Welcome

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

IF YOU WANT TO RESPOND TO A POST, CLICK ON THE WORD "COMMENTS" AFTER THE LAST LINE OF ANY POST.

Thursday, September 30, 2010

Breastfeeding and Health Policy

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.

Wednesday, September 29, 2010

Demography and Health

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.

Tuesday, September 28, 2010

Altitude and UV Exposure


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.

Sunday, September 26, 2010

Slow Food in Fast Times

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 app├ętit.

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.

Friday, September 24, 2010

Tanning Addiction

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.

Thursday, September 23, 2010

Health by Default

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.

Wednesday, September 22, 2010

Mental Wellness, continued

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.

Tuesday, September 21, 2010

Mental Wellness

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?

Monday, September 20, 2010

What Can We Learn From Colorado?

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.

Friday, September 17, 2010

Drug Use Trends and Smokescreens

People who are old enough will remember the fever pitch of anxiety about illegal drug use in the 1960s.  The nature and extent of illegal drug use was undoubtedly greater than in earlier decades, though there were no systematic data systems available to profile or depict the number of users and the types of drugs they were using.  All we had were anecdotal accounts of people participating in drug use, accounts from treatment providers, and police accounts of arrests and drug confiscation.  All of those were indicators, but had limited value in really capturing representative statistics on drug use in the over-all population. 

Starting in 1975, we had a national survey of drug use by high school seniors.  Called Monitoring the Future, this survey was a representative sample of seniors across the country.  The survey was done every year; starting in the early 90s, grades 8 and 10 were also surveyed and included in the data reports.  This national survey gave a picture of school drug use, and served as a valid benchmark with which to compare states, local communities, and schools when comparable data at those levels were available.

In later years the U.S. government initiated a national household survey of drug use by persons 12 years and older.  This then complemented the school survey, so that we had valid statistics on drug use across the population.  Both of these surveys continue to the present.

From year to year, we have seen fluctuations.  One year some drugs are up, other drugs are down.  The only time there has been a truly consistent trend was in the 1980s.  During the late 1970s, drug use reached higher and higher levels, but then began about an eight year consistent decline for all drugs included in the surveys: marijuana and other illicit drugs, alcohol, and tobacco.  Prevention methods and tools at the time were still primitive and not evidence based, so it is not possible to attribute the positive change to anything being done by schools and other agencies working on drug abuse prevention.  Perhaps it boiled down to a "Hawthorne Effect," meaning adolescents responded because of the magnitude of attention to drugs being giving across society in schools, mass media, law enforcement, faith communities, position statements by political and community leaders, and so forth, but not because of any single intervention.  Nothing explicitly tested was shown to be effective, but the bulk of all the effort was accompanied by encouraging declines in drug use.

Since the late 1980s, drug use has fluctuated up and down, with no real trend or pattern.  We have seen specific drugs become insurgent with new popularity (e.g. methamphetamines, Oxycontin) while others declined (e.g. Rohypnol, LSD).  There is a whack-a-mole quality to these changes: if we succeed in reducing consumption of one drug, another comes along to take its place.  American drug use will respond to strategic efforts by the various players, but deep seated social change is probably much more powerful.  This happened at the turn of the 19th century.  People were tired of the consequences of widespread community drug abuse, and this laid the groundwork for a set of drug control legislation passed in the first 30 years of the 1900s.

Recently, there has  been a transition from heroin and cocaine toward abuse of prescription psychotherapeutic drugs, including synthetic opiate pain relievers, like Oxycontin, anti-anxiety sedatives such as Valium and Xanax, and stimulants such as Ritalin.  Evidence is that the frequency of people visiting hospitals for overdoses of these drugs has risen dramatically.  It is too early to tell whether this is like the ebbs and lows common during the last 20 years, or really the beginning of a significant epidemic.

Another new development in recent years is the use of synthetic marijuana.  Chemists have designed a synthetic version of the active ingredient of marijuana (tetrahydrocannabinol).  The chemical is then infused into a mixture of herbs, which are then smoked.  There have been anecdotal reports of serious reactions and side effects, but it is really too early to definitively say that this drug is greatly increasing in usage or that it poses a major health threat.  There are no systematic data yet to provide answers.  News reports are not a reliable indicator of a real trend or a genuine threat.

Historian J.M Scott (1969) has said that "We animals appear set upon destroying ourselves by nuclear or germ warfare and by drugs in war and peace.  Someday by some such means-unless informed interest and public opinion gets busy-we shall possibly succeed.  Then the symbol of eternal sleep (opium) will bloom on year by year, more appropriate than ever, and utterly indifferent."  Progressive public opinion can be powerful in changing the trajectory of drug use, and health promotion workers can strengthen the speed and vigor of the process.  However, at no time are we likely to see a triumphal end to the war on drugs.

