Green with Envy, Gray with Anxiety

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

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

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

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

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.