You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Sunday, October 31, 2010

Voting for Health Promotion

At this time of year, maybe this year more than ever, the fever of electioneering is way hot.  There is a lot about our political campaigns that one could lament, but there is a core value that gives many people pride.  In the U.S. we do have a voice in determining what kind of community and nation we have.  Is there too much power held by special interests?  For sure.  Is there too much money spent on political and media campaigns by people with hidden agendas?  Absolutely.  Is it frustrating that political leaders seem to spend more time getting re-elected and less time working together to solve problems? Without a doubt.  However, there is no evidence that any other system is better, and most other places are clearly worse.  And by the way, the private sector is not so hot either: consider banks, coal and petroleum companies, health insurance corporations.

People have opinions and positions on many issues.  For people interested in health promotion, there are many health issues that either are or should be represented on election days.  In other words, for the issues we think are important, it may be that some candidates are more likely to take action to advance a particular policy.  This year there are a number of health-related issues that are being discussed by candidates, though there are many more issues important to health promotion that have not gained enough traction with the public to attract any attention by candidates.

One of the more common health issues debated is climate change.  In spite of people who believe climate change is either a total myth or at least "unsettled science," it is a slowly worsening problem that needs to be addressed sooner rather than later.  Once you find a candidate who believes the threat from climate change is real, then you've got to find one willing to risk jobs in the coal and petroleum industries, also willing to invest government funds in advancing the supply of alternative energy sources of fuel.  On some days it seems like the deniers are winning that debate and the American public seems to care about nothing but jobs.  It is hard to find a candidate willing to stand up to this barrage of opposition.  Profiles in courage are few.

The other huge issue in health policy getting discussed and debated by candidates is the health care reform bill passed by Congress last spring.  Many untruths have been told about the legislation, and since the opposition has spent the last six months shouting how it is going to ruin the nation's health care system, it is no surprise that people don't support the bill.  Of course if you ask people about specific provisions of the health care reform bill, large majorities support what the bill actually will do.  Nevertheless, even candidates who voted for the bill either don't cite it as an accomplishment in their campaign, or simply say it is a start which will need much more work in the future.  Of course about half of all federal candidates running say they will do all they can to repeal the bill.  It is not at all clear what these opponents are defending, considering all the problems in our current system.

There are many other more localized bills and policy proposals being debated in state and local elections.  In California, there is an effort to legalized marijuana.  Immigration reform has implications for health, both in terms of the way immigrants are treated but also how immigration policy will impact the distribution of wealth in the country.  Abortion is less of an issue in general, though many candidates will state their position to increase their support from various constituencies.

While still a small slice of the electorate, the libertarian banner seems more vocal and influential than in past years.  This is a mixed bag for health promotion.  Libertarians want to get rid of as much government as possible, and allow the capitalist market to create solutions to community problems.  They might say that the government should not be providing influenza vaccination, but should get out of the way so that the private system can efficiently fill this need.  Libertarians would generally oppose government regulation unless it is required to protect against immediate threat. For example, they would support a government imposed highway speed limit, but would oppose a public smoking ban in restaurants and other workplaces.  They would certainly oppose a ban on trans fat in the food industry, but would rely on educated consumers to mold the practices of the food industry.  On the other hand, libertarians would also oppose drug laws, and many people, not just libertarians, are being persuaded toward that view.  In general, it is hard to reconcile a hard libertarian view with public health, that believes government policy should be used as a force to improve life and health for all in our communities.

The challenge with voting with an eye toward health promotion is that candidates who are consistently true to health promotion values are rare.  Of course as a voter, it is generally better to be holistic in scrutinizing a candidate, not basing support on a single issue.   However, often you will find a candidate promising to support one health promotion idea or policy while disavowing support for another.  This is compounded by the difficulty of learning about a large field of candidates in multiple races.  In Kentucky this Tuesday, the average voter will be choosing candidates in 30-40 races at the local, state and federal level.  There are not many people going into a voting booth who really are well informed about all those office holder wannabees.

Our political system does give us wonderful opportunities to participate in deciding our future, including the formation of a sounder basis for a healthy population.  However, while these rights can be romanticized, exercising them can be bewildering.  At the same time, developing and advocating health promotion policy solutions is also very challenging.  Together they are even more confounding.

Nevertheless, good candidates who support health promotion initiatives are frequently elected.  There is good justification for health promotion advocates being optimistic, but it is an essential character trait for those who make this their business.

Friday, October 29, 2010

Election Day and Healthy Halloween

This time of year we frequently see health and safety advice related to Halloween: 1) too much sugar promotes obesity; 2) sticky candy risks cavities while hard candy can break teeth or braces; 3) caution about unusual looking candy that may be poisoned; 4) pedestrian hazards when costumed children are out in the street; 5) knife injury risk from pumpkin carving; 6) adult alcohol abuse encouraged by beverage makers using Halloween-themed marketing.  All these are legitimate concerns which are addressed by health promotion advocates in different venues.

This year local, state and federal general elections come just two days after Halloween.  While the annual holiday is always October 31, Election Day is on the first Tuesday of November, some years as late as November 7.  For this reason, it is unusual for there to be so little separation between the two days, and such intense competition for the attention of the public.  It is hard to miss the comparison.

The election is like Halloween in a number of ways.  The holiday is about deception, with people presenting themselves as someone or something they are not.  So are the election campaigns.  Halloween generates spending and stimulates the economy.  So do the elections, with billions of dollars of campaign spending.  Halloween tries to scare people, such as with ghosts, vampires and pirates.  Elections scare people with the ugly, hateful things candidates say about each other.

In addition to the general comparisons, the health concerns of Halloween also apply to the elections.  Some campaign candy is dangerous because the promises may prove to be toxic.  Just like the holiday candy is very appealing but has no nutritional value, many of the campaign ads and promises are empty of ideas and careful thinking.  Just like trick-or-treaters are sometimes hit by big vehicles in the street, many times worthy ideas and genuine leadership are run over by big campaign budgets from special interests.  Finally, just as people may be injured while cutting out a jack-o-lantern, candidates and campaigns must suffer soul scars from the destructive words and actions they hear about themselves and say about others.

