Vitamin D and Public Health Communications

For a number of years health researchers and communicators have been suggesting that the population may be deficient in Vitamin D and calcium, and this not only is a concern for bone health, but also may have negative consequences on a number of important chronic diseases, such as heart disease, cancer, and diabetes. It has been suggested that the shortage is due to a decrease in milk consumption and growing caution about limiting sun exposure.

No reputable health information source has trumpeted loudly the benefits of taking supplements of calcium and Vitamin D, but there has been much media discussion by "experts" and consumer health advocates, and curious consumers could go to prominent health information websites (e.g. Mayo Clinic, National Institutes of Health) and get the idea that there probably is some benefit to increasing consumption of those two nutrients.  Those consumers would also have found inconsistencies regarding how much intake is recommended and how much is safe.  The U.S. Preventive Services Task Force, well respected as a guide to disease prevention efforts in clinical care has been silent regarding this issue, except in reference to osteoporosis.
 
This week, the Institute of Medicine has issued a report regarding the health claims and hazards of Vitamin D and calcium supplementation.  The Institute determined to thoroughly review the published literature on the topic and issue a report establishing, for now, the state of the science.  The work of the review was the responsibility of a committee of experts from reputable institutions in the U.S. and Canada.  Their findings were: 1) the only certain health benefit of calcium and Vitamin D supplements is to promote bone health; 2) most people are not deficient in these nutrients, and therefore don't need supplements.  Readers are encouraged to review the report to fill in the details.
 
My reason for writing about this is not to add anything to the Institute's work and report, but to consider the implications for public education and health promotion.  We live in a world of unbridled access to health information, some dependable, some not so much.  The profession of journalism seems to be on life-support and anyone (including bloggers!) can be an unfiltered source.  Consumers are covered with a nonstop stream of health-related ideas and are often unprepared to process and detect value.  Furthermore, their task becomes even more difficult when the experts disagree or change the recommendation.  They deal with communicators who have varying degrees of skill; the least effective communicators might be the most accurate and reliable sources, but how is the consumer to know?  I analyzed the Institute of Medicine report and note that the narrative tests at college junior year reading level, hardly suitable for the average consumer.  Finally, those of us living in the health promotion professional world accept the Institute of Medicine as eminently reliable;  the average consumer is much less likely to be impressed by that name.  They have learned that organizations frequently call themselves misleading names (see also, political campaign advocacy groups).
 
There is no question that the work of health promotion would be easier if the flow of information could be managed, but that is not possible, and also not fully desirable in a free and open society.  The problem that confronts us is how to help consumers sort the rubies from the rubbish, and to apply simple rules to assess a source and the specific health information content.  At the present time, no single source is the single go-to place for people to seek answers to health questions.  Significantly not included as the single source is the primary physician, because the practice of medicine in 2010 and going forward is not really hospitable to quality health counseling, and a single practitioner cannot be as fully informed as a large organization with abundant resources.
 
The combination of proliferating sources and the changing nature of health science means that a very important role for health promotion is helping people maneuver the communication environment.  We also have to help people understand that science-based guidance will change as the research machine does it's work.  Everyone's job is to try to find the most accurate advice and follow it until such time as there is a trustworthy indication to change.  There are no simple solutions, and this will not be done with perfect effectiveness.
 

Thanksgiving Health

Part of me thinks talking about warm fuzzy gratitude as a constituent of health is trite and treacly.  Standard fare in human interest news stories this time of year is thanks to the troops serving overseas, in war and out.  The other theme is to present stories about homeless’ soup kitchens and Thanksgiving dinners for the poor, in counterpoint to those of us gorging on a Turkey Day meal, in preparation for a spending spree that starts the next day, Black Friday.

Are the soldiers’ sacrifices and relative wealth things that warrant our gratitude?  Absolutely!  Many Americans are really in the category of “haves”: good health, functional families and loving relationships, good housing and adequate incomes.  Taking time on Thanksgiving and every other day for meditation on these blessings is surely a balm for otherwise frazzled souls.  The Spanish translation for Thanksgiving is sometimes El dia de acciones de gracias – day of thankful actions.  With little basis in health science, I believe the combination of grateful thinking and motivated actions has benefits for mental and physical health.

