A Belated Eulogy for Eleanor

I was one of the few students at school who loved studying statistics. All the knowledge that you learn about people is amazing. But like many people, the parts of my life that are the most exciting to me are those that don’t fit well into statistical description.

One such extraordinary part of my life was my friendship with Eleanor. When I met her, she was 85 years old and very sharp. A part-scientist/part-painter with a PhD in English, Eleanor often went for walks and spent a lot of time outdoors sitting on her walker observing nature. It was during her daily jaunts that I began to spend time with her. We immediately hit it off as we discovered that we both had a poetic appreciation of nature, and we both loved art and science.

I met her on my own circuitous journey, which landed me a job as an activity assistant in an assisted-living facility in Mississippi. My wife, a native Mississippian, and I moved there from Seattle after we jumped off of society’s escalator of pre-planned milestones to follow our own personal goals. Within weeks of landing in small-town Mississippi, I was teaching a seated version of Tai Chi to residents of the assisted-living home.

Those classes were well attended, particularly by two residents, Franny, whom I wrote about earlier, and Eleanor. There were many moments that the three of us sat in Eleanor’s room when I felt like I was in a Samuel Beckett play. It was during these occasions that I came to know that Eleanor did not think she “understood” life but sought to understand it, like many of Beckett’s characters. This pursuit of trying to understand life that we shared was probably brought on because of traumas we had each carried like a heavy backpack on a long journey. But they pushed us to explore life and compelled us to share notes about our own unique journeys.

Often this sharing took place in her room where we would sit for hours discussing philosophy, psychology, the arts, and anything that helped us understand the trauma we had experienced. One of the things I loved about Eleanor was that she engaged many people to share whatever they knew about life, and a number of people visited her because of her openness to their experiences. Often others would join in and we would have rich and unexpected conversations.

Some of those discussions included deeply religious people who would tell us their take on the meaning of life, which usually involved heavy dogma. This often disappointed Eleanor and annoyed me, as some people went so far as to claim that my role in her life was to help her find Jesus. Independently, Eleanor and I had come to the conclusion that there is no knowing, only seeking.

Eleanor and I couldn’t relate to those who claim to “know” what life is about, like many religious people and statisticians. I believe as people who had to walk with trauma, she and I didn’t have that feeling of certainty about much in life. We lived in uncertainty and were caught in between statistics and religion.

Five years after Eleanor’s death, I haven’t met anyone quite like her, but I am still carrying my backpack and proudly upholding the values that we shared. I looked up the origin of her name, and of its many possible meanings, the one I think is most suitable to describe her is from the Latin root of the verb lenire, “to soothe or to heal.”

If anyone chooses to write about me after I die, I hope they have as difficult a time as I had in conveying a glimpse of Eleanor.

The Libertarian Endgame

On September 12, 2011, during CNN’s GOP Tea Party express debates, Wolf Blitzer posed a hypothetical question to Republican candidate Ron Paul, asking who should foot the bill for a healthy 30-year-old man who chooses not to buy health insurance and then suddenly ends up in a coma with expensive medical bills? Paul responded that freedom is about taking risks and personal responsibility, and it is not about the government taking care of everybody. Paul is a libertarian and, as such, believes that government should be as small as absolutely possible and only interfere in people’s lives for basic protection from hostile enemies and criminals.

Blitzer then asked, should we just let him die? Some in the audience cheered, “Yes, let him die!”  Many left leaning groups and individuals used this as a glaring example of the hypocrisy of the right. Republicans are a party that claims higher moral ground, conservative family values, and pro-life agendas, and yet at a party debate some verbalized support for a person dying because he couldn’t cover medical bills.

Paul himself said that we shouldn’t let him die, but he offered only altruistic church groups and charities as the solution. In 2012, medical expenses account for 60% of American bankruptcies.  So, leaving this incredible financial burden for church groups and charities to shoulder means that, in reality, many people would die.

The day after the debate, news broke that Paul’s close friend and 2008 campaign manager, Kent Snyder, died of pneumonia at age 49 after accruing more than $400,000 in medical bills. Paul and his staff raised $50,000 towards the bills, but the hospital bill was never paid off. Apparently, libertarians think it is acceptable for the hospital to eat that bill. So they overlook an important point about our medical system: we pay these bills by a back-door financial policy. Hospitals make up for this kind of unpaid bill by the raising the cost of everyone else’s medical care.

This issue is a defining moment for the US because one could easily blame the high costs of healthcare on the Emergency Medical and Treatment and Active Labor Act (EMTALA), which says hospitals that receive taxpayer money cannot refuse care to people. Would libertarians propose getting rid of the EMTALA? Is this the kind of society we want to live in?

One other reason why healthcare costs are high is that the US political system allows corporations to get so powerful that they can steer government policy towards their own interests. Using their monetary influence, they can break down regulation and fix the game in their favor. If, as libertarians believe, government should be small and only used in defense and the like, who will be there to regulate these big corporations when they are in total control? Their default answer is the invisible hand of the market. But even Adam Smith, the great hero of capitalism, extolled the benefits of the invisible hand only when there is a general well being among all citizens. 

I agree that when it comes to government intrusion on lives of its citizens, I think we should look at policies with a libertarian eye and not make a policy without a good reason. However, there is very good reason to provide health care, both for moral reasons, like those above, but also economic ones. The libertarian stance claims that when government gets involved, costs go up. Ron Paul frequently makes this argument in his speeches. I am not sure where their evidence comes from. Data shows instead that healthcare costs are lower in single-payer health systems.

When the ethical and practical reasons for a libertarian position on healthcare crumble, why continue to cling to the hard line?

Social Determinants of Health: is Psychosocial Stress the Primary Determinant and what are the Implications for the Field of Epidemiology?