What I'm talking about is not really health promotion, though a significant part of health promotion takes place in the political system of which elections are an important part.  We rely on these leaders to craft and support important health policies, after surviving the very sordid affairs elections have become.

Both Halloween and elections as currently conducted are detrimental to health.  This generation of kids will survive another round of trick-or-treating and America will survive another election cycle.  However, it is hard to not believe that health promotion is in order for both.

Wednesday, October 27, 2010

Healthy in a Hurry Revisited

During the summer I blogged about food deserts and talked about one solution being tested: using corner or convenience stores to provide access to fruits and vegetables.  This entails a public private partnership in which the store owner makes space for selling fresh produce and posting signage in and outside the store, to promote purchases of these healthy foods by consumers. On the public side, city government 1) provides management consultation to help the store owner get up to speed regarding the handling and sale of perishable produce; 2) assists with establishing a delivery chain to be sure shelf or bin space is continually replenished; 3) supplies low interest financing to offset the costs of store modification; 4) provides local communications and marketing support to build a customer base for the new foods.  The test in Louisville is called Healthy in a Hurry; so far two locations have been established with more being planned.  Photos linked here will give readers better understanding of this concept.

I serve on a team to evaluate the effectiveness of the corner store concept.  We have quickly learned that the enterprise is very complex.  We have considered a number of questions directly related to the operation of Healthy in a Hurry, but also more basic questions about food deserts.  For example, while it is true that low income residents in disadvantaged urban neighborhoods don't have stores selling fresh, high quality produce, and that these residents typically eat unhealthy diets, are those two facts related?  Are the poor diets determined by poor access, or does low consumer demand, as a first cause, provide a market in which full-service grocery stores cannot be successful?  Because we are sold on the value of healthy eating, we assume that if healthy foods are made available in the food desert, so that people are able to make healthy choices, they will.  In the real world, this may not be the case.  Access is a critical resource, but also important are peoples' motivations, decision making, values, and so forth, as well as social norms and interpersonal support for buying and preparing meals with fresh fruits and vegetables.  The evaluation team is discussing ways to obtain answers to some of these questions, but the task at hand is to look for the operation and success of the Healthy in a Hurry stores.

Immediate issues for the stores are the junction between the range of produce sold and the consumer demands of the surrounding neighborhoods.  Those people more favored by life's lottery are accustomed to buying and preparing a wide range of fresh fruits and vegetables.  They have had opportunities to be exposed to many fresh products that might be rarely part of inner city diets.  Some examples are asparagus, egg plant, apricots, and cherry tomatoes.  While a full service grocery store has a large enough customer base that someone will buy anything stocked, in one of these convenience stores, it is more critical to know what people in the neighborhood will actually buy.  A related question is How much can that consumer demand be changed?  Can we, as outsiders, influence the local residents to value and purchase new products not part of their traditional diets?  The answer is a very guarded yes.  Consumer behavior can be changed, but rarely is it a quick process.  In the case of the Healthy in a Hurry project, time is of the essence.  Unless people begin to buy these healthy food choices, the effort is not sustainable and the produce sections will go away, without long term government subsidy.

Other things are being done to enhance the diets of inner city residents.  The public schools are reducing the sugar, fat and salt content of their menus, and expanding the availability of fresh fruits and vegetables.  At the same time, they have begun to limit the selling of junk food from vending machines and school fund-raisers.  In Louisville, there is an effort to support and encourage community gardens: public property on which people can plant small garden plots.  The idea is that anything grown in a garden not only helps family budgets go farther, but usually will be healthier foods than things purchased in packages and cans.

Another strategy which is becoming more and more common is to organize and provide space for urban farmers' markets.  This is a way to bring fresh produce into urban neighborhoods.  Logistical problems include mechanisms to enable the use of credit cards and food stamps for market purchases.  In general, farmers' market fare is more expensive than produce sold in a bog box retail store, though quality is often better.  Nevertheless, price differentials between the farmers' market and a grocery store will be an issue for low income families.

Both of these strategies (community gardens, farmers' markets) are being promoted in Louisville, and many other communities around the U.S.  We don't yet have good data on who participates and how these might actually improve the nutritional status of disadvantaged Americans.

As an innovation, Healthy in a Hurry is an exciting concept.  We need to learn much more about how it contributes to health in the inner city, and how to make these stores the most effective. 

Monday, October 25, 2010

Celebrity Chef or Lunchbox Health

In the days when I was attending grade school, I carried a lunch to school every day.  The preferred container at that time was a metal lunch box, fashioned in basic shapes and colors, sometimes with graphics portraying animals, cars, or other objects attractive to kids.  Lunch boxes were gender specific in color and design, but marketers had not yet made the connection between TV or movies and a whole range of unrelated products.  I don't remember lunch boxes with designs from the Disney children's movies of that time.

On the inside of the lunch box was a lunch made by my mother.  Evey day the menu was different.  Many days I didn't know what the lunch contained until lunch period.  Just like students universally compare test scores, we always compared lunches.  The conversation went something like this: "What did you get for lunch?" "I got PB&J."  "I got cottage cheese and tomato."  (gestures indicating gagging.) "Do you want to swap?  I'll give you my sandwich and some chips for your PB&J."  And so it went.  Sometimes a classmate would forget her lunch.  The class and the teacher would usually find enough remnants so that all would be fed.

There was undoubtedly some inequity.  Some students had smaller, less nutritious lunches.  Some students had extras that others didn't.  In those days, nutritious mostly meant vitamins, minerals, and protein.  No one worried much about sugar, fat, or salt, and people believed a healthy lunch should include whole milk.