Thursday, September 16, 2010

Health versus Freedom of Conscience

For many years it has been the law in most places that children are required to be immunized for the common childhood infectious diseases before entering school. State laws establish these rules, so there is variation from state to state regarding what vaccines are required, whether there are subsequent requirements for booster shots in upper grades, and whether there are opt-out provisions for individual families. The logic behind mandates for immunization is that community welfare takes precedence over the individual right to choose. Actually, the laws don’t force vaccination. Parents have the option to bypass the public schools, through private schools or home schooling.

One of the common exemptions for vaccination requirements is religious objection. There are people who believe their religion prohibits immunization. Some fundamentalists might believe that since the Christian Bible is silent about vaccination, it should not be done. Some others believe God will take care of the faithful, and that medical procedures demonstrate lack of faith. Christian Scientists believe illness is due to emotional upset and anxiety; a positive state of mind is the main ingredient of good health. Perhaps most families seeking religious exemption are sincere in wanting to practice their own religious convictions. An unknown number of religious exemptions are smoke screens for distrust of government or misguided notions about the hazards of vaccines.

This week I learned that two U.S. states make no provisions for religion-based vaccination exemptions: Mississippi and West Virginia. Most state exemption provisions require families to articulate, in writing, the religious basis for their vaccination dissent. It is not enough to just say they are opposed on religious grounds. A smaller number of states have a vague category called “philosophical or conscience objection” which gives people a more vague opt out. Rates of religious exemption vary from state to state, but they are increasing; CDC estimates around 40,000 children per year get religious exemptions for school entrance-required immunizations. This is a small number compared to the overall school population of over 50 million. Nevertheless, the unimmunized children present a threat to themselves and to others.

This presents a dilemma for health promotion. The nation’s founding fathers were concerned enough about religion that it is mentioned first in the Constitution’s Bill of Rights, in the so called establishment clause: “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof…” On the other hand, the Preamble to the Constitution stipulates one of the purposes of the powers established by it is to “promote the general welfare.” Surely protecting our communities from infectious disease epidemics is in the category of general welfare.

Since there is no specific mention of public health in general, or immunization in particular, we are bound to follow the 10th Amendment, which by default leaves the matter to the individual states. If the time comes that religious-grounded vaccination exemption needs to be reconsidered because of rising infection rates, there will be messy political battles in each state.

Our system encourages messy public policy battles; this is one of the things that makes our system great. Many good things are messy, including healthy children, but what a blessing they are!

Wednesday, September 15, 2010

Overweight and Social Change

The U.S. Centers for Disease Control have produced a series of maps, showing state-specific obesity trends from 1985 to 2009.  You can flip through the maps, one year at a time, and get an animated view of the stunning progression of overweight in the U.S.  The two primary reasons for the change are that our food supply has become more calorie dense and we are less physically active.  If you zoom in on those two causes, many additional subfactors will come into focus, such as the shift from slow cooked home meals to now about a third of our food coming from fast food venues.  This is a topic I've discussed before, and it is widely highlighted in media, and yes, kitchen table discussions.  I want to talk about solutions.

The change depicted in the maps reflects profound changes in society.  It is not just that we need to spend a little more time talking about nutrition and beefing up PE.  Those may be part of the solution, but what will be required to reverse the obesity epidemic is sustained social change around food and physical activity and the way we live our lives.  We have learned a lot in this regard from the anti-tobacco campaign.  Smoking is down from the 1960s, not because of public education alone, but society has undergone signifant changes in attitudes and beliefs regarding smoking.  This has occured in fits and starts, as health promotion warriers tried many strategies, different venues for education and more aggressive regulations in the face of Big Tobacco.

We are really just at the beginning of the anti-obesity campaign.  I predict that changes will come sooner, because of the groundwork laid by the anti-tobacco campaign and because of new media which moves at speeds unimagined in the 60s, 70s, 80s and even 90s.  So what follows are some of the current proposals for policy changes to address overweight in our communities.

Several fast food chains target kids with the ploy of offering toys as a bonus with package meals - so called Happy Meals or other related labels.  These may be momentarily happy meals but we all know that long term they certainly are not healthy meals.  Some communities are beginning to say no.  If the venders want to use toys as a marketing gimmick, they must come with food items meeting nutritional standards, limiting calories, salt, fat and sugar.  Can McHealth do battle with McBurger?  We shall see, but this represents an increment of social change.

