Societal collaboration to reduce obesity example : School Garden, Rehoboth Beach, Delaware, USA

As I was reading the Bipartisan Policy Center’s report “Lots to Lose” on obesity ( See: Now Reading: Bipartisan Policy Center’s Lots to Lose – We can reduce our obesity burden through societal collaboration | Ted Eytan, MD ), I actually came across a real life example in my travels. Note the date on the sign. We can innovate.

Rehoboth Elementary School Teaching Garden, Est. 2012, Rehoboth Beach, Delaware, USA – View on Flickr.com

School gardens are an example of the kind of project that has been shown to be highly effective as a teaching tool but does not require a very large commitment of resources and lends itself well to partnerships with outside organizations. – Lots to Lose: How America’s Health and Obesity Crisis Threatens Our Economic Future. Washington, DC; 2012. Available at: http://bipartisanpolicy.org/library/lotstolose (p.45)

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Now Reading: Bipartisan Policy Center’s Lots to Lose – We can reduce our obesity burden through societal collaboration

This is a report about obesity, just published by the Bipartisan Policy Center ( @BPC_Bipartisan), that I have been anticipating ever since I had the pleasure of sharing the stage with people from across industries and institutions with the ability to change the trajectory of obesity in the United States (see my posts and presentations on that experience here – it really did blow my mind in terms of what’s possible)

The image on the right, taken from the report sums up quite well the difference between a social determinants model of improving health, and an individually directed one. If you go even deeper than the info graphic, though:

In sum, considerable empirical evidence exists to suggest that where people live and work has a much greater impact on their health than their interactions with the health care sector or their genetic makeup.

and

…individuals and parents, who ultimately make the decisions and set the examples that influence not only their own health but that of future generations… at the level of communities and key institutions, including government. These institutions shape the environment in which individual and family decisions get made and they can help bring about the broader changes needed to ensure that all Americans—including especially vulnerable citizens—have access to information and options that support and encourage healthy choice.

Since the United States’ health care system is not tied to the social care system the way it is in many European countries, the way to alter the “causes of the causes” (the other way to refer to social determinants) of poor health (such as obesity), is not through changing the social fabric, it’s through partnership and collaboration, which is why this report is extremely helpful.

This report talks about what can be done in our society, which includes everything from changes in our medical education system to market driven changes in large employers, the hospitality industry, and hospitals, with plenty of examples of private and governmental approaches. If you’re interested in social determinants of health and don’t know where to start, start here.

For example:

  • Existing national dietary guidelines apply to children and adults ages two and up; activity guidelines at age 6 and up, missing the most critical times in a person’s health development (The “first thousand days” – from pregnancy to age 2 )
  • The United States is the only developed country that does not comply with the WHO International Code of marketing of Breast-milk Substitutes; there is now a Baby Friendly certification that hospitals may obtain which includes avoiding the use of formula where not medically necessary (There are 143 US hospitals certified to dateKaiser Permanente and Indian Health Service have made the Baby Friendly commitment)
  • The DC Healthy Schools Act of 2010 is a model for other communities; it mandates that students have at least 30 minutes to eat their meals, provides funding for using local produce, and requires that schools provide physical education and activity through all grades.
  • There isn’t a catalog of workplace wellness programs that includes best practices and cost-benefit analysis (e.g. no “Innovations Exchange” for workplace wellness, however there is a Community Guide supported by the CDC that  ranks and scores research around workplace wellness interventions)
  • The average required time spent studying nutrition in medical schools fell from 22.3 hours in 2004 to 19.6 hours in 2008-9 (this explains why I tell people, “don’t ask me, they didn’t teach us that in medical school”)*
*Donna Shalala provided me some hope at the launch of the report as she enjoyed my second Walking Gallery Jacket (see my photo with her here). She told me that the University of Miami has incorporated a full MPH curriculum into the 4 year medical school curriculum at University of Miami. They are currently at a 33% MD/MPH graduation rate and planning for an eventual 100%!