Two things stand out about this school lunch memory from decades ago. Aside from the merits or deficits of lunch on any given day, this represented a connection between home and school, student and parent. The medium was the message, and it certainly carried some health promotion value. The second point is that even though my mother or father were fixing one lunch for me, sometimes I didn't like what I found at lunchtime, and foods were thrown away. Fast forward to the time when most kids eat lunches prepared by a cafeteria team, and it becomes clear how challenging it is to serve up healthy meals that children will eat. 

Even as early as the end of my grade school days, school lunch boxes were going away, replaced by backpack pouches.  However, the shift from home-made lunches to school lunches is parallel to society's shift from home cooked meals to restaurant meals.  School lunches represent kids "eating out," just like adults do more and more often.  There are lots of reasons for this social change, but health promotion is not one of them.

The other day I read about an effort in the New York City schools to bring successful chefs from local restaurants into the management team responsible for school lunches. The idea is to make small steps in transforming the cafeteria menus from tater tots and chicken nuggets to something more like culinary arts.  It is an intriguing idea to see if those most expert in making food look beautiful and taste even better can work within the economic limits of school budgets and meet the logistical challenges of trying to please about 1.2 million children in the system.  The key question is whether the chefs can add value to menus, so that kids will eat more healthy foods.  Up until recently, schools have relied on sugar, salt, and fat to entice students to patronize the school cafeteria offerings.  Time will tell if the chefs can blaze a trail to prepare fruits, vegetables, and low fat protein foods that don't come in cans, and in a way that fits within the school lunch budgets.

School meals have become a tool for several community goals.  They have become an important component of farm commodity stabilization, linking farm production with the stable market of school meals, facilitated by government supervision and tax subsidies.  Of course, school meals are now an important way to be sure that all children have sufficient nutrients to enable them to succeed in school.  School lunches are also viewed as a component of the school health program:  the cafeteria as a nutrition and health classroom.  There is a fond hope, without much evidence, that it is more efficient to instill healthy eating values in school lunch rooms, rather than trying to change the eating and food preparation practices of parents and families.

It is probably not possible to return to the days of the lunch box, with the values it represented.  That train has left the station.  However, trying to mold children at school to seek out healthy meals probably won't really take hold without support from parents who have gotten the health promotion memo.  Just like schools can be helped by the chef consultants, parents and families may need assistance in assembling healthy lunches, with whatever container is in vogue.  Realistically, eating out has become a basic component of our society.  Doing it less in school or in the community will not occur easily.

Friday, October 22, 2010

Staying the Health Promotion Course

Once upon a time in the 1980s, public concern about drug abuse prevention was at a fever pitch.  The issue got heavy attention in media.  Political leaders, including Presidents spoke about it.  Corporations wanted press coverage for charitable gifts made to drug abuse prevention efforts.  Grass roots efforts in local communities proliferated to confront the "menace of drug abuse."  With all this attention and support, serious government resources flowed to programs and policy strategies.  While success was not proportionate to the size of the effort, progress was made.

Today, drug abuse has largely disappeared from the popular radar screen.  There is little if any discussion of drug abuse in political campaigns.  If there are news stories about it, they get a yawn or a change-the-channel reflex.  What we don't know is whether this lack of focus and determination will lead to a resumption of the drug epidemic.  There is reason to be concerned.

We have seen this with vaccination.  In the 1950s and 60s, the public had firsthand knowledge of infectious epidemics.  The ambient fear and respect for childhood infections translated into widespread support for vaccinating children.  The new vaccines were welcomed as wonder drugs.

As the decades have passed since then, a lot of apathy has set in.  Parents today have no memory of children severely sick and disabled from infections of early life.  This has given rise to apathy when it comes to getting children immunized.  At the same time, some parents believe, without any evidence, that vaccination is a cause of autism.  In addition, birthing has seen a relative shift away from mainstream to low income minorities and particularly Hispanic families.  This presents access and health literacy barriers to vaccination, making the job more complicated.  Nevertheless, there is reason to be concerned that as a society we take our eyes off this particular ball, allowing rates of measles, mumps, pertussis and polio to rise again.

To an extent we are seeing this happen with a shift of attention away from tobacco toward obesity prevention.  It feels like our commitment to tobacco control is running out of steam.  While overweight and obesity is a very serious problem, tobacco is still with us, taking over 1,000 U.S. lives a day.  We should be concerned that society may be losing interest, and will pay a price of increased smoking rather than pushing a continuing decline.

So then, the key question is how do we in public health prolong the attention span?  How do we keep individuals, institutions and government agencies focused on a health promotion task when it is no longer exciting in the public's eye?  How do we break the cycle of fits and starts, always moving on to
 the next big thing?

I don't have the final answer, but offer two things to consider.  The first has to do with insisting on strategic planning driven by community needs, rather than funding opportunities.  Public health agencies are often seduced into designing programs because funding is available.  This gives rise to a cycle of always moving on, whether or not a job has really been completed, which of course, it usually has not.

Recently, a lot of federal stimulus money has been invested in community health programs around the country.  Communities were invited to compete for these funds.  It was not a coincidence that the ending date for the health projects is spring, 2012.  The initiation and success of these projects are part of the strategy for the 2012 Presidential campaign.  Campaign strategists want to be able to point to successful stimulus spending.  This point is not to fault the projects, but to say that beginning with funding opportunities is not always the same as beginning with local health priority needs.

The second way to help break the cycle is to rely more on theory-driven, evidence-based strategies and solutions, and to constantly fine tune our interventions with careful evaluation.  Some of the reason for losing interest is because the things we do are not effective, so people become demoralized and give up.  Demanding more connection between research and program planning, and relentless attempts to find more effective methods might keep people engaged and inspired for the long haul.

In the end, we are talking about human nature and social evolution that we have few tools to manage.  Nevertheless, it is health promotion's burden to keep people striving until the work is done, not before.

