Update from Stoker: Innovations in Public Health

Hi all, going through old blogger accounts on a Sunday afternoon discovered this is still active. Thought I would chime in with a little alumni return & report-

Since graduation I have worked with a group called Ashoka, we are a professional association and/or platform of entrepreneurs working on social issues. Here are a few of the interesting projects I have seen around our network recently:

Innovative rural health care model in India, an interesting combination of clean water, preventative and clinical care, health financing mechanisms, telemedicine and latest technologies in point-of-service diagnostics. The entrepreneur-in-residence driving the effort, Al Hammond, in a recent interview with Fast Company, video below



An effort to develop the young talent in the field of maternal health by hosting an open-source but referral based and judged competition leading to arranged mentorships with current leaders in the field.

Sakena Yacoobi written up in the Lancet, quite remarkable results in Afghanistan amidst all the turmoil.

Seeing the topics of obesity and chronic disease within the US as favorite topics here are two more people whose models I really admire, if you have the time I'd recommend both videos:
Jill Vialet, Playworks
Sanjeev Arora, Project Echo

Hope all is well in Provo, Go Cougars!

Worksite Programs to Control Overweight and Obesity

While working as a secretary for three years, I got sick of sitting down all the time and feeling like I wasn't doing anything. I walked the mile-plus to and from work as often as I could, but during the day I still felt like a slug. Not fun.

When I heard about these, I became really jealous and really wanted one for my office. It never happened.

Here's a short video explaining more:

The intervention that I looked at for obesity prevention is one for the workplace community.

This intervention uses "informational and educational strategies to increase knowledge about a healthy diet and physical activity," such as printed materials and lectures. Another aspect of the intervention is aimed to change behavior. They provide group counseling and skill-building opportunities. The last focus is on policy. The aim here is to make healthy foods more available and affordable in the cafeterias, as well as increase insurance benefits for healthy living, gym memberships, etc.

The interventions most commonly used included informational and behavioral components, with a few of them aiming for policy and environmental changes in the workplace.

All of the types of interventions showed positive results in behavior, weight, and BMI. It didn't seem to matter if the intervention focused on diet, exercise, or both, they were all effective.

Thinking back on my own experience while working, I always participated in the activity/dietary challenges that the organization provided for its workers, however I tended to stop as soon as (or shortly after) the required time was over. It seems that if we had had opportunities such as this one providing counseling and/or workshops to increase knowledge and influence behavior, I may have been more likely to actually make some lasting changes.

information about the intervention can be found here.

Interview with Lynda Blades

About a month ago I had the chance to talk to Lynda Blades, program manager for the Physical Activity, Nutrition and Obesity (PANO) program at the Utah Department of Health. She was very accommodating and we had a great conversation about the challenges and rewards of being in public health and health promotion.

She, herself, graduate from BYU and then attended the "school up north" to receive her MPH. Her career in public health has ranged from teaching healthy eating, aerobics and fitness classes at Hill Air Force Base to working against heart disease in clinical settings in Montana. Reflecting on her past experience working with individuals and small groups, she says her current position as the program director of a state, population-based program has challenges and benefits.

The challenges of working in a population-based program to prevent obesity is that it can be extremely political and slow-moving. Besides the slow pace of politics, the pace of change in population-based programs is also hindered by the rate of trickle down from structural changes to behavior change. According to Blades, it can take your whole career to see a significant change.

However, despite the challenges she enjoys knowing that her program can help create places not just attitudes. Population-based work also has the advantage of being not as didatic in approach: more encouraging than instructing.

PANO, with its motto "Making the Healthy Choice the Easy Choice", is mainly about creating partnerships between the health department and worksites, schools, healthcare organizations, and communities. Blades finds the progress they have made so far encouraging. Forming partnerships with local urban planning boards has been one of their recent accomplishments. She sees the program is becoming more widespread and mentioned the recent initiation of "worksite awards" as a victory. However, patience is required. She mentioned despite the changes it can sometimes feel difficult to feel that "you're making a dent." According to her, at those times it's important as a health educator to remember that what you're doing is going to make a difference.

Her advice to budding young health professionals? Get exposure to as many areas of public health as you can. Blades feels her work in a local health department, with an HMO, and now in a population-based effort has given her a good feeling for all things current in public health practice. She particularly mentioned the stark difference between working with a local health department and a state health department, and thinks students should try to get the benefit of both.