The evidence linking social factors to health outcomes has been researched since the 1940s (Krieger, 2001). The so-called social determinants of health has generated its own field of research called social epidemiology. The whole field hinges on social constructs or structural hierarchies embedded in human societies that heavily affect health. Psychosocial stress is one such risk factor that has been identified as an explanation for how social factors influence health outcomes. One of the big debates in public health is centered on competing theories of causation for the social determinants of health. This paper is an analysis of what the argument between psychosocial theorists and the neo-materialists says about the future of epidemiology.

One of the largest studies to garner support for the psychosocial risk factor is a case-control study by Rosengren et al. (2004). This large, multicentre study found an association between psychosocial stress and acute myocardial infarction (AMI). The researchers operationalized psychosocial stress by asking questions about eight variables: stress at work, stress at home, general stress, financial stress, stressful life events, locus of control, feeling depressed, and clinical depression. They concluded that the effects of psychosocial stress were independent of lifestyle factors such as socioeconomic status, smoking, and education and that “the size of the effect was less than that for smoking but comparable with hypertension and abdominal obesity”(p. 961).

The three dominant models of causation for the social determinants of health are neo-materialism, psychosocial theories, and the effect modification hypothesis (Jayasinghe, 2011; Marmot and Wilkinson 2001)

The neo-materialists posit that the root cause is the structure of society and the political system, and that the key to solving this problem is through development—providing material needs to people. The psychosocial theory is closer to the biomedical model in that it argues that there is a direct effect on the body’s immune system through the impact of stress from the environment, and that leads to higher rates of mortality. The effect modification hypothesis positions stress as a “risk regulator” (Marmot and Wilkinson 2001). This means that people in low-income groups have higher levels of stress, which in turn causes those people to make poor lifestyle choices, such as smoking tobacco or consuming excessive amounts of alcohol, and thus have poor health outcomes (Lynch et al., 1997).

The heated debate between these differing camps of causal models is both political and methodological in nature. The neo-materialists posit that the major factor is one’s materials or assets and that having a home, car, and computer are proxies for a higher quality of life. Research has confirmed that once one’s basic needs are met, there are significant health improvements(Macleod, et al., 2001; Lynch et al., 1997). Neo-materialists derive a large part of their evidence from studies on the ecological level, which makes it difficult to generalize to individuals. They also argue that the material level is more amenable to change than psychosocial stress, saying that reducing stress throughout the population is difficult if not impossible (Marmot and Wilkinson 2001).

The psychosocial theorists contend that people’s health is more than their material circumstances and, moreover, that understanding the exact physiological mechanisms of action provides a clearer picture of the disease process(Marmot and Wilkinson 2001). The psychosocial variable has proven to be a highly stable measure, albeit sometimes a subjective one. One of the major points of contention is that humans cannot be randomized to treatment groups; therefore we cannot truly ascertain causation because we have to resort to animal models to experiment on. This type of research brings us closer to understanding causal mechanisms, but because humans and primates are vastly different—despite being 98% genetically similar—we cannot fully accept evidence from those studies. However, there has been compelling evidence in primate models that shows conclusively that social hierarchies lead directly to higher levels of stress in those species. Many psychosocial theorists have measured stress objectively with biomarkers such as cortisol and glucocorticoids, which lead directly to atherosclerotic plaque build up, a major risk factor for cardiovascular disease (Sapolsky, 2005). Another argument made by the psychosocial theorists is that social hierarchies embedded within a country mask the neo-materialist’s hypothesis and demonstrate that key components of the psychosocial variable, autonomy and social capital, are the important building blocks to good psychosocial health(Marmot and Wilkinson 2001).

The effect modification hypothesis has strong evidence linking low socioeconomic status (SES) with poor behavioural choices, and some studies have shown that people of low SES are less likely to change their behaviour (Lynch et al,1997). This means that people in low SES groups have higher levels of stress and, due to their low income, cannot afford higher quality foods and health care, which in turn negatively affects their health. Many argue that this blames the individual and is the least productive of all theories(Lynch et al,1997). The criticism here is not so much about methodology as it is about the politically unsavory way it analyzes people.

From a reductionist point of view, the psychosocial theorists have a stronger argument than the neo-materialists because newer technological advances create the possibility that as time advances our abilities to measure will get better and better. According to the hierarchy of evidence, ecological studies are lower ranking, and psychosocial studies command a higher level of evidence. But because it is so difficult to reduce the social determinants of health into neat categories such as education or SES, there is a call from some contemporary epidemiologists for a paradigm shift away from such reductionist searches for causation.(Jayasinghe, 2011; Krieger 1994; Glass and McAtee 2006) Although reductionism works well in identifying strong infectious agents, it is ill-equipped to handle many complex systems like the social determinants of health(Jayasinghe, 2011; Glass and McAtee 2006)

This debate about causation is a digression from the real issue, which is to find workable solutions to issues raised by the social determinants of health. Epidemiology is in a state of transition or stagnation, depending on whether you view the glass as half empty or full. Many epidemiologists seem content to push an outdated model that can’t address many of today’s problems(Jayasinghe, 2011; Krieger 1994; Glass and McAtee 2006) To refocus on problem solving means moving epidemiology from a field distracted by concern with causation and controlling for bias and shifting it instead towards following Kreiger’s assertion that whatever the means of causation, be it direct or indirect, intervening on social determinants such as education and early childhood development should be a high priority in addressing health outcomes (1996).