Tuesday, October 19, 2010

Health on a Plane

Some years ago there was a film that became a byword for tasteless, mindless movies: Snakes on a Plane.  I managed to miss the experience of fears being exploited.  It there were snakes or something else menacing people within the confines of an airplane, people would feel particularly vulnerable and defenseless, being unable to escape.

Recently I was on a flight across the country, and began to think about the health threats to airline travelers.  It is a modest list.  Obviously, people are not dropping like flies, but concerns are real, and a huge segment of the population, the traveling public, is effected.

So what should travelers worry about?  Coincidentally, the first thing to worry about is worry.  For all but the most seasoned travelers, the airport and airplane experience is stressful, starting with getting to the airport on time, finding a place to park, getting through security, finding the correct gate, discovering that someone else is sitting in your seat and there is no room in the overhead bins for your bag, getting your blood pressure down when the plane is delayed for 73 minutes, waiting on the tarmac for takeoff while the backlog of planes is cleared, sitting in a cramped seat in front of a crying baby, next to someone who gets up a lot to go to the bathroom, finding that when you arrived, your bags did not......Are you stressed out yet?  In the current economic environment, airlines are trying to squeeze out as much inefficiency as possible; human comfort and tranquility do not have places in the systems modeling equations.

Perhaps the next thing is hand hygiene.  Certainly in flu season, one of the most important precautions is to keep your hands clean and away from your face, nose, and mouth.  Airplane hand hygiene is difficult because, in spite of the ad slogan - "You now are free to move about the cabin," people find it not so easy to wash hands.  Most people prefer to stay in their seats unless a trip to the bathroom is unavoidable.  Once security measures were scaled back to permit up to 4 oz. of liquid to be brought through check points, it became possible to carry and use hand sanitizer.  I have not noticed many people using hand sanitizers on planes, but this should become a social norm in the future.  It may be a mixed blessing that airplane food is going away: people will have fewer chances to eat with unwashed hands.

Closely related to hand hygiene is air quality.  On an airliner carrying 150 or more people, it is certain that someone has a cold or flu, and their coughing and sneezing puts at risk, passengers and crew alike.  If protecting health was the only concern, we would have seating in three zones: business class, coach, and sick bay.  While the public's health might benefit, it is hard to see how the airlines gain.  If you are sitting near someone who is sneezing and coughing, you can ask to be moved to another seat if the plane is not full.  You could also have the foresight to carry a surgical mask, putting it on when infection risk goes up.  In other words, there are no reliably good options.  Upper respiratory infection is a risk of commercial flying, not unlike going to work, school, church, or parties.  This risk is unavoidable, with the the backup of flu vaccine for the most severe URI threat.

Another risk is orthopedic problems, from carrying, dragging, and lifting heavy bags.  People could learn to travel lighter, and this would help.  On the other hand, the airlines' recent policy of charging for bag checking probably means that more people have carry on luggage, requiring them to move bags longer and to lift more weight.

There are a few more hazards.  People prone to blood clotting in the legs may have trouble from sitting on long flights.  Mobility is harder on planes than at home or work.  Another risk is the food choices.  We'll know society has shifted when flight attendants come down the aisle with baskets of fresh fruit.  Finally, some people suffer from headaches precipitated by altitude-related pressure changes.

What can be done about all these threats?  Maybe whoever said, "If man was intended to fly, God would have given him wings!" was right?  More realistically, we realize that risk-free living is impossible and perhaps undesirable.  Be prudent when you can.

Most of the problems outlined above are diminished or avoided entirely by train transportation, more on long distance trains, less on commuter trains.  When you can, ride the rails - for your health and the Earth's as well.

Sunday, October 17, 2010

Health and the Farm Bill

This is a story of unintended consequences and the fact that important health policies are found in unexpected places. 

We often hear families of modest means complaining that they can't afford to feed the kids healthy foods recommended by health promoters because those foods are too expensive.  While they don't really prefer happy meals and hot dogs, they can fill their kids' stomachs more cheaply with those foods than with the much more expensive fruits and vegetables.  This is not an excuse for bad behavior.  It is a fact that fruits and vegetables are more expensive than meat and grain-based food.  The question is why?

Back in the throes of the Great Depression, President Roosevelt's New Deal was concerned about rural poverty among the large segment of the population living and working on farms.  Because farming at that time was subject to booms and busts from weather and fluctuating crop prices, unrelated to anything the farmers could control, it was a very difficult occupation.  As a way to provide stability and security to this important sector of the U.S. economy, the federal government began to put in place price supports, crop insurance, and programs to guarantee distribution of farm goods.  Because field crops such as corn, wheat, rice, and soybeans were nonperishable, able to be stored, a portion of the crops could be held back from the market, keeping up prices in the boom years, avoiding shortages when crop yields were slim.  These crops were easier to support than other farm products with a limited shelf life, such as fruit and vegetables.

The intent of the New Deal programs was to assure that farmers had adequate support, to guarantee as much as possible, a stable and reliable food supply for Americans, while also helping those farmers become solidly middle class.  Here is the unintended consequence part:  Once price supports were in place, and subsidies for certain crops, and once there was an infrastructure for crop insurance, farming became attractive to corporate agriculture.  Over the years, family farms have been swept up by corporate giants, who only found this business attractive when much of the risk was removed by the U.S. Department of Agriculture.

Over the years, subsidies and price supports have continued, so that there is now built into the farm economy a significant bias toward those field crops. Only 7% of farm production comes from fruit and vegetable farming, while the lion's share is from grains and soybeans.  The bias has been entrenched by years of tradition, but also buttressed by the political clout held by the corporations, never even envisioned by the family farmers.  This means that corn, wheat and soybeans are sold by the ag corporations for less than they actually cost, courtesy of the taxpayers.  This has lead to relatively cheap foods made from grain, soybean oil, and corn-based sweeteners.  Even meat is cheaper because it is less costly to feed cattle and chickens in factory farms where they are fed grain crops rather than maintaining land on which animals forage.  Meanwhile, relative to the price of corn, wheat, rice and and soybeans, the cost of fruit and vegetables has continued to increase.