There are innovations like the Healthy Kids Healthy Future Childcare Guidelines, the Y’s Diabetes Prevention Program funded by a private insurer (UnitedHealth Group) and tied to performance, not just participation, the National Restaurant Association’s Kids LiveWell program, that has nutritional standards adopted by 15,000 restaurants, joint use agreements that allow school properties to be used for after-hours physical activity programs and parks and recreation to used for physical fitness programs in schools.

The report is appropriately realistic about the impacts and funding sources of all of these initiatives and doesn’t paint an overly rosy picture. Believe me, there are plenty of disturbing pieces of data about our health, the change in our lifestyles that’s been happening over the past 50 years, and the policies and approaches that conspire to prevent us from being well.

I think the way to take advantage of what’s in here is to go through it and find the 5-6 things that interest you or are relevant to you in your work. It could be the $12 billion that health care institutions spend on food and beverages, it could be the tax status of health investments versus medical costs in health savings accounts, I’m confident that anyone interested in this issue will find something actionable.

While there are plenty of journal articles, reports, and thick binders of this type of information, what I like about the approach here is the tying together of the individual, family, community, society in a way that’s relevant to people in the United States. Changing the perspective of the building of a sidewalk from a transportation strategy to a diabetes prevention strategy is very much in the scope of our culture. I wouldn’t go so far to say that it’s our Marmot Review (see: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review | Ted Eytan, MD) , but it’s a good companion to it :). 

No easy policy prescriptions exist because solutions to the problem depend on choices about diet and physical activity that are ultimately personal; they come down to the messages parents send their kids, the decisions people make in the supermarket aisle, and everyone’s willingness and ability to look out for his or her own health. But it is equally critical to recognize that individual choices take place in a context and are powerfully shaped by a host of external influences. That means government and other institutions have an important role to play in ensuring that all citizens have at least the information and the opportunity to pursue a healthy lifestyle.

As I always say, I’m not that smart and my ideas are not that unique. There is plenty to learn, plenty to grab on to, and an understanding that focusing on a specific person’s choices as the answer is not the answer – that’s the bad news. It’s also the good news – focusing on a specific person’s choices as the answer is not the answer. Let’s innovate.

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Now Reading: Walking not only rearranges your neurochemistry (I knew it), it grows your brain

In a world where functional MRI (fMRI) is mostly being used to figure out how people can eat more potato chips (See post: What we are up against in motivating health: Cognitive Science, Sex and advertising | The Economist | Ted Eytan, MD), I am excited to see a use of the technology that we can all embrace.

I am currently reading the excellent report from the Bipartisan Policy Center ( @BPC_bipartisan ) that just came out: Lots to Lose: How America’s Health and Obesity Crisis Threatens Our Economic Future. Washington, DC; 2012 (and will post on it later), and was immediately taken by the image on the right. It’s used to illustrate the part of the report that provides supports for changing exercise culture in schools.

I have been tweeting and talking about how I never forget a walking meeting and there’s something about the neurochemical effects that make them extra special. So I decided to follow up on this data. I didn’t find the specific reference mentioned in the image, but I found ones that are very close. And the findings are kind of remarkable. I’m not a neurophysiologist, but my excessive schooling does allow me to figure out most things written about the human body, so I dove in.

In Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nature Reviews. Neuroscience. 2008;9(1):58-65, the authors look at the data, across the life spectrum, around cognitive function and exercise. They note that there is surprisingly little research, especially in young adults. They think this is when cognition peaks (what, it goes downhill?) then and so there’s less of an interest in the impact of exercise relative to older people. And here’s what they found:

Physical activity training appears to have both broad and specific cognitive effects: broad in the sense that various different cognitive processes benefit from exercise participation, and specific in the sense that the effects on some cognitive processes, especially executive control processes (which include scheduling, planning, working memory, multi-tasking and dealing with ambiguity), are disproportionately larger.

