15 healthy people after they drank cold water, hot water or chicken soup. The results showed that both hot fluids increased the flow of mucus for about 30 minutes, with the chicken soup outperforming the hot water significantly. Another study in CHEST showed that chicken soup inhibited the movement of neutrophils (a subset of white blood cells) in the lab. So there is some evidence supporting my grandma’s regimen.

Writing this post and going through these studies reinforces my respect for the wisdom of traditional methods for symptom relief. Many of these old-fashioned remedies show some benefits, are worth a try, and won’t hurt. I think the current evidence on Echinacea, vitamin C and Zinc tend to show little or no efficacy, and zinc can have some nasty side effects, so I’d personally stay with the food remedies, and not the supplement ones—their safety profile’s better.

Regarding garlic: I’m hoping my husband won’t read this post and decide on garlic as a preventive regimen, taken continuously. Personally, I think the secret to garlic’s success is that no one ventures near you when you eat that much raw garlic. Isolation is perhaps the best way to prevent the spread of communicable diseases, including the common cold. Washing hands frequently and well is probably the best preventive measure of them all.

Happy holidays, peace and joy in the new year, and a healthy winter season,

Dr. Ayala

Silly science, silly inventions and other 2010 follies

An end of year tradition — now in its second year — I’d like to share some of the studies I failed to mention during this passing year, and pay tribute to some outstandingly ridiculous achievements in food, health and weight-loss.

Beware of the beard bugs

Fall season is celebrated with many beautiful and tasty traditions, and one fall event I really look forward to is the Ig Nobel ceremony. The Ig Nobel awards are a parody of the Nobel Prizes, and have been awarded for the past 20 years for funny, absurd or unexpected (but all too real and methodically correct) scientific research in a ceremony attended by all too real Nobel laureates at Harvard University.

As a testament to the credibility of the Ig Nobel research and researchers, I want to mention that one of this year’s physics Nobel Prize winners, Andre Geim, already has an Ig Nobel to his name — his Nobel is for experiments with graphene; the Ig Nobel for levitating a frog. We can only wonder whether both are displayed on the same shelf.

And since food safety has been on our minds this year — and for good reason — I’d like to mention the Ig Nobel 2010 Public Health Prize. Long overdue, the prize was given to Manuel Barbeito, Charles Mathews, and Larry Taylor for proving that microbes cling to beards and can be a source for microbial spread.

Their study, conducted on bearded scientists, showed that beards retained harmful viruses, bacteria and toxins despite washing with soap and water.

Perhaps that’s why we expect men (and women) working with food to be clean shaven, or for beards to be neatly covered. Can you think of famous chefs with beards? James beard had no beard. The quintessential American chef not only was clean shaven — his bald head was his trademark. Baldness is good for food.

Running to look for a clip for my long, unruly locks.

Even faster fast-food

Embarrassing, but this genius idea was not invented here – it originated in South Korea. BBQ Chicken and its South Korean sister BHC Chicken offer the ultimate hybrid, the Col-Pop: A cold drink cup topped with fast food upper layer container, ensuring maximal stuff-your-face technology at minimal effort. As reported by seriouseats: “It's perfect for handy snacking while walking, driving, talking on the phone, or—as we discovered the other day—blogging”.

Are we losing our edge? Is our lead as the fattest nation under threat? C’mon, we have to make sure we’re no 1 in at least in something. We can make a better Col-Pop. How about a cup that freshly grinds the solid part of the Col-Pop, and delivers the chewed food through the straw? Saves on chewing, frees the snacking hand.

Dieters dream come true

Girdles have been around for a while and they work! They have been boosting butts, taming tummies and shaping the shapeless, and today’s body shapers are allegedly even a little bit comfortable (let’s see men wear them!), and such an upgrade from the tight corsets that caused the fainting epidemic of the Victorian era.

But did you know that there’s clothing you can wear that can slim you down? Yes, Skineez shaping garments contain “fat fighting cream” that will “smooth, firm and soften your skin” with a “balanced combination of anti-cellulite ingredients”. The jeans, at the bargain price of 159.99 are a great deal, because: “Skineez is proven to reduce inches and firm loose skin without diet and exercise!” and “You will see results in as little as five days!”

Every time you see “without diet and exercise” an alarm bell should ring, but when a product also claims to fight cellulite, your incredulity should be at maximal alert. Girls, I hate to break it to you, there is no cure for cellulite, just like there’s no way to lose inches without diet or exercise. The only thing Skineez can add to achieve less credibility is magnetic fields and alien visits.

So how come this is on TV? I’m just as baffled. Does anyone at the Federal Trade Commission ever suffer from insomnia? Late night TV infomercials are so loaded with fraud and quackery that it boggles the mind.

