Category Archives: politics

facts & data points, healthy habits, nutrition, policy, politics

Flexitarians – 9% meat consumption reduction 1990-2009

  • meat consumption in the developed world is reducing
  • FAOSTAT indicates that in Western Europe, Europeans ate 87kg of meat per capita in 2009 vs 95.5kg in 1990
  • This is meat reduction, not increased vegetarianism
  • Vegetarianism is reported at 9-10% in Italy and Germany
  • Three quarters of Dutch consumers say they have at least one meat free day per week; 40% say they eat no meat at least three days per week
  • Flexitarianism is not cool – low identification factor
  • contributing factors include: rising meat prices; poor economic conditions; environmental concerns; animal welfare; health concerns
  • Some interesting trends in developing countries with rising incomes

“Given the enormous environmental impact of animal-protein consumption and the apparent sympathy of consumers for meat reduction, it is surprising that politicians and policy makers demonstrate little, if any, interest in strategies to reduce meat consumption and to encourage more sustainable eating practices.”

 “It is expected that increases in meat consumption will taper as incomes rise, a pattern that is already evident for China, as shown by the almost straight line of rising meat consumption against logarithmic increases in income. For Brazil, however, it seems that the tapering is less pronounced,”

http://www.foodnavigator.com/Financial-Industry/Plant-based-diets-The-rise-and-rise-of-flexitarian-eating

Plant-based diets: The rise and rise of flexitarian eating

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By Caroline Scott-Thomas+

22-Jan-2014

Related tags: Flexitarian, Meat consumption, Vegetarian, Plant-based diets, Meat

Related topics: Sustainable sourcing, Financial & Industry, Fruit, vegetable, nut ingredients,Health and nutritional ingredients, Meat, fish and savoury ingredients, Proteins, non-dairy

Meat reduction – or ‘flexitarian’ eating – is on the rise. In this special edition article, FoodNavigator asks why are consumers reducing meat, and how prevalent is the trend?

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Food Vision

In large parts of the developing world, meat consumption is increasing, but in some developed nations – including in parts of Europe – it is declining. According to FAOSTAT figures, Western Europeans ate about 87 kg of meat per capita in 2009 compared to 95.5 kg in 1990 – a drop of 9% in less than 20 years.

This reflects a trend of meat reduction, rather than of rising vegetarianism, although the proportion of Europeans who identify as vegetarian has increased too, with rates varying from about 1-2% in some countries, to about 9-10% in Italy and Germany.

Meanwhile, a new dietary pattern has cropped up. Dubbed flexitarianism, it refers to meat reduction rather than fully fledged vegetarianism.

Growing trend – but it’s not cool

Germany and the Netherlands lead the way in this ‘flexitarian’ way of eating. Research from Wageningen UR last year revealed that more than three-quarters of Dutch consumers say they have at least one meat-free day per week – and 40% eat no meat at least three days a week.

“Reducing meat consumption is a growing trend, but the majority of people keep to their current pattern of meat consumption,” say the researchers, led by Hans Dagevos from the university’s Agricultural Economics Research Institute, adding that only 13% of consumers described themselves as flexitarians.

“Reducing meat consumption is not seen as ‘cool’. There is a low identification factor.”

But even if there is little acceptance of the term ‘flexitarian’, what is behind this shift in eating patterns?

Meat-free movements

There are several key reasons: In the past few years, rising meat prices have coincided with a struggling economy, meaning that many western consumers have cut consumption on the back of shrinking incomes; shoppers are becoming more aware of the environmental impacts of eating meat; animal welfare issues have also gained attention; and consumers have started to question how healthy it is to eat large quantities of meat.

Meat reduction has also been boosted by regional meat-free movements, generally coordinated by NGOs, including vegetarian, animal protection and environmental organisations.

In another recent paper on sustainability issues and meat reduction , Dagevos wrote: “Given the enormous environmental impact of animal-protein consumption and the apparent sympathy of consumers for meat reduction, it is surprising that politicians and policy makers demonstrate little, if any, interest in strategies to reduce meat consumption and to encourage more sustainable eating practices.”

According to his analysis, flexitarians tend to value non-meat protein sources more highly than their heavy-meat eating counterparts. These include cheese, eggs, nuts, mushrooms and pulses, alongside meat sources such as chicken and fish.

Rising meat consumption elsewhere

Meanwhile, meat consumption continues to rise in developing countries – but could those in developing countries be convinced to adopt a similar way of ‘flexitarian’ eating, even as rising incomes allow them to choose more meat products for the first time?

A recent paper from the Overseas Development Institute (ODI ) pointed out that meat consumption does not rise endlessly in tandem with income, and this pattern is expected even in emerging markets – although it depends on the nation’s food culture.

“It is expected that increases in meat consumption will taper as incomes rise, a pattern that is already evident for China, as shown by the almost straight line of rising meat consumption against logarithmic increases in income. For Brazil, however, it seems that the tapering is less pronounced,” it said.

facts & data points, healthy habits, policy, politics

National Obesity Forum exaggerates crisis

Meh, but shows its important to be above reproach in public discussions…

http://www.foodnavigator.com/Legislation/We-exaggerated-obesity-crisis-pressure-group/

‘We exaggerated obesity crisis’: pressure group

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By Mike Stones+

20-Jan-2014

The National Obesity Forum has admitted exaggerating Britain's obesity crisis

The National Obesity Forum has admitted exaggerating Britain’s obesity crisis

Related tags: Anecdotal evidence, State of the Nation’s Waistline report, 2007 Foresight Report, More or Less radio programme, Obesity, National Obesity Forum, Scientific research

Related topics: Legislation

Influential lobby group the National Obesity Forum (NOF) has admitted exaggerating the severity of the UK’s national obesity crisis and relying on anecdotal evidence, rather than scientific research, in its State of the Nation’s Waistline report published last week.

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The document – which received widespread media coverage – claimed predictions made in the 2007 Foresight Report that half of Britons could be obese by 2050 had under-estimated the crisis. In reality, the problem was growing worse, it claimed.

But NOF spokesman Tam Fry told BBC Radio 4’s statistics programme More or Less, that the group had exaggerated its warnings about the scale of the obesity crisis in order to reach a wider public.

“What we were trying to do is force home[its obesity warning] …”, he said. “A little exaggeration forces the message home – that’s what we wanted to do.”

‘A little exaggeration’

Fry also acknowledged the NOF should have made clear its report was based on anecdotal rather than scientific research. “I think maybe we were a little wrong not to be more forceful about why we were drawing these conclusions,” he told the programme.

“We think it [the obesity problem] has got worse, because although we have no statistics and figures, we have a lot of observations,”said Fry. “The word coming through from clinics all over the country is the greater volume of people coming in for obesity – but, more importantly, coming in for the conditions that it engenders.” That included diabetes, cardio-vascular problems and strokes.

Since the Foresight report was completed, there had been little improvement in government action to remedy the problem of obesity, leading the NOF to conclude that the problem is growing still, said Fry.

‘Not as bad as we thought’

The programme highlighted research conducted after the 2007 study that suggested Britain’s obesity crisis was not becoming worse. Ben Carter, the programme’s obesity expert, said:“Most of the data published since 2007 has shown that things are not as bad as we thought – or at least not deteriorating at the rate we thought we would.”

US research was also quoted suggesting while the obesity problem was a serious problem, it was not becoming ever worse.

But Fry claimed there were various problems with the data. Chief among those was its reliance on body mass index, which generally under reports overweight and obesity. “There is a lot of literature that states that for a fact,” he said.

Speaking after the programme Fry told FoodManufacture.co.uk the Department of Health “had all the time in the world to say that the report was rubbish but they didn’t”.

