Health Promotion Exchange

Food Guides and Food Fights

2011-09-22T14:11:00.000-04:00

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?

Healthy Labor Day

2011-09-05T21:01:00.000-04:00

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.

Designer Drugs and Old Lessons

2011-09-01T14:08:00.000-04:00

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.

Vacations and Health Policy

2011-08-25T14:40:00.000-04:00

Lately the President has been ragged on by critics for taking a vacation. How dare he take a vacation while people are out of jobs, while there is a civil war in Libya, while the stock market is tanking, while it is Thursday? Pretty standard petty politics. George Bush also used to get hated on for spending too much time off at his ranch in Crawford, Texas. At least the criticism comes from both sides. Glad to hear we can be bipartisan about something!

There is a lot of irony with the comparison of our national attitudes about vacations and our record of active physical exercise. Workers in the U.S. lead the world in on-the-job productivity. We take fewer vacation days than workers in most other nations. The chart below shows government rules regarding paid holidays and paid vacations. In almost all the nations included in the chart, workers are guaranteed paid days off; many countries have policies that translate into a full month of vacation as a basic benefit floor. Now notice the U.S. on the far right of the chart. Workers here have no such guarantee. Of course, employers provide paid days off, but only as driven by the labor market. At a time of high unemployment, companies are not pushed to be so generous. For many reasons, we are the hardest workers in the developed world. We are not lazy as a nation!

On the other hand, it appears we lead the world in obesity. It is difficult to make international comparisons of this kind, because there is no common obesity standard; some nations actually measure height and weight in the population while others just gather self-reported survey data. Nevertheless, one international comparison finds that about 34% of Americans over the age of 15 are obese, compared to other nations listed in the chart below:

So what can we conclude? Americans are hard workers, willing to give more to employers than people in most other developed nations, and yet when it comes to putting effort into maintaining their health, they fall short. Just like it is unfair to label the President a slacker for taking a vacation, it is unfair to call Americans unmotivated couch potatoes as a basic character flaw. I think it is the circumstances that are different.

Another study compared what they called "transit trips" taken by walking, biking, or public transportation, looking at data from the U.S. and European nations. Two things were noteworthy about their findings. The first was that transit trips were inversely related to both measured and self-reported obesity: as the percent of trips taken by walking, biking, or public transit, compared to driving, increased, obesity declined. The second finding is that U.S. citizens are dead last for transit trips. Most of our trips are by car.

I think we are health-lazy, not because of character flaws or ignorance but because of public policies that don't support more active lifestyles.

Critical Thinking and Health Promotion

2011-08-23T10:05:00.000-04:00

The other day I was talking to a graduate class about critical thinking. This is a topic being increasingly emphasized in higher education in the U.S. right now. Leadership and accrediting bodies have recognized that a lot of content information mastered by students 1) does not stay with them for very long and 2) has only limited shelf life as new information replaces the old. One of the things that we believe is essential that students obtain from higher education, and even more from graduate education, is the ability and habit of thinking critically. As an aside, American students often compare very unfavorably with Chinese students when it comes to standardized scores for reading, science, math, and so forth. However, American students are better able to think critically because they are not cowed by the pronouncements of authority figures. They seem to be unaware of constraining lines around problem solutions, to a greater extent than Chinese youth. Unfortunately, U.S. students still may defeat this head start by being thoughtfully lazy. They are empowered to challenge conventional thinking, but few do so with much consistency, because they are preoccupied by popular culture. What is this generation coming to? Probably an age-old lament.

For many decades, we have assumed that students learn this along the way, just by spending time with academic thinkers (one hopes) and in the rarefied academic atmosphere. Some students will be exposed to formal logic taught by philosophy departments, but most institutions do not require these courses. It has become clear that colleges and universities must be intentional about instilling thinking skills. There has to be a strategic and structured method, and it has to be part of general education. Because this is fairly new, a teaching methodology is still emerging. Professors are comfortable asking students to think about a problem, a concept, a case, and so forth, but that doesn't mean we know how to teach students how to think about thinking. I did not feel very successful in the attempt mentioned above.

Critical thinking should be an essential derivative of education, and every young person should enter adult and professional life with a fully cultivated habit of challenging conventional ideas and unexamined assertions. This is specifically true in the domain of public health and health promotion, both on the professional and the consumer side. Consumers are bombarded with marketing information for products that have health consequences, such as soft drinks or health-related products such as over-the-counter drugs or food supplements. The volume and range of these products is so great that it is difficult for the public health agencies to give everyone the "right" answer. Perhaps we can give people a framework for thinking critically about products and recommendations that may have an undesirable impact on their health. We can help them discern whether a health web site is dubious or dependable, whether assertions for health value are factual or phoney. There is lots of work to do here.

The other place where critical thinking needs to be strengthened is in professional practice. The Patient Protection and Affordable Care Act (Obamacare) has a component directing the expansion of what is called "comparative effectiveness" research. This is driven by the growing awareness that a lot of health care practices are based on limited or no solid evidence that they lead to improved patient outcomes. A recent article in the Washington Post cites the example of a surgical procedure called vertebroplasty, designed to reduce chronic neck pain. According to the Post article, 79,000 procedures are done every year, at a total cost of about $1 billion. Yet, it has not been unequivocally demonstrated that these procedures work as promised.

What does this have to do with health promotion? The same problems found in clinical health care, procedures and products that may not be effective but are driven by other considerations, are also found in health promotion practice. The driving force in health promotion is usually not a profit incentive, but instead an unwillingness to break out of traditions, a belief that doing something is better than doing nothing, a lack of evaluation which might demonstrate failure, and settling for program investments that are inadequate, rather than pushing for more costly interventions that might actually have an impact.

Throughout my career, I have seen (and yes, participated in) many instances of health promotion programming that had no chance of being successful. Learning and applying lessons from these programs is painfully slow. We can do better, and a part of that is thinking more critically about what we do. Unlike clinical care, where ineffective practice may be life threatening, our laissez faire attitude about effectiveness means that the public's health doesn't improve. Comparative effectiveness needs to become a new normal. For every program dollar available, what is the most promising way to invest it? That is a critical thought.

Health Promotion at the State Fair

2011-08-19T16:07:00.001-04:00

Last year at this time, I posted a blog about the Kentucky State Fair food innovation, the Krispy Kreme burger. That burger got a lot of media attention in the local area, even though the concept was introduced a number of years ago in other places. Nevertheless, the attitude in the public seemed to be that "foods" like this are just part of the charm of the State Fair. The Health Promoters who raise concerns are just lifestyle Scrooges, who sap the joy out of life. If you are reading this you will have no trouble spinning this a different way, to defend the value of healthier dietary choices.

This year the next big thing with Fair fare is deep fried Kool Aid. I have no idea how one deep fries Kool Aid, but I'm betting it will get a lot of curiosity by consumers and the media. I don't know the ingredients exactly, but web sources claim it consists mostly of Kool Aid, flour and water, and then of course oil absorbed during frying. This is probably not the worst thing someone could eat. Look at this link for other

examples of foods that race to the bottom of healthy food choices.See Outrageous Foods

To some extent this is an old story. I've blogged about it a number of times, and there are lots of newspaper, magazine and TV stories about this, some lamenting, some celebrating. However, I want to build a bridge to more generic health promotion ideas.

The U.S. Centers for Disease Control has a funding program for community health promotion programs, created as part of the Patient Protection and Affordable Care Act (Obamacare). This program is called Community Transformation grants, and the concept is that a lot of what passes for health promotion is very superficial. It provides some information and encouragement for lifestyle change but doesn't really have a basic impact on society and culture as a whole. The scientific evidence base is not yet complete to really be transformative in the way our efforts influence society. However, we will know we have arrived when outrageous foods receive a widespread response of embarrassment or bewilderment, as though they were pornographic. In society today, health promoters have degrees of defensiveness that makes them apologetic rather than proud of the service they provide. To be transformative, we need to be asking not just "How do we get a fair goer to eat healthier," but "How do we change communities so that the junkiest of junk foods are no longer part of a viable business plan?"

Health Policy and Health Equity

2011-08-16T10:59:00.000-04:00

For a few decades it has been recognized that health status is not evenly distributed across the community, and that this inequality is only partially based on individual lifestyle choices. More often health disparities are greatly determined by social factors that establish patterns of poverty, housing, educational attainment, employment opportunities, neighborhood quality, community safety, and so forth. The unequal access to resources, opportunity and security is not always a function of racism and ethnic discrimination, but the effects tend to fall along racial lines. It is not just that greater affluence almost always is associated with better health, though that is true. It is also a function of the gap between rich and poor, the unequal distribution of resources.

Here are some explicit examples of health disparities. In the U.S., the infant mortality rate (in 2006) for white infants was 5.58, while the rate for black infants was 13.35, more than double. About 8.2% of white children have asthma, while asthma is found in 18.4% of Hispanic children. In the 15-19 age group, white males have a homicide rate of 3.4, while the rate in Black males is 69.1. Blacks have a coronary heart disease death rate of 162 while the rate in Asian/Pacific Islanders is 77. About 12% of those with less than a high school education have diabetes; only 6% of those with more than a high school education have diabetes. The rate of HIV infection is 7.2 for Asians, 8.2 for whites, 25 for Hispanics, and 74 for blacks. While there are undoubtedly lifestyle choices involved in some of these examples, it is apparent that social factors are huge determinants. Many times choice is limited by access to resources, which is socially determined.

