A Calorie is a Calorie

When the Reuters News Agency reports on topics in nutrition, and those articles then appear on the Yahoo Web site, they usually tell us such interesting things as how certain dietary supplements may help us to live long enough for space travel from one end of the Milky Way to the other. (For those who can't be bothered looking that up, it would take about a hundred thousand years at the speed of light.)

But when they get it right, I should praise them. (My friends who know something about animal behavior tell me that's called positive reinforcement.) Over the weekend an article was posted about a study from the American Journal of Clinical Nutrition, which I read only when I'm really bored on my trips across the Milky Way. And the conclusion was that a calorie is a calorie.



In other words, for purposes of an effective weight-loss diet, what matters is taking in fewer calories than your body needs to supply its energy needs. The source of those calories matters little.

[For my readers who like a little depth, here is the definition. A calorie is the amount of energy it takes to raise the temperature of a gram of water by one degree centigrade. The calorie of which we usually speak is actually a thousand of those (a kilocalorie), so for clarity it is sometimes called a food calorie. A gram of fat has about 9 calories, carbohydrate 4, protein 4. For the purists, yes, those are approximations.]

The researchers who published this study reached the same conclusion as the investigators who published earlier work in big-name medical journals, including the Journal of the American Medical Association and the New England Journal of Medicine. They looked at diets with various compositions, including higher or lower proportions of fat, protein, and carbohydrates. They asked how well subjects were able to adhere to those diets, how much weight they lost, and how lasting the weight-loss benefit proved to be.

The findings were simple. Weight reduction correlated best with calorie restriction, which - by design - occurred on all of the diets, calculated to reduce caloric intake by 750. Running a 750 calorie-per-day deficit would result in a weight loss of about 39 pounds in six months, whereas study subjects lost about 14 pounds, which suggests adherence was less than strict. What all of the recent studies of this type have shown, not surprisingly, is that amount of weight loss correlates best with adherence.


The conclusion one may reasonably draw from that, and the message nutritionists have often conveyed, is that you should pick the diet that most appeals to you. If you crave protein and fat and are willing to give up starches and sweets, Atkins is for you. If portion control fits your way of thinking, Weight Watchers is the way to go. If you like the idea of being a vegetarian, you should pick the approach advocated by Ornish and McDougall, which markedly restricts both fat and protein.

Of course the diet that appeals to you for short-term use (six months to a year) may not wear well, and "falling off the wagon" will inevitably result in failure to maintain your weight loss.

There is also the question of the long-term effects on health of any of these diets. The best evidence favors the Ornish/McDougall approach. Simply put, that includes only as much protein as the body needs, which means about one gram of dietary protein per kilogram of lean body mass per day. (That isn't very much, and it's difficult to do without being vegetarian). Only about ten percent of daily caloric intake should come from fat, and as little as possible of that from saturated fat.


The rest should come from carbohydrates, with the vast majority from complex carbohydrates, as little as possible from simple carbohydrates (meaning sugars).

By the way, such a diet will typically be fairly high in fiber, which is carbohydrate that is not absorbed in the digestive tract. Fiber contributes to feeling full without adding calories, is good for bowel function, and may reduce cholesterol levels.



It should go without saying (but maybe it doesn't) that exercise is good for both weight reduction and long-term health.

A blend of aerobic and weight training is the ideal method. Aerobic exercise burns calories and promotes cardiovascular health. Weight training increases muscle mass, which not only makes you stronger but increases basal metabolic rate, meaning you burn more calories even when you're sitting around.




So a calorie is a calorie. Does that mean you have to count them? This would be so much easier if the human body came with a meter that measured and displayed caloric intake and expenditure. If you could see those numbers side by side, you could aim for a deficit of 500 per day, which isn't difficult with just a little will power, and you'd lose 50 pounds over the course of a year. Now there is an invention that would make you rich!

Obamacare or Romneycare: Is There a Difference?

Last summer I wrote about the individual mandate and the question of whether this feature, and perhaps others, of the Patient Protection and Affordable Care Act would pass constitutional muster when legal challenges eventually found their way to the Supreme Court.

http://bobsolomon.blogspot.com/2011/08/thou-art-commanded-buy-health-insurance.html

The Supreme Court has set aside three days on its calendar in late March to hear oral arguments on these questions, and we can expect its decision by June.