Fry added: “Obesity is such a problem that that doctors now say 2M need gastric bands to curb their food intake. Also, gout, which used to be the preserve of kings, is now a lot more common .”

Listen to More or Less here .

healthy habits, musings, nutrition, policy, politics

Katz: The power of the possible in public health

 

The case for the power of the possible in public health is clear, compelling and data-driven. Were we to commit to the policies required to eradicate tobacco use, establish moderate daily physical activity as the prevailing cultural norm and turn healthful eating into the new “typical” American diet, we could eliminate 80 percent of all chronic disease.

http://www.huffingtonpost.com/david-katz-md/healthy-life_b_1176506.html

David Katz, M.D.

Director, Yale Prevention Research Center

 

What If? A New Year’s Public Health Reverie

Posted: 12/31/11 11:50 AM ET
 

Democracy, it has been said, is the worst form of government except for every other form. As the long season of our political discontent drags on, the liabilities of consensus-based governance are on prominent display, salient among them a perennial lack of consensus. The situation seems unlikely to improve as a new year dawns, for it is, after all, an election year.

All of which serves to deepen the longing I suspect we each have cause to feel for a world where what we believe should be done, reliably gets done. Since Plato’s “Republic,” we have acknowledged that the challenges involved in conceiving what would make the world better are the lesser impediment to enhancing our destinies. Navigating such ideas, ideals and aspirations through the gauntlet of democratic dissent and past the intransigence of the status quo is the greater. The execution step is where good ideas all too often go to die.

The unnecessary death of good ideas — and of people — is much on my mind as the new year looms, with its promise of fresh starts. For far too long already, a failure to turn what we know into what we do has cost us dearly.

The case for the power of the possible in public health is clear, compelling and data-driven. Were we to commit to the policies required to eradicate tobacco use, establish moderate daily physical activity as the prevailing cultural norm and turn healthful eating into the new “typical” American diet, we could eliminate 80 percent of all chronic disease.

Do take a moment to let that sink in. Statistics have the capacity to be stunning and dull at the same time. We tend to need faces and names to get our passions going.

So consider this. If someone you love has ever had heart disease, cancer, a stroke or diabetes — there are eight chances in 10 that better use of feet, forks and fingers would have prevented that adverse fate outright. Viewed from altitude, eight out of 10 of us who have suffered through the anguish of a serious chronic disease with someone we love — wouldn’t have had to if what we knew about disease prevention were translated into what we routinely do about it.

Health promotion is what I do, so such musings are vocational on my part. But I, too, have loved ones laid low by chronic diseases that need not have occurred. So this is up close, and intensely personal.

As the new year dawns, then, my thoughts are irresistibly drawn to what might be. What if knowledge were power? What if what we know became what we do? Preoccupied by such reflections, I indulge myself in a reverie. Here’s what I would do if I were the philosopher-king of public health in 2012.

I would declare that a flood of factors — from highly-processed food, to labor-saving technologies, to clever marketing of insalubrious products — conspires against our health. I would proclaim that every person, family and community deserves to be protected by a levee of empowering, health-promoting tools and programs. I would call on personal responsibility for making good use of such resources — but I would acknowledge that before people can take responsibility, they must be empowered. As public health philosopher-king, such empowerment would be my job.

I would eradicate tobacco use. This pernicious scourge has taken years from life and life from years for far too long already. Those currently addicted to tobacco would need authorization from a physician to get it, and would at the same time receive every assistance modern science can offer to help them quit. But the substance, and any marketing of it, would be banned for all others. No young person should ever again be seduced into this calamitous boondoggle.

I would make everyone a nutrition expert by putting an objective, evidence-based, at-a-glance measure of overall nutritional quality on display everywhere people and food come together, and thus close every loophole to marketing distortions. Then, I would attach to this metric a system of financial incentives so that the more nutritious the food, the less it costs. The incentives would not constitute a new cost, but rather an opportunity for savings. They would be paid by the entities that currently pay the costs of disease care — insurance companies, large employers and the federal government. The costs of subsidizing cabbage are trivial compared to the cost of CABG, so says the king (not to mention the world’s leading health economists). Incentivizing healthful choices could save us a lot of money. Everyone can win.

I would make physical activity a readily accessible and routine part of everyone’s day. This can be done in schools with programming that embraces the time-honored adage: sound mind, sound body. This can be done in a way that honors personal preference for different kinds of exercise. In my kingdom, every school would have such programming.

So would every worksite. And every church. And little by little, we would do the requisite hard work on the built environment throughout the kingdom so that every neighborhood and town was designed to take physical activity off the road less traveled, and put it on a path of lesser resistance. This would cost money in the short term, but save both money and lives over time. Until this job was done universally, we would not just wait on the world to change — but would provide those in acute need access to the oases of comprehensivehealth promotion that already exist.

Every school would teach children and their parents the skills required to identify and choose more nutritious food. Every cafeteria would be designed to encourage, without forcing, better choices. School food standards would be unimpeachable — and a slice of pizza would not qualify as a serving of vegetables.

Businesses would adopt schools (as they now adopt highways) to provide the resources required for state-of-the-art health promotion programming, and so that parents and children could get to health together. We are otherwise unlikely to do so at all.

Guidance to nutritious restaurant meals wherever they are available would be at the fingertips of all, in the service of loving food that loves us back. In my kingdom, we would not mortgage our health for the sake of dining pleasure — nor vice versa!

Robust economic modeling would be conducted to guide biomedical research so that it translated most efficiently into measurable and meaningful improvements in the human condition. In my kingdom, such data would drown out diatribe, epidemiology would trump ideology, and we would prioritize the practices subtended by the best data, not propagated by the loudest shouting or dictated by the deepest pocket.

In my kingdom, every clinician would be trained to be expert in lifestyle counseling, and serve as an effective agent of health-promoting behavior change.

We would construct a comprehensive sandbag exchange so that every one of us, no matter what we do or where we do it, could contribute to the levee. In my kingdom, no one would be part of the problem because everyone would be part of the solution. And as sandbagsaccumulate, we would gather evidence to know just how much needs to be done to turn the toxic tide of chronic disease. We would devise the tools needed to disseminate effective strategies, while honoring the need for local control and customization.

We would take patient-centered care to the next level by establishing a mechanism for participant-centered research, giving the true “beneficiaries” of biomedical research a chance to call the shots. We would shift subsidies and marketing from foods with the longest shelf lives, to foods that extend the shelf lives of the people eating them! We would pursue our health in conjunction with efforts to preserve the health of the planet. We would do what it takes to find ourselves eating food, not too much, mostly plants.

In my kingdom, we would do this, and more, until the 80 percent of all chronic disease we know we can eliminate were actually eliminated. Until forces that conspire against years of life, and life in years, were banished. Until eight times in 10, the phone did not ring with bad news; the ambulance did not need to be called; the anguished visit to the ICU or CCU did not need to happen. And then, we would figure out what we could do about the remaining two!

The best way to predict the future is to create it. We cannot create what we don’t first conceive. From Plato to Dr. Seuss, we have been invited to consider what the world could be like if the right people ran the zoo.

And yet we are right, of course, to renounce the tyranny of Plato’s philosopher-king — for tyranny it would be. Along with the absolute power required to implement good ideas at will comes the power to do the same with bad ideas — and it can, at times, be awfully hard to tell them apart. And then there’s the fact that absolute power corrupts absolutely. The benevolence of despotism is not to be trusted. Which leaves us thankful for our democracy — dysfunctional though it may be at times.

Still, it is vexing to stand at the gulf yawning between what we know and what we do. It is painful to concede that knowledge is not power. It is tantalizing to imagine a world where that translational divide is bridged.