Genetically modified food to the rescue

Genetic modification of food promised to make the world a better place: Increase the nutritional content of food, provide drought and pathogen resistance crops that can solve world hunger, and decrease the need for chemicals in agriculture.

What genetic modification provided, for the most part, were Round-up ready patented seeds, lots of profit for Monsanto, and lots of worry for everyone else.

And now, a great development that I have no idea how we could live without: The genetically modified apple that resists browning. A Canadian company is awaiting the USDA’s approval for its patented technology, which silences the browning reaction the apple mounts when it’s bruised or cut. Hey, it might get some fussy kids eating more apples! GMOs to the rescue of human kind.

Feel free to share what impressed you most this year.
Dr. Ayala

Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

Is low glycemic index the next big thing for weight-loss?

I’d like to take a look at two weight loss studies that got some media attention lately, one of them receiving much more notice than the other.

Mark Haub, a professor of human nutrition at Kansas State University lost 27 pounds in 10 weeks on what he calls the “convenience store diet” or what others dubbed the Twinkie diet. Haub adhered to a calorie restricted diet that consisted of junk food and a few veggies, washed down with a multivitamin and a protein shake. Haub was able to prove that a calorie’s a calorie, and what matters is the bottom line: Less calories in than out equals weight loss. His experiment is ongoing, but at this point short lived, and the small study group (of just one), lack of control, and absent objectivity make this study not-so-scientific but good enough for coverage in all the popular news outlets (CNN, LA Times, Fox, CBS, Chicago Tribune to name a few).

Which is good thing, because if we all internalized the fact that calories matter we’d be immune to scam diets – unbelievably still heavily advertized – which promise weight loss without calorie restriction.

The other study is a scientific one, published in the New England Journal of Medicine. The study included 733 participants, from 8 European countries, who already lost at least 8 percent of their body weight on a very low calorie diet. The participants were randomly assigned to one of five diets for weight maintenance: A low-protein diet with a high glycemic index (GI); a low-protein, low-GI diet; a high-protein, low-GI diet; a high-protein, high-GI diet, or a control diet which followed the current dietary recommendations without special instructions regarding protein or GI.

Short intro to glycemic index: The glycemic index, developed initially for the treatment of diabetes, ranks carbohydrate containing foods based on how they affect blood sugar level when eaten in isolation. Carbs that break down quickly, like white bread and potatoes, have a high GI, and those that release sugar into the blood stream more gradually, like fruit, have a low GI. Foods are scored on a scale of 0 to 100.

One important thing to remember about this study: The participants were not calorie restricted. They were allowed to eat as much as they felt they needed as long as they stayed within the rules regarding the protein and carbs proportion and quality.

And the results: After 6 months weight regain was 2 kg (about 4.5 pounds) higher in the high GI/low protein group, compared to the low GI/high protein group. More people in the low GI/high protein group were able to stay on track and complete the study.

At 6 months we have a clear winner here. So far so good. But let’s not get over excited.

Is the glycemic index the next big thing in weight loss?

When it comes to weight loss what matters most is calories. Any plan that results in a net deficit of calories will lead to weight loss. But, not all calories are the same, not when it comes to weight loss, and not when it comes to health. Some calories come from foods that fill you up, and some calories come from foods that create very little satiety. Some calories come from foods with virtually nothing besides sugar and junk, while other calories are part of a food that supplies many nutrients our body needs.

The low GI diet is an interesting concept. Blood glucose fluctuations elicit a cascade of hormonal reactions, which potentially affect both metabolism and hunger, and this diet’s ability to decrease hunger and control weight regain showed some promise is studies. It would be very interesting to see how this studied group fares as time goes by. Six months is still short term when it comes to weight regain.

Is GI going to be the next diet fad? GI is garnering attention and many popular commercial diets and diet books – including the South Beach Diet, Nutrisystem, the Zone diet and Sugar Busters – are based at least in part on the GI. The GI has a growing following especially in Australia and in the UK, and a new GI Symbol now appears on foods, signifying their tested GI value.

Low GI corresponds quite often with the age-old understanding of what’s good to eat. Most highly processed grain products have a high GI, whereas minimally processed grains, whole fruits, legumes, and non-starchy vegetables tend to have a moderate or low GI. On the other hand pure fructose and ice cream have a very low GI, table sugar and high fructose corn syrup have only a moderate GI, and potatoes and white rice are the root of all GI evil, with a GI of about 100.