Consider the following chart. The legend and labels are too small, limited by the functionality of this blog space. Nevertheless, it is still illustrative. Each vertical line represents a U.S. state: Utah is the top line while West Virginia is the bottom line. The dark portion of each line represents the number of healthy days per month reported by residents of that state. States toward the top have the most healthy days; those near the bottom have the least. The total length of each vertical bar represents income inequality, using a measure called GINI. The higher the GINI score, the wider is the gap between rich and poor. States near the top of the chart have the most equally distributed wealth; those at the bottom with the largest GINI scores have the most unequally distributed wealth. The main point is that there is almost a perfect inverse relationship: the lower the income inequality the larger the number of monthly healthy days; the higher the income inequality, the lower the healthy days.

State-specific Gini index of inequality in number of healthy days and average number of healthy days --- United States, 2007. Source: Behavioral Risk Factor Surveillance System, 2007.

As it turns out, the U.S. stacks up poorly compared to most modern, developed nations in average life expectancy. In many nations, men and women, on average, live longer than we do in the U.S. However, our GINI score is also higher than that found in most modern nations: the gap between rich and poor is wider here than most other developed countries. Social and economic inequality makes us sick. For this reason, many professionals believe that inequality must be one of the targets of health promotion if the public's health is ever to reach its genetic potential.

This brings us to the great ideological debate going on in our nation at the current time. One side says that our society should reward hard work, ingenuity and risk-taking, that we should encourage independent initiative and avoid making people dependent on government benefits. This school of thought puts its trust in the free enterprise system, and that if government do-gooders (like most health promoters) would get out of the way, people would naturally do what was in the best interest of them, and by extension, society as a whole. The other side says that society and markets are inherently unfair, that people are not dealt equal cards. Social and health inequalities will not correct themselves without organized community efforts, including public health and health promotion programs and policies. Unless we intervene and regulate, wealth will be concentrated in fewer and fewer people, creating a rarefied oligarchy and a permanent underclass. This is not only detrimental for the disadvantaged, but over time, is not good for society as a whole.

What do you think is the right road?

What is a Health Policy?

2011-08-09T13:55:00.000-04:00

When my father was a teenager, the family decided it was time to get their first car. Not only did they not have a car, but no one in the family had ever driven before. It fell on my father to be the designated driver. When he was handed the keys, he just got behind the wheel and taught himself to drive by trial and error. He had no instruction, no formal public information about driving safety, and most people he knew were no help because they had never driven either.

Over the last 100 years there has been great progress in controlling deaths and injuries related to driving.

This progress is surely in part due to education to help youth learn to drive safely, and a lot of public education designed to help current drivers be mindful of safe driving practices. However, we have not stopped there. Since my father's early days of driving, a lot of policy solutions have been applied.

Traditionally, a lot of public health programming has been either informing the community about various health issues, such as what constitutes a healthy diet, or offering a service, such as a flu shot or a screening test. Less often, public health and health promotion has tried to achieve its goals with policy solutions. What I want to talk about in this posting is what is meant by a policy solution. The emphasis placed on policy solutions to improve the public's health seems to be growing, so it is important to discuss what this really means and why it is important. Complicating the discussion is the fact that there is no universal definition of the term. We always have to clarify what people mean when they talk about health policy: what is included, what is excluded, what do other people call the same thing?

Sometimes a policy is a way to enhance behavior change, to make the healthy choice easier. This is sometimes called the "default" option. In a generic sense, default is what will happen unless you take special steps to avoid it. At one time auto companies were making automatic seat belts that would circle your waist to within inches of the buckling ratchet. The idea was that this system made it easier to use a seat belt than to decline. Using the seat belt became the default option. This was brought about by a policy solution. Automakers were incentivized by federal regulations and market forces to find ways to make it easier for people to use seat belts, and so they built them into the vehicles coming off the assembly line. Another example is the tension between stairs versus elevators. In most public buildings the elevator is the default option by virtue of its featured location, while those wanting to use the stairs have to look around or ask directions to find them. What if we had a sweeping stairway located directly in front of a building's entrance, while you had to search around for an elevator? The stairs would be a default option that more people would choose. Default options are determined by policies. Health promoters will sometimes label this type of policy solution an environmental strategy, because the changed circumstance or setting makes it more likely that healthful living is supported.

Other policy solutions have been to construct cars that better protect riders, and we've learned how to construct highways and roads that provide a safer driving experience. These types of policies do not have a behavioral component, but simply promote health without any individual effort. This is sometimes also called an environmental strategy, again meaning that we have changed something about circumstances that promotes health and safety. Prohibiting public smoking is a policy solution that can also be called an environmental strategy because people are passively protected from exposure to tobacco smoke. A non-policy solution to this same problem would be using education to persuade smokers to not smoke near nonsmokers. Often we combine policy solutions with supportive education designed more toward behavior and decision making. About ten years ago, policies were put in place requiring the posting of signs by cigarette vendors, notifying customers that it was illegal to sell cigarettes to minors. This was an educational message brought about by a policy.

Some policies are government efforts with a requirement or mandate on individuals. State governments use highway policies that prohibit people from exceeding a posted rate of speed. The speed laws compel people to obey, with a threatened penalty for noncompliance.

Some other types of policy solutions are instituted by organizations. For example, some employers have the policy of rewarding employees for accumulating miles of walking or running. This is a policy solution by virtue of creating a social circumstance that makes it more likely that people will exercise, above what could be expected if those same companies just relied on educational messages and communicated encouragement.

Part of the recent emphasis on health policy is because experience and evaluation show that education and communication alone, even when done according to best practice guidelines, often fall short of achieving desired health outcomes. On the other hand, some segments of society have become very sensitive about policies that mandate or prohibit actions by individuals. They see this as taking away personal freedom in an effort to build a "nanny state," which is seen as a futile effort to immunize the world against all threats to health. Health promoters have to balance the use of best-practice policies with conflicting values in communities. Unless a community is largely supportive of a policy solution, research evidence for effectiveness is irrelevant. For this reason, policy solutions are more complex to apply because of the multi-step process of identifying effective policies, persuading policy decision-makers, and preparing the community. With educational tools, we send out motivational messages and people take them or leave them. More often than not they leave them, unless they are supported with simultaneous policy supports.

Next time I want to discuss the interaction of health policy with health disparities.

Green with Envy, Gray with Anxiety

2011-08-04T14:43:00.000-04:00

People often associate colors with moods and emotional states. Usually the reference is symbolic, though some people with fair skin might actually turn "red in the face" when they are angry or embarrassed. I've noticed lately that the President has sprouted much more gray hair since he was running for office in 2007-8. While lots of jobs are stressful, the U.S. presidency has to be near the top in the amount of unrelenting pressure and demands placed on holders of the position. Most of us are not confronted on a daily basis with the reality that 40-60 percent of constituents don't approve of our performance. The President bears responsibility for the actions of a couple of million employees of the federal government, most he will never meet. He has to interact with people who totally, permanently disagree with his every action and public statement.

The question then is, "What effect did all this stress have on the rate of graying we've seen in Mr. Obama?" As it turns out, there is a two step process of hair production and hair pigmentation. The two steps are not tightly linked: some people stop producing new hair, possibly while the pigmentation capacity is still in place. More commonly, the hair production process continues long after the pigmentation capability has ceased or slowed down. Is this process influenced by stress? The jury is still out. We cannot prove that anxiety accelerates graying, though there are some plausible mechanisms whereby stress hormones could shut off pigmentation metabolism. Stress is harmful in important ways; even if we establish a link between worrying and turning gray, this doesn't really matter for most people.

As an aside, severe malnutrition or toxic exposure can impact hair growth and graying. In otherwise normally healthy people, a healthy lifestyle has no impact on balding or graying. Genetics is surely a powerful determinant here.

It is unfortunate that the pigmentation process is not more immediate and fleeting. In other words, what if graying was like a mood ring? When you were under a lot of pressure, your hair would turn gray as an outward reflection of duress. When you noticed this sudden change in the bathroom mirror, you could martial coping skills to get the stress under control. If others noticed a gray hair alert, your support network could engage and help you find tranquility again.

Of course this is whimsical thinking. The body doesn't work this way, but we do need to listen to the bellwethers of our daily exposure to elevated stress. Are we tense, short-tempered, sleep challenged, unable to concentrate as usual? It is a common experience of the modern world, robing us of quality living.

What color is peace?

Food Austerity and the Joy of Cooking

2011-08-01T09:59:00.000-04:00

Over the last couple of decades there has been an arms race of sorts in the food industry. The business plan of most restaurants seems to be cutting the cost of ingredients and finding labor-saving efficiency, in order to offer more food for less. Supersize is the order of the day. This is not just triple burgers and double French fry servings, but also ginormous entrees and desert portions that could satisfy two or three normal adults. We have largely accepted this as inevitable in a market-driven economy, leaving limited options for health promotion: to get the public to consume fewer unhealthy ingredients, either by policy regulation or by consumer behavior change. Since sugar, salt and fat taste good, it is an uphill battle. To illustrate, most people find a tossed salad to be more tasty with, rather than without a salad dressing. Is there another option besides taking away the joy of cooking and eating?

My daughter is a trained chef, and so she is fun to have around at meal times. Other times to! I like to talk to her about food, whether individual recipes or restaurants, or at the macro level, food trends and the way things happen in the food business. In her culinary training, she learned there are only three things that matter: 1) does it taste good; 2) is it attractive on the plate; 3) can it be sold for a profit? In general, healthy is not a value that is emphasized in professional cooking circles. This would seem to be anathema to health promotion principles, thinking about the long-term consequences of our eating habits. Maybe it is time for a second opinion.

