What Shapes Health? Find Out!

I've always had the perspective that my successes and wellbeing were influenced by factors far beyond my individual control. My family, friends, and influential members of my community provided me with opportunities and a perspective on life that helped me to 1) not be afraid to tackle challenges and 2) believe that I could be "whatever I wanted to be" if I worked hard enough.

So what does shape our health?

Is it genetics? 
Access to health care?
What you eat? 
Your environment?
The beliefs and culture you grew up in? 

I bet its a mix of all of these, with a special emphasis on those things in our social, political and economic context that are easy to ignore or may seem too difficult to measure or evaluate. I've talked about the importance of recognizing the social determinants of health in my April 2009 post 90210: Does ZIP Code Affect Health?

A Robert Wood Johnson Foundation webinar explores this question and many more this coming Thursday. Dr. David Williams, Professor at Harvard School of Public Health will moderate the discussion.

Register below and attend!

Thursday, March 24, 2:00-3:30 p.m. (EST)
What Shapes Health?
A panel discussion on how our environments and experiences, including those that shape development in childhood, also shape our opportunities to live healthy lives. Moderated by David Williams, Ph.D., former staff director of the Robert Wood Johnson Foundation’s Commission to Build a Healthier America.

• Register for What Shapes Health.

Lead Poisoning - A true global health problem

Around the world children are dying from lead poisoning and many more suffering from the neurological and physical health problems associated with lead exposure. In one region of Nigeria, lead poisoning has caused an estimated 163 deaths, mostly among children.

CNN ran a lead story on the tragic developments this week, even though it seems that the problem was first recognized back in January. Lead is a toxin that can cause serious neurological problems and even death in young children, as well as adults. The most commonly cited consequences of lead poisoning in the US are learning disabilities and behavior problems.

I am mostly familiar with the problem of lead poisoning affecting children and families through inadequate housing that contains lead-based paint. However, in the Zamfara State of Nigeria, the region where these recent lead-related deaths are concentrated, the source of lead exposure appears to be the minerals brought home by workers from the mines.

World Health Day 2010

Today, April 7, 2010 marks World Health Day.

I've been thinking a lot about my own health habits. It's easy to get complacent when it comes to our health. We expect that our bodies will just keep on functioning like they always have. Usually reality hits us when it's too late.

Top 3 Public Health News of 2009

This year public health undeniably became a part of our national consciousness. In order to ring in the New Year and reflect on the past year at Veritas Health, I've highlighted below what I believe to be the top three issues in public health of 2009. For those interested, the headlines link to my previous posts on the topic.

Debunking American Nutrition Myths

Darya Pino of Summer Tomato (an amazing blog with lots of health and nutrition information) promoted this video. It's amazing -- Dr. Lustig of UC San Francisco debunks popular nutrition myths, particularly related to sugar consumption by tying together the science of public health, nutrition, and biochemistry.



Hope you enjoy!

Sugar-Sweetened Beverages the Next Tobacco?

Image from the NY City Department of Health Anti-Obesity Campaign

In class this week, we discussed strategies for reducing the consumption of sugar-sweetened beverages at home. Sugar-sweetened beverages are exactly what they sound like: any drink sweetened with sugar (sodas, fruit juices, "vitamin" or flavored waters, sports drinks, energy drinks....etc.).

The larger question at hand was: Can we utilize the same strategies that brought down the tobacco industry for reducing the consumption and availability of sugary drinks?

The idea of a "soda tax" has come under scrutiny by conservatives who don't like the idea of taxing anything, as well as groups that are strongly supported (i.e. funded) by the food and beverage industry, like the Center for Consumer "Freedom." And, yes, the quotes are my doing...

However, many in public health believe that taxation will curb consumption of sugar-sweetened beverages, particularly among those who consume the most and are most likely to suffer poor health and overweight because of it. Nonetheless, soda is just the tip of the iceberg when it comes to liquid, non-nutritive calorie consumption, especially among kids. There are many other beverages that provide just as many calories and can contribute to weight gain. What will happen when the beverage industry just switches production (and all its marketing!) to these other sugary beverages? Another tax?