In other words, the part of your brain that deals with the highest level functions is better at managing itself (and you) among people who exercise. They further look at “top down control” and “behavioral control” which have greater brain activity among people who exercise. These functions allow the brain to deal with unexpected things int he environment and not-overreact.

People who are sedentary have brains that fire more in the overreaction area, and less in the control and manage area, in other words, they are less capable of maintaining steady state in the face of challenges.

Then there’s the hippocampus, where the memory lives. In animal Exercise causes the brain to grow (yes, grow, as in new cells) throughout life.  The babies of mothers who exercise also have more cells in this part of the brain at birth ( shoutout to you, Alan Greene, MD ).

How does this happen? They don’t know for sure but they think it’s because of…. neurochemistry. Blood levels of brain proteins (BDNF) increase after exercise treatment, as does generation of blood vessels and actual neural cells. There’s a twist – in animals that are “socially isolated,” the good effects of the neurochemistry are delayed an stunted. 

Get it? Exercise + being social  (AKA “the walking meeting”) = better brain functioning, actual brain growth, better management of one’s self and the environment. 

In Davis CL, Tomporowski PD, McDowell JE, et al. Exercise improves executive function and achievement and alters brain activation in overweight children: a randomized, controlled trial. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2011;30(1):91-8., the researchers randomized sedentary, overweight, children aged 7-11 to no exercise, exercise 20 minutes every day, or 40 minutes every day and looked at their brain function AND pulled out the fMRI machine to look at how their brains worked real time.

And…they found the same thing, the brains of the children actually work differently after 3 months, and those with 40 minutes a day showed a greater change than the 20 minutes a day kids. 

Although the fMRI images in the article don’t exactly correlate to the ones here, they show the same pattern of better “Executive Function” – increased activity in the front part of the brain (bilateral prefrontal cortex) and decreased activity in the back of the brain (bilateral posterior parietal cortex). These are brains that are able to 

regulate one’s behavior (e.g., inhibiting inappropriate responses, delaying gratification) [which is important] is important for a child to succeed in elementary school (Blair, 2002; Eigsti et al., 2006). This effect may have important implications for child development and educational policy.

Oh, and they also scored better on math testing.

These authors’ best guess of how this happens is the same as the ones above, it’s from neurochemistry, stimulated by movement, not as as side effect of better heart health:

Thus, rather than being mediated by cardiovascular benefits, the cognitive changes due to exercise may be a direct result of neural stimulation by movement.

There has been some talk lately about whether exercise is beneficial for 100% of the population, and the problem with that discussion is that it focuses on a very narrow set of biological markers (blood pressure and blood lipids).

This ignores a vast array of other benefits that extend beyond the heart to the mind, body, and the soul. Not to mention family, community, society. In other words, exercise may not bring a person to 100% health; it brings them closer to Total Health. Check it out, schedule a walking meeting today :).

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What I learned about Healthy Institutions at the Bipartisan Policy Center Nutrition and Physical Activity roundtable

The places we live, work, and play are part of the social determinants at health, and most of these places are not health care institutions. This is why the Bipartisan Policy Center’s Healthy Institutions Roundtable, part of the nutrition and physical activity initiative, was so educational for me. Here’s a rundown of what I learned. They’ve posted the video of day #2 on their website. Definitely worth a look.

Oh, and I have to give kudos for permission given by the team at BPC to “tweet as much as you like, feel free to include attribution.” Sharing is power.

Hospitals and Hospitality

This was the panel I was on, representing Kaiser Permanente. I have previously posted my remarks here.

The Healthier Hospitals initiative, represented by Seema Wadwha, it’s director, was represented. This is important for hospitals across the United States because it gives them a roadmap to deliver care in a way that is healthy for patients, healthy for staff, and tools to do it. This includes sustainable food purchasing, healthy building, etc. This is just getting ready to launch, you’ll hear more about it very soon.