The other related problem is that the U.S. Department of Agriculture has a schizophrenic mission: to promote prosperity in the farm sector while also promoting the availability of healthy foods for Americans.  Those two goals are partially in conflict.  While the USDA has done some good things for healthy nutrition, the pull of industry lobbyists and powerful farm state politicians has overshadowed the goal of promoting healthy Americans.  Up until recently, this has meant that the U.S. school lunch program foods have not been as healthy as they might have been; for years, school lunch menus have favored meat and bread, but shorted fresh fruit and vegetables.

These farm policies are contained in what is called the Farm Bill, a piece of legislation which is renewed every five years; the most recent version of the Farm Bill was passed in 2008, and it will be up for renewal in a few years.  So here is the challenge.  What if instead of spending hundreds of billions of dollars to support corn, wheat, and soybeans, we used our tax dollars to subsidize fruits and vegetables?  If the government was underwriting the cost of those foods, farms, and especially corporate farms, would respond to the incentives.  Furthermore, consumers would respond if apples, oranges, grapes and broccoli were a third to a half as expensive, while bread, grain-fed meat, and foods high in corn-based sweeteners and soy oil were more expensive in a similar proportion.

Often these background forces are more powerful than public education in molding consumer health behavior.  Health promoters need to pay attention to the provisions of the Farm Bill.  It is hugely important health policy.

Thursday, October 14, 2010

Erbal Ealth

I hope readers get that the title is not an error.  I wanted to reinforce the idea that relying on herbs for health promotion often is done with information missing.  However, I want to start the story at the beginning.

The other day a student forwarded a research article on the effectiveness of an herbal spice called turmeric as an anti-cancer agent.  The research raised the possibility that turmeric will prevent the growth and spread of breast tumor cells.  For readers not deep into cooking, like I am not, turmeric is a spice commonly used in Asian cooking, and might be thought of as a cross between ginger and pepper.  The average person in India has significantly higher consumption of turmeric than the average Westerner.  I haven't done a literature search to see if this study is corroborated by other studies with similar or different research designs, but one study does not equal settled science.

Nevertheless, it turns out that the age-adjusted breast cancer mortality in India is 7.4 per 100,000 while the comparable rate in the U.S. is 11.31.  I hope you are saying to yourself, "That is an interesting finding, but it doesn't prove anything."  First of all, it will be important to verify that record keeping in the two nations are the same.  While it is safe to assume that all, or nearly all breast cancer deaths in the U.S. are accurately recorded and reported, that may not be true in India.  They have a much bigger population to monitor, and their health care system ranges from magnificent to barely functioning.  Assuming record keeping is not a factor, we then must consider other factors responsible for breast cancer.  An important difference between India and the U.S. is the proportion of women who are overweight or obese; excess body weight is a risk factor for breast cancer.  In short, while this research study on turmeric's value in combating cancer is encouraging, there is much more we need to know before any health promotion advice can be given with any assurance.

This is typical of the huge herb and nutritional supplements market.  Wild claims are often made, most often too good to be true.  On the other hand, it is certainly true that there are healing properties found in plants, but because of the profit motive, promises made about these products are often completely disconnected from fact.

We might rely of the federal agencies, the Food and Drug Administration and the Federal Trade Commission to guide and protect consumers with respect to herbs and medicinal plants.  However, because of anti-government and anti-regulatory advocacy, the FDA does not require review and approval before these products are brought to market.  The FTC has the job of checking the accuracy of marketing claims.  However, the huge array of products and the overwhelming number of vendors, including web-based, means that the agency has not, so far, been able to keep up with the task.  The bottom line is that as a consumer, you are mostly on your own in trying to critique the health promotion potential of herbs and "nutraceuticals."  There is the standard advice to check with your doctor, but she may not have any specific information about these products.  It is impossible, even in medical school, to teach physicians what they need to know about all the products patients shouldn't use.

One final note is that sometimes people say "It may not help, but it can't hurt!"  Not so.  Some of these products are not safe, regardless of the claims made about them.  The best source I've found for reliable information is the National Institutes of Health, Office of Dietary Supplements.  If you rely on Google, absolutely beware of the source.

Wednesday, October 13, 2010

Little League Health

One night this week I watched my grandson play his last Little League game for the fall season (fall ball).  He and his team mates have improved a lot, somewhat due to practice but mostly due to physical growth and development.  One thing that is unmistakable is that every kid on the field, about 24 for two teams, is normal weight.  Not one player was overweight.  In the general population of this age group, about 1 in 5 would be overweight or obese.  So why are these ball players all thin?

There are several reasons.  Obese children might self-select out, choosing not to participate because they lack the confidence or ability to be successful.  Given the fact that at this level of play, all the kids are beginners, it is unlikely that even an obese child could not play.  However, the kids that do play are probably a little more active than most kids their age.  The key word is "little" because baseball at this level is rarely strenuous and many times stationary.  Players stand stock still until a ball comes near.  On offense, they sit until it is time to bat.  I doubt the average player burns more than 2-300 extra calories during a game.  Even some of that amount is compensated by snacks given to the kids at the end of games.

Another possible reason is that these ball players are not thin because they are in Little League, but they are physically active by inclination and family encouragement, leading them to play in school and community sports.  The key point is their fitness is not driven by teaching them about the importance of physical exercise and a healthy diet.  Kids this age are not motivated by long-term health benefits; in fact, a message about anything being good for health usually would not resonate with them at all.  So the question is what is the essence of motivation that makes these kids physically active, and how could that be sprinkled like pixie dust on all kids?