Taxation of tobacco has been a primary strategy in reducing its consumption and preventing people from starting to use it. Yet, taxation of tobacco has gone extremely high! Right now the federal tax on tobacco is $1.00 per 20-cigarette pack, and states can tax tobacco even higher ($3.46). Would a soda tax ever get that high? Not likely. Harvard researchers suggest that just a $0.01 per ounce of soda would be enough to change consumption patterns of consumers; a typical 20 oz. soda would be marked with a 20 cent tax.

However, the strategy that I am most excited about is social marketing -- advertising that promotes healthy behaviors and discourages unhealthy ones. If you haven't seen the sugar-sweetened beverage ads out of New York City, check out my other post on this topic. Marketing can't just tell you that something is bad, it must suggest alternatives.

If you are looking for alternatives to sugary drinks here are a couple promoted on the Harvard Nutrition Source website:

• Plain (or Infused) Water -- I think this means throwing some lemons or cucumbers in with the plain water to add flavor without the calories.
• Tea -- Go light on the sugar and honey, of course.
• Coffee -- Choose milk over cream, go sugar-free.
• Sparkling water -- add a splash of 100% fruit juice for flavor, without packing in the calories.

The website even has a recipe for a healthy "fresh fruit cooler," which is a great alternative to store-bought smoothies. Notice, drinks that are "sugar-free" because they utilize artificial sweeteners are NOT included in this list.

Right now there is a national movement to get junk foods and soft drinks out of schools. While I believe this needs to happen soon, most kids get unhealthy foods outside of schools. A 2006 study by Harvard researchers found that 60-80% of sugar-sweetened beverages were consumed by kids at home.

This suggests that we need a national movement, not just to change school environments to provide healthier beverages, like water and low-fat milk, but also change social norms around providing sugary drinks to kids in homes.

What would sway parents to pass up purchases in the beverage aisle and stick to **free** tap water and nutrient-rich milk for kids?

That's a tough question. The strategy needs to incorporate environmental change, excellent social marketing of the health dangers of daily consumption of sugary drinks, and grassroots/community efforts. If we can get sugar-sweetened beverages out of schools (where they have no right to be!), perhaps we can raise awareness about the issues so that we can get them out of homes, too!

Could the tobacco model work? Perhaps. It may be important to look to other public health campaigns; however, to get the most insight into what public health strategies will be most effective. How about alcohol control campaigns?

Healthiest Nation In One Generation - Video

Racial Disparities in Boston Swine Flu

Health status differs by race and ethnicity. This is not news to people working in the health arena, in fact an entire department of the Boston Public Health Commission is focused on reducing racial health disparities. Often such inequities in health are assumed to be a result of genetic differences or differences in income or socioeconomic position. However, social and environmental factors are also an important consideration.



The latest racial health disparity to reach the front page of the Boston Globe is the increased prevalence of swine (H1N1) flu cases among African Americans and Hispanics in Boston. Stephen Smith of the BG reported that H1N1 cases are clustered in neighborhoods with a high proportion of residents of these racial and ethnic backgrounds.


Dorchester, Roxbury, and East Boston were particularly hit hard this Spring and Fall by the swine flu. Why might this be the case? The two theories presented in the BG report include:

1. Crowded living conditions -- densely populated areas may precipitate the conditions needed for person-to-person transmission of the virus.
2. The composition of the local public schools -- the over-affected neighborhoods have a large Hispanic and immigrant school-aged population may have facilitated the spread of the virus in these communities.

These two theories represent the major challenge of social epidemiology. Are health differences a result of the people? or the place?

If the increased prevalence of H1N1 among African Americans and Hispanics is due to the people, then changes to living conditions would have no effect on the residents' health. If the increased prevalence is due to living conditions, then why try to change individuals' knowledge or behaviors? Activities targeting people would have no impact.

Likely the reason for increased risk of swine flu among these racial/ethnic groups is a combination of the two. Hispanics may be more likely to have recently traveled to or been in contact with someone who was in a high-prevalence area (such as Mexico City) or those most affected may have less knowledge of flu prevention activities. On the other hand, housing conditions and other neighborhood characteristics (lack of health care/vaccine access, less penetration of media messaging on how to prevent flu, etc) may have resulted in the heightened risk.