And so I do. I ponder the power of the possible as the New Year dawns — and invite you to join me. We don’t need a philosopher-king to change the world, just a small (or preferably large!) group of thoughtful and committed citizens. That could be us. This could be the year. What if?

-fin

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz

healthy habits, nutrition, policy, politics

Fixing obesity :: Hard, yes. Complicated, no.

We are drowning in copious quantities of poor-quality (even willfully addictive) calories, and labor-saving technologies all too often invented in the absence of need. We have run out of time to see that this is like the other kind of drowning, a clear-cut case of calamitous cause-and-effect, albeit in slower motion, playing out over an extended timeline.

We could fix obesity. It’s hard, because profit and cultural inertia oppose change. But it’s not complicated. (And maybe it isn’t even as hard as we tend to think.)

As we look out at an expanse of bodies sinking beneath the waves of aggressively-marketed junk and pervasive inactivity, wring our hands and contemplate forming more committees — I can’t help but think we’ve gone right off the deep end.

 

http://www.huffingtonpost.com/david-katz-md/obesity-epidemic_b_3292179.html

David Katz, M.D.

Director, Yale Prevention Research Center

Fixing Obesity
Posted: 05/17/2013 12:05 pm
 

Earlier this week I spoke at a symposium on nutrition and public health at the Tuck School of Business at my alma mater in beautiful Hanover, N.H., Dartmouth College. Among others on the panel with me was Richard Starmann, the former head of Corporate Communications for McDonald’s. Those with even a modest number of Katz-column frequent flyer miles can readily guess how often he and I agreed.

One point Mr. Starmann made, more than once, was that rampant obesity and related chronic disease was enormously, intractably complicated and would require diverse efforts, a great deal of private sector innovation, minimal government intercession, lots of time, lots of money, and many conferences, committees and panels such as the one we were on to fix. I had trouble deciding where to start disagreeing with this one.

For one thing, if you have ever served on a committee, you likely know as well as I that the surest way to never fix something is to convene a whole lot of committees and panels to explore every possible way of disagreeing. Just look at our Congress.

But more importantly: Obesity is not complicated. And neither is fixing it. Hard, yes; complicated, no!

Before I make that case — emphatically — a brief pause to note the essentials of informed compassion. Yes, it is absolutely true that some people eat well and exercise, and are heavy anyway. Yes, it is absolutely true that two people can eat and exercise the same, and one gets fat and the other stays thin due to variations in genetics and metabolism. Yes, it is absolutely true that some people gain weight very easily, and find it shockingly hard to lose. Yes, it is absolutely true that the quality of calories matters, along with the quantity. Yes, it is absolutely true that factors other than calories in/calories out may influence weight and certainly health, including such candidates as the microflora of our intestinal tracts, exposure to hormones, GMOs, and more.

But on the other hand, once we contend effectively with the fact that we eat way too many calories, that “junk” is perceived as a legitimate food group, and that we spend egregiously too much time on our backsides rather than our feet — we might reasonably address only the remaining fraction of the obesity epidemic with other considerations. I am quite confident that residual fraction would be very small.

Which leads back to: We can fix obesity, and it isn’t complicated.

As a culture, we are drowning in calories of mostly very dubious quality, and drowning in an excess of labor-saving technology. I have compared obesity to drowning before, but want to dive more deeply today into the implications for fixing what ails us.

Let’s imagine, first, if we treated drowning the way we treat obesity. Imagine if we had company executives on panels telling us why we can’t really do anything about it today, because it is so enormously complicated. Imagine if we felt we needed panels and committees to do anything about epidemic drowning. Such arguments could be made, of course.

For, you see, drowning is complicated. There is individual variability — some people can hold their breath longer than others. Not all water is the same — there are variations in density, salinity, and temperature. There are factors other than the water — such as why you fell in in the first place, use or neglect of personal flotation devices, and social context. There are factors in the water other than water, from rocks, to nets, to sharks.

The argument could be made that anything like a lifeguard is an abuse of authority and an imposition on personal autonomy, because the prevention of drowning should derive from personal and parental responsibility.

The argument could be made that fences around pools hint at the heavy hand of tyranny, barring our free ambulation and trampling our civil liberties.

We would, if drowning were treated like obesity, call for more personal responsibility, but make no societal effort to impart the power required to take responsibility. In other words, we wouldn’t actually teach anyone how to swim (just as we make almost no systematic effort to teach people to “swim” in a sea of calories and technology).

Were we to treat drowning more like obesity, we would have whole industries devoted to talking people into the choices most likely to harm them — and profiting from those choices. One imagines a sign, courtesy of some highly-paid Madison Avenue consultants: “Awesome rip current: Swim here, and we’ll throw in a free beach towel! (If you ever make it out of the water…)”

If we treated swimming and eating more alike, we would very willfully goad even the youngest children into acts of peril. An announcer near that unfenced pool would call out: “Jump right in, there’s a toy at the bottom of the deep end! And don’t worry, the pool water is fortified with chlorine — part of a healthy lifestyle!”

I could go on, but you get the idea. But you also, I trust, have reservations. As you recognize that treating drowning like obesity would be ludicrous, you must be reflecting on why drowning isn’t like obesity. I’ve done plenty of just such reflecting myself, and here’s my conclusion: time.

The distinction between drowning in water, and how we contend with it, and drowning in calories and sedentariness, is the cause-and-effect timeline. In the case of water, drowning happens more or less immediately, and there is no opportunity to dispute the trajectory from cause to effect. In the case of obesity, there is no immediacy; the drowning takes place over months to years to decades. It’s a bit blurry.

Really, that’s it. If you disagree, tell me the flaw — I promise to listen.

We have the time perception of our ancestors, contending with the immediate threats of predation and violence on the savannas of our origins. We are poorly equipped to perceive calamitous cause-and-effect when it plays out in slow motion. One imagines viewing ourselves through the medium of time-lapse photography, and suddenly seeing the obvious: We topple into the briny, obesigenic depths of modern culture, and emerge obese. Cause and effect on vivid display, no committees required.

Consider how differently we would feel about junk food if it caused obesity or diabetes immediately, rather than slowly. Imagine if you drank a soda, and your waist circumference instantly increased by two inches. It likely will — it’s just a matter of time.

We generally deal effectively with cause-and-effect catastrophes that have the “advantage” of immediacy. One obvious exception comes to mind: gun violence. If the “pool lobby” were to address drowning the way the gun lobby addresses gun violence, the solution would somehow be more pools, fewer fences, and no lifeguards. But that will have to be a rant for another day, so let’s not go down that rabbit hole.

Instead, let’s flip the comparison for a moment. What if saw beyond our Paleolithic perceptions of temporality, recognized the cause-and-effect of epidemic obesity and chronic disease, and treated the scenario just like drowning?

We would, indeed, rely on parental vigilance and responsibility — but not invoke them as an excuse to neglect the counterparts of fences and lifeguards. We would impede, not encourage, children’s access to potentially harmful foods. We would avoid promoting the most dangerous exposures to the most vulnerable people.

We would recognize that just as swimming must be taught, so must swimming rather than drowning in the modern food supply and sea of technology. We would teach these skills systematically and at every opportunity, and do all we could to safeguard those who lack such skills until they acquire them. Swimming is not a matter of willpower; it’s a matter of skill-power. So, too, is eating well and being active in a world that all too routinely washes away opportunities for both.

