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


Thursday, September 22, 2011

Food Guides and Food Fights

Sometime during my childhood the U.S. Department of Agriculture developed and disseminated the Basic Four Food Groups guide to healthy diets.  The focus of this educational device was on assuring the ingestion of recommended nutrients.  Through the lens of history over the decades that have passed since then, the Basic Four seem like shoddy guidelines, riddled with Big Farming and Big Food special interests.  However, when the Basic Four were born, they were quite mainstream, and were considered a serious effort to enhance the dietary intake of Americans. At that time there was broad concern that many individuals and groups were not getting all the vitamins and minerals at the recommended levels.  Later on while the Basic Four were still in place, I was a public health student, and took a nutrition course, in which we learned about diet-related maladies such as scurvy, pellagra, rickets, and kwashiorkor.  We were primarily interested in deficiency, with very little attention given to obesity. 

Aside from the health science merits of the Basic Four Food Groups, it largely failed as a didactic device.  It became the poster child for irrelevant health promotion messages, and was usually discarded if not totally forgotten after middle school health class.  Nevertheless, at the beginning of the establishment of the Basic Four concept, the obesity epidemic we see now had not started, and even the diet-related risk factors linked to heart disease were yet understood.

In the early 19902, the USDA replaced the Basic Four with the Food Pyramid. It was a step forward in including broader health advice, such as "Use fats, oils and sweets sparingly,"  but it still was putting too much emphasis on dairy products and meat sources of protein.  It was not hard to see the influence of food and farming lobbyists at work, but the Food Pyramid was small, incremental progress toward addressing
chronic diseases related to diet, not just the deficiency diseases so common in earlier decades.

The Food Pyramid was recently replaced by a new plan called "MyPlate."  This has been given a lot of energy by Michelle Obama, who has made a focus of her time as First Lady to try to promote better eating and more exercise, as a way to decrease the child and adult obesity epidemic.

My plate represents another increment of progress, with the guideline that half of one's diet should be fruits and vegetables.  No longer is a preference shown for meat protein.  Not shown in the diagram, but in the narrative accompanying the illustration is the encouragement to preferentially select whole grain foods rather than refined.  On the other hand, dairy is still featured, with the stipulation that people should seek low fat and fat free options.  Unfortunately, there are millions of children and adults who are lactose intolerant, so this plan seems to leave them out in this regard.  There is no question that MyPlate could be better in some ways, but it is light years ahead of the Basic Four. 
It is created in the kitchen of national politics.  Given the pressures brought to bear on the White House and the federal government, MyPlate represents a very satisfying achievement in health policy advocacy.

Very recently, the Harvard School of Public Health has release its own rewrite of all these food plans.  The subtext is one of impatience with the political climate that has been imposed on evidence-based health practice.  This plan is called Healthy Eating Plate.  This dietary guideline is absolutely on target with the best evidence of healthy nutrition, suitable for all.  However, the implied criticism of MyPlate is a little unfair, since Harvard does not have to respond to all American stakeholders, just the scholars and

scientists.  The other problem with Healthy Eating Plate is its complexity.  While MyPlate is lacking in a few areas with respect to health guidance, it is a plan that is quite easy to explain to the lay public.  Healthy Eating Plate is more correct, more complete, but also presents a great challenge for disseminating to average Americans. 

If you are reading this you probably have more than a passing interest in health promotion.  What do you think are the challenges of driving the widespread adoption of guidelines as detailed as Healthy Eating Plate?

Monday, September 5, 2011

Healthy Labor Day

Some quick Googling tells me that Labor Day in the U.S. was first officially celebrated 129 years ago.  It is primarily to mark the contribution of America's great workforce, currently about 139 million strong.  When we think of workers, we think of people whose hourly labor is the basis for their compensation, as opposed to investors and hedge fund managers, whose work consists of capital gains rather than productivity as usually understood.  There is a strong component of Labor Day related to collective bargaining and the protection of workers' rights against corporate interests.

We might wonder about worker health on Labor Day.  Over the last 100 years, the evidence indicates that work-related injury and death is less likely to occur today than in the past.   It wasn't until the middle of the last century that anything approaching comprehensive data on worker health was even available: a reflection of the minimal importance placed on the welfare of workers in earlier times.  Small government advocates today bridle against government provisions designed to protect the health and safety of workers, but it is clear that the free market would not be so benevolent.  The gains we have seen in protecting and preserving worker welfare is a tribute to a long series of legislative and regulatory measures, not the natural working of markets.