While fine cooking does not spare sugar, fat, salt, all things nutrition health promoters warn about, its redemption is serving size. Fine dining does not offer “all you can eat,” and serving sizes tend to be modest. They are most interested in quality, and compete on that basis, rather than striving to send people out the door stuffed.

I began thinking about this the other day as I was analyzing data from the National College Health Assessment, which was completed on the campus of the University of Louisville (and many other institutions) in 2010. This is a national survey instrument that individual schools are invited to administer on their campuses. All of the questions relate to health issues relevant to college-aged young adults. One of the questions was “Would you like to learn how to cook? About 70% of the students said yes. I found that startling, because we have the stereotype that young people prefer fast food, and are not open to other alternatives. In this instance, cooking skills are an enabling factor in the parlance of health promotion theory; people might be more prone to eat healthier if they had more confidence in navigating around a kitchen. These students seem to be affirming this idea.

Maybe as health promoters we should consider the values of real cooking? The effort to get people to eat a more austere diet, devoid of all the things that people like but that predict health consequences down the road, has been minimally effective. Perhaps we should follow the lead of the culinary artists. Embrace the joy of cooking, just learn to eat modest portions. Advance the notion that more of poor quality is not as good as a smaller amount of great cooking. In addition to having potentially better health value, it offers slow as a value in our stress-burdened lifestyles.

This is not a simple solution to a very complex problem, but might deserve another serving of consideration.

Health Promotion and Freedom

2011-07-27T10:06:00.001-04:00

This morning I was exercising on a step machine, and among the screens in the TV bank in front of me was one showing the Bill O'Reilly show. He was arguing (as he usually does) with a "wellness advocate" whose name I don't remember, but who other wise made a powerful impression on me because she was able to hold her own against the usual bullying and ridicule from Mr. O'Reilly. The topic was whether or not we should tax junk food, such as sugared drinks, french fries, donuts, and so forth. The advocate was framing the issue as a way to protect the nation's health, while O'Reilly spun it as a matter of freedom from government interference.

What do you think? For people who have professional concern for promoting the nation's health, what is the right balance between complete laissez fair and dictating everyone's food choices? Up until perhaps 20 years ago, the primary public response to advancing nutrition-related health was school and public education, with the idea that an informed public would make food choices in the best interest of their health. There were two problems. The first was that a lot of the responsibility for nutrition education rested with the U.S. Department of Agriculture, that had a conflict of interest, because their primary purpose was to promote U.S. agriculture, and particularly meat, dairy and field crops like corn and soybeans. With that central mandate, it has been hard for USDA to be honest about encouraging people to make their diets centered around vegetables, fruits, beans and whole grains, with meat and cheese proteins as more of a garnish or an occasional selection rather than a dominant portion of diets. The second problem with government-sponsored food education is that even at its best, it has been completely swamped by mass media from the junk food industry. We never saw an ad for the Food Pyramid during a Superbowl, but rather, Doritos, Coke, and MacDonald's.

In more recent years, health advocates have assertively moved toward policies and regulations to support healthier food choices. The government has some limited restrictions on health claims made by foods and beverages, and terms like "low fat" and "enriched" are scrutinized by the Food and Drug Administration. In addition, packaged foods are required to post ingredients and basic nutritional information on labels, so that consumers are able to inform themselves when shopping. More recently, health promoters have begun to suggest calorie information be posted on menus and menu boards in restaurants, and putting restrictions on the content of school lunches. Some of these new policy proposals are as yet unproven, but time will tell what contribution they make to America's health.

The issue on O'Reilly's show was the imposition of what once was called a "sin tax" on nutrient-empty foods. This idea circumvents trying to motivate people to choose better foods, but instead, provides economic incentives to do the right thing. Such taxes have been shown to be effective for tobacco and alcohol. If you make something more expensive, people will buy less of it. The other justification is that the price exchanged from the buyer to the vender does not cover the social cost of using that product. The consequences of the obesity epidemic are imposed on society at large; junk food makers do not get the bill. Imposing taxes is a way to recoup the cost to our health care system.

While I agree with maybe 3% of O'Reilly's views on anything, I think it is a fair question for us to think about the benefits of using social policy for health promotion versus imposing restrictions on people against their will. What is fair and balanced with this issue?

Health Promotion Resolutions

2011-01-07T15:06:00.000-05:00

Dyed-in-the-wool health promoters, on either side of a graduation are familiar with a theory called the Transtheoretical Model, sometimes also called stage theory. There are just a few basic ideas needed to understand this theory. People are at different points of readiness to change any particular health behavior: some are not interested in making a health-related change, some are in the process of changing, and some are trying not to relapse in their change. The corollary is that health promoters must tailor their intervention efforts to the varying needs of people at different levels of readiness. I want to relate this theory to New Year's resolutions.

It is customary for people to make pledges for self-improvement when they turn the calendar for the new year; often the intentions are health-related. Usually a price will be paid in doing something that takes discipline, changing time and schedule, and requires flexibility by significant others. This tradition is still a good one: Surely it is better to say "This year I want to quit smoking!" as opposed to "This year I want to put on 75 pounds!" The problem of course is that most people have trouble carrying out their pledges. Today we are one week into the new year and already the relapse curve is rising. Why is it that doing good things for ourselves is so difficult?

We can think about this in terms of the Transtheoretical Model. People who decide to make health-related changes are in a stage of readiness in which they are thinking about reasons to change and the benefits and barriers of doing so. They are in that stage because of personal life events and broader social influences. It is just by chance that their inclination to change coincided with the custom of New Year's resolutions. Health promotion agencies should be preparing people in November and December, so that when January rolls around they are in a frame of mind supportive of change. This does happen, but the effort is not extensive enough to reach most people.

Continuing the theme of resolutions and theory, people more times than not will relapse. It is not that the pledges were not genuine. It was that they don't have the supports to move to the next levels of stage theory. In order for people to act on their intentions, they need to have access to resources and must learn competencies and skills. People are genuine when they say they want to lose 25 pounds in the new year. What is lacking is a way for them to learn the necessary skills, such as how to grocery shop, plan meals, eat in restaurants, and obtain social support in ways that advance losing the weight. Do they have access to safe places to exercise? Without those things, their motivation isn't channeled into positive action.

Another problem is that for many health-related changes, once the change is made and the goal is attained, communities don't provide resource and motivational ramparts to sustain the achievement long term. We may say let people take care of their own stuff, and that is a legitimate point of view. On the other hand, without communities taking a role in helping people, we can expect to see lots of health promotion relapse. That is a choice society makes, but at the present time it is not an informed choice.

If you are a consumer trying to change, look for help in the surrounding community. If you are a health promotion advocate, be the change you want to secure.

Health Promotion 2011

2011-01-03T12:37:00.000-05:00

The turn of the calendar from one year to the next often is accompanied by looking backward and looking forward. Today I want to look forward to things that I think will happen in the world of health promotion. Based on events in the world of practice and current trends and events, these are things I think we can anticipate happening, having an impact on health status and health promotion practice in the U.S.

Texting and driving will be a developing story. As texting is still on the upswing, more and more states and communities are taking action. Journalists will be looking for results from the various efforts to discourage texting while driving. There will be more public education addressing cell phone and driving safety, such as the current PSA developed by the U.S. Department of Transportation.

It may be that the ultimate solution will be a technological one. For example, what if there was a way for cell phones to interact with a car's electrical system, so that while the car is moving, outgoing calls and all texts, in and out, were blocked? In coming calls could be received, but for all other cell functions, the car would have to be parked. Perhaps phones would come with a pre-installed app with a GPS function detecting motion. As long as the car is moving, all phone functions are disabled. These ideas are only speculation, but today's theme is the future in health promotion. This whole story is fascinating to watch, and will present many new ideas for health promotion practice.

Another area I would like to make predictions about is the campaign against overweight and obesity. There will be on-going public education in multiple venues and formats: school instruction, mass media, patient education, workplace health programs, and so forth. Most of this education will be only modestly effective at best. This is due to several factors working against relevant diet and exercise behavior change. First, current patterns of physical activity and nutrition are deeply ingrained in the culture and social norms, making change much more difficult. Next, there is huge opposition from food and beverage makers and fast food vendors - sugar, fat and empty calories represent massive profits. These corporate interests will work as hard as possible to counteract the health promotion messages. Finally, our success in reversing overweight is abysmal. Many people lose weight, but the segment of dieters who lose weight permanently is very small. The state of the art and science of weight loss is still primitive. There is no reason to expect this to dramatically change in the near term.

The real action with respect to the anti-obesity campaign will be with policy solutions. This is going to heat up in 2011, because many politically conservative leaders and organizations are starting to push back against what they see as "nanny state" over reach by big government. For example, in December of 2010, President Obama signed into law the Healthy, Hunger-Free Kids Act, which among other things establishes nutritional standards for foods regularly sold in schools. One side sees this as a way to improve the nutritional status of children while the other side thinks it tramples on local control of schools and the prerogatives of parents. The intensified focus on the obesity epidemic is going to collide with conservative ideology, and this will be seen more and more in 2011 and going forward.

A final issue that seems to be heating up is the use of smokeless tobacco, in the form of mouth-absorbed tobacco (e.g. Snus) or electronic cigarettes. The only reason this is coming up now is that tobacco companies are redoubling their efforts to sell products, and because the door is increasingly closed on conventional cigarettes, these other options are seen by Big Tobacco as viable alternatives to support their business.