Your “eye for resemblances” is likely as good as mine, so I leave a full inventory of all the anti-obesity analogues to defenses against drowning to your imagination. They are, of course, there for us: analogues to lifeguards, fences, swimming lessons, warnings against riptides, beach closures, personal responsibility and vigilance, public policies, regulations and restrictions, and a general pattern of conscientious concern by the body politic for the fate of individual bodies.

The only real distinction between drowning in water and drowning in calories related to causality is time. One hurts us immediately, the other hurts us slowly. The other important distinction is magnitude. People do, of course, drown, and it’s tragic when it happens. But obesity and chronic disease affect orders of magnitude more of us, and our children, and rob from us orders of magnitude more years of life, and life in years.

No one with a modicum of sense or a vestige of decency would stand near a pool, watch children topple in one after another, and wring their hands over the dreadfully complicated problem and the need for innumerable committees to contend with it.

We are drowning in copious quantities of poor-quality (even willfully addictive) calories, and labor-saving technologies all too often invented in the absence of need. We have run out of time to see that this is like the other kind of drowning, a clear-cut case of calamitous cause-and-effect, albeit in slower motion, playing out over an extended timeline.

We could fix obesity. It’s hard, because profit and cultural inertia oppose change. But it’s not complicated. (And maybe it isn’t even as hard as we tend to think.)

As we look out at an expanse of bodies sinking beneath the waves of aggressively-marketed junk and pervasive inactivity, wring our hands and contemplate forming more committees — I can’t help but think we’ve gone right off the deep end.

-fin

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

complex adaptive systems, healthcare, healthy habits, musings, nutrition, policy, politics, rapid learning health systems, storytelling

Katz smashes it again… it’s the culture, stupid.

“Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm.”

…but how do we operationalise culture change…. it is massive task, but it needs to happen. Purpose perhaps?

http://www.linkedin.com/today/post/article/20140121144506-23027997-obesity-and-oblivion-or-what-i-ve-learned-under-general-anesthesia

Director, Yale University Prevention Research Center

Obesity and Oblivion- or- What I’ve Learned Under General Anesthesia

David L. Katz, MD, MPH

January 21, 2014  

I am going to tell you what I’ve learned under general anesthesia, but I ask you to bear with me kindly and wait a few paragraphs for that revelation.

I am a rambunctious guy, pretty much always have been. I have always loved active recreation and was one of those kids who had to be reeled in for dinner from outside play with a winch and a cable. As an adult, I placate the restlessness of my native animal vitality with about 90 minutes of exercise every day. In addition, I hike whenever I can, and pretty much share my dogs’ attitude about it: the more miles, the better. I studied the martial arts for years. I am a lifelong, avid alpine skier, and an ardent equestrian– privileged to share that latter brand of rambunctiousness with my beautiful horse, Troubadour, who seems to enjoy running and jumping as much as I do, and is far better at it.

This is all part of family tradition. Women in the family are generally quite active, and some have their share of perennial restlessness. But the guys are a case apart. My son’s rambunctiousness is, quite literally, famous of song, story, and program. The ABC for Fitness™ program Gabriel directly inspired is now reaching hundreds of thousands of kids around the country and world, and paying forward the benefits of daily exercise in schools. Gabe helped me appreciate the importance of asserting that the proper remedy for rambunctiousness in our kids is recess, not Ritalin.

And then there’s my father, whose restlessness is the granddaddy of all, and the stuff of legend, or at least family lore. We celebrated his 74 birthday last summer with a hilly, 56-mile bike ride.

By and large, the effects of this rambunctiousness are extremely positive. My animal vitality is spared the constraints of leash or cage, and rewards me reciprocally with energy, stamina, and productivity. But everything has a price. My particular brand of rambunctiousness has involved pushing limits, and limits have a tendency of pushing back. The result is several concussions (I am now a consistent helmet wearer), too many stitches to count, roughly 20 broken bones, and general anesthesia to restore the mangled anatomy of some joint or other not fewer than a half dozen times.

Which leads, at last, to what I’ve learned under general anesthesia: Nothing. Nada. Zip.

Nobody learns anything under general anesthesia. General anesthesia involves unconsciousness; oblivion.

And on that basis, I consider it a societal travesty that hyperendemic obesity and the metabolic mayhem that often follows in its wake are treated ever more frequently, in ever younger people, under general anesthesia. Our answer to obesity is, it seems, oblivion.

True, bariatric surgery is effective. But it is also expensive, and subject to all of the potential complications of surgery. We don’t really know how long the benefits last, particularly for the children and adolescents who are candidates in growing multitudes. We do know that lasting benefit requires ancillary lifestyle change, and that there is often some, and sometimes a lot, of weight regain despite the rewiring of the gastrointestinal tract.

And we know as well that we are relying on scalpels in the hands of others to do what forks in our own hands (and feet in our own shoes) could do better, at dramatically lower cost and risk, if our society committed to empowering their more salutary use. We have evidence to suggest that schools and aptitudes acquired there could do for weight what scalpels applied under anesthesia do. But in my experience, they could do so much more. As a medical advisor at Mindstream Academy, a boarding school producing weight loss to rival bariatric surgery, I have been far more impressed with what the kids find than what they lose, impressive though the latter may be. They find pride and proficiency; confidence and competence; skillpower and self-esteem. They learn, in other words- as nobody ever does under general anesthesia.

Our society’s tendency to “over-medicalize” has been chronicled by others. The consequences extend to expecting from our clinics what only our culture can deliver. Among the most vivid illustrations of this is the lifelong work of my friend, Dean Ornish. Dr. Ornish was involved in groundbreaking work that showed the capacity for a lifestyle overhaul to rival the effects of coronary bypass surgery. With evidence in hand that feet and forks (and a short list of other priorities attended to) could do for coronaries what scalpels could do, Dr. Ornish set out to make his lifestyle program a reimbursable alternative to surgery. He succeeded, earning Medicare reimbursement after – wait for it- 17 years! I don’t know that Dean has the patience of a saint, but he apparently does have the patience of a cicada.

It took 17 years to gain reimbursement for lifestyle as a cost-effective treatment of coronary artery disease, whereas surgery was reimbursed from the get-go. That’s how we roll, and then wring our hands about the high costs of health care.

With that in mind, I ask my fellow parents reading this column; I ask the grandparents, godparents, aunts and uncles to contemplate this: How many of our sons and daughters, nieces, nephews, and grandchildren will have passed through the O.R. doors if it takes us two decades to establish lifestyle intervention as a culturally sanctioned alternative to bariatric surgery? However many that is, I can tell you exactly what they will all learn while under general anesthesia: Nothing. Nada. Zip.

Knowledge and experience are the foundational elements of culture itself. Culture derives from the capacity of our species to learn, and pay forward our learnings to our contemporaries and our children. Among the impressive manifestations of effective school-based approaches to adolescent obesity is the capacity, and proclivity of the kids to pay their newly acquired skillpower forward. When last I visited Mindstream Academy, one of the young girls there, who had lost some 80 lbs, was most proud to tell me about her father back at home who, courtesy of her long-distance coaching, had lost about 40. There is nothing to pay forward following the oblivion of general anesthesia.

Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm. That remains unlikely so long as we put our money preferentially where our medicalizations are. The AMA has proclaimed obesity a disease, but that’s just symptomatic of our culture tendencies. It is more a disease of the body politic than of the often healthy bodies that succumb to it in a culture that propagates its causes.

The healthiest, happiest, leanest, longest-lived populations on the planet do not attribute such blessings to the proficiency of their surgeons or the frequency of their clinical encounters. They attribute them to the priorities and prevailing norms of their culture.

Nobody learns anything under general anesthesia. General anesthesia is oblivion. If we keep prioritizing the medical over the cultural, oblivion over enlightenment, my friend Dean Ornish will remain a lonely pioneer. And the cicadas, when next they emerge, will see nothing new. They will have cause to roll their protuberant eyes at us and trill out: same as it ever was.