These hypotheses are even more complicated since residents in the over-affected Boston neighborhoods are also at higher risk for a variety of health issues that could compromise their immune systems, increasing their susceptibility to more severe cases of the H1N1 virus. Are those other health issues due to the people? Or the place?

The answer to that question has important implications for the type of prevention programs and actions that will be taken in the coming months to prepare for flu season. Would you try to change individuals' behaviors and raise awareness? Or would you tackle the social and built environment?

Resource constraints make it difficult, if not impossible, to attack every issue from all sides - which would you prioritize and why?

90210: Does ZIP code Affect Health?

Perhaps it is obvious to non-physicians that medical care accounts for a small proportion of peoples' overall health. Education and income are two of the strongest predictors of good health. As James Marks writes in a blog for the Huffington Post:

"College graduates can expect to live five years longer than those who do not complete high school...and people who are poor are 3x more likely to suffer physical limitations from a chronic illness."

These findings extend to other diseases such as diabetes, heart disease, and cancer.

So why is there still such emphasis on personal responsibility for poor health? Where we work, our social networks, and the communities we live in have more to do with our health (physical and mental) than the two hours a year that we spend in the doctor's office.

I applaud Marks for being bold and stating the obvious (for those of us social determinants folks out there...)

"As we consider health reform in 2009 let's think about the neighborhoods and towns in which we all live and ask ourselves: What are the barriers standing in the way to better health?"

We've learned our lesson from crash-diets and "good intention" gimmicks. It is not enough to try and be healthy (...I tried really hard to not eat that other half of the chocolate chip cookie this afternoon). We need to create environments where healthy living is normative, where it is expensive and cumbersome to buy unhealthy snacks and to sit on the couch or in a chair all day long. These changes involve community changes. It involves caring for the collective rather than blaming the individual. 

For example, it took compromise to create smoke-free public spaces that now exist all around the country. Now, we should slowly, but surely, look to create healthy environments in other ways. Those who oppose these efforts often don't realize that healthy environments create opportunities, they don't diminish them. The green movement hasn't stifled industry, it has given it a chance to innovate and progress into a new era. 

Let's take a cue from history and move forward with health reform. Rather than relying on medical-model and health-care driven solutions, let us first consider community and environment. Then we may find ourselves on the path to population-based health and wellness.

What Wealth [Inequality] Means for Health

President Obama's recent budget proposal has been declared unanimously "ambitious." The health component of Obama's plan includes $634 billion dollars in spending over 10 years as a "down payment on health care reform." According to an article in the San Francisco Gate, approximately half of this amount would be generated by limiting charitable and mortgage interest deductions on taxpayers above the 28% income tax bracket and more would come from reducing Medicare payments to private insurers.

Given that I have little expertise in economic growth and government fiscal planning, I cannot comment to any great extent on the details of the budget plan nor its impact of the growing deficit and national debt, etc. However, I am excited to reflect on what it could mean for public health. 

An October 2008 report ranked the US just behind Mexico and Turkey for having highest income inequality of all OECD (Organization of Economic Cooperation and Development) countries.  In fact, many studies have found that countries with more equal distribution of wealth have -- at ALL levels of income -- better health outcomes. That means that not only does living in a more equal society confer health advantages to the poor and disadvantaged, but it also benefits the health of the wealthy. Notably, the health of the poor is improved to a much greater degree than the health of the wealthy (think of what $5000 could mean for someone making $20,000/year compared to someone making $200,000) through such redistribution. 

So how might this work?

1. Increased income may improve a person's ability to access needed resources (e.g. health insurance, transportation to health care, living in a toxin-free environment, buy healthier foods)
2. Increased income may improve a person's mental health and reduce stress (resulting in lower rates of chronic disease, such as hypertension and cardiovascular disease)
3. Redistribution of income may promote programs and services for the poor

In areas of great income inequality, housing segregation, stereotypes, and blame hamper the rich from investing greater resources towards disadvantaged populations. For example, why support a new 'free clinic' when you can build a state-of-the-art hospital with the latest health technologies? All too often highways, rivers, and walls separate the haves from the have nots -- and do not allow us to come together and learn from each other. 