I think part of the answer is to change prevailing family patterns and values in our culture.  What if families organized themselves as though movement was important.? I don't really believe the statistics that the average person watches 4-6 hours of TV per day, but whatever the number is, it is not sustainable if we want a healthy population.  Nevertheless, someone needs to figure out how to instill into new parents a social norm of walking, biking, running, playing, and doing it every day.

Here is the bad news.  As I observed the Little League playing field, all of the kids were thin, but most of the coaches were overweight.  What happens between playing days and coaching days for that transition to occur?  This is another challenge.

In health promotion practice, there are not many out-of-the-park hits.  There are more typically bunts, base-on-balls, single hits, maybe an occasional steal.  Winning the game and the world series of changing day to day lifestyles is very much a long term proposition.  More times than not, we have to try again next year.

Tuesday, October 12, 2010

An Ounce of Prevention Not Worth a Pound of Cure?

The U.S. historical figure Benjamin Franklin (1706-1790) is credited with a body of aphorisms or sage sayings.  I don't know if he was a collector or whether he was an inherently astute and wise person, and was able to harvest these sayings from his own intellect and experience.  Perhaps it was both.  In any case, one of the most widely quoted is in the title, comparing the value of prevention versus cure.  It is conventional wisdom that this is true.  Like most things health-related, concepts are more complex.  While in most circumstances, it is better to prevent than cure, the general principle must be qualified.

In the federal government health bureaucracy there is a  unit called Agency for Healthcare Research and Quality.  The title is revealing of the general mission of the organization; it is most meaningful for health professionals and health promotion workers, but there is some material provided for interested consumers as well.  One of the agency's specific functions is carried out by the  U.S. Preventive Services Task Force.  This group of 16 experts, with credentials in prevention, evidence-based medicine and primary care, was first established in 1984, to provide a systematic way to guide prevention service in primary health care.  Using sytematic reviews of the published medical and health promotion literature, the Task Force outlines evidence for a long list of preventive services sorted into three types: screening, patient counseling, prophylactic use of medications.

Based on all available evidence, the Task Force will assign grades A(strongly recommended) through D(not recommended) and I for insufficient evidence.  So for example, prostate cancer screening for men over 74 gets a D, not recommended.  For men between the ages of 45 and 79, taking a daily aspirin to prevent myocardial infarction (heart attack) gets an A, strongly recommended.  Using ultrasound in the second trimester to improve pregnancy outcomes gets an I, for insufficient evidence.

The following widget will bring you to a list of screening services that might have some applicability to readers.  Just fill in the basic details and submit.  This will show the  grading of each screening service, with explanations for the basis of the grading.

This effort, and ones like it, have been dragged into the political process, and cited as examples of government bureaucrats getting in between you and your doctor.  That is an unfair charge.  First of all, bureaucrat is a term that doesn't mean anything useful.  It is a throwaway term, not one that communicates anything precise.  As outlined above, the members of the Task Force are highly trained professionals.  Most of them do not work for government.  Their work is science driven, and they are accountable for their decisions regarding the services they review; the basis of their grading has to be explained and defensible.  Finally, by and large, the recommendations are guidelines, which are in fact widely ignored.  For example, most men are given the PSA prostate cancer screening test, even though it is not recommended by the Task Force.  The point is to help the system use resources in a way that will maximize health outcomes and minimize untoward consequences and side effects.  In a system as large as ours, it is unrealistic to think that getting all primary care physicians and nurse practitioners to know and comply with the recommendations will be easy or quick.  It is an effort in the right direction.

Some of the recommendations have led to system changes through insurance mechanisms.  For example, routine colonoscopy is not recommended for people under the age of 50.  A person under 50 could self-pay and get a colonoscopy, but many insurance companies will not pay for the procedure.  On the other hand, 2nd trimester ultrasound has become standard practice, supported by insurance, but the Task Force has not found enough evidence to support it.  Rome was not built in a day......

This issue has broad relevance to health promotion, even though these services are primarily delivered by clinical care providers.  There is an education and communication process that must be part of any effort to promote adoptation of any specific preventive service and compliance with the recommendations as a whole.

Ben Franklin did not realize how compicated prevention and cure would become, 200 years later.

Monday, October 11, 2010

Urban and Rural Green

A few days ago I drove from Louisville, where I live and work to Frankfort, the capitol of Kentucky.  Louisville has about 1.2 million people in its metro region, while Frankfort has around 35,000 people.  If it wasn't for the institutions of state government, Frankfort would be a sleepy town.  In between Louisville and Frankfort are about 40 even more rural miles: tiny villages, farmland, wooded hills and rocky knobs.  In the transition between the extremes of urban and rural, I began to think about what green living means in cities, versus what it means out in the country.

It is ironic that rural communities are not more green than they are.  First of all, most American farming is very energy dependent.  Farms use lots of water, lots of chemicals, lots of petroleum for all the mechanized equipment used, as well as transportation of farm produce to a point of sale. In the case of animals, eggs and milk production, farms also generate huge amounts of waste: solid, liquid, and gas (methane).   Because of sparse population, rural communities must rely on personal vehicles; public transportation is not feasible.  In addition, people in small towns often have to drive greater distances for grocery and other shopping, and day to day services.  While most people in rural communities heat with electricity or natural gas, burning wood is certainly common, and is more likely to occur in the country, where sources of wood are more plentiful.  Coal mines are also in isolated small towns; even people nearby who worry about green lifestyles are in a bind because those mines may be the only source of living-wage employment.  It may be that services to make home energy use more efficient, such as better insulation or improved window sealing are less available in small towns, just because there is not enough demand to support such businesses. 

To the extent that life in small towns is slower, it may be that there are some advantages compensating for the green deficits mentioned above.  For example, compared to city dwellers, rural residents might be more inclined to have their own vegetable gardens, using transported produce from distant factory farms less often.  It is also easier for rural residents to compost.