My reservations about this stem from two points.  First, gratitude in most people comes in fits and starts.  There is a dose response of thankfulness: it seems that many of us are stuck in MORE, with occasional glances at ENOUGH.  With this reality, the occasional moments of grace, such as happen on Thanksgiving are welcome, but only go so far.

The other concern is the distribution of the sources of gratitude.  We are encouraged by religious leaders that thankfulness is a state of mind, not a reflection of our circumstances.  A lofty sentiment, but much easier for those with most favored social stations.  The easy platitudes about being thankful may be a defense mechanism with which we dismiss the raw injustice in our communities.

I’ve not heard anyone describe the epidemiology of blessings, but because there are winners and losers in the lottery of life, some people hare sicker and die younger.  While we luxuriate in the health promotion of quiet gratitude, our challenge is to change the social factors determining that so many have so few blessings.

Do Health Observances Promote Health?

For many years a unit of the federal government has provided a web site clearinghouse for special days, weeks, and months designated to commemorate particular health issues. The site is called the National Health Information Center and the list of events is called National Health Observances. For example, the first Monday in May is called Melanoma Monday, the 3rd week in March is National Poison Prevention Week, and February is American Heart Month.  The purpose of the health observances clearinghouse is to be a resource for health promotion professionals as well as journalists, pulling the observances all together in one place.  The purpose of the observances themselves is to highlight a particular health problem, enhancing public understanding and promoting public support for research.  Knowing that November is Lung Cancer Awareness Month might inspire a journalist to write a feature story on that topic, or for a health promoter to organize a local event coinciding with the national observance.

I understand that real journalists turn away from the list of health observances because the list is contrived, not real news.  The commemorations are entirely arbitrary with respect to scheduling; nothing unique happens in November regarding the nature and extent of lung cancer, though it is an important problem throughout the year.  The journalists also object because organizers sometimes use the observances as fund raising opportunities.  Because of financial entanglements, following the lead of a designated "month" runs the risk of compromising the objectivity that is an ethical benchmark for professional journalists.

So what is the value of the health observances?  Some of the events are sponsored by health organizations with a large national profile: the American Heart Association is the organizer behind National Heart Month.  For AHA and similar organizations, the health observance is just part of a year-long calendar of public education and fund raising.  They might use the February emphasis to reach out to media with press materials, but also might coordinate local community events.  While the national media campaign is conceptually done from 30,000 feet, the local events will enlist individual activists lending local credence to this cause.

Other events may be initiatives mounted by an individual or small group: December 5-11 is National Handwashing Awareness Week, an event promoted by the Henry the Hand Foundation, not exactly a household name.  For such an organization, the clearinghouse will actually bring people to their website, and might generate interest and engagement that would not occur without the health observance.

These events can play a minor role in health promotion.  The keys are that they must do more than disseminate information, and the information they do provide must be at a language level accessible to the public; that means at a reading grade level of 6-8.  In addition, the observances will have a greater impact if there are functions of the websites and of the campaigns that will engage people in more than just health information.  Community connections are essential to build momentum for these social marketing campaigns.  Energy is created through local advocate participation in raising money and staging awareness activities.

This is a very American quality to our health promotion efforts.  One of the up sides to the value our culture places on individualism is that people take initiative to  make their voices and pocketbooks be heard.  We don’t celebrate a “let the government go it” month.

Secondhand Drinking?

Once it was recognized that tobacco smoke was harmful, it wasn't long before people connected the dots and began to worry that if a smoker was doing something harmful, then maybe it was harmful to breathe in smoke from someone else's cigarette.  The suspicion eventually was declared fact, and now it is thought that so-called "secondhand smoke" kills about 38,000 per year in the U.S.  Usually those hurt by secondhand or environmental tobacco smoke either live with one or more smokers or work where there is a lot of smoking going on.  Substantial harm doesn't come from fleeting occasional exposure, but risk goes up when exposure is prolonged and intense.