Another popular proposal is to put added tax on sugar sweetened beverages.  Children and adults comsume large quantities of sugar dense drinks, including regular soft drinks, fruit-flavored punches, and in my part of the world, sweet tea.  These bring large jolts of sugar, adding substantially to the calorie load of diets.  We've learned from the tobacco wars that taxing can be an effective tool: make something more expensive and people will buy less.  Around the country, health advocates are beginning to experiment with legislative proposals to make suger sweetened beverages more expensive.  This would represent more social change if it makes fundamental impact on our diets.

Some other ideas include menu labeling, zoning restrictions on the density of fast food venues in urban neighborhoods, requiring candy-free check out aisles in retail stores, banning infant formula giveaways by companies to new parents in hospitals, banning free refills of soft drinks, changing zoning restrictions to permit farmers' markets in city locations and making it possible for those markets to accept food stamps, promoting the development of community gardens, restricting the design and location of junk food billboards and out-door advertising, and putting nutritional rules on food purchasing by schools and other government agencies.  These are just a few of the proposals being discussed.  The legal and practical basis for some of them is still emerging.  It is also unknown what impact they will have.  It will take time to sort it all out.

Taken together, the policy changes are likely to mold and shape our culture, so that in 25 years, the food and activity environment will be unlike what we know today.  It is an exciting new frontier for health promotion.

Tuesday, September 14, 2010

Texting and Tasking to Death

Our culture has a relentless moving quality to it. There is nonstop pressure to be more productive, to seek out entertainment, to talk to other people, to see more things before you die. I don’t know where we stand currently, but in the recent past, Americans were at the top of national rankings for the productivity of the average worker, and we were taking less vacation than workers in most other modern countries. We have come to believe that we can multi-task just fine, and that it is essential to keep up the pace of the life we’ve made for ourselves. All of this frenetic kinetics is enabled by stimulant drugs such as caffeine, and many other illicit ones.

This brings us to the fairly recent phenomenon of texting while driving (TWD). It is stunning how quickly this activity has captured the attention of the public in a way most things never will. The typical texting driver is a teenager, mainly because a disproportionate segment of all texting is done by teens. However, increasingly, TWD is done by male and female adults, including professionals like truck drivers, and even an increasing prevalence of senior citizens. The immediate safety issue is TWD but the broader issue is multi-tasking in all sorts of circumstances.

There is a raft of new state laws trying to prohibit or restrict TWD. They vary in what aspects of this behavior they regulate. They also vary in whether the restriction targets all drivers or just youth, and whether the police can stop a driver primarily for TWD or whether there has to be another primary reason providing a rationale for a traffic stop. As of yet, the evidence for effectiveness is small, so any of these public policies are truly just experiments. Over time, the body of evidence will grow, and this will guide legislators to craft restrictions most likely to improve safety. However, there is lots of evidence to support the idea that TWD causes accidents.

So here is a quiz question. What exactly is it about TWD that is dangerous? Is it A) hands off the controls? B) eyes off the road? or C) mind off the task of driving? The answer is important, because if A or B were the reasons, there would be technological solutions to make TWD safer. The best answer is C, a mind divided between driving and communicating with another person is not safe. The bad news is that this is just as true for phone conversations while driving, even with a Bluetooth device. It turns out that we are not as good at multi-tasking as we think. Students think they can study while watching their favorite TV show, because they multi-task well. Parents think they can fix supper, help Janie with her homework, and talk on the phone all at the same time. We have convinced ourselves that we can do these things, that we are good at more than one thing at a time, and that life requires this frantic activity.

TWD research teaches that we need to slow down: on the highway, in the hyperactive need for instant communications, and in the pace of life in general. Perhaps TWD is a metaphor that might help us find more quality and quantity of life.

Monday, September 13, 2010

Health and 9/11

In public health sometimes the term environmental strategies is used.  In a behavioral context, it is not about protecting water purity or restaurant sanitation.  Instead, it is about designing circumstances where good health is more likely to occur.  For example, in many places, we try to encourage people to climb stairs rather than taking elevators. How? By improving stairwell lighting, by adding art work, perhaps piped in music, and by posting motivational messages to encourage people doing something good for their health.  Another example can be found in urban areas, where cities will provide bicycles for people making short trips from one location to another.  Rather than using taxis or their own cars, if there are loaner bicycles available, people will use them.  Neither of these examples guarantees healthy choices, but creates a circumstance to increase the odds.

Sometimes environmental strategies are trying to make it easier for a health impulse to win the day over conflicting attitudes and values.  At other times, environmental strategies are more directive, taking away peoples’ free choices.  For example, more and more jurisdictions are banning the use of cell phones by drivers.  These initiatives will not prevent people from speeding or tailgating, from being drowsy, or otherwise being reckless, but are designed to increase the likelihood that people are focusing on the driving task, creating safer conditions for all vehicles and pedestrians.