There are undoubtedly going to be many other health challenges coming to the forefront in 2011. For example, I wonder what will happen this year regarding 1) climate change and 2) pandemic flu? One of the things that makes health promotion always interesting is the parade of new issues always coming along. Stay tuned.

Texting and Health Promotion Policy

2010-12-31T12:01:00.000-05:00

Recently I’ve been reading research reports on the effects of cell phone use, particularly texting, on driving safety. Because of the rapid diffusion of cell phone technology and the practice of sending text messages, the research has been proliferating, but has not kept up with the diffusion wave.

The immediate reason for my interest in cell phone safety is that Kentucky has passed specific legislation prohibiting texting or e-mailing while driving for all ages, and prohibiting all driving cell phone use by those under age 19. The new rules went into effect summer, 2010; actual penalties begin January 1, 2011.

The rationale for Kentucky’s legislation and parallel bills around the country is that cell phones interfere with safe driving. In my searching I’ve discovered an obscure web site – http://www.distraction.gov/– maintained by the U.S. Department of Transportation. The larger issue is distracted driving, of which cell phone use is only one example. Distraction in driving can occur in three ways. Manual distraction is when a driver’s hands are doing something besides driving, such as using a phone, applying make-up, or interacting with a global positioning system. Visual distraction occurs when a driver is not looking at the road and surrounding traffic. This is a problem for most drivers when we look at things on the side of the road or inside the vehicle. Finally, cognitive distraction is the circumstance where drivers are thinking about something other than driving. Most drivers are unable to keep all of their brain power focused on driving, even if they are alone in the car. From the outline of types of distraction it is obvious that all drivers are distracted at times.

The forms of distraction come together in a perfect storm with texting. When a driver is conversing with a passenger, the distraction may only be cognitive, but not manual or visual. While all distraction increases risk for collisions, texting seems to present more danger than most other distractions, since it constitutes all three forms of distraction. The other factor that makes texting so concerning is that it is more frequently done by younger people, who have other characteristics that make them less safe as drivers.

Part of the reason many states are outlawing texting is that not only is it dangerous and worth trying to decrease if not eliminate, but the laws are effecting predominantly youth, who have very little political power and influence. If laws were to be directed more broadly at distracted driving, there would be more intense and more organized political opposition.

A final point is about the actual risk of driving while cell phoning. A lot of the research is done with driving simulators. Research subjects go through a series of typical driving challenges, with and without cell phone use. In general, these studies consistently show that drivers using phones perform more poorly, indicating higher risk for collisions. This science supports what most people would think intuitively. However, I wonder if it is more complex?

All cars come with radios, and operating and listening to a radio while driving is distracting from the task at hand. However, drivers also have collisions from fatigue and “highway hypnosis.” Those problems may be moderated by having a radio. If we compare perfect driving performance with radio-assisted driving, the perfect driving will have a lower collision rate. But if we compare real world driving with radio-assisted driving, the radio-accompanied driving may actually be better. It will be interesting to see in the future whether hands-free cell phone use actually has a safety benefit in real world driving.

At the present time we rely on public education to persuade people not to use cell phone functions while driving. In addition, there is a growing body of policies trying to restrict and regulate drivers with cell phones. It is too early to know what works and what doesn't. Educational messages are fairly simple (Don't
!) so that makes communication easier. However, cell phones and texting in cars have become ingrained in our culture, so this makes the behavior change process more challenging. I think it will take a lot more people to have personal narratives about cell phone induced collisions before there is a critical mass of public credibility given to the issue. As far as policy restrictions, support seems to be growing, but it is not clear yet what policies actually matter.

People are skeptical about enforcing cell phone with driving policies, and obviously that is a challenge. However, that was and still is a concern regarding seat belt laws. Forty years into the seat belt campaign, we still don't have universal compliance with the laws. However, it is clear that the combination of educational messages and legal mandates have been effective in bringing seat belt habits to the level of a social norm, making our highways much safer than before. We must work for that same outcome with drivers and cell phone use.

Mental Health and Public Policy

2010-12-20T12:04:00.000-05:00

As I've discussed in earlier postings, health promotion applies tools to help individuals change their behavior, as well as applying tools to change communities and social circumstances to support and promote better health. In recent years I've been persuaded that health policy is much more powerful than I've thought in the past, and probably more powerful, in general, than individual behavior change strategies. There are lots of examples of the two prongs of health promotion with infectious diseases, chronic diseases, and injuries. When we turn to mental illnesses, the picture is not so clear.

Mental illness can cause death, and in the case of suicide, about 30,000 in the U.S. per year. Intentional violence can also be related to mental illness, but the mortality toll is less clear than with suicide. Aside from those most severe manifestations of mental illness, the greatest concern is disability. By some estimates, mental illness is the greatest cause of disability in the U.S., and probably also in most developed nations. Surveys of mental illness estimate that in an average year, 30% of the adult population will have a mental disorder, including phobias, post traumatic stress, general anxiety, depression, and drug dependence. More than half of cases are serious or moderate severity, though those classifications may be more art than science. Nevertheless, something like one of every 17 adults will have a"seriously debilitating mental illness in a year's time.

Because of the population impact of mental disorders, they must be considered through the public health lens. There has been interest in perfecting our ability to measure the nature and extent of mental disorders in communities, and to tease out the personal and social risk factors to guide interventions. Unfortunately this research has not advanced to the point where there are simple recommendations for progress. What I mean is, if you want to avoid lung cancer, try not to breath in smoke, particularly from cigarettes. For most people that's all they need to know.

For mental health, there are no simple guidelines. Physical and emotional conditions of early life certainly are important - if you have a choice, try to be born into a family with two parents present and emotionally engaged, middle class income, with an extended social network, including relatives, neighbors, coaches, music instructors, and other supportive adults. This statement is obvious, but also supported by research. Our dilemma is how to assure that every child is chosen and every family is successful in its social mission of nurturing children. We dable with this through public and private programs, but there is such a strong tradition of family independence in our culture that we frown on outside intervention, except in the most egregious cases, so that the safety net has lots of holes through which disadvantaged children fall.

A significant portion of health is socially determined, with correlations between a person's vitality and life expectancy and where they are located in society - physically, socially, and geographically. Those on the bottom rungs of income, education and status typically will have the worst health, including mental health. This is a self-feeding cycle, so that disadvantaged persons have the smallest chance of achieving the best health, and because of sickness and disability, are more challenged to move into higher levels of education and income. Theoretically, this circumstance should be responsive to public policy tools and strategies, but as a society we have not made much progress in this regard. We don't even agree on whether government has a stake, or whether individuals should be empowered only by market incentives.

Perhaps none of the above thoughts are new to most people. I think it important to point out that mental health is to some extent a function of broad social policies. If we believe that society and governments should seek to promote the best mental health possible for citizens, this will not take place unless we put in place policies which assure social conditions in which people can thrive in every way. This will be a long, uphill climb.

Conservative Misunderstanding of Public Health

2010-12-13T10:22:00.000-05:00

In some circles, the blame for our current troubles as a nation is all government, all the time. The notion of government is synonymous with waste, fraud and abuse. Every government employee, no matter how highly trained or hard working is reduced to "government bureaucrat." There is also the widely held belief that government workers are more highly paid than private sector employees. However, when factors such as education and experience are taken into account, it is not so clear that there is a disparity. In fact, the pay disparity may be in the other direction - highly trained government employees are paid less than equivalent workers in private companies. Since most of public health effort takes place in government, these attitudes and stereotypes matter.

Last week I had the privilege of interacting with a group of employees at the U.S. Centers for Disease Control. I was there providing a training workshop, serving a group of about 50 civil servants in various specialties of public health. I found them to be eager learners who are sincere about making an impact with their endeavors. They were not unlike hundreds of public health workers I've either taught or otherwise associated with over the last three decades. These are people who go to work every day, trying to contribute to the public welfare by decreasing tobacco exposure, diminishing community violence, protecting people against environmental toxins, and reducing the toll of infectious diseases. At CDC as well as countless local and state public health settings, I have not found pikers sitting around trying to avoid real work until they can retire.

The facilities in which the training took place were not opulent, but in fact quite ordinary and basic. That is also what I've found in hundreds of state and local public health offices and settings. In fact, comparing my observations of these public sector facilities with my experiences in the private sector, such as in hospitals, insurance companies, and various corporations, the private sector sites have uniformly been better appointed, more spacious and well endowed. While not all private facilities are luxurious either, it is just not true that public agencies are spendthrift for personnel or places of work.

Are there waste and abuse in government, including public health? Most certainly. Can you find public health workers who are unproductive, not serving the public good? Without doubt. But these things don't only occur in government. There are workers in the private sector, including employees not in unions, who don't serve their employers well. There is waste in every workplace, not just in government. That is not to accept this as a good thing, but it is to reject the conservative narrative that fraud and abuse are unique to government.

Public health agencies have a responsibility to be good stewards of the public's dollars. Managers should expect evaluation of functions and accountability from employees. This is good practice in every organization. It is not hard to find examples of government services that are not very effective, and we need to always be trying to be better. But, does anyone feel well served by insurance companies and banks? Painting public health workers, as all government employees, as illegitimate is unfair, based on a lack of information. There is the old expression, "What you're not up on, you're down on." Because people don't understand public health, it makes an easy target.

And so I want to express my thanks to those mostly invisible public health workers who go about doing their jobs, trying to make healthier communities today and going forward into the future. Those CDC professionals I met last week are a proxy for the public health workforce. Many people don't know what they do, but those of us who do, must stand in their defense, with appreciation and support.