It doesn’t have to be that way. We could choose oblivion a bit less often, and stay conscious instead. Conscious, we would have a chance to think outside the box of surgical gloves- and perhaps thereby perceive a new world of opportunity.

-fin

Dr. Katz was recently named one of the most influential people in Health and Fitness (#13) byGreatist.com. His new book, DISEASE PROOF, is available in bookstores nationwide and at:

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253
http://twitter.com/DrDavidKatz
http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

healthcare, healthy habits, policy, politics, quotes & aphorisms

2014 AMA Health Priorities

Steve Hambleton
– population health
– reduce unwarranted clinical variation

Chris Baggoley
– dementia

Lesley Russell
– value-based payment

 

The five most pressing health priorities in 2014

21/01/2014

Trying to identify just five top priorities in an area as complex and ethically fraught as health care is a tough challenge, but that was the task Australian Medicine set for seven of the nation’s leading health advocates and thinkers, including AMA President Dr Steve Hambleton, the nation’s Chief Medical Officer Professor Chris Baggoley, health policy expert Dr Lesley Russell and World Medical Association Council chair Dr Mukesh Haikerwal. Here they provide their thought-provoking and insightful responses.

AMA President Dr Steve Hambleton

1.  Make population health a cross-portfolio priority for all levels of government
Population health is not just about treating illness. It’s also about keeping people well, and all portfolios (Agriculture, Defence, Education, Employment, Environment, Finance, Foreign Affairs and Trade, Health, Immigration and Border Protection, Industry, Infrastructure and Regional Development, Social Services, Treasury etc) need to do their part to fight the threat of non-communicable diseases which stem from tobacco, alcohol, over-nutrition and under- exercise.

2. Continue the investment in closing the life expectancy gap between Aboriginal and Torres Strait Islander peoples and all Australians
All governments need to keep up the investment, but not just in the health portfolio. There is stark evidence that investing in the social determinants of health and a good education, starting at birth, are major predictors of health outcomes.

3. Fix e-health and the PCEHR
We must be able to talk to each other in the same language -general practice, hospitals (public and private), public outpatients, private specialists, aged and community care. Too often the right message just does not get through. Let’s get the (e) rail gauge right and use it.

4. Reduce unwarranted clinical variation
The fastest way to save health dollars and achieve better outcomes is to (as Professor Lord Ari Darzi advised at the 2012 AMA National Conference) “close the gap between what we know and what we do”.  We know we are doing a good job and are very cost effective. If we embrace the move of learned colleges toward clinical audit and self-reflection we can make best practice even better.

5. Invest in research
The human papillomavirus vaccine will save millions of lives. Research delivered and refined the place of statins, also saving millions of lives. We need new ways of treating infections, perhaps more antibiotics or better ways to use the ones we already have.

Professor Chris Baggoley, Australian Government Chief Medical Officer

It is not easy to nominate five priority areas for action, given that there are so many deserving areas that require our ongoing attention. Of course, in my role there are a number of areas where my direct involvement is needed to help made a difference.
Understanding that this list excludes other equally deserving priority areas, my list is:
1. Antimicrobial Resistance, where concerns we are facing a post antibiotic era are widely shared across the globe. Australia is taking a leading role: we have adopted a One Health approach, a safety and quality approach (via the National Standards), and we are increasing our surveillance of resistant microbes and antimicrobial usage.

2. Emerging Infectious Diseases. The appearance of avian influenza H7N9 in China in 2013, and the Middle East Respiratory Syndrome Coronavirus in 2012-13, has redoubled the focus of all areas of the health system to prepare to manage emerging infectious diseases, and this must remain a focus for 2014.

3. Immunisation coverage. Public interest in the benefits of high levels of childhood immunisation was a particular feature of 2013, especially following the National Health Performance Authority report breaking coverage down to Medicare Local and postcode areas. Vaccine-preventable diseases should be prevented, and our attention to this aspect of health care in all areas must remain a priority.

4. Dementia. While the first three areas are part of my daily work, this is not the case for dementia. Nonetheless, the case for research into the causes and prevention of dementia is apparent to all of us.

5. Improving the nation’s mental health. Much work is underway to improve our mental health. Improved community and professional understanding and reduction in stigma will assist sufferers of mental health illness to seek help, and assist their recovery.

Dr Lesley Russell, Visiting Fellow, Australian Primary Health Care Research Institute, Australian National University

National

1. Addressing health disparities

Prime among these is the need to Close the Gap on health disparities for Indigenous Australians, but we should not forget the disparities suffered by people with mental illness, people with disabilities, the homeless, and those who are isolated, both geographically and socially. These gaps will only be closed by a broader focus on the social determinants of health through a whole-of-government approach.

2. Changing the way we pay for healthcare services

It’s time to move away from fee-for-service to a financing system that is (1) focused on value rather than volume; (2) rewards improved health outcomes and cognitive services as much as procedures; (3) encourages effective teamwork and collaboration; and (4) recognises time dedicated to education, mentoring, research, essential paperwork and communication.

3. Reworking the healthcare workforce

If we are to address the health and healthcare needs of the 21st century in a country as large and diverse as Australia, then we need an appropriate workforce and a system that enables every healthcare profession to work to full scope of practice. That means widening who can prescribe and who can work independently. The new workforce must include more Aboriginal and Community Health Workers to assist with outreach, education, care coordination and cultural sensitivity.

International

4. Antibiotic resistance

The growing threat of multiple resistance requires a major international effort involving the agriculture, food and health sectors and an increased focus on research to deliver solutions and new antibiotics.

5. Climate change

Everyone’s way of life and even national security is under threat from climate change. Developed nations like Australia must show leadership in tackling both the causes and the impacts. In the absence of government action, communities must step in to lead the way.

Professor Stephen Leeder, Professor of Public Health and Community Medicine, University of Sydney

1. National data collection and evaluation – the collection of national hospital safety and quality data is critical to monitoring the use of drugs and controlling the rise of drug-resistant infections. Information is also needed to track progress in preventive health, such as in addressing obesity. Repeated surveys, done by the same people using the same survey instruments, are needed to judge our progress.

2. We need to tell the story of what we are achieving in health care for the tens of billions we invest in it. The community who pays deserves to hear. Health Ministers need to enunciate what the goal of providing health care is, backed by stories that illustrate what is achieved every day in caring for people. These stories are needed to keep compassion alive in our democracy.  “Look where my Medicare tax dollar goes!” would be a great thing to boast about, and would enable ordinary taxpayers to see that their tax contributes to something of immense social value.

3. Fixing IT. We are 20 years behind best practice. We can see what it looks like in the US. It requires a huge investment, but the pay-off in quality is immense.

Martin Laverty, Chief Executive Officer, Catholic Health Australia

1. Causes of ill health need to constantly inform both health policy and practice. Two-thirds of Australians are overweight, 16 per cent of Australians smoke, and 13 per cent drink at levels of risk. Implementing Senate recommendations on social determinants of health would revive efforts to prevent Australians, particularly the most disadvantaged, from suffering avoidable chronic illness.

2. Coordination of health services around a person’s unique needs must become more of a priority, to improve patient outcomes and reduce waisted expenditure. Ideally, any person with an ongoing health complaint would have a health plan worked out and appropriately managed to focus on right treatment in the right place, ongoing medication management, avoidance of duplicated service, and prevention of further disease.