After talking to her I was impressed both by her professionalism and her commitment to her program, despite its challenges. PANO is in good hands.

PANO was on the brink of publication of the Utah Nutrition and Physical Activity Plan 2010-2020 when Lynda Blades and I had our conversation. I checked back the other day and saw it was out and online! Check it out at the PANO webiste! You may see changes coming to your Utah neighborhood soon.

CATCH Program to Reduce Child Obesity

For an obesity prevention class I reviewed the CATCH program to reduce child obesity in schools. It's program components are pretty neat and it's been shown to be effective in Texas in a little as four years. Read on to find out more about it!

CATCH (or the Coordinated Approach to Child Health) has as its main goal creating healthy children and healthy school environments. It does this through an integrated team of elementary school principals, elementary school teachers, PE teachers, food service supervisors, and (when implemented with an accompanying community-based initiative) community representatives.

The program includes family fun nights/events, teacher-led activity breaks in school, social marketing efforts, CATCH community "best practices" workshops, a host of other training and coordination meetings, and a menu of options which communities can choose to include as part of their personal CATCH implementation. Some of these activities include providing opportunities for students to have a taste healthful foods, implementation of school gardening programs, implementation of physical activity breaks during classroom hours and organization of after-school physical activity programs. Because each community gets to choose the options that are right for them, this allows the program to tailor itself to specific community needs.

This program can be compared to Shape Up America, Be Active Eat Well, and other school-based obesity prevention programs. CATCH relies heavily on the recommendations for school health programs from the Division of Adolescent and School Health.

CATCH has measured success by lowering BMI measures from student self-reported height and weight. CATCH schools also show improvements in dietary choices as measured by the CATCH SPAN questionnaire. These effects are much more prominent when the CATCH program is implemented with its community-based component. This program has been demonstrated effective mostly among low-income schools.

If I were a principal struggling with a burden of obesity, I might look to CATCH for some answers...

The Hill

A few weeks ago I was able to attend the Advocacy Summit in Washington DC with many of the other MPH students in my class. We had an amazing time touring the city and learning about advocacy. We had the privilege of hearing from many public health professionals about various health issues. One of the speakers was introduced as a man who had worked extensively on obesity prevention, specifically in policy related changes. I decided to follow up with this speaker whose name is Dr. Richard S. Hamburg. He is the director of government relations for Trust for America’s Health. Trust for America’s Health is a non-profit, non-partisan organization focused on prevention, protection and community.

Dr. Hamburg received a BA in Political Science and a Masters in Public Administration from the SUNY Albany. He worked for a state assemblyman from Queens from 1979-86 as his staff director at the Capitol in Albany. He then joined the American Heart Association as their director of government relations in NYC from 1986-88, and then joined the AHA’s national government relations office in 1988, where he stayed through 2004, ultimately as their national director of government relations. He joined Trust for America’s Health in 2005 as their director of government relations, and became deputy director late last year.

Dr. Hamburg and his colleagues are very focused on childhood obesity and are advocates for better nutrition and physical activity in schools. He feels that policy is an important part of the answer for solving the obesity epidemic in the United States. His passion is policy, but it is also one of his frustrations. His biggest challenge is focusing the attention of policymakers on the issue of obesity and educating them that it is not simply an issue of personal responsibility. He believes there are barriers to sound nutrition and physical activity that need to be removed by the private sector and government.

One of his biggest successes is the passage of the federal stimulus funding package in early 2009, containing $650 million for wellness and prevention funding to reduce tobacco use, promote physical activity and healthy living. He thinks this is a major step for the public health community. Successes like this give him hope that more efforts will be spent to fight obesity in the future.

Dr. Hamburg encouraged me as a public health student to stay current on the health issues not only where I live, but throughout the country. He also of course put in a plug for policy work and how essential that element is to public health. His work in policy is impressive to me because I was better able to see the effectiveness behind health policies in improving health behaviors. I thought it was interesting how he didn’t start out working in policy, but was lead there after witnessing the vast array of health problems in our country. I had an enjoyable experience learning more about policy and advocacy at the Advocacy Summit and also through learning more about Dr. Hamburg.

"Counting Calories"

I watched a 60 Minutes segment--Counting Calories--for class on the menu labeling efforts in New York. It aired in 2007 so it was a few years out of date, but presented interesting arguments both for and against menu board labeling in fast food chains.