As with most Americans I've been thinking about 9/11 the last few days.  It is striking how that day has changed so much about our world and our world view.  To me it feels like the left book end to a lot of episodes and events, all of which add up to a national funk.  Since then we've been mired in two wars and the never ending war on terror.  Following the go-go real estate period, our financial system and employment marketplace have crashed, with no quick return on the horizon.  We've become more and more persuaded that climate change is real and threatening, though there are still some (a dwindling number) claiming is it only a special interest boogey man.  Not least, our politics and governments have become fractured and dysfunctional, seeming to be unable to fulfill their missions of making our lives better through public works of all kinds.  According to an analysis published by Newsweek magazine, not only are we not #1, we are #11 among most prosperous and successful nations.  I am anxious to see the right bookend fit into place so we can move away from this dark shelf: one with more fresh air and light streaming on it.

So, let's put an optimistic spin on our circumstances.  Maybe this is an environmental strategy occuring naturally, without our intentional design.  American ingenuity will find ways to adapt to energy conservation in unobtrusive ways.  For example, most people have become accustomed to the compact fluorescent bulbs.  I don't hear a lot of grousing about smaller, more energy efficient autos.  There is a movement to rethink our living spaces: McMansions are becoming less the ideal for the upwardly mobile.  In fact the symbolism of upward mobility may be changing.  Society is changing, so that more people will walk or ride bikes.  We are a long way from the European habits of transportation, but our society is moving in that direction.  Housing in the future will not follow the pattern of suburban sprawl, but instead will be in village clusters, better for naturally occuring exercise and neighbor to neighbor interaction.  Some of these changes will be uncomfortable, but in the long run there is an upside: more healthy lifestyles, more simplicity, and a gentler impact on planet earth.

Perhaps in the future, life will focus more on being, less on getting.  Not all bad.

Friday, September 10, 2010

Tobacco and Health Have Nots

Last year I started watching the show Mad Men, and for a number of weeks was really into it.  This is out of character for me because I don't really watch much television, but was fascinated because the show takes place when I was growing up.  Characters on the show are portrayed as adults at the time I was a teenager.  I guess it was a flashback for me.  After a while I had to look away.  It was not good people against bad people that bothered me.  I found it such a bleak and dreary moral landscape, and I couldn't deal with a micro world where people treated each other with complete disregard for respect and decency.  Perhaps that was reality in the business world at the time, but I just couldn't see it as entertaining.  Nevertheless, one of the things so much on display on the show is that every man smoked cigarettes, and most of the women.  There was no hint of social disapproval.  People smoked whenever and wherever, with no thought that someone might object.  Smoking was entirely normative, and viewed as a symbol of success, prosperity, and sophistication.  That was mostly true in those years.

In the 40 plus years that have passed since the time portrayed on Mad Men, profound social change has occurred regarding smoking attitudes and behavior.  While female smoking is up a little since the early 1960s, male smoking has gone down by half.  More than that, smokers are constantly aware that "Yes, I do mind if you smoke!"  You will never see a public figure, unless in a dramatic movie or TV show, smoking a cigarette in public.  It has become something which causes smokers just a little bit of shame. 

For this and other reasons, smoking now is becoming clustered among the outcasts of society.  The educated and affluent are initiating smoking at a smaller and smaller rate, and smokers in this social strata are quitting at a higher and higher rate.  They do this because they are more aware than ever about smoking risks, they are sensitive to the social image of smoking, and they have easy access to cessation resources, including a regular source of primary medical care who is likely to encourage them to quit smoking until they do.

In contrast, smoking is becoming clustered among the poor and those with limited education.  About 21% of all adults smoke cigarettes, while smoking is done by 31% of those living below the poverty level.  For those over the age of 24 (by when most people are finished with higher education), 29% of those who failed to graduate from high school smoke cigarettes but only 6% of those with a college degree. Check here for more information.

These socioeconomic comparisons are becoming fairly well known.  Less understood is the clustering of smoking among those with mental illness.  There is more and more evidence that those with a diagnosed mental illness smoke at a substantially higher rate compared to persons without a history of mental illness.  About 23% of those with no mental illness history smoke; those with some lifetime history, or more recent history smoke at 35% and 41%, respectively.  It is estimated that those with a recent mental illness diagnosis smoke about half of all cigarettes consumed in the U.S.  Incidentally, there is evidence both ways, showing that prior smoking leads to more mental illness, while other evidence suggests that mental illness leads to smoking. Check here for more information.