Holiday Traditions and Social Change

2010-12-09T12:48:00.000-05:00

As a preface to comments to follow, I want to make a full disclosure: I really like eggnog, fruit cake (Yes, I do), many types of Christmas cookies, and look forward to sumptuous holiday meals. Sometimes health promoters sound shrill and joyless. THEY TAKE THE FUN OUT OF LIFE. I don't believe that, but because we are often challenging people to stop doing things they enjoy, or start doing things they don't enjoy, it is easy to be the Grinch meets Scrooge.

Having set this stage, I also wonder why so many of our holiday traditions are not healthy? By the way, I'm mostly thinking about the holiday cycle that starts in the U.S. at Thanksgiving and goes through New Year's Day, encompassing Hanukkah, Christmas, and Kwanzaa. Other cultures and religions also have holidays, but I am less familiar with the health ramifications of, for example, Diwali or Ramadan.

In the U.S. and Western cultures, the "holidays" are marked with many social traditions, including special events, both religious and secular. Our social definition of celebration usually includes eating too much, too rich, too often. I challenge readers to visualize celebrating and merry making in ways that are truly health promoting. Can you imagine sharing carrots to commemorate New Year's Eve? How about the kids setting out a fresh pear for Santa? Does a celebration have to be unhealthy?

The answer is that our culture, and maybe most cultures, have developed over hundreds and thousands of years, during which a variety of forces have come together to shape our traditions and our sense of what is fitting in a given situation. So for example, culinary arts have developed to feature salt, fat, sugar, and alcohol - none of which are completely bad, but with typical culinary arts, the only thing important about food is to taste and look good. Of course in the present day we have technology that enables more refined foods. Up until the 20th century, it wasn't really possible to have a lot of high sugar foods, at holidays or any other time.

My point here is to illustrate that holiday food and drink customs and traditions are socially enmeshed. They are driven by many factors, some not even conscious. We can chip away at unhealthy practices by typical health promotion interventions, but to change the entire frame will require basic social change. We can promote better understanding about how our holiday activities are related to over-all health, and illustrate some better options. This is a common effort in many communities, but it doesn't have a huge impact because of the social background.

I won't say it is hopeless to think that the holidays could celebrate with health rather than unhealth, but it will be difficult. On the other hand, there are examples of positive social change that led to health benefit. I remember the time when it was customary for fathers to give cigars to their male family and friends at the birth of their children. That custom has gone away, even though I have never heard of any direct efforts to discourage the practice. Society has undergone basic underlying change with respect to our attitudes of what is appropriate regarding tobacco. This profound change is possible with food, but it won't be simple or quick.

In the meantime, let's lift a glass to good health.

Health Information Overload

2010-12-03T12:13:00.000-05:00

This week I attended a workshop to learn about EndNote, a software program designed to help with library research and citation management. With EndNote you can search the world wide web for journal articles, books, and web-site based materials. In the case of journal articles, those articles that are available electronically in full text can be downloaded onto your computer for future reference. Once references are located, the software will capture the citation and incorporate it automatically into a new document, and will configure the citation into the reference style you are using, such as the American Psychological Association format; there is also a provision to automatically convert the reference style into the preference of hundreds of specific periodicals. Truly an amazing tool. My context is the memory of undergraduate days when we would spend a lot of time in the stacks of a library, writing notes and citations on index cards. That sounds like the stone age by comparison.

As I was learning all the various functions of EndNote I was impressed again with the mind-boggling volume of intellectual material published every year. Like all disciplines guided by science and research, health promotion tries to keep up with the latest consensus on effective practice. That means being sure that we are promoting the most accurate health science information, but also that we are applying skills and techniques with the strongest evidence for effectiveness. This is not new. It is just that the volume of new information is expanding so quickly that few people can really keep up. This is true for consumers, as well as front-line practitioners, and finally academics and researchers. I spend at least half my workday in front of a computer, so that I have almost constant access to information sources. I can't keep up, except in a few very narrow areas. The pratitioners and consumers have almost no chance.

So what we have is a mixed blessing. On the one hand, the accumulated knowledge is certainly far more than ever before, but the gap between what is actually known (somewhere, by someone) and what is put into practice by others is perhaps also greater than ever. Since our capacity to learn is not growing, and the speed with which our brains can process information has not changed, solutions to this dilemma must come from the production and dissemination side. EndNote is an example of something that can deliver more information faster and more efficiently, but I still have to find time to read those articles!

Somewhere in the future, we can hope there will be technological advances to couple our brain functions with new tools that can actually speed up the process of absorbing and synthesizing the flow of information. Perhaps there is a way to break the mass of new information into new "cognition units," something other than traditional language-based words and sentences. Maybe there will be ways to more efficiently filter the information that comes to us. Professional journals are supposed to do that, but they are swamped by the tidal wave of scholarship being produced. Magazines also serve a filter function, but the filtering used by the editors may be biased for commercial reasons.

For now, I have to live with the uneasiness that the graduates I proudly escort into careers will most likely fall farther and farther behind once they leave the university resources behind and have to function based on the tools they have and what seems right in the moment. I'm hoping that the research enterprise will increasingly concentrate on dissemination, not just pumping out new science content information. Perhaps social media will have a role in this, beyond the current focus on chatting about relationships and life's trivia. There are giant leaps waiting to be taken.

Vitamin D and Public Health Communications

2010-11-30T16:50:00.000-05:00

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

2010-11-25T18:04:00.000-05:00

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?

2010-11-24T18:04:00.000-05:00

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?

2010-11-18T09:57:00.000-05:00

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

2010-11-17T12:07:00.000-05:00

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

2010-11-16T07:23:00.000-05:00

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

2010-11-15T07:51:00.001-05:00

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

2010-11-11T11:14:00.002-05:00

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

2010-11-07T16:28:00.000-05:00

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

2010-11-04T13:25:00.000-04:00

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

2010-11-02T12:32:00.000-04:00

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.

Voting for Health Promotion

2010-10-31T22:41:00.000-04:00

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.

Election Day and Healthy Halloween

2010-10-29T08:49:00.000-04:00

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.

Healthy in a Hurry Revisited

2010-10-27T14:20:00.000-04:00

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.

Celebrity Chef or Lunchbox Health

2010-10-25T12:56:00.000-04:00

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.

Staying the Health Promotion Course

2010-10-22T08:28:00.000-04:00

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.

Health on a Plane

2010-10-19T22:01:00.000-04:00

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.

Health and the Farm Bill

2010-10-17T09:38:00.000-04:00

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.

Erbal Ealth

2010-10-14T13:09:00.000-04:00

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.

Little League Health

2010-10-13T14:53:00.000-04:00

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.

An Ounce of Prevention Not Worth a Pound of Cure?

2010-10-12T16:52:00.000-04:00

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.

Urban and Rural Green

2010-10-11T12:35:00.005-04:00

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.

Probability and Health Message Impacts

2010-10-06T09:01:00.000-04:00

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.

Animals, Vegetables and Health

2010-10-04T22:49:00.000-04:00

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.

Minimum Age Health

2010-10-03T18:53:00.000-04:00

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.

Breastfeeding and Health Policy

2010-09-30T10:28:00.002-04:00

Currently I'm playing a minor role in a very large obesity prevention program being conducted by the Louisville Metro government, through the Metro Health Department. Funding for this program is from the Communities Putting Prevention to Work program, part of federal stimulus spending. The title is a double entendre: it is hoped that as a result of the program, disease prevention and health promotion forces will devise ways to make communities healthier (and thinner), but it is also hoped that the program will help to kick start the economy, with local spending supporting existing and creating new jobs. It will be some time before we know if either objective is achieved in Louisville and the other U.S. cities receiving similar funding.

One of the initiatives in the obesity program is to establish policies in city government that will make it easier for women with newborns and infants to breastfeed while continuing their employment. The focus initially is on city government alone, because Metro government has no control over what other employers do; it is hoped that if the experience of city government is successful, other employers will see the wisdom and value of following suit. By the way, there certainly are local companies that make some provisions to support breastfeeding by female employees, but no inventory exists.

Though the evidence regarding the importance and value of breastfeeding has been established for years, there is still a lot of ignorance surrounding the practice; ignorance is perpetuated by the infant formula industry, that promotes their products with mothers while they are still in the maternity unit of the hospital. Several medical and health organizations have official policies encouraging breastfeeding. For example, the American Academy of Pediatrics suggests that babies only receive breast milk through the first six months, and that mothers continue breastfeeding at least through the first year of life. Benefits of breastfeeding accrue for both babies and mothers. The interest of the obesity project is on the weight control value of breastfeeding for babies and mothers.

Nursing mothers can lose small but significant amounts of weight because they are transducing their own diets into a food supply for the baby, rather than energy and stored fat for themselves. Obviously, other factors will determine if there is a net weight loss during nursing: food intake, physical activity, and genetic tendencies and metabolism. Likewise, there is reliable evidence that babies who are breast fed tend to have a lower prevalence of obesity in childhood. The same caveat applies, that other factors, such as diet and exercise, can swamp the weight control value of breastfeeding. Given the proportions and consequences of the obesity epidemic, even small influences on mothers and children are worth pursuing.

The key questions for the obesity project are 1) What can employers do to support breastfeeding and 2) Why should they care? A business case can be made to support workplace provisions to support breast feeding. Note that we are talking about either actually nursing in the place of employment or mothers expressing or pumping milk which is stored for others to use to feed her baby while she must be away at work. Actually nursing on the job is not common, though may be increasing with more flexible patterns of work productivity. However, mothers and employers are increasingly recognizing that workplace pumping is not only feasible, but has some advantages for the employer.