3. Health workforce constraints and industrial barriers still haven’t been resolved to ensure Australia will have enough medical, nursing, and allied health staff to meet Australia’s growing and ageing population. Role redesign of who does what in the health system remains essential, but as a nation we’re no closer to being able to solve workforce constraints because of entrenched industrial perspectives.

4. Consumer choice underpins the new National Disability Insurance Scheme, and is being introduced into home care for the aged. Better choice in health and aged care also needs attention, so that competition and contestability can drive improvements in financial and clinical outcomes.

5. End of life care needs the entire community’s attention. Health professionals and health consumers need to give new consideration to talking about, determining, and then implementing future care plans. Pastoral care for those in the final stages of life, indeed for any person dealing with significant illness, needs elevation as a priority for health and aged care providers.

Dr Mukesh Haikerwal, Chair of Council, World Medical Association, former AMA President

With a new federal administration in place, a fiscal Armageddon heralded and the health settings for Australia being less favourable, the usual troupe of kite-fliers have been showing their wares in the ‘silly season’. What I think we need is to secure the fundamentals and enhance and support sensible collaborative work practices.

1. Support more care out of hospital – don’t penalise quality holistic care in general practice.

Embed the notion of general practice as the bedrock, not only of primary health care and all out of hospital care, but also for health care delivery across the nation. The costs of the same care out of hospital, when appropriate, are a fraction of the cost in hospital.

2. Enhance hospitals and support the care provided there, and stop perverse penalties.

Support the existing hospital infrastructure that is struggling with the burden of increased demand and expectation from patients and from governments, which absurdly see them penalised for trying their hardest to cope with this. There needs to be a move from blame to re-setting costs and targets based on realistic care need evaluations, allowing for inevitable variation.

3. Embolden and formalise clinical leadership in health in a meaningful way.

Use clinical Senates – groups of cognisant, focussed individuals suggesting and supporting innovation in health care delivery. Enhance their work by trialling and evaluating changing concepts before whole-of-system adjustments, so that unforeseen consequences are outed and adjusted for in real situations with real doctors treating real patients.

4. Use e-health and telehealth logically in clinically safe and acceptable forms over and above the PCEHR, especially secure messaging delivery and web-based videoconferencing.  

Use innovative technologies in health (e-health and telemedicine) for clinical purposes, with clinical needs and drivers at the forefront. We do have potential technology to support and enhance (but not replace) trusted, proven good clinical methods. This is over and above, but could include, the PCEHR. Secure email to connect information is the key element.

5. Innovate with translational research in real clinical situations, proving concepts before rolling them out.

In care settings, sequential work across disciplines and health care establishments, with clinical participants nutting out how to best to innovate. Use just one set of agreed best practice guidelines that promote translational research that have been promulgated to, and agreed by, relevant medical groups. Make sure the economics and medicine are understood: it may cost more to implement in the beginning, but it will save on costs down the track.

Dr Brian Morton, Chair, AMA Council of General Practice

1. End of life care – There is an expectation that modern medical technology and care will extend life, but at what cost to the quality of life? The preparation of an Advanced Care Directive when competent will bridge this gap.

2. Lifestyle health issues – The genesis of many health issues are related to poor lifestyle choices which then require medical solutions. We need brave governments to implement public health interventions to de-medicalise preventive management.

3. Obesity – a whole-of-community response is required to manage the obesity “epidemic”, including responsible marketing and labelling of foods, appropriate food helping sizes, ready access to exercise programs, dietetic advice and legislative recognition that obesity is a risk factor for multiple chronic diseases.

4. Prostate cancer – A rational evidence-based and consensus approach is needed regarding screening and management.

5. Alcohol – A multifactorial societal approach is fundamental to alcohol management.

healthcare, policy, politics

PHI GP cover threatens budget and universality

“Aside from equity issues and potential distortions in the allocation and delivery of health services*, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.”

*HAH!!!

https://ama.com.au/ausmed/medibanks-gp-cover-threatens-universal-health

Medibank’s GP cover threatens universal health

21/01/2014

A Medibank Private scheme to give members privileged access to a range of GP services threatens to create a two-tier health system and could fracture the relationship patients have with their family doctor, the AMA has warned.

As the Federal Government proceeds with preparations for the sale of Medibank Private, it has been revealed by The Australian that in November the insurer commenced a trial with medical centre operator IPN in which its members are bulk-billed for GP consultations and get access to several service “enhancements”, including guaranteed appointments within 24 hours and after-hours home visits.

The arrangement is so far being trialled at six IPN clinics in south-east Queensland (including one at which AMA President Dr Steve Hambleton practises), and it circumvents a Private Health Insurance Act prohibition on insurers paying for services that are eligible for Medicare rebates by limiting Medibank Private funding to assistance with covering the administrative and management costs of the trial.

But AMA Council of General Practice Chair Dr Brian Morton said the scheme violated the spirit of the law, and corroded basic principles regarding equity of access to care.

Dr Morton said that although the AMA wanted to see health insurers more involved in primary health care, the approach being trialled by Medibank Private was flawed.

“We do want to involve private health insurers in general practice, but we don’t really see this as the best way of doing it,” Dr Morton told The Australian, adding that any provision to allowed funds to cover primary health services should be open to all patients and GPs.

Anticipating that private funds might seek to give their members privileged access to GP services, the AMA in 2006 released a Private Health Insurance and Primary Care Services Position Statement(https://ama.com.au/position-statement/private-health-insurance-and-primary-care-services-2006) setting out the parameters for the expansion of health fund into primary health care and the dangers that needed to be avoided.

In its Statement, the AMA said that a “limited” expansion of private insurers into primary care may be of some benefit, but only where it provides or pays for services not covered by Medicare.

“There are inherent risks in supporting an expansion of health insurance fund services into primary care,” the Position Statement said, noting especially that “limiting certain services to those who can afford private health insurance, particularly those related to preventive health measures, represents the establishment of a two-tiered system.”

Other concerns identified by the AMA included the potential for the focus of health services to shift from quality and continuity to cost cutting; for insurers to develop models for rationing care; for the development of imprecise patient selection techniques; for a shift away from the provision to patients of information and education “related to their health needs”; and for patients being encouraged to visit participating GPs, who may or may not be their regular family doctor.

In its Position Statement, the AMA warned that any scheme or arrangement that created such risks or undermined the universality and equity of Medicare “will be rejected by the medical profession”.

But so far the Federal Government has adopted a hands-off approach to the Medibank trial.

Health Minister Peter Dutton told The Age that he saw no evidence that the arrangement contravened the legislation, and appeared to give some encouragement to the initiative in a statement to The Australian Financial Review.

“I want every Australian to have a good relationship with their GP, so I wouldn’t rule out any changes,” Mr Dutton said. “Like the Australian Medical Association, I am open to greater involvement of the insurers, who cover 11 million Australians, to keep those people healthy and getting more regular access to primary care.”

Aside from equity issues and potential distortions in the allocation and delivery of health services, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In a note obtained by The Australian Financial Review, the Health Department in 2008 estimated the scheme would spur a 5 per cent increase in demand for GP services and GPs would increase their fees, adding a massive $3.4 billion to the Government’s Medicare rebate bill over five years.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.

The nation’s second largest health fund, Bupa, has joined the criticism, warning that although insurance cover for GPs charges would likely be a boon for providers, it would drive up the Government’s health bill.

The trial arrangement, and a suggestion that Medibank could assume responsibility for helping to administer the National Disability Insurance Scheme, has prompted speculation the Government is trying to boost the interest of investors in the purchase of the health fund, whose possible privatisation is currently the subject of a scoping study.

The pilot of private health cover for GP services has also come as the National Commission of Audit ponders a proposal for a $6 charge for GP visits [see also, $6 co-payment an illusory health saving].