References:

1.Krieger, N. Theories for social epidemiology in the 21 century: an ecosocial perspective. International Journal of Epidemiology. (2001);30:668-677.
2.Rosengren, A., Hawken, S., Yusuf, S. et al. Association of Psychosocial Risk Factors with Risk of Acute Myocardial Infarction in 11,119 Cases and 13,648 Controls from 52 Countries (the INTERHEART study): Case-control study. Lancet. (2004);364:953-962.
3.Jayasinghe, S. Conceptualising population health: from mechanistic thinking to complexity science [electronic article]. Emerging themes in Epidemiology. (2011). 8:2 http://www.ete-online.com/content/8/1/2.
4.Marmot, M., Wilkinson, R.G. Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. British Medical Journal. (2001);322:1233-1236.
5.Lynch, J.W., Kaplan, G.A., Salonen, J.T. Why poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic life course. Social Science and Medicine. (1997); 44(6):809-819.
6.Macleod, J., Smith, S.D., Heslop, P., Metcalfe, C., Carroll, D., Hart, C.Are the effects of psychosocial exposures attributable to confounding? Evidence from a prospective observational study on psychological stress and mortality. J Epidemiol Community Health. (2001);55:878-884.
7.Sapolsky, R.M.The influence of social hierarchy on primate health. Science. (2005); 308(648); (doi: 10.1126/science.1106477).
8.Krieger, N. Epidemiology and the web of causation: has anyone seen the spider? Social Science Medicine. (1994);39(7):887-903.
9.Glass, T.A., McAtee, M.J. Behavioural science at the cross roads in public health: extending horizons, envisioning the future. Social Science and Medicine. (2006); 62:1657-1671.
10.Krieger, N., Zierler, S. What explains the public’s health?: A call for epidemiologic theory. Epidemiology.(1996);7(1):107-109.

Extreme Diets: Perfect for Reality TV

I wrote my last blog post, Moving towards a whole foods, plant-based diet, after earning a degree in Public Health that focused on chronic disease etiology and prevention. Then I accidentally bumped into a book called The China Study. When I read that book, little did I know I would be thrown into a storm of nutritional chaos theory in which academics are coming to blows over which diets work, how to lose weight, or whether one can even lose weight at all. My professors didn’t even mention this controversy.  Here is my take on this contentious issue.

The basic controversy can be split into two major groups, the “meat is bad” group and the “meat is good” group. Yes, I know it is a bit more complicated than that, but in lieu of writing a dissertation I am simplifying the arguments. Nestled within the “meat is bad” crowd, you have the low fat people, some of whom eat chicken and pork but steer clear of red meats, some vegetarians—which include every imaginable dietary configuration—and the extremists, the vegans. They are pitted against the “meat is good” group, among whom you will find the anti-carb Atkins crowd, the just-plain-carnivorous steak-a-day people, and the ultimate in carnivore, the Paleo-people, some of whom actually run down their own food with spears.

Meat is Bad

First, let’s look at the low fat “meat is bad” crowd. I think it is pretty intuitive that meat feels unhealthy. It is slower to digest, and fat is clearly visible on the product. So it is not too hard to see their basic argument: fat from animals is high in saturated fats, the kind of fat that clogs your arteries, and, putatively, is a major cause of heart attacks. There are many observational studies that support this claim. However, the evidence is highly inconsistent. Two important details often skirted over are that meat has lots of the good fat, too, and that carbohydrates can affect blood cholesterol levels as much as meat.  We also can’t overlook the fact that high consumption of meat is associated with colon cancer. The mechanism is not fully understood, and it could be the nitrates in preserved meats and not the actual meat that causes colon cancer. Also, there are concerns that cows are an inefficient food source because the inputs (feed) outweigh their outputs (meat). So if everyone were a vegetarian, food costs would be lower and the world would be a better place. But the purpose of this paper is to discuss heart disease and obesity.

One troubling flaw in the “meat is bad” argument is that Americans have been eating less red meat and less saturated fat since the low-fat craze of the 1980s, yet obesity has risen to epidemic proportions. It is also a fact that when people switch to a low-fat diet they increase their carb intake. In addition, there is recent research showing that cutting out too much protein lowers lean muscle mass, which is not a good thing.

 

Then there is the issue of dairy. When people become vegetarian, most think they have signed on to a healthier lifestyle when, in fact, they often replace their meat consumption with dairy, in the form of cheese, milk, cream sauces, etc.  India is the country with the highest prevalence of vegetarians. Vegetarianism has been integrated into Hindu religious practices and culture for thousands of years, and people there get most of their protein from lentils and dairy. Yet India has the highest levels of diabetes and obesity in the world.

Then there is veganism. Vegans disavow all meat, dairy, and other animal products, and they are seen as higher up on the dietary purity pyramid. I have eaten in many vegan and vegetarian restaurants. Anecdotally, I find that many of these dishes have high levels of salt and/or sugar. I think this is because evolutionarily our palettes are wired for salty, sweet, bitter, and sour, and our cells need fat to rebuild. So we have evolved to crave these tastes, and when you eliminate one of those tastes, you need to replace it with more of another.  

 

But the real clincher in my questioning of the “meat is bad” perspective comes from the science. In 2010, a thorough meta-analysis published in a prestigious nutrition journal pooled the results of 21 well-regarded studies on saturated fats and health. It showed no significant effect in the relationship between saturated fats and risk of CHD or stroke.  This is definitely a big blow towards the "conclusion" that a low-fat diet is a healthy diet. It also demonstrates how intractable nutritional dogma is because the low-fat diet is still taught in medical schools and health science departments and appears in guidelines used by public schools.

These two dietary choices seem to be based more on romance than evidence, from the health perspective. (I realize there are other reasons, such as ethics and environmentalism, that people choose these diets.) I was never able to put my finger on it until I opened up my undergraduate biology textbook to prepare for a nature walk with my son’s 2nd grade class. I saw an intriguing diagram of the relationship between autotrophs and heterotrophs. An autotroph is any organism that makes its own food, e.g. plants through photosynthesis. Heterotrophs are organisms that cannot do this, which means every animal on the planet has to hunt for food, either by eating the autotrophs or by killing and then eating those who eat autotrophs. Obviously, we are heterotrophs, but we have brains that have adapted a conscience, which means we can see the purity of making our own food and conversely see the pain that killing causes. I believe that some people have a romantic desire for a “pure” diet that appeases their conscience.   