For fast food labeling:

• Americans need to SOMEHOW be more aware of what they eat when they eat out! A study done by a Cornell professor showed that people consistently under-estimated (by half!) the amount of calories they were consuming at restaurants.

Against fast food labeling:

• The fast food chains shouldn't be singled out just because they already do nutritional analysis of their foods or simply because they're a big and unpopular target. If they're going to be singled out then it ought to be done on the basis of some more objective measure (eg: the number of calories people consume at their stores, etc.)

Practically speaking, the controversy surrounding the passage of this regulation is a definite sign that any time of labeling measure is going to be an uphill battle. Public health professionals interested in taking the food industry on ought to have well-thought out arguments.

The debate continues because menu labeling measures have now appeared in health care reform legislation. The question is, is menu labeling the answer?? Thoughts?

***Look up the video: its' narrated by Lesley Stahl, produced by CBS.

The 750 Pound Man

I was taking a bite of food when the film started. I immediately lost my appetite.

The story started with John Keitz, his wife Gina, and his mentally handicapped sister Jessie being kicked out of their home. Their landlord refused to renew their lease. The paramedics in that city had developed a system to get him out of the house and to the hospital using a whale harness and a specially designed ambulance.

He checked into a hospital in Ohio saying that he was finally going to lose weight. His reaction to the nurse when she brought in a salad? "I want a hamburger."

They had to use a huge sling to get an accurate weight. While they were rolling him onto the sling he had to be put on oxygen because even that much movement was too hard on him.

While working with the physical therapists, when they asked him if he was ready he said, "If you wait until I'm ready, I won't get better." At least he knew that much. He was going to have to be pushed out of his comfort zone. However shortly following that, it was reported to the head nurse that during the night he ate chips, popcorn, sun chips, and little debbie cupcakes. She had to go in and remove his stash. He tried to convince them that he knew how to manage his snacks.

Most people become obese because they don't know how to cope with difficulties.

When there's not a lot of muscle, there's not a lot of fat being burned, so it's necessary to start slowly, especially when the patient is bed-bound.

He got an infection that originated in his skin (he had a lot of skin problems due to his lack of movement, and the constant pressure on the skin), then moved to his blood stream. He died of septic shock - it killed his organs. Due to his condition, he wasn't able to fight off the infection.

He died at 39.

I think it's really sad when people are in that situation, but at the same time, I can't help but think of what precautions and steps they can take to catch things early and keep themselves from getting to that point.

A nice side story of the video talks about a guy who's in the same nursing home that John is in. Nathan is about 13 years younger than John's 39 years, and not nearly as heavy. He checked himself into the nursing home for the morbidly obese at 400-some pounds. I think it's great to show a story like that. Yes, he's morbidly obese, but he's still walking, and he knows it's a health problem. At the end of the video, he had lost 70-some pounds since checking himself in.

for more, go here.

Healthy Body Healthy Mind

I was able to watch the DVD entitled Healthy Body, Health Mind, which is a TV series. The particular episode I watched was focused on overcoming obesity. The TV series is produced by the Information Television Network (http://www.itvisus.com/programs/hbhm/ ). The series is centered on doctors making home visits to average Americans and discussing their health issues with them and then advising them how to make healthy changes.

I thought this program was a unique idea of discussing obesity with the public. Instead of being a health DVD that someone might only find at a library, the producers of this series was able to reach television watchers across the country. In this particular episode the doctors made visits to obese adults and one overweight child. One of the main priorities the doctors had was to inform the individuals about the danger of having excess carbohydrates in the diet. Several of the individuals ate low fat foods and enough fruits and vegetables, but they were not losing any weight. The doctors and other health professionals taught them how to count carbohydrates and which foods to avoid. Some of these recommendations were to avoid white flour products, rice cereals, pastas, and certain fruits like raisins, pineapples, and bananas. I thought this was an interesting focus to take on obesity. Usually counting carbohydrates is associated with diabetes, but it also pertains to eating a healthy, balanced diet. To learn how to count carbohydrates, check out this website, http://www.diabetesnet.com/diabetes_food_diet/countcarbs.php.

Often times we hear “eat a healthy diet” as a response to how to overcome obesity; however, from this DVD I learned that focusing on a specific part of a healthy diet can possibly be more effective and manageable. They stressed the idea of food substitution, and that dieting does not have to become a chore, but rather a conscious effort to be healthy. I liked this emphasis because remaining on a diet for a lifetime is usually not possible. Small dietary changes are more effective and sustainable for weight loss.