Interestingly, one of the questions to be argued is whether a challenge to the law can even be brought. The challenge, you see, is based on two essential points. One is the individual mandate, and the other is the expansion of Medicaid, both described further below. But neither of those provisions of the law has yet taken effect. So there is a question of whether the law can be challenged at all - at least for the present - because no one has yet been affected by the law. Without getting too deep into the weeds of jurisprudence, I'll just say there is a law called the Tax Anti-Injunction Act (dating to 1867) that says no one can bring a legal action to restrain the collection of a tax before the tax has actually been imposed. The argument is that the individual mandate and the requirement that states expand Medicaid should be similarly regarded, meaning no one can challenge these provisions until they have actually taken effect.

It's hard to say how the Court will rule on this question. The justices may rule narrowly that the 1867 law does not apply because the provisions of PPACA at issue are not, strictly speaking, taxes. That would allow the Court to get on to the business of deciding the key issues without the delay introduced by waiting until the law has taken effect. On the other hand, there is a general principle in federal jurisprudence that the constitutionality of a law can be challenged only by someone who has been directly affected by it, and no one else has standing to bring such a challenge.

Assuming the challenge is not thus delayed, that will bring the Court to the two central questions about PPACA. First, is the individual mandate constitutional? I examined that question in my earlier essay last August. Briefly, the argument is that the authority to impose such a requirement is not vested in Congress by the Constitution because it is not encompassed by the enumerated powers or the necessary and proper clause and does not fall within the realm of regulating interstate commerce.

If the individual mandate is held unconstitutional, PPACA may, as a practical matter, fall apart. But there is another question the Court will then have to decide, which is whether a finding that the individual mandate is unconstitutional nullifies the entire law or whether that provision is severable from the rest of PPACA, which can then (at least legally) stand without it.

Finally, there is the question of whether the move to cover more Americans with health insurance by requiring the states to expand Medicaid eligibility is "coercive" and amounts to "impermissible commandeering." The Court could hold that forcing the states to do this is a violation of the Tenth Amendment to the U.S. Constitution. That argument has been previously used against federal laws requiring states to participate in the administration of a federal program. Medicaid, however, is regarded as a joint federal-state program, so this is an area of uncertainty. The pro-PPACA side will argue that the states administer the program, and that administration has long been governed by some federal mandates. The funding for Medicaid is partly state and partly federal, and so the federal money essentially comes with strings attached. The anti-PPACA side will argue that the expansion of Medicaid will not be paid for with federal tax dollars (although there is some short-term federal funding to help with this), and that makes the forced expansion coercive, representing "impermissible commandeering" of state authority - and state money.

In recent debates among candidates for the Republican presidential nomination, former Massachusetts Governor Mitt Romney has been taken to task for having fostered the expansion of health insurance coverage in his state ("Romneycare") through an individual mandate, yet opposing the individual mandate contained in PPACA ("Obamacare"). Romney says his state's individual mandate and PPACA's individual mandate do not operate the same way. His Republican rivals say there is no difference at all.

But there is a big difference if the central issues are constitutional. Congress may not have the authority to require us to buy health insurance, but the states surely do - just as they can force us to buy car insurance. (Maybe a state Supreme Court would say it's not the same thing, because you don't have to buy car insurance unless you choose to own and operate a car, while health insurance is mandated as a condition of being alive. But the question does not turn on the powers of Congress.) And Congress may violate the tenth amendment by forcing states to expand Medicaid eligibility, but a state can certainly do that of its own volition, or figure out any number of other ways to expand coverage.

So Romney's argument is that even if you don't like what they did in Massachusetts, the state legislature enacted that approach by an overwhelming majority, and the people of the commonwealth like it. Thus, he opposes PPACA, saying it should be up to the states to solve the problem, and each should be free to design its own approach.

His critics ultimately dismiss such distinctions as missing the point: that the way to solve the problem is not by government mandate but by allowing free markets to operate in such a way as to make it overwhelmingly attractive, and affordable, for everyone to procure health insurance.

As my mother used to say, I'd like to see a big oil painting of how that will work.

Mitt, Newt, and Barack: When Does Baggage Become Freight?