Because breastfed babies are healthier, it can be expected that medical costs will be lower and absenteeism by mothers caring for sick children will be less. There is also the belief that when employers support mothers who want to keep breastfeeding, they are strengthening employee retention; worker turnover and retraining are very costly. Data to support these claims are limited but evidence is growing.

What can employers do to support breast feeding by women? The first is to establish a social norm or a corporate culture which establishes breastfeeding as something the company values. It will take some social change before most workplaces are really on board with this concept. Nevertheless, employers can provide a place on site where women can go to pump milk; the room should be clean, quiet, appropriately furnished, and secure for privacy. Ideally, this room should have a sink, and an electrical outlet to power a breast pump. Employers can offer flexible lunch and break schedules to better accommodate the needs of these women. They can provide a refrigerator for milk storage. As mothers and human resource units work together to meet this need, other policies and provisions will be identified over time.

Don't miss the important point. This is an example of creating structural support for healthful living. We can't entirely rely on education to persuade people to make healthy choices. Health promotion also requires attention to supportive circumstances.

Demography and Health

2010-09-29T15:21:00.000-04:00

In earlier posts I've made reference to Thomas Malthus, the English economist born in 1766. He is most known for his ideas regarding the balance between population growth and food. The logic goes something like this. Humans have offspring in geometric proportions (1 to 2 to 4 to 8 to 16 to 32....) while food can increase only arithmetically(1 acre of farm yield to 2 acres to 3 acres to 4 acres, and so forth). With these calculations, it would be inevitable that in time there would be hunger, because the need for food would surpass the supply. Coming to bear on this balance would be disease (Malthus might use the word "pestilance") and war. The end result of Malthus' projections was that population would inevitably be in check because a growing population would always be limited by starvation, illness, and violent conflicts. Economics is called the "dismal science" for a reason.

Malthus died in 1834, just prior to the beginning of dramatic population growth in the West. He never knew about effective methods of birth control. He could not imagine the technologies of agricultural science, enabling stunning growth in crop yields and new ways and places for food production. All the advances of public health and health promotion would come mostly after the century of his death. Shame on us, the regular frequency of war hasn't changed, but the population death rate due to war has improved: remember that the U.S. Civil War was our most deadly on a population basis.  We now have the expertise to treat battle wounds that in the past would have most certainly been fatal, and our weapons, though more deadly, are also more precise.

We now know that Malthus' original idea is too simplistic, and that there are many more ways that ingenious humans can intervene collectively to support and sustain population health and growth. It is not inevitable that a growing population will be smacked back down by a roaring epidemic or a deadly conflict. Nevertheless, our health status and health promotion methods are and will continue to be effected by population patterns and demographic change. So, what are some things likely to happen in the future which will influence health in the population?

It will be a while until the results of the 2010 U.S. census are released; statistics will be disseminated incrementally as parts of the data analysis are completed. Nevertheless, there are some things we know now about the U.S. population, based on recent demographic analysis. Many of the trends in the U.S. are paralleled in other developed nations.

One dramatic change that will continue into the future: our population is looking more and more like an inverted triangle. The size of the population in childhood and adolescence is smaller and smaller, while the population over 50 is getting larger and larger. Fertility in the U.S. and most developed countries is not great enough to grow the population; the average couple is having too few babies to make a second generation larger or even equal to the first. All of our population growth in the U.S. is from immigration and from people living longer lives.

There is a market place of ideas on all sides of the current immigration debate. However, there is one immovable fact. Unless we permit immigration to continue, population will shrink, and there will be fewer and fewer young workers to support more and more older citizens needing medical and social services.  By the way, we are one of the few developed nations in the world with growth. Immigration is a logistical problem in terms of integrating new arrivals into our economy and communities, but it is a huge advantage we have compared to Europe or Japan.

In addition, health promotion services will shift in focus to older clients and target groups. In the past, not much attention was given to designing health promotion interventions for people in their 60s or older, because the cost benefit ratio was too small, and seniors themselves had little expectation that they would live long enough to benefit from lifestyle change. Because the horizon of age-related disability is being pushed back to the 80s, 90s and beyond, there will be new attention to understanding the health promotion needs of this segment of the population.

The other major demographic shift is coming like a slow-motion tsunami.  Just before mid century, it is projected that there will be no racial or ethnic majority in the U.S.   People "of color" will increasingly make up our population, but no single group will dominate, at least in numbers.  To the extent that the different racial and ethnic groups have a unique culture, this will certainly present challenges to make health promotion programming relevant to varying communities. Changes in minority vs majority will bring about political power shifts that will change the way we think about and act on health disparities.

I believe these population pressures, aging and diversity, are important factors driving much of the political rancor going on in our nation right now. People feel bludgeoned by changes that they don't understand and can't really change, but which are substantially driven by demographic trends. Unless we learn to get along better, these fights will intensify in the future. The train of these population changes has left the station. However, interesting challenges lay ahead for trying to address the health needs of a quickly evolving nation.

Altitude and UV Exposure

2010-09-28T08:17:00.002-04:00

A generation of people has grown up understanding the link between sun exposure and skin cancer. It is less understood that the relationship is complex, mediated by skin type, family history, personal history of sunburn, a weak immune system and altitude. The theme of this posting is on the interaction of altitude with skin cancer and other risks. By the way, about one in five of us will develop skin cancer some time in life.

From an ordinary perspective, altitude is a measure of distance above sea level. In this context, altitude is how close something is to the sun. Higher altitude is closer to the sun. In addition, there is a blanket of gases and particles surrounding the earth, and it partially protects us against more severe damage from the sun’s UV radiation. Low altitude means the atmospheric blanket is thicker, providing more protection, while higher altitude has a thinner blanket providing less protection. Altitude differences are reflected in greater risk for skin cancer at higher altitude. Estimates are that for every 1,000 feet of altitude above sea level, UV exposure increases by 5-10%.

Another variable is latitude. Again, think not above sea level, but distance from the sun; distance to the sun decreases with altitude, but also with proximity to the equator. For example, a 10,000-foot mountaintop at the equator is closer to the sun than a similar altitude peak in a northern or southern latitude, such as Norway or New Zealand. One group of researchers measured UV levels in high altitude Vail, Colorado, sea level in New York and in Orlando, Florida. UV radiation was 60% more in Vail than in New York, while the farther south location of sea level Orlando had equal amounts of UV radiation as the high altitude location in Colorado.

A further complexity is climate change. There is geological evidence that sea level was once much lower than it is now. For example, think about the land bridge between Russia and Alaska. At that time, people on average were able to live at a lower altitude, farther from the sun, with more atmospheric protection against UV rays. No records exist, but based on current understandings, there would have been less skin cancer, and cellular mutations induced by UV light would have been less frequent. This circumstance might have led to a longer life expectancy, though the effect would have been counter-balanced by the absence of medical technology, dietary gaps, and less than ideal sanitary conditions. As climate change takes place in our own reality, average altitude will increase as seawater rises. This predicts more skin cancer and UV related cell mutations.

These changes are imperceptible because they take place so slowly. This reminds me of the story of the person who decided to move when he learned that most auto accidents happen within 25 miles of home. Obviously most people will not change their residence because of UV considerations. However, there are two important take-home messages. Sun protection is always important, but increasingly so at higher altitude or closer distance to the equator. The second is that climate change is not just a concern for polar bear habitat. It presents serious threats for our life on planet Earth.

Slow Food in Fast Times

2010-09-26T17:54:00.000-04:00

If we can believe the statistics, TV is America’s teacher. Virtually everyone in school watches TV, and while broadcast and cable screen time is less than classroom instructional time, it is giving it a run for the money, especially when we remember that kids watch TV on weekends, on holidays, and during school summer breaks. In addition to the school-aged group, preschoolers are frequent TV watchers and, of course, adults also watch lots of television. Adults spend more time at work than watching television, but there are not many other things that compete with the time commitment people make to watching. For this reason alone, it is not feasible to disregard the health implications of our TV diet. In addition, there are certainly content messages which have important health impacts.

Recently I’ve been thinking about the phenomena of food and cooking shows. What are they teaching and what are we learning from them? Though not the first TV cooking show, Julia Child’s earliest shows in the 1960s were no different from current programming: the only things that matter are taste, appearance, and the subliminal messages about how to live life. These shows are reality shows, in the sense that content is not produced by creative writers, but is based on unscripted activity going on in front of the camera. On the other hand, just like writer-driven shows, the cooking shows are designed to bring viewers to an imaginary world, one more glamorous and exciting than what is experienced by the typical viewer. So in the 1960s, viewers were invited to imagine that they could serve up gourmet meals, just like the ones Julia brought from the great kitchens of Paris. These shows are entertaining in complex ways. Other commentators have traced similarities between current cooking shows and pornography!

As a died-in-the-wool health promoter, and therefore open to the charge of taking the fun out of life:), I am troubled by the disregard of health considerations on the food and cooking shows. The current national concerns about diet-related health problems such as heart disease, stroke, diabetes, and even certain types of cancer, don’t seem to have broken through to the Food Network. Perhaps part of the appeal of these programs is to not only invite people to imagine a life of glamour and refined taste sensations, but also to step into a world, at least temporarily, in which everyone is healthy and lives forever. No worries about too much salt, sugar, fat or calories, just bon appétit.