After watching this DVD, I had a greater interest to learn how to count carbohydrates. I want to learn more about the difficulty level of counting carbohydrates and how sustainable this program is. Last weekend I was able to attend the Diabetes Expo in Sandy and I heard a lot of diabetics talk about the difficulty of counting carbohydrates at each meal and snack. It would be very helpful to find an easier way to do this in order to help diabetics and others eat healthier and lose weight. It would be interesting to follow up on other interventions using carbohydrate counting to lose weight and compare the success with other types of diet interventions.

Community Gardens

In preparation for the grant proposal (due today!), our group has looked over the Community Gardens project, and even modeled our own grant proposal around some of the main tenets of the Community Gardens project. Here is a brief overview of Community Gardens.

The vision of the project is to increase opportunities for Utahns in low-income neighborhoods to participate in gardening to improve health.

Goals:
1. Educate the public about the value of gardening to improve healthy eating and physical activity patterns and the availability of community and at-home gardening resources.

2. Create new community partnerships and a policy team to develop community gardens and home gardens in low-income neighborhoods in Salt Lake and Weber Counties.

3. Improve access to healthy options by working together with low-income neighborhood leaders and community members to develop community gardens, offer gardening workshops, and provide technical assistance for at-home and community gardens.

Stakeholders for this project included KUTV2 News and Univision (a Spanish language media partner), Governor Huntsman's Office, Utah DOH, Wasatch Community Gardens, Utah Department of Agriculture and Food, Utah Department of Human Services, Utah Commission on Aging, the SLC Mayor's Office, Weber-Morgan Health Department, 5 A Day Association of Utah, IFA, Girl Scouts of America, University of Utah, Utah State University - Extension, and Borski Organic Farms.

It is obvious that this project reached far into community organizations to build support among those who were already plugged into potential community resources.

The project's activities included collecting proposals from community organizations throughout the state to start community gardens. 10 proposals were selected and funding was provided to develop community gardens associated with schools, churches, low-income housing communities, and boys and girls clubs. The aim of the project was to target low-income communities, and with the exception of a charter school, all of the projects had access to low-income participants. A tool library was maintained in case additional supplies were needed. They could be borrowed by an individual project and then returned.

The intitiative can be compared to Wasatch Community Gardens, which is a group of community gardens thoughout the state. One of the aims of this program was to strengthen the capacity of Wasatch Community Gardens.

As far as evaluation, the final report from the project states that evaluation fell outside the timeline of the project. That sounds like a cop-out, and I hope that evaluation has been performed to determine if future efforts should be made to expand upon this program.

Supersize Me!

Every time I eat at McDonalds, I feel sick afterwards. This is not to say that the food doesn't taste good (because it does), but there is something about that food which my body likes to reject. Because of its effect on me, I avoid eating at McDonalds at all costs. In the past 5 years, the only times that I've eaten at McDonalds were in China when either my wife or my visiting mother couldn't take eating any more Chinese food. So when I rented "Super Size Me" a couple of weeks ago, I knew that it likely couldn't increase my repulsion for the double arches; however, the documentary while not increasing my disgust, did give me some wonderful facts to throw around about what McDonalds' food will do to your body.

The director and star of this documentary, Morgan Spurlock, decided to eat nothing but McDonalds food for 30 days. He had to try everything on the menu at least once and had to super size his order every time that the cashier invited him to do so. Before he started this experiment, he was medically tested by 3 doctors and found to be in remarkable health. By the end of the month, he had gained nearly 25 pounds (17 of these pounds were gained in the first 12 days), consumed 5,000 calories a day, and ruined the health of his body. All 3 of his doctors warned him that if he continued on this diet, he would soon die. His cholesterol, triglyceride, and liver enzyme levels were off the charts.

After the experiment was over, it took about 15 months for Morgan's body to return to how it was before the experiment started. BAD NEWS.

Lesson learned? Fast food is not good for you, and it will kill you if you eat it all the time. I know that this food is really cheap and calorie dense, and because of that readily becomes a staple to those of lower socio-economic class. This shows that there is a need for policy to help people have the freedom to make better eating decisions.

There is, however, a matter of free will in the matter. Should people be allowed to eat whatever they want? Isn't it their life? Morgan did find that he was becoming dependent (addicted) to the food, though, and that is another thing to consider when weighing policy options.