During the campaign for the presidency in 2008, there was much criticism of Barack Obama for the people with whom he had chosen to associate over the years. Bill Ayers and Bernadine Dohrn were among those mentioned frequently. They were active in the Weather Underground, a communist revolutionary group co-founded by Ayers in 1969. Of course Obama was a child in 1969, so his connection with an organization that bombed public buildings to protest the Viet Nam war has some degrees of separation. But his judgment was questioned.

Then there was the Reverend Jeremiah Wright, pastor at Obama's church. Critics questioned how Obama could have sat and listened - for years - to sermons given by someone whose rantings included that made most famous by the 2008 spotlight, "God damn America!"

So what do we think of guilt by association? It seems we think far too much of it. Many were more than willing to condemn Obama for these associations, because they believed they reflected his own philosophical leanings.

The ravings of Jeremiah Wright and the violence of the Weather Underground never caused me to worry that Barack Obama was secretly an America hater and a racist. I did, however, wonder, in reading about the associations that affected his intellectual development from adolescence through his adult life, whether he was much more socialistic in his thinking than he was willing to admit in public utterances as a candidate - with the notable exception of the "spread the wealth" remark to Joe the plumber.

There are always things about a candidate's past that may bother some voters. This year we have been treated to quite a series of them. As the Republican field has been winnowed, the focus on such things grows ever more intense. Mitt Romney's record as a venture capitalist and his work in the corporate world (labeled with the remarkable term "creative destruction") are as sure to engender outrage from the left as Obama's socialist proclivities have from the right. And now his tax returns show that his income is derived primarily from investments, with the consequence that he pays federal income tax at a rate far lower than those of us in the middle class who go to work five days a week.

And then there is Newt. First stop: three marriages, with transitions marked by infidelity as wife #1 was traded in for #2, and then #2 for #3. Then ethics charges during his term as Speaker of the House in connection with an investigation of possible tax evasion. The IRS concluded there was no violation, but Gingrich was thought to have interfered with the House ethics investigation, and he was reprimanded and fined by his colleagues for that. Most recently, he has worked as consultant (not a registered lobbyist) for organizations seeking to work more effectively with Congress in pursuing their interests. That a former congressman would do that is hardly surprising, but many Americans don't like what they call a "revolving door" that engenders cozy relationships between government and areas of the private economy that government is supposed to oversee and regulate.

Mitt Romney has called it "influence peddling," a wonderful choice of a pejorative term. Anyone who has spent even a few hours strolling the halls of the House and Senate office buildings on Capitol Hill will tell you there is an awful lot of influence being peddled.

[I am an influence peddler myself. I go to Capitol Hill to talk to my elected representatives about issues of importance to emergency physicians and our patients. Part of the reason I get in to see them, and they take some time to listen to me, is that doctors in my specialty have a political action committee that gives politicians money for their re-election campaigns. That's the way the system works. Many of us really don't like that fact, but we are stuck with it.]

Newt Gingrich's background has enough targets for snipers to keep them busy from now through the end of the primary season - or the general election, if he should happen to become the Republican nominee. Mitt Romney's record might not be quite as target-rich. We shall see.

One wag (I love that phrase, because it's so useful when you cannot recall to whom you should attribute a clever remark) said of Gingrich, "He doesn't have baggage. He has freight."

Sometimes I wonder whether these politicians go through their lives applying a test to every contemplated course of action: how will this look in X years if I some day run for president? Something tells me the answer is no.

The incumbent president is running on a record in office and a renewed vision for four more years. That is the stuff that will be the focus of my attention this year. And Mitt and Newt have their own records, in the office of governor of Massachusetts and that of congressman from Georgia and Speaker of the House, and their own vision of the future. This is not to say I don't care what else they've done in their lives. It's just not front and center. In my view of presidential politics, that just isn't where it belongs.

Eye of Newt

Last night the eye of Newt was on CNN's John King. The setting was a debate among four candidates for the 2012 Republican nomination for president, just two days before the South Carolina primary. King was the moderator. After the candidates introduced themselves to the audience, King posed the first question to Newt Gingrich.

Gingrich is an intriguing political figure. A long-time (two decades) Georgia congressman, he served as Speaker of the U.S. House of Representatives for four years in the 1990s. He holds degrees in history, including a Ph.D. from Tulane University. He has written numerous books, mostly in the realm of public policy. His role in the Republican takeover of the House after four decades of Democratic control, and his collaboration with President Clinton to rein in federal budget deficits and reform the welfare system are well known, at least among those who follow public affairs.