Meat is Good

At the other extreme is the “meat is good” argument, which is based on evidence that our early hominid ancestors began eating meat more than a million years ago and that, from an evolutionary perspective, our bodies have had time to adapt to a diet of meat. In contrast, humans have only been cultivating the land for grains and veggies for the last 11,000 years, which some argue is not enough time for our bodies to have adapted. Thus, it becomes highly unlikely that meat is the cause of our suddenly expanding waistlines. Some archaeologists believe that the adaptation to meat aided in our brains becoming larger.

Bolstering this argument is the fact that many primitive peoples, such as the Hadza and Inuit, have survived on diets of almost pure meat, and they rarely were afflicted with any of the chronic diseases associated with obesity until coming in contact with westernized foods such as refined carbs and sugar. Gary Taubes, author of Good Calories, Bad Calories (GCBC), brilliantly argues that dietary fat is wrongly accused as the culprit in heart disease and points the finger at sugar as the real killer. Taubes’s argument is very convincing. He is backed up by some of the most respected researchers in the field of nutrition who have published papers on taxing and regulating sugar, especially sugar sweetened beverages. Certainly from an evolutionary perspective, for many primitive societies, sugar was a seasonal delicacy and thus its consumption was regulated by nature. That sugar—particularly in drinks like syrupy lattes, white flour, and fried foods—is bad for you is not a contentious issue.

The flaws in the “meat is good” argument lie mostly in the extremes of their position. Look at the way Atkins demands stopping all carbs, at least temporarily, and the diet has produced a processed protein snack market. And although Taubes quietly acknowledges that there are good carbs and bad, his questioning of assumptions that fruit is healthy because no one has ever done a random controlled trial testing its efficacy distracts from his main message and leads people to dismiss his entire argument. Taubes is committed to his position and even posts his diet (bacon, sausage, burgers, and steak daily) and his triglyceride levels on his blog, but the fact that he enlisted a psychiatrist friend to order the tests strikes me as kind of weird.

Then there are the Paleo Diet people who really get into the purity aspect of man the hunter, the meat consumer. To me this position borders on Paleolithic fantasy, with romantic images of man the pure hunter carnivore. Although the idea that our bodies are adapted to eating meat is a valid argument, this camp just takes it to a level of impracticality so glaringly obvious that it’s hard to believe how zealous Paleo people can be. Humans have been genetically modifying food, wild or domestic, since we learned how to control our environment through selection and domestication. So it is impossible to find a truly sustainable Paleo diet on this planet. In addition, there is an unrealistic assumption that there was a homogenized caveman diet. Some Pleistocene era people lived near coasts and some in woodlands. Carbs and grains were certainly available. So again, I see this dietary choice as grasping for an unattainable purity on the other extreme.

Made for TV Confusion and Chaos

I could see people from both sides literally duking it out on the Discovery Channel. It might make for good television when science gets mixed in with zealots fighting over their extreme position, but I am tired of dietary purity and fantasy and I just want the facts. I just want to eat good tasting and healthy meals. So, to me the question really boils down to this: what would you do if suddenly you were diagnosed with coronary heart disease?

One reasonable voice can be found from the author, Richard Wrangham, who wrote the book Catching Fire: How Cooking Made Us Human. He makes a convincing case that cooking food maximized our caloric intake and thus freed humans to develop larger brains. Even Darwin said that cooking was humanity’s greatest discovery aside from language. The Paleo people are correct in that foods that are high in calories and low in nutrients (foods such as fast foods, candies, and frozen meals and that are abundant in obesogenic environments) are nowhere to be found on the African savanna. These are the kinds of foods that our bodies have not evolved to metabolize properly and, unfortunately, they are perfectly suited to our busy lifestyles. Meat is a whole food and it is something we have evolved to eat and digest. But that doesn’t mean eating a prime rib every night is great, and it doesn’t mean root veggies are going to make you fat.

Another way of looking at these extreme positions is seeing where they overlap. Consider a Venn diagram, with an overlapped area (below). This is where both arguments tend to agree on a whole-food diet and both also agree that highly processed foods are not healthy. So really the BIG disagreement is that at one extreme, eating meat is bad and at the other, it is good, with a whole spectrum in between. In this situation, I stick to the center, the overlapped area. Based on current available evidence, controversial as it is, I believe we need to stick to a traditional balanced diet that includes meats and lots of good carbs, such as whole grains, fruits, and veggies.

This validates the Italian-American food values I was raised with. My family believed in eating fresh, whole foods.  There wasn’t a focus on meat, but it was never demonized or romanticized either. I am now inspired to continue with that tradition of making well-balanced, home-cooked meals with fresh ingredients.  We all must find some common ground and admit that using less sugar and salt, very little white flour, limiting alcohol to a drink or two per day, and increasing veggie consumption are the safest bets for health. Personally, I’d stay away from extreme diets, like Atkins, Paleo, and veganism. Many of those diets have some research behind them, and they are not totally implausible, but they always seem to go out further that the evidence suggests. As the prominent scientist Medawar once said, “The intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not.”

Moving towards a whole foods, plant-based diet

I love to cook, and when I say cook, I mean I love Mario Batali and Anthony Bourdain meals, heavy on the meat, fat, and cheese. I never had much of a sweet tooth, but I certainly cannot deny that I crave animal fat. You could put a fresh, homemade chocolate cake in front of me, and not even a taste bud stirs, but make a juicy dish of braised shorts ribs and I become one of those kids in a Mischel experiment.

Recently, my brother and I got into a little argument. We never argue. During a banal phone conversation, he claimed that if everyone turned vegan, the world would be a better place. Being the one with a Master’s degree in health science, I disputed his claim. I threw out some facts, which mostly demonstrated my own bias against veganism.

A few weeks passed, during which time I stumbled across T. Colin Campbell’s book The China Study. The author tells the story of growing up on a dairy farm, drinking milk and eating meat every day, and then coming to the realization that animal-based foods cause cancer, heart disease, and a smorgasbord of chronic diseases.