In summary, go rent "Super Size Me" and let me know what you think about it. It will be a well-spent $1.99 at Blockbuster.

Targeting the Taqueria

Steps to a Healthier Salinas

Targeting the Taqueria: Implementing Healthy Food Options at Mexican American Restaurants

http://hpp.sagepub.com/cgi/reprint/10/2_suppl/91S.pdf)

I love this intervention for many reasons. First, it is a perfect example of a culturally tailored message. Instead of attempting to change Mexican cuisine, this intervention encourages taqueria owners to simple make a few food preparation changes to make their menu items healthier. They also tailored all of the educational material to the proper audience, which helped diffuse the information more effectively. Second, this intervention empowers members of the community to take responsibility for the health of others. I feel that if the whole community came together to promote good health we would see much lower rates of obesity, diabetes, and other health problems. It will be interesting to read the results of this intervention when the analysis is complete and to see how this intervention can be implemented in other areas.

Vision and Goals

The vision of this intervention was to develop partnerships to promote healthy communities with nontraditional partners, such as the owners of taquerias in Salinas, California. The intervention was aimed to use community health workers to help foster cultural links between underserved communities and efforts to improve health outcomes. The goal was to empower the owners of taquerias to offer healthier menu options as well as encourage their customers to choose the healthier options. In the beginning of the study only 16 taquerias were chosen to become partners; however, an end goal of the intervention was to include all taquerias in Salinas in the partnership.

Stakeholders and Leaders

The stakeholders in this intervention were the CDC because they funded the program as well as the owners of the taquerias and their staff members. Another stakeholder could be the people living in Salinas who frequent taquerias because they were affected by the intervention. The initial leaders of the intervention were members of the Stanford Prevention Research Center; however, their goal was to empower the taqueria owners to become the eventual leaders of the intervention

Actions Taken by the Program

• The first step was to become familiar with taquerias and their owners and then to stress current health issues in their community that they could help prevent.
• Partnering with local taquerias to help them become promoters of healthy foods for their community.
• To educate taqueria owners about offering healthier food options such as whole beans, whole wheat tortillas, and fresh fruit.
• To provide food preparation suggestions such as using less fat in food preparation, increase vegetables in menu items.
• Improving access to healthy food options in disadvantaged communities.
• Providing taqueria owners with a “healthy nutrition tool kit” which included information about diabetes, social marketing of healthier foods and health education visuals (such as portion size posters).
• A small grant program was developed through the ‘Steps to a Healthier Salinas’ that allowed taquerias to apply for funds to help change their photo menus to look more appealing and healthy.

Comparable Programs and Possible Partnerships

This intervention is one of the eight initiatives funded by the CDC to help foster healthy communities in the United States. I have read a few of the articles and all of them focus on community partnerships and empowerment. A similar intervention to “Targeting the Taqueria” was an intervention entitled “Rock on Café” (http://hpp.sagepub.com/cgi/reprint/10/2_suppl/100S). This intervention also worked with nontraditional partners to improve the nutrition of a specific group of people. Instead of taqueria owners, cafeteria workers were empowered to make healthy changes in the school lunch menu to help prevent obesity and diabetes among children. The target audiences were different, but the principles of the intervention were very similar. I feel like the taqueria intervention would partner very nicely with a community garden effort. Fruits and vegetables are often not included in one’s diet due to economic barriers or not having access to these foods. Having a community garden in the disadvantaged areas of Salinas would allow individuals to cook with and eat more vegetables and fruits when they dine at home. Taqueria owners could also use the community gardens to supply their vegetables and fruit for their menu items. This could reduce costs and enhance feelings of community ownership. A great article on a community garden intervention in an underserved community can be found here: http://hpp.sagepub.com/cgi/reprint/10/2_suppl/146S.

Measurement of Success

The results of this intervention have not been published yet and they have not defined how they will measure their success. In the conclusion statement they mentioned, “It is hoped that this innovative, tailored intervention, which is responsive to community needs, will have a sustained positive influence on the large and growing Mexican American population that is at high risk for obesity, diabetes, and other chronic diseases.”

I feel that success could be measured in a variety of ways:

*The percentage of taquerias that have adopted healthier food options in Salinas

*Feedback from the taqueria customers about the healthier food, their health, etc. gathered through qualitative data (surveys or in-depth interviews)

*Increased awareness of diabetes and obesity among taqueria customers in Salinas

*The percentage of customers choosing healthier menu items