And yet Gingrich is also known (perhaps too well) for private affairs. He has been married three times, and there have been many news stories about how infidelity marked the transitions between the marriages. In a nation in which one of the most publicized societal statistics is that 50% of marriages end in divorce, and there are frequent magazine cover stories about the prevalence of adultery, this is hardly shocking. But for a leader in a party that emphasizes private virtue and family values, this is trouble.

Gingrich was raised a Lutheran but later embraced Catholicism, formally converting about three years ago. He says he has repented his sins, sought God's forgiveness, and is firmly committed to his third marriage. Voters who care about his private life will make up their own minds about his sincerity.

In a 2010 interview with Esquire magazine, Gingrich's second wife, Marianne, said that in the late 90s Newt admitted he was having an affair with the woman who would later become wife #3. She claimed he hoped she would accept the existence of that relationship, but she would not, and the second marriage ended in divorce. In an interview, on camera, with ABC News the day before this presidential debate, Marianne said Newt was asking for an "open marriage." The timing of that interview - on the eve of a primary the pundits all say Gingrich really must win to gain momentum and have a real shot at the nomination - is remarkable, to say the least.

And then last night John King (which means CNN) decided to pose the very first question of the debate to Gingrich and to make Marianne's interview the subject of that query. As the camera alighted on Newt's visage, he remained calm until King finished referring to the news story and asked Gingrich if he would like to talk about it.

It was then that the eye of Newt - well, both eyes - fixed upon John King as he issued his response. In Shakespeare's phrasing from MacBeth, King's "charm of powerful trouble" unleashed a "hell-broth" that surely did "boil and bubble." Newt said it was "despicable" that CNN would choose to begin the evening's debate with that question, declaring that it was emblematic of the sort of "vicious" media attacks that keep decent people from choosing public service.

In the TV audience there were surely some who thought Newt deserved the question and that he should not include himself, an admitted adulterer, among the "decent" people who might be reluctant to enter public life because of journalists' propensity to pry into private lives.

But the fact that this was the very first question of the evening was nevertheless shocking, and Gingrich's tongue-lashing of King, CNN, and the news media drew a thunderous standing ovation from the audience in Charleston.

His relationship with Marianne began as an adulterous affair during Newt's first marriage. Some would say she should hardly have been surprised at what happened 15 years later. Surprised or not, she was surely bitter and clearly still is. In the words of Zara, in William Congreve's play The Mourning Bride (1697), "Heaven has no rage like love to hatred turned, Nor hell a fury like a woman scorned."

I am not the least surprised that Marianne, thus scorned, remains deeply bitter these many years later. I am surprised, however, that CNN would use this story to bait Newt Gingrich, who is the conservative movement's pit bull, famous for attacking the media for biased reporting and all manner of yellow journalism. Newt called CNN's decision despicable. I couldn't agree more.

John King, on behalf of "The Most Trusted Name in News," threw this pitch right down the middle of the plate. Newt saw it coming. Like The Babe, he pointed his figurative baseball bat at the center field bleachers and knocked the ball out of the park.

Get with the Guidelines!

Or not.

This slogan has been adopted by the American Heart Association for its campaigns aimed at getting practicing physicians to follow recommendations made by the AHA for evaluation and treatment of patients with heart attack, heart failure, and stroke.

Why are such campaigns needed? It seems the problem is that guidelines promulgated by medical organizations like the AHA are sometimes not followed by doctors in making decisions about how to care for their patients. And so the AHA has decided it is not enough just to develop and publish guidelines. It must also use marketing techniques to promote the guidelines and get doctors to follow them.

If you'll permit me a brief digression, I'd like to say I think the name for these efforts was ill-chosen. It is clearly akin to "Get with the program!" Nowadays, that command should, I think, be preceded by "Dude!" So what the slogan says to practicing physicians is, "Hey! We are the experts. We have published guidelines for patient care. Why aren't you following them? What is wrong with you?"

I'm going to go out on a limb, because my opinion is based on decades of anecdotal observations rather than systematic, scientific study, but I think doctors have egos a bit more inflated than those of folks in the general population, so this phrase may not be well-received.

More to the point, however, "Get with the Guidelines" is derived from "get with the program," which - according to the McGraw-Hill Dictionary of American Idiom and Phrasal Verbs - "implies that there is a clearly known method or 'program' that is usually followed."