On the other hand, the trend in the U.S. is for more and more of our food to come from fast food venues. This means that the contrast is not between cooking like Rachel Ray or Emeril Lagasse and the American Heart Cookbook. It is between the food shows and supersized drive-by food. At least on the food shows, real food is featured. The celebrity chefs do cook with fruits and vegetables, and while often the featured recipes are calorie dense, suggested serving sizes tend to be moderate. Until recently, it has been next to impossible to find anything remotely health-promoting on the menu of a typical fast food venue, whereas that is not the case with food shows.

One more point is the contrast between fast and slow. One of the things that makes cooking shows seem more like entertainment than cooking skill teaching devices is that featured recipes require substantial time for preparation and cooking. They really do highlight “slow food” as opposed to fast food. In our upside down world, people frequent fast food restaurants because they don’t have time to cook and they want more time to watch TV! Somehow the concept of slow food, investing care and devotion to one of the most basic tasks of life is something that our modern society leaves out. It remains to be seen if reality cooking shows can ever represent reality in back of the cameras.

Tanning Addiction

2010-09-24T16:31:00.000-04:00

Recently I've been reading about the association of indoor tanning and addiction. Concerns about tanning's health consequences are not new, though we still don't have precise understanding of the mechanism by which ultraviolet light exposure causes cancerous changes in skin. Limited estimates indicate that indoor tanning may double the risk for melanoma, the most life threatening form of skin cancer. Indoor tanning is done by around 15% of adults, and it has increased in recent years. The exception to the trend is teenagers, whose tanning has gone down, perhaps because of legal restrictions on teens going to tanning salons without parental permission. Most of this has been discussed in the media for many years.

What is new is the notion that tanning may be addictive behavior. People seek out tanning for cosmetic reasons, because a golden skin color is valued in some circles, and people believe a tan gives a "healthy glow" to a person's skin. Obviously this is a very subjective perception, but it is one held by millions of Americans. Recently there has been research suggesting that UV light has an impact on MSH, a skin hormone, which then causes the release of endorphins: a name derived from "endogenous morphine." There are receptors in the brain for endorphins, and their stimulation will have effects similar to opiate drugs. Under experimental conditions, withdrawal symptoms have been induced in regular tanners who were administered endorphin blockers in proximity to tanning. It is therefore becoming accepted that frequent tanning can become compulsive in an addictive way. The question is, what does this mean for health promotion?

Addiction is an emotionally charged word, and it has many shades of meaning. Once upon a time, addiction was only used for certain types of drugs such as cocaine and opium. It was not until the 1980s that there was any scientific consensus that tobacco was addictive. In the popular mind, there is uncertainty whether alcoholism is addiction, or some other type of syndrome. The word addiction has also been applied to a wider range of compulsive behavior, such as gambling, shopping, sexuality, and even uncontrolled anger, called "raging." The problem with all this is sorting through a lot of ambiguity. If someone makes an unwise purchase, are they then a shopaholic? How about two, four, or ten. What is the threshold? As it stands now, if you think you have a problem, you do. On the other hand, if someone else thinks you have a problem, but you don't recognize it, you are in denial. This kind of circular thinking complicates what can certainly be, for some people, very destructive behavior.

Addiction comes in degrees. Some behaviors of choice are more reinforcing than others. The key question is what are you willing to give up in order to be reinforced by something. Smokers are able to live otherwise normal lives, because their drug is cheap and the consequences are usually postponed by years. In contrast, alcoholics because dysfunctional: they are willing to lose wealth, family, job, safety, and even freedom, rather than give up their drug. Yet, even people with the worst addictions have been successful in overcoming their dependence.

The relevance to health promoters is this: according to dermatologists, there is no safe tanning, outdoors or indoors. Health consequences are significant enough that we should continue to warn people of the risks, and as we can, initiate policies, such as restrictions for minors, to help people reduce the risk. If there is an addictive property to tanning, it will make the health promotion task more complicated, but not impossible. After all, millions of addictive smokers have quit. We have pharmaceutical aids to help addicted smokers; perhaps in the future parallel aids will be developed for addicted tanners.

The more we understand about tanning, or any other health-related behavior, the more effective we can be in devising solutions. The tanning addiction story is not finished yet, but it will bring an interesting wrinkle to the task of helping people avoid serious skin cancer.

Health by Default

2010-09-23T08:59:00.000-04:00

Sometimes people use the expression "It was like rolling off a log," to mean that something is very easy to do. It is not often that we would use that expression for health promotion. Often individual effort to change or health promotion as a professional activity is difficult at best. It takes relentless effort to bring about individual and community change in health status or behavior. There is no doubt that these efforts can be successful, but it requires someone to keep on keeping on.

With that background, I want to write about what is called the "default option." We have created communities in which the unhealthy option is the path of least resistance. For example, when you order a restaurant salad, it often comes with cheese, croutons, bacon, and a generous portion of regular salad dressing. What if instead, the salad automatically came with just the vegetable ingredients with low fat dressing on the side, so that a customer would have to request the other ingredients. That's the default option. What happens routinely is default. Because health practices are often not supported by default conditions, health promotion has begun to think of ways to make the default option the healthier option.

Here is a different example. A couple of years ago I was in Washington, D.C. attending a conference. Several times a day I would walk the same route between the conference location and my hotel, and I began to notice that I would have to stand several minutes at a number of street corners, waiting for the traffic to stop and the crossing signal to go on. Meanwhile, the traffic lights were synchronized to facilitate the steady flow of cars, with minimal wait times at intersections. It may be an impossible dream, but can we envision a city in which pedestrian flow is what takes priority; instead of making walkers wait, we make cars wait? And in fact, instead of using the lion's share of our transportation funds for accommodation of vehicle traffic, we shift those funds more and more toward making it easier and more inviting to walk, bike, and skate as transportation? Could we make walking the default option, while driving a car requires a conscious and determined decision?

In most public buildings of more than one floor, usually very close to the front entrance is an elevator. This is the default option. To take the stairs you have to be determined, going out of your way to search for the stairwell's location. Once you are on the stairs, often there is poor lighting, no heating or air conditioning, poor housekeeping and sometimes a feeling of poor security because of an isolated location. Could we turn this around, to make the stairs the default option? What if we designed buildings so that upon entering, a person's eyes are immediately drawn to an attractive set of stairs, featuring bright lights, mounted art work, clean surfaces, and perhaps piped in music?

The general concept is to find ways to make the health promoting choice the easy automatic choice. This could be applied to eating spaces, exercise resources, green lifestyles, driving safety, and many other issues. Creative health promoters can find many ways to introduce default options into multiple-strategy health promotion programs. Defaults tend to define social norms, so that with concerted effort to change defaults toward health promotion, social change will come about.

Here is an example of this last point. When I make plane reservations through internet travel services, almost always, the sites will try to bundle a hotel reservation with the airfare. If I choose to go forward, they will then present a list of hotel choices; the hotels offered and the order in which they are presented on the screen may be based on distance from the airport, commercial agreements between the airlines and the hotels, or other factors programmed into the travel sites. What if the hotels presented were selected because of the health quality of their food services or their convenience to public transportation or the presence and nature of fitness facilities on site? Over a period of time, the hotels would begin to change in response to this commercial incentive. This represents social change, and that is what will ultimately bring about a more physically fit population.

There may be many issues with which the default function doesn't really work. However, the biggest barrier to its use right now is that health promoters have not used much creativity to explore the option. I hope that will change in the future.

Mental Wellness, continued

2010-09-22T09:29:00.000-04:00

Yesterday I was writing about the lack of attention given to promoting mental health and wellness. There is a very large psychiatry enterprise consisting of psychiatrists and clinical psychologists, inpatient and outpatient treatment facilities, and of course, a huge segment of the pharmaceutical industry. About 24% of adults and 20% of youth have a diagnosable mental disorder during a one year period. Given that burden of mentall illness in society, it is striking that there is so little effort put into preventing mental illness and promoting mental health.

Traditional public health agencies rarely have any involvement with mental health. Even when they do community health assessments, the level of analysis is minimal. For example, the national Behavioral Risk Factor Surveillance System has a question on mental health: “For how many days during the past month was your mental health not good?” While this is a start, there is no effort to identify underlying factors. While there is a whole set of questions on diet and obesity, there is only this single question about mental health. Healthy People gives some attention to mental health, but there is not really much about primary prevention. The U.S. Centers for Disease Control barely touches on mental health, with the exception of suicide prevention.

Schools could have a role to play in helping kids establish good mental health, but their usual practice is to identify students with problems and refer them for assessment and counseling. Schools are very involved in drug abuse prevention, and some of the prevention curricula address emotional adjustment.

Taking a step back from schools brings us to families. Clearly the early influences of family life and the interaction of children with parents and other adults has a huge impact on their emotional development. Family research has learned a lot about how to raise happy and well adjusted children, and some of this information is directed toward parents by schools, mental health agencies, faith communities, pediatricians, and other public and private organizations with concern for children's welfare. Because of the nature of families and their place in a democratic society, concepts regarding children's mental health are only recommendations. Organizations inclined to offer parent education programs often have to fight the stigma that moms and dads attending such programs must not be very good parents.

Though good mental health among the population is in society's best interest, there are not many ways we can take public actions to assure or support it. Because depression is associated with poverty, society's efforts to provide income supplements, housing subsidies, and health care for disadvantaged persons are indirect but important measures to take in promoting mental health. In the most severe cases of child abuse and neglect, the government can step in to provide a child a more nurturing environment. Unfortunately, all of these measures are not fully effective. Trying to eliminate poverty is diabolically difficult, and many children endure degrees of family dysfunction that never reach the attention of appropriate officials.