I previously posted about NC Prevention partners work in this area as well. The power of the story comes into play here – you can’t think that the liberation of hospital cafeteria workers to serve healthy food, and community members to come to hospitals to eat healthy food strikes an emotional chord, but it does, and it did.

We were joined by Jim Milkovich, Corporate Director of Puchasing, Hyatt, who spoke about work underway to feed hotel associates in a more mindful way, and bring healthier choices to guests as well. They’ve launched Hyatt Thrive (hmmm…like the name!) which has a health and nutrition component, as well as Recharge 365, which is targeted toward employee dining. The main Hyatt Thrive portal is here. Of note, Hyatt (along with Kaiser Permanente) has joined Partnership for a Healthier America.

The role of “taste”

My big a ha here was how much the hospitality and entertainment industry focuses on good taste as the metric. It was mentioned multiple, multiple times, by panelists throughout the day. I have thought about this a lot and had some impactful conversations:

  1. At the event, about where do our children currently learn what good taste is? I was reminded of studies in the early part of last century that showed that babies tended to choose healthier choices when offered a variety.
  2. Later, in a tour of the Center for Total Health with Liz Rockett ( @Liz_Rockett ) about what taste is surrounded by when we are growing up – a combination of discipline, caring, love from the people who serve us food.

Maybe there’s a conversation to be had about taste as the end vs the means or something like that…

Federal and Local Government

Here I was exposed to the concerns of our armed forces, and really zeroed in on the work, locally, of our DC schools.

The DC Healthy Schools Act is really a landmark piece of legislation, and as described by Jeff Mills, Food Services Director, has motivated a typically underperforming educational system to do amazing things. Take a look at the requirements in the link above. This includes a free breakfast to all students, served in the classroom, after the bell rings, so that no one goes without a healthy meal in the morning.

Sport and Entertainment Venues

Here’s an area where I was fascinated beyond all recognition, because I am not aware in my world of what happens in this world. We heard from John Fithian, President, National Association of Theatre Owners, about how healthier foods have been (in his words) “a commercial disaster.” At the same time, we heard from Jennifer Cox, VP of Culinary, Levy Restaurants, that experiments in healthier options have been tried with some success in the premium section of entertainment venues. I heard about the concept of “stealth health,” which means making healthier versions of “iconic” foods that do not dilute their value.

Overall, I was just impressed that this group was here to talk about what they have been doing. At the same time, wondering, wondering, if there were stronger connection to the health system if collaboration could result in some real innovation. I think it could, and everyone wants to help, including the customers (in my opinion).

Employee Wellness

Because this session was recorded and available on the BPC website, I’ll refer readers there to learn more.

I have previously posted about the return on Employee Wellness Programs, and I was personally delighted to meet Ron Goetzel, Ph.D., who has done so much groundbreaking work in this area.

We are fortunate to be in a time and place where we are understanding the benefits of excellent medical care and its limits in promoting total health. I am hearing the term “social determinants of health” more and more, and appreciate Bipartisan Policy Center for bringing together the diversity of experience in this area. I’m looking forward to seeing the results of their efforts.

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Hospitals having healthy food environments, and cafeteria cashiers leading in them – NC Prevention Partners

At the Bipartisan Policy Center’s roundtable on healthy institutions, I sat on a panel with Anne Thornhill, from North Carolina Prevention Partners, who talked about their Red Apple Project. This work resulted in tobacco-free health campuses across North and South Carolina.

The video below is about the work, with a focus on healthy food in hospitals. Anne told this story on the panel and I asked to follow up, which I did via this video. If you go to 4:35, you’ll meet Karen McCrae, a Cashier at Blue Ridge Healthcare. Listen to how she describes the initiative in her hospital. I was actually listening to the video in another window on my computer and when Karen came on I thought, “Oh, there’s the hospital administrator talking.”