Ironically, the establishment of the reality of secondhand smoke damage may have been more powerful than public knowledge about the health effects of primary smoking.  Many smokers enjoyed smoking, even though they became aware of the damage done, but were willing to continue and take their chances.  There was an attitude that you have to die from something, so why not take a chance with something that fills a need in the smoker's life.

The social dynamics of secondhand smoke were entirely different.  Once it became common understanding that secondhand smoke was damaging to the health of others, that made smoking socially unacceptable  Whereas in the past, smoking was thought to be sophisticated and chic, the secondhand smoke awareness made smoking seem akin to belching in public; socially unacceptable.  Whereas no one used to ask "Do you mind if I smoke?" that was the question smokers always had to ask.  This developing social stigma was a powerful incentive for millions of smokers to make quit attempts.

This brings us to alcohol.   We have known for quite some time that for most people, the hazards of alcohol drinking can be portrayed with a U-shaped curve (see below).  For overall mortality, total abstainers have elevated risk compared to moderate drinkers, whereas drinking beyond a moderate level quickly drives mortality risk to rise dramatically.  While alcohol in small amounts has some protective value for heart disease, stroke and diabetes, rising consumption brings increased risk for liver disease, highway injury, neurological damage and seizures, alcohol-related violence and suicide and damage to unborn children.  There is a huge array of other social and personal problems that come to the individual drinking alcohol excessively.

In general, we have not seen the concept of "secondhand" applied to alcohol.  Remember in this context, secondhand would mean consequences harming third parties, incidental to their being in the presence of drinkers.  It is clear that the analogy is useful and legitimate.  People are harmed by abusive drinking by others.  Binge and heavy drinkers are responsible for injury and death to other drivers and pedestrians.  Many acts of violence and suicide, if not caused by alcohol, are committed under the influence of alcohol, which is clearly a contributing factor.  There is a lot of vandalism and property damage done by intoxicated drinkers; this includes damage related to motor vehicle accidents as well as intentional vandalism of private and public property.  Alcohol abuse on university campuses makes the living circumstances such that most people in middle class neighborhoods would not tolerate.  This includes vomiting in people's cars and in public places, rowdy behavior disturbing sleep and study time,  Finally, there is a substantial amount of sexual assaults committed by alcohol impaired persons.

Up until now, these secondhand alcohol effects have not generated a social stigma.  Especially on college campuses, this behavior is accepted as normal and acceptable.  It is possible to recognize this acceptance as a contributing factor making campuses a toxic social environment for alcohol abuse.  People drink this way because the consequences don't lead to social condemnation.

Secondhand alcohol effects are real, and effect millions of bystanders.  It remains a challenge for health promotion to design ways to martial the power of social support and social shame to mold people away from destructive alcohol drinking.  Failing that, we continue to rely on education campaigns and policies to limit the harm.  While educational programs have not shown much success, there are many policy solutions that could make a dent in primary and secondary alcohol exposure.  Examples include making alcohol more expensive with tax increases, putting limits on where alcohol may be purchased, registering the names of keg purchasers, to hold them accountable for abusive drinking which may occur after the purchase.  It will take time to build a social consensus to accept and establish policy solutions. Attitudes which accept secondhand alcohol effects as normal are the same ones which are barriers to policy solutions.

Alcohol is America's number one drug problem, perhaps because a lot of people really don't think it is a problem.

Warning about Cigarette Warning Labels

Recently there has been a lot of media attention regarding new tobacco warning labels proposed by the U.S. Food and Drug Administration.  The ads are graphic, large, and much more prominently placed on the cigarette packages.  Here is an example of one of the new labels:

This is an interesting story which has evolved over several decades.  For many years tobacco was categorized as an agricultural commodity, not a drug, and so federal jurisdiction came through the U.S. Department of Agriculture rather than the FDA.  Because of this arrangement, tobacco was supported as a crop, instead of being treated like the dangerous drug that it is.  Of course this was politically rigged by powerful tobacco supporters in the federal government. 