Campbell was a respected researcher at MIT, and his early research on casein (milk protein) showed that it facilitated cancer tumor production or tumorogenesis in the livers of rats, while vegetable protein suppressed tumor production. He conducted an impressive range of studies on animal models demonstrating that dietary fat from animals, either in milk or meat, facilitated cancer more than leading carcinogens such as aflatoxin. This evidence led him to conduct one of the largest human nutrition epidemiological studies, in China.

This observational study compared lifestyle, dietary factors, and standard biological measures to investigate the amount of influence on all major chronic diseases across most of China, a country with a vast array of regional differences.

One of his major points is that only a small percentage of cancer development can be explained by genetics, while what we eat plays a much larger role, even more than known chemical carcinogenic exposures.

Important findings from the China Study:

1.     High dietary fat is positively associated with heart disease (by increasing bad cholesterol in the blood) 

2.     High animal protein consumption is positively associated with high cholesterol

3.     High animal protein consumption is positively associated with breast cancer

4.     Low animal protein consumption is associated with later menarche in women (through estrogen)

5.     Later menarche is strongly protective against breast cancer

6.     Late menopause is associated with higher breast cancer

7.     Animal protein consumption extends exposure to estrogen because it initiates early menarche and later menopause

8.     Animal protein is associated with many other chronic diseases as well.

If you Google “critiques of the China Study,” you will find some solid, honest criticisms. There is no question that there are some flaws in the study. However, what large-scale, cross-cultural study doesn’t have issues? I myself worked on one in India, and I can say this is a difficult type of study to pull off without flaws. Some of the critiques I read say that Campbell is biased towards a plant-based diet and only looks at studies that confirm his perspective. I think this criticism is off-target. Campbell may very well be biased, but he is totally transparent on every level. There are no hidden deals with the fruit and veggie oligopoly, unlike the meat and dairy industries’ backing of research favorable to them.

Others say he extrapolates too much from his research, and I agree with this to a point. My biggest issues with Campbell's argument are these:

1.     China in the 1980’s had many differences with westernized nations, going well beyond diet alone.

2.     He does an excellent job explaining the pathogeneses of some cancers and casein but I am not clear on other cancers.

3.     World cancer stats from 2002 show India with less incidence, prevalence, and mortality than China. This could be explained by China’s increase in animal protein consumption due to increases in incomes, but incomes in India have risen as well. (Although most Indians are vegetarian, they consume high amounts of milk, cheese, yogurt, and other animal-source foods.) More on this below.

4.     Comparing rural population health to urban population health is problematic.

5.     Western-based questionnaires, although translated, are challenging in a different cultural context. For example, people in China could define some food items differently than people in the US.

Even though I feel there are some over generalizations, the author is very clear about the weaknesses of study designs and provides a breadth of evidence, including randomized trials involving diet. The fact that the author provides so many peer-reviewed studies is a strong aspect of the book.

His advice uses a precautionary principled approach. He notes that one should do some research on plant-based proteins and a few essential nutrients that plants do not provide.  He also points out that diet has a huge effect on one’s metabolism and that in turn affects one’s physical activity. So he is not saying, as some criticize, that all you need to do is change your diet. He says that it is the biggest factor to change and also points out that moderate exercise is necessary.

Another strength of the book is that Campbell provides detailed explanations of why other competing dietary theories miss the mark. More often than not, popular diets do not provide any evidence to check the claims they make. This book’s credibility lies in how Campbell frames his argument using a Hill’s criteria-type of evidence evaluation, which lays out all the mechanisms of actions and pathways, discussing and citing research other than his own, thus adding consistency, coherence, and plausibility to his argument. He doesn’t just present one argument or one pathway like so many dietary theories. Another fact that adds credibility to Campbell’s argument is that the American Cancer Society added their own dietary recommendations, while less stringent about animal-based protein, they recommend increasing vegetable consumption. This is intriguing because the author discusses that they were previously opposed to Campbell’s position regarding any association between diet and cancer. Clearly, Campbell is a pioneer in this area.

His dietary recommendations might be even more extreme than evidence dictates, but as he repeatedly advocates a more safe-than-sorry approach. This is where I feel he is especially refreshing in an area like health and nutrition, where industry has infiltrated every nook and cranny to propagate its agenda, from government agencies to universities. There is so much conflicting information that no one actually knows how much animal protein is too much. So it seems prudent to err on the side of consuming a lot less than the more generous recommendations allow.

Perhaps the biggest question lingering for me is that I would like to see Campbell address India in his analysis. During my own research in India, I conducted a 200-person survey of western fast food eating habits. India is a fascinating case because it is a country of vegetarians, but the disease that claims the most lives is cardiovascular disease (CVD).

For India’s Hindu majority cows are sacred, which changes diets in two ways:  a taboo against killing cows means little beef is consumed, and milk is considered a divine gift so it is consumed whole and is incorporated into many dishes. My longstanding criticism of vegetarianism applies here. Just because someone is vegetarian doesn’t necessarily mean that they eat “healthier.” Lots of junk food is technically vegetarian, and many vegetarians substitute high consumption of dairy products for meat.

Using Campbell’s argument, high dairy consumption could explain high CVD mortality in India. But I am not sure how cancer fits in. I will have to research cancer rates, but I do know that diary consumption in India is at least equal, if not significantly more, than in China. So I am curious if Campbell’s theory of casein as a cause for cancer addresses this inconsistency.

While there may be leaps in some of Campbell’s claims, I have no doubt that diet plays a huge role in health and disease. The associations he has compiled are truly impressive. Equally impressive is the fact that he is not trying to sell his own cookbook or proprietary food system. He lays out very simple, clear guidelines for people to follow to change their diet. It is not some 3-week crash diet but is nothing short of a paradigm shift of typical eating habits.

After reading The China Study, I am definitely decreasing my consumption of animal-based protein (and my family’s, since I do most of the cooking). It will be a slow and demanding process, but the evidence seems clear. Tonight: roasted zucchini, pan-roasted turnips with poppy seeds, and radicchio pancakes. Bon appetite!