Leadership at all levels is possible around health, food, sustainability. You can learn more at the NC Prevention Partners site as well as at the Healthier Hospitals initiative. Enjoy.

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Preventing the causes of the causes of poor health : Healthy Institutions, at Bipartisan Policy Center Nutrition and Physical Activity Initiative

This blog is written with the premise that i learn something new every day, and last week, I learned so much my head is reeling.

After presenting on (and learning about) climate change and health care (many posts on that), I immediately emerged at a two day roundtable event held by the Bipartisan Policy Center (@BPC_bipartisan) on Healthy Institutions, as part of their Nutrition and Physical Activity Initiative:

Large institutions play an influential role in the eating habits of the American public. Places like hospitals, hotels, schools, workplaces and sports venues procure and serve millions of meals annually. These institutions are uniquely positioned to make changes in concessions, vending and catering that can have significant impact on the food choices, and health, of millions of Americans. Leaders in delivering healthy foods are emerging in both the government and private sector. How can we use these examples to engage more leaders to do the same?

To get ready for this event, I needed to learn about key areas where Kaiser Permanente is creating and supporting healthy institutions. I wrote out my comments, because I get nervous when I am representing the hard work of others :). Here’s what I said, on the panel covering “hospitals and hospitality.” Note the theme of recognizing the leadership of individuals.

I’ll post what I learned from the other impressive organizations I sat with and watched separately. Comments welcome.

Kaiser Permanente is the largest non-profit health care system in the United States. We have a lot in common with everyone here in what we do, and a lot of overlap as well. We are a large employer, with 178,000 employees, 16,000 physicians, 46,000 nurses. We are a large health plan, with $48 billon in revenue, We are a large health system, providing care for 9 million members.

We can be looked to as an institution where incentives are aligned. Because we provide pre-paid, integrated care, there are strong partnerships between our physicians, nurses, health plan, AND members! In our situation, we benefit from people using hospitals less and using hospitality more, health and life happens outside the health care system – that’s the way our model works the best.

I am a family physician in The Permanente Federation, which supports the 9 medical group of Kaiser Permanente and Group Health Cooperative. My presence here is an example of that partnership, thanks to Loel Solomon from Kaiser Permanente Community Benefit, which provides $1.8 billion in support of the connection between health care and the places where people live work and play.

I want to talk about what we do as an organization, and will also mention some of the areas we are active in related to the other priority issues of this work, so that we can be a resource moving forward as needed. We are one of the original supporting organizations along with Inova health care of Healthier Hospitals, and are planning to sign the pledge at our Center for Total Health not far from here.

In the area of nutrition, I think one of the most important investments we’ve made is in a person. We actually have a Sustainable Food Program Manager, her name is Kathleen Reed, and she has a masters’ in sustainable food systems. She works in National Nutrition Services and she’s been with us since, 2008, which says how new this field is. We have had a Comprehensive Food Policy since 2006, which connects the health of the food to the health of the system that delivers it – a food system that is ecologically sound, economically viable, and socially responsible.

There are three milestones in our journey that I’d like to share, and the first one is about the recognizing and supporting the passion of individuals. Preston Maring, MD, is an OB/Gyn at Kaiser Permanente, Oakland, and is a force of nature. In 2003, he started the first Friday Fresh Famer’s Market outside the Oakland Medical Center. There are now 39 more, from Hawaii to Maryland. This program is still managed in a grass-roots kind of way, with champions at each market who work with Kathleen. A survey of patrons was done in 2010. 50 percent of the respondents were KP physicians and staff, 31 percent patients, 12 percent people who work and live in the neighborhood. 74 % said they eat more fruits and vegetables as a result of shopping at farmer’s markets, 33 % said they sometimes schedule appointments around the Farmers’ markets schedule. Preston is that food guy – he brings table top cooking demonstrations to medical meetings and teaches us that cooking and eating healthy is easy. I’ve learned a few things!