The tobacco companies resisted public pressure to post health warnings on their labels and advertising material on 1st Amendment Constitutional grounds:  U.S. citizens are not only guaranteed freedom to speak, they are guaranteed the right not to speak when particular speech harms their interest.  Tobacco companies in effect mocked the Constitution, by claiming the same rights as citizens and applying free speech protections for marketing a product killing millions of people.

Eventually, an ironic twist occurred when the cigarette companies decided that warning labels would provide them with liability protections.  The avalanche of liability suits was just beginning, in which people were claiming damages by the companies selling products causing people to be sick and die.  The companies could then point to the warning labels as a defense, saying that people were informed that cigarettes were harmful, and therefore the companies could not be blamed.  This argument got traction in the court system, so that very few of the liability suits resulted in awards being given to sick smokers.  While the labels provided legal shelter for the companies, in actuality, the labels had little impact on consumers.  The labels were relatively small and unobtrusive, and tended to fall into the background of all the other label material.  From a health promotion theory perspective, the warning labels were disconnected from other strategies designed to encourage smoking cessation.  The labels helped tobacco makers more than consumers.  This continued for many years.

Finally, in 2009, legislation passed giving the FDA authority to regulate tobacco products.  Here is a link for the so-called "Tobacco Control Act."  The provisions of the bill went into effect in June of this year, and the agency is just now working on the revised warning labels.  For more information about the proposed labels, click here.  While it is gratifying to see an aggressive effort to stop the dishonest marketing of cigarettes to the public, including kids, we need to be cautious about high expectations.  While the labels are eye catching and impressive in design, it is too early to know how prospective or current smokers will respond.  It is a rule of thumb that information alone is almost never enough to change health behavior.  Time will tell whether these new ads will be more impactful than the old ones.  I'm guardedly optimistic.

Diabetes Futures

When I was a health science student I remember learning about the old time practice of tasting urine to detect a fruity taste indicating diabetes. During that lecture green students would become green with nausea contemplating a bygone era incomprehensible in our modern sanitation sensitive world. We have come a long way in measuring and treating diabetes in more sophisticated ways.

While testing and treatment have advanced, the actual frequency of diabetes has continued to rise in dramatic fashion. Projections on the rise in diabetes are based on sophisticated statistical methods. While many people die from diabetes, many people with diabetes die from other things, meaning that our most complete measure of the population’s health, the death certificate, is not a valid measure of the overall prevalence of diabetes. Though diabetes can be a ravaging disease if not managed well, often people with diabetes die from other things. This can be either because the disease contributes to other chronic illnesses, like coronary heart disease, which become an immediate cause of death, or because improved treatment prolongs life enough for diabetes patients to succumb to unrelated diseases like cancer.

After death statistics, the next consideration is the number of people sick. We don’t do as well with nonfatal illness counting. We try to extract data from a very disconnected health care system. These efforts include the National Health Interview Survey, the Health and Nutrition Examination Survey, the Behavioral Risk Factor Surveillance System, the National Ambulatory Health Care Survey, and the National Diabetes Surveillance System. Diabetes is included in all of these data collection systems because it is such an important health problem, effecting one in ten adults (diagnosed). However, even with all these data sources, there is still an element of uncertainty: we don’t have a data system which captures the actual health care records for all people diagnosed with diabetes, and certainly not for the thousands of people undiagnosed.

With these caveats on the current extent of diabetes, there is now a projection that diabetes will increase from about 1 in 7 adults(diagnosed and undiagnosed) in 2010 to between 1 in 5 to as high as 1 in 3 by 2050. Several factors are attributed for the increase. First, the population is living longer, and more elderly life spans means more diabetes. Next, treatment is more effective, so that people with diabetes are living longer, inflating the sub-population with the disease. In addition, the groups in the population with higher rates, such as Hispanics and Pima Indians are growing at a rate faster than the general population. Finally, the increase in obesity in the population is directly related to the increasing diabetes prevalence, including the growing count of children and teenagers having what used to be called “adult-onset” diabetes.

The only reason to measure these trends is to guide plans to intervene. Are we doomed to a third of adults having to manage diabetes? Of course screening and treatment could improve, so that a higher proportion of diabetes patients can live otherwise normal lives. It might be that in the future, diabetes consequences will be less frequent, less severe: even though more people will have diabetes, there could be fewer people suffering diabetes blindness and amputations.