Stay tuned for more updates on my dietary paradigm shift, as well as commentaries on the counter position that we owe our great gains in human evolution to a meat-based diet. That claim is important in the Paleo-Diet, the Atkins Diet, and Gary Taubes’s interesting book Good Calories, Bad Calories, which I’m reading now.

How our environment makes us fat

You could walk down the aisle of any place where people gather, like a mall or a Wal-Mart, and hear some remark pertaining to obesity. In fact, weight bias is a popular topic among health researchers. As someone who was obsessed with social psychology as an undergrad, I was not surprised to find the fundamental attribution error (FAE) at the core of this bias. The theory is simply that people often attribute personality faults to other individuals, but they rely on situational or environmental factors to explain their own behavior. In the case of obesity, many people often think of obese people as lazy and not very smart. Many people, especially in the US, think it comes down to personal responsibility.  However, if they themselves were obese they might blame too many hours at the office or too many family obligations for not having time to eat right and exercise, stacking the odds against weight loss.

Just to be clear, humans do make choices, but as the saying goes “genetics loads the gun and the environment pulls the trigger.” People usually make the easy choice. It is easy to blame obese people for their girth, especially in lieu of delving into the complexity of the obesity problem. So we shall dig a little deeper.  

The origin of homo sapiens could be 30,000 years ago or longer. For most of that time we lived in smaller groups, getting our food from hunting and gathering. The agricultural revolution didn’t happen for another 20,000 years. Thus most of our adaptations would have come about for the hunter-gatherer environment. Conservation of energy would have been key to surviving under those conditions. That means we would only use our precious energy if a lion were stalking us or if we were starving. If not, we would sit around and save resources until that lion attacked or food sources dwindled. Humans rarely had to worry about too much food; usually we had too little. Therefore, humans haven’t evolved to become sated. We have no upper limit to our food intake. Have you ever watched an episode of Man vs. Food? Nature was our fitness coach and our dietary regulator.

Add to this a market-driven food system with a laissez-faire governmental approach and you have a recipe for disaster. This is the most supported explanation for the rampant obesity problem facing the world today. How could 60% of human beings on this planet become lazy and fat in just a few generations? And most importantly, when our food system was based on natural cycles the prevalence of obesity was far less. With regards to evolution, our bodies have not had time to adapt to this new and seemingly endless supply of food.

Health researchers use the term “obesigenic environments” to describe environments that foster obesity. These are places that have a high density of fast food outlets, with little access to fresh fruits and vegetables, and with a scarcity of parks and green spaces. So the opportunities for eating healthier and for getting physical activity are decreased. Over the past few centuries, humans have created more and more comfortable environments for themselves, further disconnecting from nature’s regulatory features. Therefore, “fat and lazy” is not truly an accurate description of people who are obese. It gives short shrift to the massive changes humans have brought about during recent history.

If you are obese or know someone who is it might be more productive to take these factors into consideration before making a flippant remark or even blaming oneself for being overweight. By taking this perspective, more opportunities open up to intervene. Our work environments, our food shopping environments, and our neighborhoods all have contributed to our obesity problem, and they are the areas that quite possibly present some solutions. Interventions to built environments have been shown to help people increase their physical activity. By increasing access to fruits and vegetables people will make healthier choices. So instead of making the fundamental attribution error, maybe we should work towards identifying places to change the immediate environment so the easy choice can be the healthy choice.

The Prevention Paradox: an Argument for the Use of Individual-Centered Approaches for the Promotion of Healthy Body Weights

When a country is bombarded by multiple disease epidemics, the question of resource allocation is essential. Many people in public health first seek a population-level approach such as banning soda machines in schools. These large-scale interventions have been shown to shift the population towards a healthier mean (Puska, 2002). In spite of this, obesity manifests itself in a population in a complex and stochastic manner that often pits the food industry against public health and the health of individuals. For this case in particular, we need to take a two-pronged strategy, combining population approaches at individual-level interventions. One group doing this is the Centre for Healthy Weights - BC, a prototype clinic and provincial resource centre based at BC Children’s Hospital in Vancouver (2011).

The population approach to behaviour change was the brainchild of Geoffrey Rose, based on his research in Kenya, where he noticed that the population-mean blood pressure of Kenyan men was lower than men in England (Rose, 1985). This observation led him to use epidemiology for diagnosing a population instead of an individual. This produced a plethora of population-level interventions such as seat belt use and tobacco control measures.

Ever since Rose, public health has touted interventions at the population level as the most effective both in terms of cost and impact (Gaziano et al., 2007). We often forget that he also wrote about the weaknesses of population-level prevention. He explained that the “prevention paradox” leads to poor motivation for an individual to change his or her behaviour, and this in turn affects physician motivation (Rose, 1985). The prevention paradox explains how behaviours that are statistically risky at a population level might not actually result in an individual developing the disease. We all know the proverbial 90-year-old who smoked a pack of cigarettes a day, ate junk food, and is a better bowler than their younger teammates. The fact is that statistics cannot make predictions at the individual level. So in conjunction with a population approach we need to work with individuals to create positive lifestyle changes, particularly those people with a propensity towards visceral adiposity. Geoffrey Rose called this approach of using “interventions that are appropriate to the particular individuals advised to take them” a “high-risk” strategy (p. 35,1985).

This is why targeting at-risk children for lifestyle change, like the method used by the Centre for Healthy Weights - BC, is one way to expand beyond a population approach. The centre doesn’t use a one-size-fits-all strategy because obesity is a complex epidemic, manifesting itself differently in each individual. Thus it also calls for a contextualized approach, which customizes behaviour change according to an individual’s needs. This helps families navigate through the complex minefield of risk factors created by technologized societies. By delivering health education based on the strengths and weakness of the particular family, the customized health education approach helps each family learn how to make sustainable healthy choices. For example, if a family that has good eating but poor exercise habits gets referred to the centre, the interdisciplinary team will work with the family to overcome obstacles to integrating physical activity into their lives while supporting and acknowledging the family’s strengths.