The frame which comes into focus is that smoking is becoming associated with society's outer limits: the poor, the undereducated, the outcast, and those not quite accepted in mainstream society.  What a stunning change from the days of Mad Men!  It remains a challenge to social justice to find the purpose and creativity to provide prevention and cessation resources tailored to meet the needs of these segments of society.  If we succeed, all will benefit, even the Haves.

Thursday, September 9, 2010

Health in the Hearing?

This week Bristol Palin is coming to Louisville to speak at a fundraiser for a Christian pregnancy support center. She has been invited to speak, not because of any great wisdom or insight she might have about life as an unwed mother, but because her name will sell tickets to the fundraising diner. This posting is not really about Bristol or any other Palin, but it is about the concept of using her as a speaker, and how that is related to health promotion concepts.

Shortly after Bristol’s son was born, she became active as a national speaker on postponing sex until marriage. The basic formula goes something like this: 1) I thought I knew what I was doing and that it was going to be so great; 2) Before I knew it, things got out of hand; 3) Then something happened that I never would have believed could happen to me; 4) Now life is so much more difficult because of bad decisions I’ve made; 5) with the help of family, friends, church, and community services, I am slowly getting my life back; 6) I strongly urge you not to do what I did.

This sounds very harsh and uncharitable, but it is not meant to be. There are people who specialize in these types of presentations about pregnancy, drug abuse, gangs, self-mutilation, and other destructive behavior. Many are very sincere while some are just good at stage craft. Some are paid and others are zealous volunteers. The outline in the previous paragraph can be made to fit all of these issues, just by changing the examples. Usually, local communities will invite these speakers to talk to middle and high school kids at school events, sometimes at churches, but such speakers also make appearances on college campuses as well.

Unfortunately, motivational health speakers are not supported by any evidence of effectiveness, except the effectiveness of getting speaking invitations. There are two problems. The first is one I’ve written about before: relying on information alone to change behavior is almost never effective. The health speakers may be very entertaining and engaging, but they are still just offering information. Facts usually do not have the motivational staying power to influence decisions about behavior that occurs on a frequent, long term basis. Facts about influenza might influence a person to get a flu shot, but once the needle is out, no other thought about the flu is required. On the other hand, teen sex or drug use or cigarette smoking or shop lifting or diet behavior all require a continuous decision making. A more comprehensive set of factors must be managed to have any chance to influence those types of decisions.

The second problem has to do with adolescent cognitive development. The reason parents and other adults with programming budgets like the motivational health speakers is because they have messages that we desperately want kids to hear. However, what we hear is not what kids hear. When we hear a speaker give a heart-felt presentation on how pregnancy ruined her life, it resonates with our understanding and our values. But, our relational field of vision is much greater than that of kids, and we have enough life experience to understand ways in which life can be profoundly challenging. On the other hand, kids see a, usually, youthful speaker. He or she speaks in youth speak, wears hip clothes, knows how to engage the audience, and makes a lot of money. Kids tend to gloss over the ruined life part and focus on the now. How bad could it have been? She got pregnant, and now schools and churches pay her money to speak.

Sincere but trivial and simple-minded thinking is not a winning strategy for designing good health promotion or public policy. Make a note to yourself whether you are in public health or politics.

Wednesday, September 8, 2010

Health and Hubris

The other day as I was writing about bad food served at the Kentucky State Fair, I found my resolve wavering on two counts. First, our State Fair food is not different from what is served at parallel events around the nation. Our featured menu items may be bad, but not uniquely so. The second reason for pausing is that to some people, my views about a sick-promoting diet may sound sanctimonious and smug. Health promotion zealots run the risk of being viewed as smarty pants who think they know it all. We may not be much fun at parties, picnics, and potlucks.

So how can health promotion facts be shared without alienating people? How do we get people to change their health habits when we have given the phrase “health habit’ anti-social baggage? Is it possible to be a role model and spokesperson for good health practice while still being welcome at ordinary social interaction and events? Do we sometimes cross a line in our health crusading, becoming someone people don’t want to have around?

I think relative risk matters here. Unless there is strong evidence that something will strongly influence health for most people, it is not worth imposing on people. There are very minor (low relative risk) risk factors and major (high relative risk) risk factors. It is hard enough to bring about change with the major risk factors, such as smoking or driving without a seatbelt. Why waste resources and social capital promoting change for something that doesn’t really matter much? I remember being told as a child to not eat in between meals. Snacking can contribute to overweight, but otherwise is really not clearly a harmful thing, I’ve known people who followed health information religiously, making it a matter of daily discipline. Unfortunately, their diets and health habits were so extreme it made it very difficult to interact with other people not so inclined. A lot of their rigor was trivial from a health science point of view.