Second, we have a program called Healthy picks, which brings healthy foods, sustainably sourced, to all Kaiser Permanente cafeterias, 50% of the choices in vending machines across Kaiser Permanente, 100% in pediatric waiting areas, and now inpatient care. With regard to menu labeling, we did a controlled study in 2008 in six hospital cafeterias and found a 10% shift to healthier choices for side dishes and snacks when we examined register receipts after just one month. If patrons changed nothing about their eating outside the cafeterias, we calculated up to a 5 pound difference after a year.

Third, sustainable purchasing. It is not enough for us to get the healthiest food for ourselves and our members if we undermine the environment around all of us. In 2006, we began purchasing local produce from family farms through a partnership with the Community Alliance of Family Farmers. We set a 3 year goal in 2010 to increase sustainable purchases from 7 percent to 15 percent. We met the goal in 10 months. Now, 50 % of our fruits and vegetables are sustainably produced, 190 tons worth. Going from frozen vegetables and fruit to fresh is a huge satisfier for patients, among the most vulnerable in society. For dairy, we currently purchase growth-hormone free milk and yogurt, with a goal of sourcing within 200 miles, humanely produced, and expanding to include other dairy products. And…we are working to support a food system capable of supplying not just us, but all of health care.

And a +1, healthy meetings. We have created a nutrition guide for healthy meetings, publicly available, because we also work with the hospitality industry and shape the food that is served at our events. This is an example of us bringing our medical, nutritional, environmental expertise to all of the community.
In the area of physical activity, again I want to point out the value in all of us in recognizing and harnessing passion. Bob Sallis, MD, is a family physician in San Diego, a national expert on physical fitness, and pioneered “Exercise as a Vital Sign” . It’s codified in our electronic medical record, so we’ve changed the definition of what vital signs are – they now include blood pressure, temperature, pulse, weight, respirations, and exercise minutes per week. That alone changes the medical definition of what health “is.”

We created “Everybody Walk” which is a national commitment to support walking across America, with funded walking projects, including the completion of the Metropolitan Branch trail in Washington, DC. And if you want to see a high tech version of this commitment, come to the Kaiser Permanente Center for Total Health, which has this 80 foot touch wall devoted to walking. Not to cardiac care, not to joint replacement, walking. We have a national walking program for our employees and team based competitions. My absolute favorite, though is “walk with a doc’ which is starting to happen at medical offices all over the United States. PS I walked here!

I wanted to highlight a few of the guests’ work here that relate to the other topic areas of the BPC’s initiative: Geri from Food Research and Action Center, and DC Hunger Solutions, to help DC Schools implement the DC Healthy Schools act, to make healthy meals available to all schoolchildren (dchealthyschools.org). Gus Schumacher from Wholesome Wave, who works with Kaiser Permanente as an employer to take worksite wellness incentives and deliver them in the form of double value coupons at farmers’ markets. Also Ryan and Susan from Partnership for a Healthier America, which we are one of the founders of – related to the other issues that BPC is looking at, we have committed to all of our hospitals being baby-friendly for breastfeeding mothers by Jan 1, 2013. Jonathan and Katie from the Y who you’ll hear from tomorrow and who’s work we admire. I got to see Matt Longjohn, MD their medical director present to us last October and they are doing impressive work in obesity treatment and prevention. I know we collaborate with a lot of organizations, so if I have missed anyone please let me know!
This is a lot of interaction within our system and as a community citizen, which is what really excites me about being a physician here. I am around for the next two days and can provide more information as part of the other topics discussed, AND I plan to tweet and blog what I learn here because we always want to perform better for our members and society.

I’m now going to speak on behalf of all health professionals (if I may!) and that is to say that when we walk out of our medical offices, hospitals, and other facilities, we don’t want to feel undermined or defeated by the environment around us, and it turns out we don’t have to be. This is really an opportunity for us to feel supported where we live, work, and play, too. Thank you!

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