Although a contextualized approach would not be cost-effective for the whole population, we must remember that Rose himself, in his classic paper “Sick Individuals and Sick Populations”, called for using a high-risk strategy and a population strategy side by side (1985). In fighting a complex problem like obesity, the question of cost-effectiveness might not be the right question. On the one-hand, the CHW might not appear to be cost-effective, but considering how healthy options are thwarted by so many factors in this consumer-driven society, we need to embrace behavior change at the individual level while working at the population level to make the healthy choices easier.



References

Centre for Healthy Weights – BC (2011). Services. Retrieved on March 12, 2011 from http://www.bcchildrens.ca/Services/SpecializedPediatrics/CentreHealthyWeights/Services/default.htm

Puska, P. (2002). Successful prevention of non-communicable disease: 25 year experiences with North Karelia Project in Finland. Public Health Medicine, 4(1):5-7.

Gaziano, T.A., Galea, G., Reddy, K.S. (2007). Scaling up interventions for chronic disease prevention: the evidence. Lancet, 370:1939-146.

Rose G. (1985). Sick individuals and sick populations. International
Journal of Epidemiology, 14: 32–38.

Concept Mapping: Quelling the Anxiety of Complex Problems

Some public health problems are pretty straightforward. Implementing a vaccination program in an area of high incidence of polio, for example, might be fraught with political or infrastructure obstacles, but we know if we administer the vaccine to the population, polio will decrease and lives will be saved. This is a “tame problem.” On the other hand, there are large, abstract issues whose boundaries are unclear, which are aptly called “wicked problems” (Rittel and Webber, 1973).

One such wicked problem is insidious, spanning all levels of society, from the cell to the population, and it has kept me up for more nights than I care to admit. This is the social determinants of health, the complex web of socioeconomic conditions that affect the health of individuals as well as communities (Raphael, 2004).

A video on the social determinants of health by Lemongrass Media commissioned by Vancouver Coastal Health clearly demonstrates the predicament. It features a married couple representing people of high socioeconomic status (SES) and two unmarried individuals representing people of low SES. This cinematic juxtaposition of high and low SES brings home the message that social factors and money affect the quality of one’s life and health. That stark contrast also brought up many emotions for me when witnessing how people of lower SES struggle with being able to access the services needed to raise a child or even pay for necessary medications (2010).

One of the obstacles endemic to addressing wicked problems is how overwhelming they can be, setting in a kind of stress-induced paralysis (Finegood, 2011). A common stress management tool is to break down a large problem into smaller problems and tackle them one by one. This is where the process of concept mapping can be extremely useful.

Another way of looking at concept mapping is creating a “thinking tool,” which can help access one’s tacit beliefs regarding an intractable problem. The authors of Sketching at Work describe their book as a guide to visual problem solving, stating that concept mapping “invites the drawer to explore a change in perspective” (Eppler and Pfister, 2010, p. 7).

In my own process of concept mapping of the social determinants of health, I realized that I previously thought researching causation and helping people were the same thing. But making a concept map helped me realize that this wicked problem is so complex that if we took the time to fully determine causation before acting, more and more people would be lost.

When I sketched out the pathways that led to poor health I saw how one’s level of education is clearly connected to the kinds of jobs one can attain and how that leads directly to the amount of income one can make. Those pathways are interconnected with healthcare access, food choices, autonomy, security, and awareness of risk and disease. All of these factors are interrelated and extremely complex. Real people are dying every day, and there comes a time when scientists have to put the search for causation on hold and apply their powers to ameliorating the problem. I finally understood why Kreiger and Zierler call for epidemiologic theory to go beyond the narrow focus of “modeling causation and explaining error” (1996) and instead espouse that whatever the means of causation, be it direct or indirect, intervening in social determinants such as education and early childhood development is a high priority.

Because drawing a concept map helped me get to a deeper understanding of this wicked problem, others on the causation bandwagon might be served by making their own map. Fixating on causation in part perpetuates the problem by creating a delay in action. Changing perspective is important in helping science become more aware of the complexity of the problem and move towards figuring out solutions without understanding exact casual mechanisms.

References:

Eppler, M.J., Pfister, R. (2010). Sketching at Work. Switzerland:University of St. Gallen.

Finegood, D.T. (2011).The complex systems science of obesity In J. Cawley, (Ed.), Handbook of the social science of obesity. (p 1-48). USA: Oxford University Press.

Krieger, N., Zierler, S. (1996). What explains the public’s health?: A call for epidemiologic theory. Epidemiology, 7(1):107-109.

Lemongrass Media (2010). Videos: Social Determinants of Health. Retrieved on January 26, 2011 from http://mainsite.lemongrassmedia.net/pop-health-the-new-agenda/

Raphael, D.(2004) editor. Social Determinants of Health:Canadian Perspective: Canadian Scholars’ Press Inc. Toronto

Rittle H.W.J., Webber, M.M., (1973). Dilemmas in a general theory of planning. Policy Sciences, 4: 155-169.

Justifying Simplicity in the Face of Complexity

Anyone contemplating the problem of chronic disease plaguing countries in the second or third stages of the epidemiologic transition has to be awed by its overwhelming complexity. Of course, many of these diseases are heavily influenced by modern dietary patterns interwoven with many biological and social factors (Popkin 2001; Glass and McAtee, 2006). Here in Canada the problem is no less significant, and Health Canada is working hard on this problem. One area that I will focus on is the food guide, which was developed as one small tool in this battle.