How well or poorly do doctors follow guidelines? And do they generally have guidelines to follow?

Kumar and Nash, two physicians, last year published a book called Demand Better! Revive Our Broken Healthcare System. Fortunately for those of us who may not have the stamina to read the whole book, it was excerpted in an article in Scientific American last March. Two over-arching themes are noteworthy. First, there is a sound scientific basis for what doctors do only about 20% of the time. Second, when such a sound basis does exist, clinicians follow "evidence-based" guidelines only about half the time.

When I read the article in Scientific American, I found it disturbing. Not because it said doctors often don't follow guidelines, which I already knew. (In fact, I am among those physicians who sometimes don't follow guidelines, although I haven't tried to calculate the percentages.) And not because the article says we make a lot of decisions without having strong scientific evidence for guidance. Anyone who knows anything at all about modern medicine knows we have more questions than answers, and we are constantly doing research to find those answers.

No, I found it disturbing because it could easily lead the reader to the conclusion that doctors don't know what they're doing. Perhaps you agree with me that conclusion would require an unfair leap, because you have substantial confidence in modern medicine. But the article reports David Eddy, MD, PhD, a healthcare economist with Kaiser Permanente, expressed his opinion in just those words.

Now let me bring ego back into it, because it's hard for me not to be offended by that characterization. So I Googled Dr. Eddy and found that, at least according to what I could learn on the Web, after his residency training in surgery, Eddy was never a practicing clinician. That doesn't - in and of itself - mean he is wrong. It does, however, mean his pronouncements about the work of practicing doctors are made without that insight.

So what about following guidelines? Kumar and Nash cite a Rand Corporation study about how often doctors practice in a way consistent with 439 different "quality indicators." They found that physicians often failed to do things that were recommended (nearly half the time) and sometimes did things that were not recommended and considered potentially harmful (about ten percent of the time).

Apparently the folks at Rand believed the quality indicators they were examining were rooted in guidelines from professional organizations that were firmly based on scientific evidence. That raises an obvious question. Why are doctors not following these guidelines? Do they not know about them? Do they not believe in them? Are they waiting to see whether their colleagues are following them?

The answer is probably all of the above.

I like to think my own practice of medicine is rational and guided by scientific evidence. At the same time, I freely admit that I must make many decisions each day that are not guided by evidence because, to the best of my knowledge, relevant evidence does not exist. And so I am forced to fall back on what I have been taught, what has seemed to work in my experience, and what my colleagues do.

Now here is a key point: the existence of guidelines and the availability of compelling scientific evidence are not one and the same. What I mean is that professional organizations sometimes publish guidelines that are not accepted by some practicing doctors. This is true even when those organizations claim their guidelines are evidence-based. You see, some of us are naturally skeptical, and we want to evaluate the evidence for ourselves.

We have a few questions. First, do we agree with the conclusions reached by the "experts" who evaluated and rated the strength of the evidence? Second, do we agree with their decisions about what to recommend based on the evidence? Third, could their conclusions have been subject to any outside influence (for example, sources of funding)?

When an organization issues guidelines for the treatment of pneumonia, and the process of developing guidelines was partially funded by a company that makes an antibiotic for pneumonia, it raises questions. When another organization issues guidelines for the prevention of blood clot formation in hospitalized patients, and the development and promulgation of those guidelines was partially funded by a company that makes an anti-clotting drug, it raises questions.

As mentioned early in this essay, the American Heart Association issues guidelines for the treatment of stroke. There is a clot-busting drug that the AHA recommended for treatment of stroke not too long after the drug was approved for this by the FDA in the mid-90s. Many doctors were skeptical of this recommendation. Many remain skeptical. More recently, the AHA issued a new advisory that said some patients can be treated with this drug up to four and a half hours after the onset of the stroke instead of the previous guideline of three hours. Many doctors are skeptical, and the expanded "treatment window" has been catching on fairly slowly.

I have reviewed the evidence, and it is my opinion that the AHA is flat wrong. But we are not all scientists keenly interested in critical examinations of scientific evidence. Some of us are highly influenced by what we experience directly. Recently a patient at my hospital was treated with the clot buster beyond the original three-hour window. She experienced the most feared complication of use of this drug: bleeding into the area of the brain affected by the stroke. If I hadn't already been convinced by my own review of the science that treatment beyond three hours was a bad idea, how do you suppose my thinking would have been affected by this negative experience?