Adrian Rollins

healthy habits, nutrition, policy, politics

Tobacco, Firearms and Food

“But the job of government is not to encourage profitable businesses at the cost of public health; it’s to regulate them so that the public is served. Who is this country for, anyway?”

http://www.nytimes.com/2014/01/15/opinion/bittman-tobacco-firearms-and-food.html

The Opinion Pages
Tobacco, Firearms and Food

Mark Bittman Jan 14, 2014

Let’s say your beliefs include the notion that hard work will bring good things to you, that the golden rule is a nice idea though it may occasionally have limits, and that it’s more or less every person for him or herself. Your overall guiding force is not altruism, but you’re not immoral; you’re a good citizen, and you don’t break any major laws. This could describe many of us; most, maybe.

Now suppose you’re in the business of producing, marketing or selling tobacco or firearms — products known to sometimes kill others. You need not be a corporate executive or a criminal arms dealer; you might be a retailer of cigarettes, a person who sells them along with magazines, a marketer, a gun shop owner. In any case, your conscience is clear: you’re selling regulated legal products and, as long as you’re obeying the regulations, you’re doing nothing illegal. (“Wrong” is a judgment call.)

You sleep well, believing that the government would further regulate your product if it were necessary. And if regulations were to change, you’d change with them. But to act otherwise — to hold back your energy from production or sales just because of moral or social pressure — would be foolish, and put you at a competitive disadvantage.

For many years after knowing about the lethal nature of tobacco, our government did little or nothing to limit its consumption. That’s changed gradually in the last 50 years, and more dramatically since 1998, because of successful lawsuits and because the Food and Drug Administration often tries to pursue its mission. (For a variety of reasons not worth going into, firearms are more challenging to regulate. Let’s leave it at that for now.)

O.K., so suppose we pass legislation that discourages you from producing or selling tobacco or firearms while at the same time actively encouraging you — supporting you — to change to producing apples or cotton or washing machines or screwdrivers; as long as you could see a way to increase profit, you’d probably look at the new opportunity. After all, it’s not as if you wantto produce agents of death. You want to make the best living you can selling stuff that’s legal and that people want. Markets change, and flexibility is important, and the government can and does affect your business, even if it’s by inaction.

Now let’s apply this same way of thinking to the major food categories — and for the purposes of this discussion there are only three — and what it’s like to be a farmer or producer, or a manufacturer, processor, distributor, retailer of this stuff. Again, you’re agnostic about what you sell, but you’re profit-conscious. And the government can and does affect your business; it can help your business (“you didn’t build it yourself”) or hurt it, as it should if your business is harming others.

Let’s call the first food group industrially produced animal products. Producing and selling as much as possible is the way to go here, since the penalties for damage your product does to human and animal health and to the environment (including climate) are virtually nonexistent. You can treat the animals as you like and damn the consequences, from salmonella contamination to antibiotic resistance to water contamination to, of course, cruelty. There are even incentives, in the form of subsidized prices for animal feed.

The next group is most easily labeled junk food; you might call it “hyperprocessed.” This comprises aisles and aisles of “edibles” sold in supermarkets and restaurants, and is often “food” that’s unrecognizable as such, ranging from soda and other sugar-sweetened beverages to things like chicken nuggets and Pringles and tens of thousands of other examples. These are mostly made from commodity crops, especially corn, soybeans and wheat. Federal subsidies abound in many forms here, from direct payments (in theory, these are ending, to be replaced by a bizarre form of crop insurance) to the ethanol mandate to virtually unregulated land use that permits toxic overapplication of fertilizers and other chemicals. There is also that same failure to recognize the public health and environmental costs of what is probably the least healthy diet a wealthy nation could devise. You could even say that the Supplemental Nutrition Assistance Program (SNAP, usually called food stamps) acts as a subsidy to junk food, since nothing limits using food stamps for food that promotes disease. It’s worth noting that for the past century the bulk of university research, much of it paid for with tax dollars, has gone into figuring out how to increase the yield of the crops and processes that turn out this junk that sickens.

Then, in the third group, there’s everything else, from fruits and vegetables — absurdly called “specialty crops” by the Department of Agriculture — to animals raised in sustainable and even humane ways. But here, disincentives abound: farmers may be encouraged to allow some land to go fallow, but not to be planted in specialty crops, and research money, subsidies, insurance, market promotion and access to credit are directed toward industrial food production, distribution and sales. These inefficiencies make most of this real food, which is health-promoting and closer to environmentally neutral, appear to be more expensive. (Only “appear,” though. If you account for the costs of environmental and public health damage, industrially produced junk food and animal products actually cost more.)

One could imagine a government that encourages more life-giving (and less disease-causing) agriculture just as one can acknowledge that sanity prevails when government steeply taxes tobacco and encourages its farmers to move on to something else. (I’m not saying, by the way, that tobacco farmers have been treated fairly; much more could have been done — and still could be done — to help them transition to other profitable crops.)

Of course this is disruptive; change the status quo, and someone is hurt. But the public health disaster created by our commodity-pushing agricultural policies is only getting worse, and calls for the same kind of action in industrial agriculture that we’ve seen in tobacco and, to a lesser extent, in guns. That kind of action will happen only when we have political representatives who care about food, health and the environment.

We can pressure corporations all we want, and what we’ll get, mostly, is healthier junk food. Really, though, as long as sugar is profitable and 100 percent unrestricted (and subsidized and protected!), marketers will try to get 2-year-olds hooked on soda and Gatorade.

But the job of government is not to encourage profitable businesses at the cost of public health; it’s to regulate them so that the public is served. Who is this country for, anyway?

data saving lives, entrepreneurship, healthcare, healthy habits, nutrition, policy, politics, quantified self, rapid learning health systems, research methodology

HICCUP: Health Initiative Coordinating Council

This manifesto aligns tightly with my own vision of how preventive health funding should be financed – data-driven and in a for-profit context.

HICCup

 

The HICCup experiment: Manifesto

Just imagine:

It’s 2019 and the mayor is having a bad day.  She wants to spearhead a new community program for bike-sharing, but she’s not sure the town can afford it.  Meanwhile, one of the new council members is pushing for an overhaul of the school lunch program.  She sighs as the assistant deputy mayor walks in.  “What now, Henry?” she asks with a slight edge in her voice.  But Henry is cheerful: “Mayor, I think we may have a way to fix this. I was just reading about the HICCup Experiment in a town just like ours…. It seems that if we did both the bike program and the school lunches, and made some other changes..”

“But what about our rising health care costs?” asks the mayor.

“That’s the point,” says Henry.  “HICCup showed that we can actually reduce those costs if we do multiple interventions simultaneously…even though none of them by itself would make a difference. And there’s an investment banker who just called us that’s eager to work with us to finance the project.  They’re asking us to set up a meeting with the big employers and Mercy Saints Health. Using the HICCup data, they think they can finance it all out of the health-care cost savings that would result, as long as we commit to following certain protocols.”

And the vision:

Now it’s 2040.  The mayor’s teen-aged son, also called Henry, is discussing his history project on the HICCup Experiment with other members of his MOOC.  “Of course,” he concludes, “the HICCup Experiment proved that multiple interventions can dramatically include the overall health of a community.  But the Experiment itself wouldn’t work anymore, as a funding vehicle.”

“Why not?” asks Susan, who clearly hasn’t done her homework.

Henry responds patiently with the obvious answer: “Because there are very few places with inflated, unnecessary health care costs anymore.”