Our society does take steps to help people cope with stress and anxiety. This comes in the form of media information, classes, a variety of products, such as herbs and massage devices. Currently we are fixated on "wisdom" from the orient (yoga, tai chi), as though Asians know more than others how to live stress-free lives. The stress remedies are like the variety of diets. They will probably all help someone reduce stress, but very few will lead to long term peace and serenity.

Another idea that is worth pursuing from a public perspective is resilience. Child development researchers have found that there is a subset of children who are survivors. In spite of growing up in a dysfunctional family, living in poverty, having only one parent, or parents with mental illness, or other kinds of disadvantages, they become happy, functional, successful adults. The key ingredient with resilient children may be having a prosocial relationship with another adult, such as a coach, a youth paster, or even a neighbor, to compensate for deficiencies in support and nurturing from one or both parents. Another resilience factor is bonding with the social values of school. Children who learn to value school and identify with the optimistic mission of educational opportunity and have good relationships with teachers are much more likely to be resilient in the face of other challenges at home and in the community. Schools, faith communities, and various other agencies can take steps to strengthen resilience among young people, laying the ground work for life long good mental health. This is application of the concept "It Takes a Village to Raise a Child."

Mental health promotion is way behind other types of health promotion. In the generations going forward, more time and energy must be invested if we want to see progress over the mental illness pandemic.

Mental Wellness

2010-09-21T14:26:00.000-04:00

The University of Louisville has around 3,000 employees, and provides health insurance to most of those workers. The insurance program makes it possible to assess the health status and needs of this workforce, and this information is used to plan programs for improving employee health, seeking ways to manage employee health costs. Of course, information about individual workers is absolutely confidential, but even composite statistics for the workforce as a whole are not routinely broadcast to the community. For example, the University doesn’t necessarily want the public to know how many workers are HIV positive, or how many employees have attempted suicide.

Recently it was made public, barely, that the most common type of prescription drug taken by University employees is an anti-depressant. This is not unique to U of L, but would be typical in most employee groups. Depression is very common among Americans in general. I’ve been thinking about this from a health promotion perspective, and wonder what are the implications for improving health versus responding to illness.

There is a concept of wellness, which traces its roots at least as far back as 1948, with the adoption of the World Health Organization’s constitution. That document includes the famous definition: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The phrase “not merely the absence of disease..” lays out the wellness concept. You can be given certification by a physician that you have no illness, but you can then adopt practices to become healthier still. Included in the wellness concept is also that health is not a dichotomy with which people can be categorized as sick or well. Instead, it is a continuum running from death bed to optimal health; while terminal illness is definable and easy to recognize, optimal health is an ideal, something to which people can strive, but never be really certain when it has been attained. Part of wellness is in the journey towards better, not the destination itself.

We have spent decades since 1948 identifying and promoting ways to promote wellness in the physical dimension. People are used to finding exercise and diet programs in their communities, at their workplaces, in their faith communities, and through out mass media. While there are certainly many sedentary people who eat terrible diets, it is now accepted as normal to be surrounded with information and resources to promote wellness focused living. Given the extent of mental disease, and the proportion of the population with emotional problems, it is a significant gap in health promotion that relatively little is done to strengthen mental wellness in the population.

Part of this gap is because mental health and disease knowledge is in a relatively primitive state of developoment. There have been public assertions that much of the practice of community therapists is based on anecdotes and tradition, rather than science-based diagnostic and treatment principles. Whereas we have lots of data which outlines goals for wellness enhancement, such as diet, exercise, smoking cessation, sleep, and sun exposure moderation, the evidence is much less certain regarding how to promote mental health.

There are dietary supports for good mental health, including adequate intake of B vitamins. However, usually people have adequate B vitamin intake even if their diets are high in salt, sugar, and fat. B vitamin deficiency is now more common among senior citizens who have a diet very limited in variety and calories, and among young people with eating disorders who just are not eating enough. For those groups, vitamin deficiency imparied thinking and emotional adjustment may be something which could be prevented.

Maybe we should promote happiness. There is actually a field of study called "happiness science," in which psychologists conduct research to better understand what makes people happy, and how it might be promoted. This is a very small field that does not attract very many research dollars. There is even some debate about whether happiness is objective enough to warrant attention by serious scientists. Recently there have been reports that peoples' happiness grows with increasing income, to the point where their income is sufficient to meet all their basic needs, followed by a plateau in which happiness remains constant in spite of growing personal wealth. Perhaps related to this are the findings of the World Values Survey, which among other things, assesses the happiness of international survey subjects. In their rankings, the U.S. is not number one, but is in the top ten. In the first and second slots are Venezuela and Nigeria. This certainly raises questions about the validity of the survey methods. It does illustrate that happiness is difficult to define for a group or an entire nation, and therefore difficult to measure.

Some people claim that participation in faith communities promotes happiness and mental health, primarily through social support and relationships which naturally occur, and a promised sense of peace of mind from religious devotion. Unfortunately, the evidence is mixed regarding how mental health is impacted by religious observance and participation.

There is another construct called meaning in life, often traced back to Viktor Frankel, who's book "Man's Search for Meaning," lays out a basis for happiness, fulfillment, and purpose through meaning in life. Having a strong sense of meaning in life does not preclude mental health problems, because many mental diseases are biochemically based, and as far as we know, unrelated to our lifestyles or anything we do to be mentally well. Nevertheless, is seems certain that one way to promote mental wellness is to find ways to instill in children and adults a sense of mission and purpose, that what they are doing matters, beyond meeting their daily needs. People should relate to the world in such a way that day to day activity, whether fun, exciting, and pleasant or not, is connected to a bigger purpose that matters and is fulfilling. This trait falls on a continuum with some people totally disconnected from any meaning while others are fully in tune with a big purpose. Unfortunately, it is not at all clear why some people sense meaning to their lives and others not so much, nor how to promote this trait.

When one thinks about the large number of people who struggle with mental illness of all sorts, and the many people who report being unhappy, and the large numbers of people who are drawn to self-medicating their unhappiness, anxiety, and lack of purpose with mind altering drugs, it is clear that health promotion advocates need to invest far more time in finding ways to promote better mental health in the population.

Where do we start?

What Can We Learn From Colorado?

2010-09-20T08:09:00.000-04:00

It is health promotion fantasy land to think that the way to stop the nation’s obesity epidemic is to design and disseminate theory-based diet and exercise programs alone. What is required is much more complex. To illustrate, consider Colorado.

In the listings of obesity percent by state, Colorado leads the nation: about 18% of adults in the state are obese, compared with 34% for Mississippi, the most obese state, and 27% for the nation as a whole. How can this disparity be explained? Is it possible to take lessons from Colorado’s success and bring them to Mississippi and the rest of the nation?

Colorado is a little younger, on average, than Mississippi. Since obesity increases with age, a small age difference could contribute to more obesity in Mississippi. African Americans are more obese than whites or Hispanics: percent obese is 36%, 24%, and 29%, respectively. In Colorado, only 4.4% of the population is black, whereas in Mississippi the percent is 37%. More overweight blacks would make Mississippi’s obesity problem bigger, just from a demographic pattern. However, it is more complex than this. The District of Columbia is second only to Colorado in low obesity. Yet, 54% of the D.C. population is African American. These are very different populations, as D.C. blacks are much more likely to be educated and holding middle class jobs, while blacks in Mississippi are more likely to be undereducated and poor. These demographic patterns are critical influences in determining obesity prevalence and must be addressed in the long term.

National surveys (Behavioral Risk Factor Surveillance System) show that Colorado citizens do more recreational exercise than Mississippi residents. BRFSS determined that 81% of Coloradoans had any physical activity in the past month, while only 67% of Mississippi residents were equally active. This is certainly an important factor. The other side of the equation is diet.

From 1971 to 2000, average daily calorie consumption increased by 168 for men and 335 for women.. The change for women is 22%, proportionately high but in absolute terms, 335 calories is not such a huge amount. Consider the following list of foods with calorie content close to 335:

1 cup apricots, dried            310 calories
1 avocado                           340 calories
1 cup chile con carne           340 calories
2 oz. cashews, dry roasted   330 calories
1 cup hash brown potatoes 340 calories
1 slice pumpkin pie              320 calories

Adding any one of the above items to your daily diet would hardly seem excessive overeating, but a little added over a period of time leads to consistent weight gain, unless balanced by a proportionate increase in activity.

Some times exercise is just a matter of motivation and discipline: we make ourselves be active because we know it is a wise habit to nurture. On the other hand, environments can make a big difference in the amount of exercise we get. Colorado is a mountain state. Its average elevation is 6800 ft., and the difference between the highest and lowest point is in the top five of all the states. I think this means that the average person is more likely to be walking up or down a grade than in the flatter states, such as Florida, Delaware, and Mississippi. This doesn’t mean that Colorado residents spend all their time hiking on mountain trails, but the common ups and downs add just a little more exercise and opportunities to burn a few more calories.

So what are the lessons? Some of Colorado’s obesity advantage results from circumstances having little to do with health knowledge or motivation, but are related to geography and demographics. However, differences in race, education, or elevation do not explain the nationwide increase, since those things have not changed much over time.

The things that impact obesity are not dramatic. We did not get to 33% obesity overnight, and the average person did not double their calorie intake. Slow, small changes over time are responsible. Solutions will not be dramatic either.

If you want to lose 10% of your weight by next month’s wedding, extreme measures are required. If you want to change weight status for an individual or the community at large, slow, small steps are what will make it happen. That’s a lesson that applies to many weighty matters in life.