Another consideration is readiness.  You may have learned about the latest new thing in health knowledge, and want to share it with everyone you know.  However, the information will not be meaningful for everyone.  Most people are not sitting around waiting for your wisdom.  Sometimes inquiring about a person's interest will be a useful guide to their readiness to learn and benefit.

Often health promoting ideas are disseminated through media campaigns, and typically with government or private nonprofit funding. The fact that a given health concept has attracted funding from a legitimate agency without commercial conflicts, usually means that the concept has been vetted for accuracy, and has risen to the top of the health promotion market place. Usually this funding will major in majors, not minors. People will still take it or leave information given in this way, but usually don’t feel personally criticized. The media method of promoting health ideas is the least threatening because it is abstract at the individual level. It is only with individual interactions where health claims can make people uncomfortable. A measure of humility and sensitivity is important, unless you have a very close relationship with a person.

It is important to also not have a strongly assertive urgency about our health promotion modeling. Change doesn’t always have to be radical, over night, and usually it isn’t. Being a long-term mentor to support a developing bent toward better health is much more promising and well received than trying to be a benevolent dictator or a scold.

Obviously people find meaning in many things. Some see purpose and inspiration in something that seems fanatical and dubious to others. It is wise to remember that good health is driven by a few things we can change and many things we can’t. Rather than driving yourself trying to be a perfect health promoter for others or yourself, a more promising approach is to follow the big health ideas and then be joyful in what life brings day to day.

Tuesday, September 7, 2010

Health and Labor

Yesterday in the U.S. we celebrated Labor Day, in commemoration of the contribution made by ordinary workers to the prosperity and well-being of our nation.  It is an interesting amalgamation of two themes: it recognizes an American idea that people can achieve success and prosperity by hard work within the free enterprise system, while at the same time recognizing the role that labor organizing and collectivism have played in raising the standard of living of Americans.  Somehow these incongruous values come together in a uniquely American way.  Aiding and intersecting with fruitful labor are health status and health resources.

There are many ways in which health intersects with work.  Employment is one of the basic determinants of health.  It is hard to sustain long-term health without the resources provided by work, such as good food, housing, and access to medical care.  Long-term unemployment usually predicts declining health status for the unemployed worker as well as dependent children.  By extension, communities with high unemployment will typically be places with poor, community-wide health indicators.  These places don't have the economic vitality to attract the resources on which a health society are based.  Because of the traditional practice in our country for local property taxes to be a large part of school funding, communities with high unemployment (and therefore low property values) will often have poorly performing schools which provide a very tenuous foundation for long term prosperity and healthful living.  We have not had a lot of success breaking this cycle.

From the opposite perspective, labor is facilitated by good health.  A portion of unemployment and underemployment is due to disability and worker health problems, both physical and mental.Though not a perfect correlation, those individuals and segments of society with the best health status are likely to have the  best employment success, with other factors also important.  This is also true for school-aged children.  Those kids with the best health are likely to be the most successful in school, with other factors again very important.  This provides the rationale for school meal programs, and other health promotion efforts mounted in schools.  If we really believe no child should be left behind in school, the health barriers to success must be minimized and if possible removed.

Our society seems to be heading toward a growing group of disadvantaged individuals and families and a small segment of those very affluent.  The lower income group suffers from many severe health disparities: their health status is substantially worse than other people more affluent.  The solution to this problem is partially to provide more focused and vigorous health promotion programs for the disadvantaged groups.  However, at least equally important will be to find social policies to create and expand more and better employment opportunities.  Work opportunity is a more basic necessity for health than are public health programs.  Full employment is an important partner of health promotion.

Friday, September 3, 2010

Look for the Health Label

This year at the Kentucky State Fair, a number of culinary marvels were introduced. In addition to standard Fair fare like funnel cakes, deep fried Twinkies, and cheese and bacon hot dogs, Fair visitors were enticed with Krispy Kreme hamburgers. It was not actually brand new: a variation of the burger was sold as early as 2006 at a minor league baseball stadium, and celebrity chef Paula Deen actually has a recipe. This diabolical creation comes with a ¼ lb. beef patty, lettuce, tomato, red onion, with the options of cheese and bacon. Ms. Deen’s recipe calls for a fried egg as well. Finally, instead of a bun, the sandwich comes between two Krispy Kreme glazed donuts. The calorie load is about 1,000 or more, depending on condiments. This was designed to enhance the dining pleasure of Beavis and Butthead. It has the anti-basic four food groups: sugar, salt, cholesterol, and grease.