How this might affect the middle class is something that I haven't been able to fully flesh out. I think that it is likely that they would benefit from these measures; though proposals that hurt entrepreneurial activities and small businesses could certainly serve as a disincentive for some who are trying to bridge that gap between the middle and upper class. Furthermore, it may need to be reassessed whether those making $250k should be labeled as "wealthy" to the same extent as those making much more. As an interesting Fox News (yes, Fox) article pointed out "HENRYs [high earners, not rich yet] carry significant mortgages, pay heavy property taxes, make charitable donations and sock money away for their children's college education." The slight increase in income tax coupled with the lack of deductions for mortgage payments and charitable giving may decrease the spending of people earning this much -- further deteriorating the economic situation. I just don't know.

My final assessment: this economic plan could be one of the single-most important factors that improve population health in the United States in the 21st century. While individuals may not see an overwhelming effect on their health, society as a whole could benefit greatly.

What the Stimulus Means for Public Health

President Obama passed the Stimulus Bill (a.k.a. the American Recovery and Reinvestment Act) on Monday. Immediately, I got an email from APHA announcing how pleased they were "with the $1 billion investment in disease prevention and wellness activities...[and]with the inclusion of $2 billion to improve community health centers and expand services and $500 million for the training of primary care providers." Additionally, I received an email sent from the Director of Nutrition Policy at the Center for Science in the Public Interest who praised the inclusion of funding for community-based prevention and wellness programs, equipment for the National School Lunch Program to help schools prepare healthier meals, and increased support for WIC recipients. 

You make ask, "why is public health part of this stimulus plan?" or even argue that it has no place in it. I disagree.  Maintaining the health of our nation during this economic crisis must be a priority. Healthy workers are productive workers, just as healthy mothers have healthy babies. Healthy babies grow into healthy adults.

Just as the education system will suffer greatly as a result of budget cuts and spending freezes, so will those serving in public health see their budgets shrink and their resources dwindle. Thankfully, the education system will receive $100 billion in investment through the Stimulus Bill (see Nicholas Kristof's Sunday column for his take on this). The $3 billion for public health pales in comparison to that amount. Nonetheless, I think that the public health priorities included in this bill will speak volumes for the types of activities that the administration will pursue in the coming months and years.

It is worth noting that what is good for education is also good for public health. Higher educational attainment is associated with lower risk of disease and death for most health problems. Reducing disparities in education may serve to improve the public's health more than any technological innovation in medicine (e.g., electronic medical records) could hope to. I hope we do not lose focus of the fundamental causes of poor health, to do so would be a tragic misstep.

Happiness & Health

What makes you happy? 

What betters your quality of life?

What leads to a long life?

These three questions can be answered by one simple word. Not a gene nor a new-and-improved medical intervention can guarantee happiness or a long life. It is not how much money you earn (or save) or even where you live. Increasingly, evidence is showing that relationships make a difference in how happy and healthy people are.

Two people who I have the utmost respect for recently asked these questions and both came to the same conclusion; that our social relationships (i.e., how we connect with others) matters for our emotional, psychological, and physical well-being. Our social ties -- friends, family members, coworkers -- have an incredible influence on our happiness and health. A few weeks ago in class, Ichiro Kawachi provided numerous examples of emotional and material support provided by friends and family during times of difficulty and how this can improve health outcomes and positive health behaviors. 

Then this past weekend I was listening to a podcast by John Ortberg who was talking about what makes human life flourish (i.e., people be joyful). He said we experience genuine caring it is like "the roots of your soul are getting fed, and that's coming up into your being and making you strong. Every life has to have that connectedness." He gave many examples of how our relationships, specifically, taking risks and being vulnerable in relationship is critical to fostering joy in our life. And if life is full of joy, despair and anxiety are less likely to take their toll on health. 

If you are more interested in the idea of social relationships, happiness, and health check out these resources:

• Social Capital and Health by Ichiro Kawachi, SV Subramanian, and Daniel Kim
• EveryLife Needs a Cheering Section sermon by John Orberg, MPPC
• Bowling Alone: The collapse and revival of American community by Robert Putnam