[It is important to remember the old maxim, "The plural of anecdote is not data." In other words, one's own clinical experience may not reflect scientific truth. If you flip a coin 1000 times, you will get pretty close to 500 each of heads and tails. If you flip it ten times, you could be way off from five and five, and you could be misled about probabilities if you don't keep in mind the effect of sample size.]

Finally, none of this takes into account the variables that must be considered when deciding whether and how to apply treatment guidelines to an individual patient. Treatment according to the guidelines may be inconsistent with the patient's preferences and values.

My point is that there are reasons - some very sound, some just a reflection of human nature - why doctors are slow to embrace guidelines. Anyone who says it's because they "don't know what they're doing" has a very incomplete understanding of the world.

Magic Underwear

Mitt Romney and Rick Santorum, the two candidates for the Republican presidential nomination who finished in a virtual tie in the Iowa caucuses, are a Mormon and a Catholic.

In 1928 Al Smith was the Democratic nominee for president, and he was the first Catholic to be a major party candidate. After losing to Herbert Hoover, Smith again sought the Democratic nomination in 1932 but lost to Franklin Roosevelt. Many were convinced the United States would never have a Catholic president, and there was much talk in 1960 about religion when John F. Kennedy was the Democratic nominee and some said he would take direction from the pope. JFK took on that question very directly and effectively:

"I am not the Catholic candidate for President. I am the Democratic Party's candidate for President who also happens to be a Catholic. I do not speak for my Church on public matters — and the Church does not speak for me."

But I am convinced the election of 1960 should not have been the squeaker it turned out to be. If not for the anti-Catholic vote, I believe Kennedy would have won by a much larger margin over Nixon. The "experts" said Kennedy got 70-80% of the Catholic vote, as that demographic showed its solidarity with the candidate, and that "cancelled out" the anti-Catholic vote.

I'm not buying that. Norman Vincent Peale, an influential Protestant minister (and author of the famous book, The Power of Positive Thinking), organized a committee of over 150 members of the clergy to oppose Kennedy. Peale said our culture was at stake and that election of a Catholic could mean the end of the First Amendment (meaning that Kennedy, under pressure from the Church, would seek to make this a Catholic country).

The influence of this anti-Catholic sentiment on the election cannot be easily gauged. There was no exit polling in 1960, and even if there had been, it is doubtful that many people who voted for Nixon because of anti-Catholic sentiment would have admitted that to a pollster.

Forty years later there was surprisingly little talk about religion when U.S. Senator Joe Lieberman was the Democratic candidate for vice president, the first Jew to be on a major party presidential ticket. And more than half a century later, little mention is made of the fact that Rick Santorum is Catholic.

The First Amendment to the United States Constitution says, "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof...." This means, among other things, that there is to be no official Church of the United States, as there was a Church of England, the existence of which was the principal reason for the first phrase. The Framers were determined that religious liberty would be a hallmark of American society.

Yes, we have had our problems with tension between Protestants and Catholics ever since the first big wave of Catholic immigration in the mid-1840s (remember the Irish potato famine?). But the election of Jack Kennedy seems to have taken us past that, at least in presidential politics.

Why, then, is it considered trendy - rather than highly politically incorrect - to make derisive references to polygamy, which officially ended as a matter of Mormon church doctrine in 1890, and "magic underwear?"

The practice of protestant Christianity includes little of the sort of religious ritual associated with Catholicism, Judaism, or Islam. And so I can understand that Protestants find the ritual wearing of a religious garment somehow strange. The first time a colleague mentioned "magic underwear" to me last year, I had no idea what she was talking about, because I had never read or heard very much about the Church of Jesus Christ of Latter-Day Saints (known for short as LDS or the Mormon Church). So I did some reading. And, in the process, I learned a bit about the Temple garment worn by many members of the LDS church. I won't elaborate on it here, as those interested can easily read about it for themselves (see, for example, the Wikipedia article at http://en.wikipedia.org/wiki/Temple_garment).

So, again, I can understand that most who know little or nothing about Mormonism would find this strange. What I cannot understand is why, in a nation that has been a beacon of religious liberty and tolerance to the world for well over two centuries, it is today considered somehow acceptable or appropriate to make this a subject of ridicule. We are better than that.