There is a freak show quality to food like this, and perhaps that’s why it is sold at the State Fair. News stories highlighted the caloric overload, but the themes were mostly the unique charm of State Fair food. The TV and press stories were an invitation to observe this annual celebration of agriculture, including a splurge with these Fairly unique junk foods. More astute Fair goers could look at the Krispy Kreme burger and know that it is not a wise choice from a health promotion perspective. However, no calorie or nutrition information is provided at the point of sale.

One of the more recent innovations in promoting healthy eating is requiring the posting of nutritional information on menus and fast food restaurant item display boards. We have had nutrition labels on food packages since about 1990, though ingredients were posted long before that. Over the last 20 years the labels have been expanded, to include more information, such as transfat content. Because such a large portion (about 1/3) of our diets are obtained from restaurant and fast food meals, a lot of our actual food supply goes unlabeled. Consumers are not able to make health promoting food choices if necessary information is not available.

The federal government (Food and Drug Administration) is developing regulations to require restaurants with 20 or more venues to post caloric content by menu and menu board items. Regulations apply to restaurants, as well as coffee shops, bakeries, candy shops, ice cream shops, mall cookie counters, vending machines, and other commercial food services with at least 20 locations. This will happen by March, 2011. Many local communities are also beginning to enact ordinances for restaurants with fewer than 20 locations. In the next five years, this will become the rule rather than the exception, and many health-activated consumers will be pleased to have another tool to make food choices fact-based.

There is always a but…..

Health promotion theorists have observed that people vary greatly with respect to their readiness to change health habits. It is only a small segment of the public that is ready to use menu calorie labels for food decisions; for most of the dining public the information is totally irrelevant to their daily lives. This is not a reason not to move forward with menu labels, but it is a reason to have modest expectations.

Another problem is that menu labeling relies on what theorists call the information model: if you give people the information they will act in a rational way in their best interest. If only it was that simple. People balance different things that they value, and health doesn’t always come out on top. Furthermore, there are often many other factors which determine change, including social support, skills, sense of risk, and so forth. Most people are not right on the verge of change, waiting for the missing ingredient of health information. Lifestyle change is not like mixing water with Tang in one simple step.

A final problem is that menu labeling, while promising, is not integrated with a strategic plan to improve America’s diet. The FDA will issue these regs, and they will help some consumers in a free-standing way. However, the FDA is a silo among many other agencies in federal, state, local governments and the private sector. All of these can play an important role, but it rarely happens that they are all working together in a coordinated way.

We live in a truly exceptional nation that values divided government and maximum dispersal of decision making authority. It is designed to promote opportunities for all to have a voice. This also means that progress is slow. We can predict two things in this context. Our democracy will continue to move forward, though sometimes in a herky-jerky way, and I expect the Krispy Kreme burger will again be a hit at next year’s Kentucky State Fair.

Thursday, September 2, 2010

Complexity and Protecting the Public's Health

Recently I became aware of a case that illustrates some of the complexity of promoting the public’s health. My daughter is a restaurant manager at a resort in a northern location. The site has consistently been 20-25 degrees cooler than Louisville and the mid-section of the country. Now that fall is approaching, rodents are seeking warmer indoor temperatures. In the restaurant office they have found signs of infestation, including rat urine and droppings and paper and other items which have been chewed and ruined. There have also been signs of rodents in food preparation and storage areas, and this is likely to get worse unless something changes in the meantime.

I first became aware of this situation when my daughter called to ask if one could get sick from exposure to rats, and what the symptoms might be. This was not a question that had a chance of putting me at ease about her living on her own! While there are urban legends which greatly exaggerate the danger from exposure to rats, it is still true that exposure to rat droppings and urine can cause infection with hantavirus, salmonella, and a number of more serious, though rare, illnesses.


It seems like a simple task to eliminate rats and mice. They could get some cats, but they would not be permitted to roam in a food service facility. They could use rat poison, especially since there are no children in the area who might accidently ingest those chemicals. The downside is that the mice and rats may be well on their way to creating nests in the walls of the building. After eating the rat poison, it is likely that they will go back to their nests and die. The smell of dead rodents is not an option for a public food service establishment. This is getting complicated.

It turns out that there are several authorities with jurisdiction and several values in competition. The manager of the resort, my daughter’s boss, has to balance employee health against the cost of abatement of the problem and the potential impact of bringing in an inspector. There is also the potential cost of ruined food, or even worse, having to close the business while the rat problem is solved. The resort administrator cannot just go to a local home store to buy rat poison or traps. There are many rules and regulations that come to bear.

This resort is a corporate vendor on federal land. There are federal officials and rules regarding the use of effective chemicals that are safe for the human user. There are other officials and rules regarding the protection of the environment from toxic chemicals; while they are eliminating the rats, they have to be sure the chemicals won’t harm endangered animal species in the area.