In comparison, urban communities also have a set of green pluses and minuses. People in cities usually have more options for public mass transportation, though our public transportation dollars are still heavily invested in cars, so that the infrastructure for transportation by bicycle, bus, train, light rail, and so forth is still not very advanced in most places. Even with mass transit systems, every city, including Louisville, has wasteful traffic jams, bad for air quality and energy conservation.  Because of population density, people are usually closer to shopping and services; they don't have to drive so far, and may have the option of walking to the store, the Post Office, the library, and so forth. Because of the congregation of vehicles and industries, there are usually more air quality concerns in cities. Water resources may be more at risk, but there are also more extensive resources to prevent water pollution.  Recycling is more common in cities because there will often be systems in place to collect, receive and process the recycling materials stream; this will less often be found in small towns and villages.

On the other hand, residents in both rural and urban communities can use compact fluorescent bulbs, they can turn off lights and other electronics not being used.  They can use electrical appliances like dish washers and clothes dryers more efficiently, and they can turn down heating temperatures and turn up cooling temperatures.  Whether in the city or the country, people can buy more fuel efficient vehicles, they can install more fuel efficient thermostats, and they can change furnace filters in a timely schedule. People in both types of communities could avoid heavily packed goods, though it is hard to do; more than individual consumers, decisions about packaging are dictated by WalMart and the large retailers.

While there are green advantages and disadvantages attached to living in cities and living in the country, we can all learn to care for the earth more consistently.  It is a state of mind that needs to be epidemic.

Wednesday, October 6, 2010

Probability and Health Message Impacts

Like many Americans, recently I received a flu shot.  As far as I can recall, I've never had the flu; some years I've been vaccinated and some years not.  It is a calculated risk either way.  If you don't get the  vaccine, you may not get the flu.  If you do get the vaccine, you may have immunity with no symptoms, mild symptoms, or severe side effects.  Those severe side effects are very rare, while around 35,000 Americans die each year from influenza infection.  The odds are in favor of those who are vaccinated.  Nevertheless, it is a hard sell for the public.

This is similar to many health promotion measures.  Every year there are deaths of people who are out exercising and in the process have a fatal heart attack.  Statistically, it is probable that vigorous exercisers will have many health benefits, including longer life.  However for some the probability will fail and they will suffer harm which might have been avoided if they were more sedentary.

There are a couple of problems with playing probabilities to promote health.  For many people a partial promise is not very motivating.  They want absolute assurance: if...then.  Of course, health is not like that; there are few if any guarantees.  From a practitioner's perspective, it is difficult to bring about change if you are only able to offer a 30% reduction of risk, for example.  Unlike business promoters, we are constrained by ethics to be truthful, even when it blunts the health message.

Another complication is when money and resources are an issue.  I have a family member who has a close family history of colon cancer.  This person is very worried about risk for colon cancer - not an unreasonable concern.  Many insurance carriers, including hers, do not cover colonoscopies for people under 50, because the "harvest" of possible cases found is very low.  In other words, if the insurer provides a colonoscopy for every 50 year old, enough full-blown cases of colon cancer will be prevented, so that the cost of screening is less than the cost of treating all those cases that would not have been prevented.  At 40 or less, too few cases will be prevented to justify the business expense of screening, even though people like my relative would benefit, perhaps even to a life-saving extent.

On the one hand, someone might condemn a system that doesn't put lives always first.  On the other hand, one might believe that resources, even in health care are finite; we have to use investments in prevention and treatment in such a way to protect and promote health most effectively for the most people.  Both sides of the argument have merit.  However, the issue here is not to screen or not to screen, but the difficulty of crafting public information messages to address these and many more health matters.

Communication to the public will be more effective if messages are clear, uncomplicated, direct, and unequivocal.  One of the hardest tasks of health promotion is to communicate effectively when none of those qualifiers apply.  This is a partial explanation for 45 million smokers after 50 years of communicating an anti-smoking message.  In the face of this reality, we can take much satisfaction that there are 5 million fewer smokers than we once had.

Fortunately, there are many theories which can be used to do battle against resistance to health communication.  For example, if you want to promote flu vaccination, should you say 1) Physicians recommend the vaccine; 2) If you don't get vaccinated you might die; 3) Most of your friends are getting vaccinated?  Theories shed light on whether one or more of these approaches will be most effective.  In addition, there is a geeky sounding field of research and practice called decision science.  It doesn't get much public attention, but is learning more and more about how and why people make the decisions they do, and how to tip decisions toward health promoting action.  This field will provide more tools for health promotion in the future.  The next time you see or hear a health message, you might wonder what marionette is behind the scenes trying to help you protect your health and promote your wellness.

Monday, October 4, 2010

Animals, Vegetables and Health

Usually the posts in this blog are in the abstract, dealing with factual information.  I try to present material for which there is evidence, rather than tell a personal story or give an editorial opinion.  Today will be different.  I want to talk about vegetarian diets.  Even though I think there are facts to shape the discussion, I also believe this issue is very personal, not one about which I want to be directive or dogmatic.

Not long ago my daughter, who is a chef by training, gave me a book about using animals for food: Jeffrey Masson's "The Face on Your Plate."  Some years ago I had read Matthew Scully's "Dominion: The Power of Man, the Suffering of Animals, and the Call to Mercy," and Eric Schlosser's "Fast Food Nation: The Dark Side of the All American Meal."  There are many other books in this genre, but these are all quite good in making you think about the nature of our diets and how they connect with the animal world.  When you take an honest look at the evidence, it is hard to deny several compelling arguments.

I don't think vegetarianism is primarily about health.  For one thing, I don't think you can make any assumptions about the healthfulness of a person's diet because they tell you they are vegetarian.  A vegetarian's diet is healthy, not because it doesn't contain meat, but because it is rich in fruits and vegetables, whole grains, low fat diary or dairy substitutes for vegans, adequate protein and other nutrients from a variety of beans, sufficient fluid, and no more than moderate amounts of alcohol.  There are not many advantages to be gained by a totally meat free diet compared to the diet outlined above which also includes small amounts of low fat meat servings.  Nevertheless, in population studies, vegetarians often compare very favorably to those with other types of diets.