A few other things that will curb your enthusiasm for the GI: It’s difficult (and costly) to test, there’s inter-lab variability, although the type and proportion of sugar or starch in a food affects GI, so do a lot of other factors in the meal—the way the food’s been cooked, the presence of fiber, protein, fat, alcohol or acid will all affect the glucose response—and there’s plenty of inter-personal variability. Finally, the GI of the food matters much less than how much of that food you’re eating. To be quite honest, even diligent adherence to GI charts will leave you guessing about your own sugar level fluctuation after a meal.

At this point, GI for weight-loss is neither practical nor is its validity fully established.

Here’s another thing that troubles me: The GI concept can help create a whole new line of health-halo adorned highly processed foods, and be abused in much the same way as other nutrition buzzwords have been before it. Adding vitamins to junk has added nothing but confusion, and replacing butter with hydrogenated vegetable oil actually blocked arteries. Replacing sugar with fructose will lower the lab-tested GI while — most likely — add nothing to our health and may do harm.

Have you tried using the glycemic index?

Dr. Ayala

Distracted into trouble

I overheard a short exchange between my three kids several years ago. My daughter is my youngest, her brothers just a few years older than her, and she must have been no more than 5 years-old at the time.

My daughter: “You don’t know how to handle dad. I’ll handle him for you.”

Her brothers: “How?”

“You go into his office when he’s really busy and ask for it. He’ll say yes because he wants you to go away. Then you leave. Grown-ups don’t go back on their words”.

“And mom”?

“She hates overruling dad”.

Outwitted by preschoolers! My daughter figured out how to use distracted decision making to her advantage, and we grown-ups are dumb enough to believe we’re great multi-taskers.

My husband is a huge multi-tasker. He’s actually not bad at it. But even he’s not as good as he thinks, and definitely not good enough for my daughter.

And all this could be quite funny if this over confidence in our ability to engage in more than one thing didn’t cost so many lives.

Distracted driving

Here are a few facts, courtesy of the “Official US Government Website for Distracted Driving” (I‘m sure they didn’t mean it that way—they must be against distracted driving…):

• In 2008, almost 20 percent of all crashes in the year involved some type of distraction (National Highway Traffic Safety Administration - NHTSA).

• Nearly 6,000 people died in 2008 in crashes involving a distracted driver, and more than half a million were injured (NHTSA).

• The younger, inexperienced drivers under 20 years old have the highest proportion of distraction-related fatal crashes.

• Drivers who use hand-held devices are four times as likely to get into crashes serious enough to injure themselves (Source: Insurance Institute for Highway Safety).

• Using a cell phone while driving, whether it’s hand-held or hands-free, delays a driver's reactions as much as having a blood alcohol concentration at the legal limit of .08 percent (Source: University of Utah).

One would think that common sense and a few statistics would be enough to prevent us from fumbling with an electronic device while driving, but that ain’t so.

So, thirty states have put into law bans on texting while driving. It’s a welcome, rational step, but unfortunately instead of turning the device off it has led overconfident drivers to put the device lower in their lap, where it can’t be seen by police.

Self-confidence is a beautiful thing. Cockiness enables people — even young kids — to occasionally do unbelievable things. But when it comes to driving it’s a huge mistake to believe that you’re an above average driver. First of all because you’re not – statistically speaking it’s unlikely – and besides, handling heavy machinery at high speed is not an innate human skill, and even if you’re better than most you’d better be humble. We’re incredibly attuned to some things in our surrounding – I believe many of us can hear an infant‘s cry even with a lot of background noise – but not to the unexpected dangers of the road. To be a decent driver we need both hands and our head as engaged as much as humanly possible.

A crop of new apps and gadgets surface daily since the no-texting bans were signed into law. Some are no more than clever ways to stay within the letter of the law while providing new – equally distracting – ways to text, email and call while driving.

If you feel you have to have an app for that here’s what you should look for: an app that helps you stop using the phone. Even SAFECELLapp, which rewards drivers with cash for not using their phone when the app is turned on and the car’s moving, is much more distracting than simply turning the device off.

What if someone needs to reach you? They’ll reach you later, or find another solution. The world worked just fine fifteen years ago, when most kids could not reach mom at all times and executives weren’t constantly plugged.

It’s hard to pay attention

I could have added, for visual effect, scary footage of accidents. I won’t. Instead, let’s do a little experiment. Please don’t peek at the end of the post before you complete the video.
 
If you’ve heard about this experiment before, you’d have known what to expect, but when this video is shown in a controlled situation, 50 percent of people don’t see the gorilla, even though the gorilla is there for 9 seconds, and thumps its chest in the middle of the screen. If you still believe you can multitask and pay attention to more than one thing at a time I recommend Christopher Chabris and Daniel Simons’ “The Invisible Gorilla” – a fascinating read.

Please, just think about this: Would you feel comfortable if your kids’ school-bus driver texted while driving?

I welcome your comments,

Dr. Ayala