The current state of the art with diabetes health promotion leaves much room for improvement. For decades we’ve tried ways to help people follow diabetes-specific diets, practice healthy foot care, take medication correctly, and prevent diabetes-related damage through physical activity and weight management. This work will continue, but increasingly there will be a search for policy solutions which bypass the messy business of trying to change people’s behavior.

I've become convinced that the most promising frontier for diabetes prevention as with all health promotion, is the creation and establishment of policies which change the food and exercise environment.  There is much work to do to determine whether a given policy works, to navigate the political system to make it possible to apply the policy, and to do long term evaluation to be sure the policy is having the intended effect without undesirable unintended consequences.  Sometimes policies will be seen as antagonistic to free markets, but sometimes policies will give rise to entrepreneurial opportunities.  Long term sustaining of policies will be more assured if we can create a win for all involved.

Health Consequences of Elections

We have become accustomed to warning labels on many commodities: health advisories on tobacco and alcohol, safety labels on many consumer products, and signage in rental cars reminding us about the danger of driving without a seat belt. Perhaps we should have warning labels on election ballots: Caution – Your candidate selection may be hazardous to your health. Now that the elections of two weeks ago are over, I’d like to reflect on what the campaigns and the results mean for health promotion, and talk about the dangers that may be ahead.

Certainly in all the elections there were some purely local issues. However, aside from the many local issues, perhaps the biggest campaign issues which seemed to turn the election were job creation and Obamacare. Both of these have implications for health promotion. Employment is impacted by health in both directions. Health is an important prerequisite for a job, and full employment is one of the most basic ways to promote good health in society. It is clear that the nation’s health status did not cause the current recession and unemployment crisis, nor will health programs contribute much to digging us out of the economic hole in which we find ourselves.

On the other hand, if we can really think about the future and not just the next business cycle, health and continuing prosperity are inextricably linked. There is great concern about the disconnect between educational performance and readiness for technical jobs of the 21st century. Certainly in disadvantaged segments of communities, malnourished kids or kids struggling with asthma are not able to be as successful in school as they might otherwise be. In addition, as our workforce gets older and the retirement system squeezes workers to stay on the job a few years longer than was common in the recent past, it will be important to help those older workers maintain wellness levels as high as possible.

The Patient Protection and Affordable Care Act of 2010 (Obamacare) is obviously a health issue, front and center. Some of the most angry rhetoric and ugly campaign ads were directed at this so-called “massive government takeover” of the “best health care system in the world. Perhaps some of the partisans actually believe that charge, but forgive me for being cynical. We have government control of most of the education system, police and fire services, the Postal Service, and libraries; government assuming these functions has not ended life as we know it. Furthermore, Medicare is an entirely government health care system, and most people think it works quite well in providing good care in a cost-effective way. Health care reform is mostly designed to help the 15% of the population with little or no access to the system now, while people with health insurance may see little if any change. When it comes to the relative quality of our health care system, compared to other nations, we don’t stack up very well. The claim that we have the best health care system in the world may be true for some consumers, but is not an accurate picture of what most people experience. A harsh reality that the opposing politicians don’t want to recognize is that even people with good insurance now may be only one serious illness away from medical bankruptcy, or at least losing their coverage. For people with good employer-provided health insurance, what would happen if they were sick enough that they could no longer perform their job. Once they lose the job, health insurance goes with it. This is a risk to a majority of citizens, not just those with no health insurance now.

The health care reform legislation passed earlier in the year includes three basic components. First, no one can be excluded from insurance coverage because of pre-existing conditions. Next, people have to be in the system; people will be required to buy health insurance if they are not already in one of the government programs (Medicare, Medicaid, Veterans’ Health Care). The only way health reform will work without dramatically increasing cost is to include everyone, including those young and healthy in the risk pool. The third component is a system to pay for all the new people brought in the system, including incentives for small businesses to provide coverage for workers. The system, which will be phased in over a number of years, represents a dramatic change in public policy, broadening the safety net so that everyone is assured a floor level of health care. While change is hard for people to accept, the current system of health care doesn’t seem worthy of fighting for, unless you are one of the few people well served as a fortunate consumer or a well-compensated provider. Those two categories are shrinking unless we accept the challenge to mold the system to one that will serve all the people.