Aside from the great strides we've made in protecting workers from toxic exposures and safety hazards, companies have steadily increased their investment in programs to improve worker health in other ways.  It is somewhat ironic that as we've progressed in paying attention to work-related injury and illness, the nature and extent of health problems unrelated to work have become greater concerns.  Almost half of workplaces now have worksite health promotion programs, such as nutrition and weight control, physical exercise and smoking cessation.  There is stronger and stronger evidence that investments in these health programs produces a return.  Depending on the nature and extent of programs and facilities provided, companies can recoup more than the expenditures.  These programs tend to be in larger corporations, in which the economies of scale make employee health promotion more feasible.  The challenge is with smaller companies of a hundred or less.

Recently there has been exploration of a proposal to provide state tax credits for dollars invested in worksite wellness.  The idea is that if a small business was to invest, for example, $5,000 in such programming, he or she could get most or all of it back in corporate tax credits.  Any additional benefits, such as decreases in worker sick days or health insurance costs would essentially come for free.  The rationale behind this proposal is that state government health agencies have a mission to improve citizen health, and so it is appropriate to invest in these proven programs.  The problem is that in difficult budget times, such as we've seen in the U.S. for the last couple of years, health program tax credits represent a loss of revenue that must be made up by cutting somewhere else.  Some would make the case that over the long run, lower health costs will help the economy and eventually pay back the cost of the tax credits.  Though a plausible argument, it is a leap of faith without any evidence at the present.

So the two great challenges of worker health are to continue the safeguards against work-related injury at a time when many people charge this is government over-reach, and to find ways to extend the benefits of health programming to all workers, at a time when there is tremendous pressure to ship jobs overseas.  We can rely on the spirit of Labor Day to champion this cause for social and health justice.

Thursday, September 1, 2011

Designer Drugs and Old Lessons

Today during my usual early morning workout I noticed the CBS TV channel had a report about the growing problem of "designer drugs."  I almost fell off the bike when I heard the young news anchor talk about designer drugs, as though they are a new development.  This is not a new problem.  Designer drugs have been around for almost 100 years, though that term was first coined in the 1980s.  The current discussion in lots of media venues seems to be disconnected from that history.

Designer drugs refer to a group of drugs that are similar, not in effects, but in the way they are made.  As opposed to drugs from plants, such as opium, tobacco or marijuana, designer drugs are produced in a laboratory.  Of course the legal pharmaceuticals are designer drugs in that sense, except the term is used for the drugs most definitely illicit.  Designer drugs exist for a number of reasons.  The first is that designer drugs can be operated like a cottage industry, out of a garage or basement.  The bad guys who concoct designer drugs are able and inclined to avoid the even worse bad guys who run the traditional supply and distribution routes of illegal drugs - cartels and organized crime bosses.  The second reason for designer drugs is the search for the new high.  Illegal drug users are often sensation-seekers, and so part of their motivation is to try something new.  Designer drugs are marketed as better or at least different from drugs already on the scene.  Third, some designer drugs, because they are new, can defeat the screening capacity of drug testing technology.  Finally, because of the legal platform for the war on drugs, prohibitions are based on specifically named drugs with a particular molecular structure.  Innovative chemists can take an illegal drug, slightly alter the chemical structure, and at once create a new drug experience with a substance that is legal, at least until the laws catch up.   

Designer drugs typically are either opium-like, dulling the senses, or stimulants.  Some of the designer drugs can also induce hallucinations.  Ecstasy is the classic designer drug, but more recently we've seen synthetic marijuana ("K2") and stimulants labeled "bath salts" which are actually injected or smoked.  Designer drugs and responsible drug use are mutually exclusive because it is not possible to verify actual ingredients or dosage.  Traffickers in designer drugs do not subscribe to the Better Business Bureau.  Consequently, this is definitely a case of "let the buyer beware."

Because of the varied nature of designer drugs, there are no comprehensive population counts.  We have statistics on the use of specific drugs, such as Ecstasy, but not for the group as a whole.  The individual drugs in this category are all in single digits for annual and past month consumption.  Mainstream lifestyle's do not accommodate these drugs; most people would consider this "hard core" drug abuse, an experience very different from the person who occasionally smokes marijuana.  While designer drugs cause relatively few deaths and serious health effects, they clearly present a level of danger above and beyond the risks from marijuana or even most prescription drug abuse.

So why are we seeing a resurgence of designer drugs?  Because we didn't really learn how to prevent them the first time around.  The reasons for their proliferation in the 1980s are still in place.  Typical educational tools and campaigns are generally not effective with designer drug users, though in general, perceived risk is associated with decreased drug consumption.  Since these drugs are entirely out of mainstream society's supervision, because they are illegal, there are few if any policy solutions (such as requiring an active ingredients list) that can be applied.

Perhaps the new generation of drug abuse prevention professionals will have more success in combating these drugs than the original workers who actually remember the first drug warrior, Richard M. Nixon.