The other conflict is between the interests of the public versus those of the restaurant and resort. The restaurant doesn’t want to serve contaminated food, and certainly doesn’t want the publicity of cases of food-borne illness being reported in the local media. On the other hand, restaurants operate on a slim profit margin; this one is only open from May through October because of the tourist season in the area in which it is located. The restaurant’s concern is not only about corporate profit, but also about jobs. Between 20 and 30 people are employed at the restaurant, and the combination of a weak economy and a rural area almost entirely public land means there are few other employment options. Closing down a restaurant because of the rodent problem will not only cut corporate profits, it will cause economic hardship for all the workers. Of course the compromise is for the management to collaborate with the appropriate officials to eliminate the problem just as quickly and efficiently as possible, to avoid the most serious consequences.

Finally, while the rodent abatement plan is being devised and implemented, all workers will have to be especially vigilant regarding hand hygiene. Efforts to educate and promote compliance cannot be limited to posting signs. There are several behavioral theories which can guide the development of effective strategies to help promote worker safety. Management should not expect to do this independently, but should seek out consultation from experts with training in developing health promotion programs. Economy of scale efficiency will be realized if the hand hygiene program is exported to other similar corporate facilities.

All of the issues illustrated in the above narrative have only academic interest, until the circumstances happen in your community, in your place of employment, in your favorite restaurant, and to your family member or friend. Then it is comforting to know that someone has thought about and dealt with these concerns before, and knows what to do.

Wednesday, September 1, 2010

Health and the Head

The drumbeat for child and youth exercise is slowly intensifying as we try to create more and more ways to promote active lifestyles. In addition to lots of education directed at kids, parents and pediatricians, there are many policy solutions proposed, such as finding ways to encourage more children to walk to school, and requiring that PE classes have a minimum amount of actual movement. Rates of exercise among youth and adults have remained unchanged or dropped slightly in recent years; significant social changes will be required to get more people moving.

With that as background, it is ironic that those kids who are most active put themselves at risk in a way that couch potatoes do not. I’m talking about sports-related concussion, or traumatic brain injury (TBI). TBI comes with a range of severity, from short term (a few days to a few weeks) symptoms to permanent disability to death; 90% of deaths from sports-related head injury were among high school or younger players. Because a concussion isn't always accompanied by unconsciousness, many times players and coaches think it is ok for a player to return after a brief rest. This sometimes adds increased insult, making minor TBI more severe and consequential.  In addition to direct health consequences of TBI, sports-related head injury has social effects.  One study found that high school athletes with a history of two or more concussions had lower GPAs than similar athletes with no TBI history.

We hear a lot about high profile professional athletes, particularly in football, suffering brain injuries on the field in violent collisions with other players. The spotlight is shining on the sports leagues (particularly the National Football League) to see if they take serious action to try to prevent concussions and to keep players off the field until independent medical experts give them clearance to return.

It is only a short jump from professional football concussions to TBI among college and younger youth in organized sports and other activities.   From 2001 through 2005, there were about 250,000 8-19 year olds visiting emergency rooms for sports-related concussion injury.  In middle and high schools, football is the sport with the highest risk for concussion. For girls, soccer is the most risky. Risk and actual TBI come during games, but also during the longer exposure times of practices. Outside organized team sports, bicycle riding has the highest risk for TBI among leisure exercise activity.

Unfortunately it is not likely that sports-related concussion can be fully prevented. Whether it is aggressive contact sports like football or hockey, or fast, vigorous and close contact sports like soccer or basketball, or baseball, with a projectile sometimes aimed at or near players’ heads, these injuries are going to occur, unless most competitive team sports end. 

Not only is it impossible to prevent serious force impacting the heads of players, it is also impossible to prevent injury. There is growing public pressure to promote helmet use in soccer, skiing, and bicycle riding. Unfortunately, helmet technology still is not able to protect fully against TBI. Playing rules can help to minimize head collisions, but complete prevention is illusive. It is also absolutely critical to promote secondary prevention, where all involved recognize the possibility that concussion may have occurred, and take precautions appropriate for the high stakes involved. The CDC has a program called Heads Up, designed to help coaches, school officials, and parents make better decisions regarding TBI.

The sports enterprise is full of metaphors and inspiring object lessons to inform everyday life. These references usually have to do with giving complete and total effort to winning (Take one for the team!"), to sacrificing for the sake of a team effort ("There is no I in team!"), to long, lonely practicing of skills("Practice with a purpose, play with a passion!"). These are all values that serve life well. However, concussion is not a time for players to give themselves for the team, to leave it all on the field. The educational task is to help all - players, coaches, parents, spectators - to recognize and respect the serious consequences of TBI.