The completed elections brought in a large number of people who are opposed to progressive change, with the belief that the free market is always better than anything organized by government. The next few months and years will be a battle to see which ideas about change prevail.

Preempting Health

Many years ago I was associated with a tobacco control coalition in a local Kentucky community. Among all the things we wanted to do was pass a local ordinance banning smoking in public places. We were told that state law didn’t permit such an ordinance because tobacco legislation at the state level precluded tobacco related legislation by cities and counties in the State. This illustrates the concept of preemption (pronounced pre-emption).

Preemption is often the bane of health-related policy. It is inserted into legislation or regulations, at the federal or state level, to prevent independent rules being put in place at a lower level of government. Most often, preemptive language is inserted into government policies during “back room” negotiations. Often these dealings represent corruption in which special interests manipulate the democratic process for their own benefit.

Why do corporations or organized industries seek to preempt policy making at the state or local level? Usually it is because such policies have a real or imagined harmful effect on business activities. Lobbyists for industries often believe that it is easier to bring about preemption with a relatively weak rule at a higher level, rather than having to deal with all the entities at the lower level.

In the case of my tobacco experience, the tobacco companies were convinced that public smoking restrictions would hurt their profits. Of course they couldn’t say this publicly and expect a very sympathetic response from communities, so they would disguise their real motives by talking about job losses and the problems caused if every community had different rules regarding public smoking. As an aside, both of those arguments have been shown to be bogus.

Our first step was to build support for challenging preemption at the state level. There was a campaign to get individuals to sign petitions, demanding that state government change the preemption restriction. At the same time, local governments were asked to pass resolutions, establishing the principle that cities and counties should be able to determine their own rules for public smoking.

Ultimately is was determined that the specific tobacco preemption language was not consistent with the Kentucky state constitution. This created a legal pathway for local smoking ordinances. Since that time there has been a steady stream of communities deciding that banning public smoking is right for them. Currently about half the State’s population is covered by a smoke-free ordinance, though a minority of local jurisdictions has enacted such ordinances. Public smoking bans are opposed for a number of reasons, but eliminating preemption language in the state statute has made it possible for advocates on both sides to work through the democratic process.

Whether the issue is local regulation of smoking, school food service rules, community jurisdiction over large hog farms (called concentrated animal feeding operations), or many other issues, preemption is a barrier to good public health and is rarely in the public’s interest.

On an interesting final note, Kentucky right now is seriously considering a state-wide ban on public smoking. That this is being considered is a stunning turn of events in a State where, not that long ago, tobacco was a sacred cow, health concerns be damned. I don’t know who the powerful players are behind the scenes, and why they think it is time for a state-wide ordinance, but for sure, tobacco control advocates will be looking for any preemption language, to be sure that local communities don’t lose their democratic rights of self determination.

Seasonal Health

Yesterday I was on a stretch of highway on which I frequently drive, and noticed a lot of road kill, much more than normal, it seemed.  I began to wonder if there might be an explanation.  Is there something about mid-fall that might bring more animals out crossing roads?  Are animals more restless due to a change in mating behavior, or has the food supply changed, requiring them to range farther to find enough to eat?  Maybe animals are slower moving in cold weather, making it harder for them to avoid a vehicle crossing their paths.  Of course it could be that the night weather was foggy, cutting down on driver visibility enough to put more animals at risk.  At least one more possibility occurring to me was that there may have been more traffic on the road, either because of some event occurring in the area, or perhaps there was something happening in trade and commerce, such as trucks delivering goods as stores gear up for holiday sales.  What we need to answer these questions is a veterninary epidemiologist.