For me, the most compelling arguments in favor of a vegetarian diet are the environmental impact of diets and the impact of meat-centered diets on the animals in our food chain.  Prior to the practice of farming as a method of raising food, animals served as a convenient source of nutrition.  While not a perfect diet, eating the flesh of hunted animals or fish was enough, supplemented with wild plants, to sustain life at least into the third or fourth decade.  In those days, population was sparse enough that the impact on the ecology was not extensive.  With the massive increase in the demand for food, occasioned by the explosion of population beginning in the 19th century, it is now clear that plant farming is much more efficient than using animals for food, in terms of energy required, land use, production of waste, and toxic contamination of the environment.  Factory farming is environmentally destructive and unsustainable on a global basis.  The books above will give thorough descriptions and documentation of the environmental harm done by making animals so central to our diets.

The other main issue boils down to the treatment of animals.  I don't believe like many do, that killing animals for food is inherently immoral.  This is very much a personal belief rather than an established fact, but I think it is possible to raise and use animals for food in a humane way.  However, market forces have taken any human values out of this practice.  Skilled accountants and engineers have found ways to extract the greatest possible profit, with no regard for humane treatment of the animals, for the safety of workers in the processing plants, or for the impact of the industry on the the areas nearby their plants.  Meat processing plants (the name is so much more pleasing than slaughterhouse) are places where animals are treated in their lives with great cruelty, leading up to a brutal death.  Unfortunately, this is the predominant method of animal agriculture in our country.

The question is if there is such a thing as animal cruelty.  Some would say that animal cruelty is conceptually impossible because animals have no free will, are not thinking or feeling, cannot do formal problem solving, and have no self-awareness or sense of future.  Evidence is growing that none of this is true.  However, if someone is persuaded that cows, pigs, and chickens are no different in character from stones and clay, then perhaps it doesn't matter what happens to the animals which end up on our plates.  On the other hand, if one can visualize or admit to the possibility of animal cruelty, it is then hard to deny that what happens to our food animals in factory farms and processing plants does qualify.  The argument is similar to the argument about prisoner torture:  it is not about the terrorists, it is about us as a people.

Vegetarianism, and the even more certain veganism, are no longer oddities;  most of us know more than one person as a friend, family member or co-worker who fore swears meat in their diet.  On the other hand, there is no great social change underway to eliminate animals from the food chain.  It is a very difficult decision for people with great social consequences.  Food is central to so much of our lives, and making what is truly a radical change - no meat - is not something people are in a hurry to do.  I think the environmental consequences are going to push very hard on the prevailing dietary practices in the coming decades.  Given the violence and brutality found in so many places in our culture, it is unlikely that we'll see a groundswell of sympathy for cows, chickens and pigs any time soon.  It is something to chew on, however.

Sunday, October 3, 2010

Minimum Age Health

Because of its many unintended consequences, national alcohol prohibition was overturned by the 21st Amendment to the U.S. Constitution, ratified in 1933 by all states but South Carolina.  Shortly after this legalization of alcohol sales, most states enacted the minimum purchase age of 21.  The ideology driving prohibition, alcohol is bad, was forced to concede after a dozen years of evidence that prohibition caused more problems than it solved.  Some states and local communities continued the overall ban on alcohol sales right up to now, but most states compromised with age laws.

In the 60s and into the early 70s, many states dropped their minimum drinking age, based on a contrast: 18 year olds could die in the jungles of Vietnam but couldn't buy a beer stateside.  In addition, prevention theorists promoted the idea that part of the appeal of alcohol among youth was the "forbidden fruit" mystique of something only adults could have.  The way to diminish abusive drinking was to take that away, by making alcohol ordinary and routine, by providing more access rather than less.   This national experiment took place in the 1970s.  A few years in, evidence showed that youth drinking was up, not down.  Youth were experiencing more highway injuries and deaths than when the legal age was 21.  In the following years, the states brought the age back to 21, which is where it is today.  The agument has not gone away, however, particularly among those who don't remember the history of lowering the age in the 1970s.

In addition to the alcohol age restriction, we have other health-related age rules.  These include a minimum purchase age for tobacco (18 in most states, older in some), minimum age for driving, for employment, gun purchase, and marriage.  Many states prohibit helmet-free bicycling under a certain age.  What is the rationale for these laws?

We impose age restrictions for a variety of reasons.  If there are developmental limits on safety, such as with young drivers, age restrictions seem appropriate.  For some things it is a matter of children or youth not being capable of making an informed choice; most adults are persuaded that 12-13 year old adolescents are incapable of understanding the nature and consequences of marriage, and so we do not give them that privilege.

The rationale for alcohol purchase age was that youth needed to be protected from the seduction of alcohol until they were and are "of age."  The sub-theme is that youth are not capable of making an informed decision, and must wait until the legal age of adulthood.  Most adults approve of minimum purchase age laws, though they might quibble about what the appropriate age minimum should be.  Even parents who are comfortable serving alcohol to their children at home, usually do not want them to be able to buy alcohol on their own, without supervision.  Note that these laws not only take away choice from youth, they also take away the right of parents giving permission.  This is because the consequences of adolescents making bad choices with alcohol, parental permission or not, are a threat to us all.

Sometimes public support is a critical element with age restrictions.  For example, what if we had minimum purchase ages for donuts and fried onion rings.  There is no public support for such a policy, but logically someone could make the case, citing the same concerns underlying tobacco purchase minimum age laws.  It remains to be seen whether our concern for the national obesity epidemic leads to changing social attitudes regarding sheltering youth from extreme calorie foods.  Right now this seems very unlikely, but in the past I never would have thought there would be smoke-free ordinances in Kentucky, but this has happened.  Age restrictions can be a useful health promotion tool, but these policies always go up against the libertarian impulse so characteristic of American culture.