The background

It is hard to find anyone in health care who does not believe that spending an extra $100 now on healthy behavior – exercise and proper nutrition, counseling for pre-diabetics, risk monitoring, and so on – could yield more than $120 in lowered costs and improved outcomes later. The numbers are fuzzy, of course, and there are plenty of methodological caveats, but there is little dispute about the plausibility and desirability of such an approach.

Yet neither individuals nor communities seem to act on the basis of this knowledge. Moreover, it’s likely that spending $110 now has no impact, as other factors dissipate any gain, but spending $110 million now (vs. a health-care budget of $100 million) should indeed return savings of $20 million annually over time.  Individuals often lack willpower or access to healthy food or convenient exercise facilities, and are surrounded by poor examples that encourage instant gratification rather than effort and restraint. And, on a broader, institutional scale, the money spent and the money to be gained do not belong to the same pocket.

Enter HICCup!

The goal of HICCup, the Health Initiative* Coordinating Council, is to facilitate the launch of five to eight community-wide experiments dedicated to proving that this can work, and to learning from both successful and unsuccessful efforts.  HICCup is a self-appointed counseling service and will persuade and guide local institutions to embrace a long-term perspective and launch a full-scale intervention experiment in their communities. For practical reasons, there are a few guidelines – but anyone who wants to do this without following our rules is welcome to do so.   (*Yes, it used to be “health intervention…” but initiative is more friendly and positive, and still let us keep the logo!)

For starters, HICCup will focus on communities of 100,000 people or fewer. The majority of each community and its institutions must be enthusiastic for the initiative to gain traction. If the community members mostly work for just a few employers and obtain health care from just a few providers, that makes the effort of corralling the players easier. And, of course, you need community leaders – mayor, city council, and others – who will work together rather than undermine one another.

So, how will this be funded? Not by HICCup, which is only a coordinating body.  The trick is for an investor in each community to capture some of what is being spent already on health care. As a rough calculation, assume $10,000 in annual per capita health-care costs, or $1 billion per year in a community of 100,000. (There are also all the separate costs of bad health, which are much harder to count or capture.)  That money ultimately comes from individuals and employers who pay it in taxes, insurance premiums or direct payments; the place to intercept it is somewhere between the payers and the health-care delivery system.

Instead of spending $1 billion a year, imagine spending $1.1 billion the first two years, but, say, only $900 million in the fifth year (possibly a $300 million savings off projected costs of $1.2 billion by then). That sounds like an attractive proposition – but only if someone else will make that initial investment in return for a claim to those presumed later savings.  These numbers are just for illustration; figuring out actual and predicted numbers for each community will be a key task.

The first challenge is for each HICCup community to get the involvement of a benevolent but ultimately profit-driven billionaire or hedge fund, or a philanthropic fund that sees a way to do good while earning money for future goodness. There are a lot of billionaires out there, some with vision. There are health-care companies that might bite, hedge funds looking for large-scale projects, and so-called social-impact bonds. There also are large employers that might decide to work with other employers in certain communities.

The funder makes a deal with whoever is responsible for the health-care costs (buyers): The funder makes upfront investment in health interventions and pays the health-care costs, against continued payment from the health-care buyers of the $1-billion yearly baseline, with the funder to keep (most of) the savings against originally predicted rising costs in later years. The money may be paid by employers, private insurers (which collect it from individuals, who, in the United States, are now required to buy insurance) or from government health-care funds, which will be the trickiest source.

One way or another, the investor/experiment manager will need to figure out how to realign some of the sick-care facilities and workers to some other role, including prevention, serving outsiders or some other use entirely.  That’s the second challenge HICCup experimenters need to address – one that is being addressed in part by the creation of Accountable Care Organizations, but without community involvement in preventive health.

All together now!


All these entities will be taking a substantial leap of faith. But we believe they can succeed – especially if they work together through HICCup to figure out the numbers, study the effects of small-scale healthy-living/preventive health-care efforts, and encourage one another to move forward. Regardless, each investor must work with existing institutions – if only to get at the revenue stream initially and benefit from the lowered costs in later years.

Although grants are a nice source of funding for demonstration projects and research, the best way for HICCup’s vision to catch on and be widely copied is by adopting a for-profit approach that attracts broader investment once it is shown to work.  Indeed, if a benefactor makes a donation, they feel good when they send off the money. An investor feels good only after the investment actually pays off.

Community officials and voluntary organizations also need to sign on…or  they can drive the process and find the benefactor/investor. They will also contribute by implementing complementary changes in school meals and gym classes; enacting zoning and other changes to encourage cycling, walking, and the like; hiring health counselors and care workers; and perhaps working with local restaurants and food stores to subsidize healthy choices and discourage unhealthy ones.   Local media can report on the experiment’s progress, and each community will likely engage in healthy rivalry with other HICCup experimenters.

Though it won’t get to keep the direct health-care cost savings, each community will get all the ancillary benefits of a healthy population, including an enhanced reputation.  Indicators of population health include not just rates of obesity, diabetes, high blood pressure, and diseases and related costs, but also whether the elderly can live (and be cared for) at home, absenteeism, school grades and graduation rates, employment statistics, accidents, and the like. Although the funder keeps the reduction in health-care costs, the community gets the benefit in the many payoffs from a healthier population over time.

Open enrollment

HICCup will not choose which communities participate. They will be choosing them selves. HICCup’s role will be to advise them and help them to communicate and learn from other communities going through the same process. We also want to be a clearinghouse for vendors of health-oriented tools, services, and programs. There are many bargains to be struck between communities and vendors offering discounts in exchange for wholesale adoption of their tools or programs.

However, there is one unbreakable rule: To work with HICCup, communities must collect and publish a lot of independently vetted data (without personal information, of course). For starters, they will need benchmarks of current conditions and projected costs, and then detailed statistics on the adoption of the measures, their impact and costs, and what happens over time.  HICCup will welcome input from lawyers and actuaries!

It is now time to try this on a broad scale. Five years from now, we will wonder what took us so long to get started. So, again, who will those investors be?

healthy habits, policy, politics

Education matters to health more than ever before

  • education matter more know because the economy has evolved to be more knowledge-based
  • white women are the key group affected by this change
  • whites as a group are no longer top of the heap
  • the graph below indicates that hispanic women of all educational levels are longer lived than most other groups of any educational exposure – interesting

 

education_health_rwjf

http://www.rwjf.org/en/research-publications/find-rwjf-research/2014/01/education–it-matters-more-to-health-than-ever-before.html

Brief (PDF): education_health_rwjf409883

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Education: It Matters More to Health than Ever Before

We know with greater certainty than ever before that Americans with fewer years of education have poorer health and shorter lives. In fact, since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.

Why is the link between education and health more distinct today? In the current knowledge economy, education paves a clear path to good jobs and a steady income. Completing more years of education creates better access to health insurance, medical care, and the resources to live a healthier lifestyle.

This brief and video are products of the Virginia Commonwealth University Center on Society and Health’s Education and Health Initiative, a program to raise awareness about the links between education and health. This is the first in a series of four briefs that will explain these complex connections, discuss the role of health care reform, and demonstrate why investing in education can cut health care costs.

Key Findings

  • People with less education are living shorter, sicker lives than ever before.Americans with less education face higher rates of illness, higher rates of disability, and shorter life expectancies. In the U.S., 25-year-olds without a high school diploma can expect to die 9 years sooner than college graduates.
  • These health disparities are even more prominent among White women.While overall life expectancy has generally increased, it has decreased for Whites with fewer than 12 years of education—especially White women. White women without a high school diploma are living shorter lives than they did in 1990.
  • Investing in education saves lives and dollars. More education leads to higher earnings that can provide access to healthy food, safer homes, and better health care. In contrast, people with fewer years of education generate higher medical costs and are less productive at work.