I don't know if there is such a field, but human epidemiologists have taught us the factors related to human injury and deaths on our roads, and there are seasonal patterns.  You will expect to see more highway accidents in winter months, because road conditions tend to be worse.  On the other hand, the rate of bicycle and motorcycle accidents goes up in the summer months because there are more riders in warm weather, fewer in the winter.  One study found more child pedestrian accidents in summer, perhaps because children are more likely to be out in warm weather, but more adult pedestrian injuries, in winter.  This last observation is harder to explain.

There are seasonal variations with many other health concerns.  For example, colds and flu spike in the late fall and winter months, but generally are lowest in incidence in the summer months. The explanation is that as weather turns colder, indoor air quality declines.  People spend more time indoors in close quarters with others.  Heating systems dry out skin and mucous membrane barriers, making people more vulnerable to those types of infections.

Violent death and injury increase in the summer, presumably because heat is a stressor, and people are involved in more social interactions for potential conflict.  In the winter people tend to cocoon more, with less social contact.  With youth, summer represents more unsupervised time, providing opportunities for trouble.

Allergies usually spike in the spring and summer, because of the plant constituents in the air, and people spending more time out-of-doors.

In far northern or southern regions that experience extremes of frigid conditions, we expect to see seasonal variations in cold-related illness and injury.  Likewise, there are seasonal variations in heat stroke and exhaustion.

Cardiovascular disease also increases in the winter, with several reasons suggested.  Smoking and secondhand smoke exposure increase in winter months.  People are more sedentary, and body weight tends to increase in the winter.  In addition, it is proposed that because of reduced sun exposure, Vitamin D levels drop, having an impact on cardiovascular system dynamics, including an increased cholesterol level.  Finally,  cold temperatures impact the components of blood, particularly the tendency of blood to clot.

As is apparent from the various types of seasonal patterns in health, causes are a combination of biology, ecology, social organization and behaviors related to annual events and cycles.  As far as we know, wild animals are oblivious to these changing risks, and are incapable of taking timely precautions.  Humans on the other hand can learn from these patterns, applying appropriate steps to avoid things putting them at higher risk.  While there are seasonal variations that effect us in this way, there should not be seasonal variation in intelligence and thoughtfulness about it.

The Pursuit of Happiness

One of the most famous phrases from the stirring U.S. Declaration of Independence(1776) is "the pursuit of happiness," cited as an unalienable or natural right which cannot be taken away by any legitimate government.  The obvious implication is that happiness is something people not only should have, but should be able to acquire more.  This raises questions about human beliefs, and is related to health behavior.  Some persons think of happiness in a passive sense - either you have it or you don't, not something over which we have control.  Other people are much more confident in their ability to create happiness, to control the things that bring about happiness. 

This contrast is also found in health promotion.  Some individuals and social groups think about health and disease with indifference and submission.  Not that they don't want good health, but they feel powerless to play any role in assuring it.  To the extent people feel health is determined by luck, the devine, or the demonic, they will be less inclined to a self-activated approach to health promotion.

Today we would reflexively say people have a right to the pursuit of health, but in the sensibility of 1776, people had almost no basis for being proactive about health.  It would be about 175 years before the epidemiologists would give us guidance for health promoting life habits.

To come full circle, happiness is becoming more recognized as a component of health, and to many people something which can be cultivated with practice.  The catch is how.  While there is an emerging field of research called happiness studies, there is not really what might be called "best practice" or established principles.  If you Google "improving happiness" you  will get a huge number of sites which usually describe their advice as "tips."  That is code for "These might be helpful and just seem like good common sense."  You will find things like organize your life better, get more sleep, slow down, spend time with good friends..... You get the idea.  No one will argue with these suggestions, but they are hardly definitive.  Imagine if you went to your physician, and all she could offer were tips of a general nature, but nothing specific with a proven record of effectiveness?  We expect that about medical care, and we should expect it about health promotion practice.

The problem is that our understanding of what makes for happiness is incomplete.  For example, we reject the notion that money can buy happiness, but surely to some extent it can support conditions in which happiness is easier to come by.  Is it realistic to think that a person who sleeps under bridges just needs to think optimistic thoughts in order to be happy?  And how is it possible that someone with severe disabilities can still be happy in their life?  And yet there are.

Here are a few things that come closer to being science-based.  Happiness requires a healthy brain, which is promoted by good sleep habits, good nutrition, exercise, and caution with things brain-toxic like too much alcohol.  Eye health requires changing field of vision - too much unvaried focus, such as extended reading or screen viewing is not good for the eys, which need the opportunity to have a distant focus from time to time.  In the same way, brain health is probably not as well promoted by constant imersion in the same job or task, but will do better with changing attention.  This is like taking a brain vacation every day, and sometimes for longer periods.  Social support from family and friend relationships is also an important building block of happiness.

One way to promote happiness, though I admit not established in science, is reminding ourselves about the good people and good things around us.  I hear an awful lot of whining from people, in many circumstances, and not enough gratitude.  "I can't get no satisfaction" has become the national song of Americans.

In the future we should look for more and more definitive principles of happiness science.  In the meantime, think happy thoughts.

The Worst Drug

This week I came across a news review of a report published in the British medical journal, The Lancet.  The report was about an effort to rank the harmfulness of 20 commonly abused drugs.  Rankings were done by 15 experts on drug addiction, policy and toxicity, all from Great Britain.  They used a complex scoring system which considered physical and psychological harms to the individual user as well as harm to society at large.  The number of users in British society was part of the calculation.  The findings of the project caught the attention of news organizations because we are programmed by the drug warriors to think of cocaine, heroin and methamphetamine as the worst drugs.  Instead these experts determined that alcohol was the most harmful drug.  Here are the rankings:

The upshot of the report is that government policies which categorize drugs for the severity of restrictions have limited connection to the actual harm caused by specific drugs.  For example, Ecstasy and LSD are highly restricted and regulated, though not very harmful, while alcohol, the most harmful drug, is restricted hardly at all.

In the U.S. we have a parallel circumstance.  In 1970, the U.S. Congress passed the Controlled Substances Act, which created categories, called schedules, of drugs according to their potential for harm, their addictive risk, and whether or not there are legitimate medical uses.  For a good cure for insomnia, try this link for details on the Act.  You may need a stimulant to get through the text of the Act.  Since the original passage, there has been debate regarding the validity of the placement of various drugs.  For example, Schedule I, defined as the group of most dangerous drugs, includes heroin, but also marijuana and LSD.  While there is no argument that heroin addiction is a destructive lifestyle and a blight on the communities in which addicts live, the case can be made that use of heroin is made much more harmful because of well-intentioned government policies.  Today, it is hard to find an expert voice who will say that marijuana is a particularly harmful drug.  Notably absent from the schedules of the Controlled Substances Act are alcohol and tobacco, which at the time, were not considered drugs by most people, including members of Congress.

In my view, the findings of the British experts are paralleled in the U.S.  Our greatest drug problem is alcohol.  Tobacco kills about five times as many people as alcohol, but smokers live entirely normal lives until about 25 years in they get life-threatening chronic illnesses like cancer, heart disease and chronic obstructive lung disease.  There are almost no social harms caused by tobacco, and in fact, there are social benefits in employment and trade.  Alcohol doesn't kill as many people, but destroys the user's life once consumption passes the moderate level of drinking.  This leads to serious and worsening health problems, loss of employment, family turmoil and breakup, domestic and public violence, highway accidents, homelessness, poverty, huge productivity losses and treatment costs.  To be fair, alcohol has some medical and social benefits.  The evidence is strong that moderate alcohol use, particularly with wine, has medical benefits, though this fact does not mean that everyone should drink.  In addition, alcohol has social benefits in employment, trade, and tax revenues.

The fact that alcohol is used by two thirds of adults, and that there are some health and social benefits, makes health promotion messages and policies complicated.  Health communication directed at the public doesn't incorporate nuance well.  Effective communication needs to be direct and unequivocal, and for this and other reasons, we struggle as a nation to educate and influence to find benefits from no more than moderate consumption while trying to block all the destruction alcohol can do.

We are soon going to face this with marijuana as well.  The momentum behind legalization of that drug seems to be gaining speed and strength in states and local communities.  The challenge will be to build up public precaution about the potential hazards without blocking the real or imagined benefits.