When looking at the latest iteration of Health Canada’s food guide the first graphical element I see is a dizzying array of information simultaneously competing for attention. Further compounding the problem is a cacophony of nutritional messages that come in every shape and form of media, from TV to magazines to Twitter. The overall picture can totally bewilder anyone trying to make healthy lifestyle changes. It is no surprise that public health’s efforts to change behavior are equally as complex as the problems they are trying to change, but does the messaging have to be complex, too?

One important theory from social psychology says no. The limited resource view, developed by Roy Baumeister, states that the brain has only so much glucose to devote to given tasks, and when glucose levels become depleted people will give up more challenging problems (Baumeister et al, 2003;Baumeister and Vohs, 2007). One such challenging problem is changing one’s behavior. People of low socioeconomic status (SES) tend to be taxed by social exclusion, prejudice, and higher levels of work stress (Marmot, 2005). Thus, when faced with challenges like losing weight, exercising, or changing dietary habits, many people simply throw in the towel and quit (Baumeister et al, 2003). I think Health Canada’s food guide can take some advice from this theory and simplify its message.

Here are my three recommendations to Health Canada’s Food Guide Advisory Committee. One is to make a commitment to simpler, more meaningful messages that an average person can understand and follow. Forget about the recommended daily allowances of dairy, grains, proteins, and oils and fats plus leave off the last page with 8 other recommendations. It’s too much information. Focus on the part with the biggest bang for the buck: fruits and vegetables.

If there is one thing you can suggest about increasing health through dietary change it is increasing consumption of fruit and vegetables. Increased fruit and vegetable consumption is associated with eating less processed foods and reducing mortality from coronary heart disease (CHD) and many types of cancer (Crowe et al, 2011:Dauchet et al., 2006). Those two diseases claim the most lives of Canadians (WHO, 2005).

My second recommendation to Health Canada would be that instead of spending so much money and effort on a printed food guide that is widely distributed, I would use the budget differently. I would scale down the food guide and make it web-only, targeted to health educators, institutions who specifically need it, and motivated individuals. Then I would hire a marketing/PR firm to develop a really simple, punchy logo/image and ad campaign to focus on the essential message, one that becomes engrained in the public psyche.

Finally, my third approach would be to work like gangbusters to convince partners in the battle against chronic disease, such as the Heart and Stroke Foundation, BC Cancer Agency and others, to support Health Canada’s message for increasing fruit and vegetable consumption.

Creating a movement of social change needs a consistent, simple message. The average person is being bombarded by all kinds of information; they are stressed and they don’t have the cognitive resources to make the kinds of changes that the current food guide recommends. They just need a simple message to follow.



References

Baumeister, R., Vohs, K.D. (2007). Self-regulation, ego depletion, and motivation. Social and Personality Psychology Compass , 1(1):115-128 DOI:10.111/j.1751-90042007.0001.x

Crowe FL, Roddam AW, Key TJ, et al European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart Study Collaborators. (2011). Fruit and vegetable intake and mortality from ischaemic heart disease: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study. Eur Heart J 2011; DOI:10.1093/eurheartj/ehq465.

Dauchet, L., Amouyel, P., Hercberg, S., Dallongerville, J. (2006). Fruit and vegetable consumption and risk of coronary heart disease: a metanalysis of cohort studies. Journal of Nutrition, 136(10):2588-2593.

Glass, T.A., McAtee, M.J. (2006). Behavioural science at the cross roads in public health: extending horizons, envisioning the future. Social Science and Medicine 62:1657-1671.

Marmot, M.(2005). Social determinants of health inequalities. Lancet, 365:1099-104.

Psychosocial Stress and CVD

It seems like eons that I have been trying to write a blog post that discusses how social factors influence health without losing the depth and complexity of the issue. Recently, I made a simple short status update on Facebook about psychosocial stress and cardiovascular disease(CVD). Quickly, some of my friends from all corners of the US chimed in and enriched my understanding of the topic. I then sat down trying to write another post after being influenced by all of my friend's input. Soon, I realized that this discussion took a more organic approach; similar to that of a grad seminar session, and it was already captured in print. After getting the permission of all but one of my friends/contributors, I posted it. I am so thankful to have such curious friends who love to engage in these types of deep discussions.


Chris Aloia:
Doing a lot of reading on psychosocial stress and CVD. Wow, mind blowing!

Katherine Moss: What's CVD?

Barbara Martinez: Cardiovascular disease

Katherine Moss: Ahhh thanks.

Name withheld and writing rephrased: Can you elaborate on what you are studying? It seems obvious that stress causes disease is there anything else?

Chris Aloia: a direct causative pathway has not been established etiologically, at least in humans. Most of the research points to stress as a modifier. Meaning that high stress causes poor lifestyle choices, which lead to poor health outcomes. Only a few researchers consider stress a direct cause. So there is a big debate that has been going on for at least 10 years and it has my full attention.

Dana Janezic: The evidence is there for a direct cause in baboons though so it really won't surprise me when they find it for humans.

Chris Aloia: yeah, Sapolsky again! But you can't randomize humans to stress. I think one group in Germany did it once, it is called torture. But there have been some awesome studies by extremely clever researchers. I buy it as a direct causal agent. The implications are intense!

Katherine Moss: Kind of gives new meaning to the phrase "broken hearted"

Dana Janezic: I'm of the school that thinks that when it comes to testing humans, we will be creative enough to come up with tests that don't involve torture. I really don't understand people who just give up and relegate human sciences to soft sciences... when we live in a world where people were creative enough to figure out how to test for the existence of neutrinos.

You're absolutely right, the implications are paramount. Think about the 30 year fixed rate mortgage in these terms. 30 years is a long long time for bad things to happen to a person all the while they have the stress of the obligation on that monthly note. It's particularly interesting when you consider the fact that the 30yfrm is a political creation...

Aaron Irons: Stress can indeed be a direct cause of cvd, whether left brained methods of perception, research or experimentation come to a widely held consensus or not. I mean that respectfully, while recognizing inherent biases in perception and thus accepted routes of validation which can become so familiar and accepted that the mental structures used to do analytical analysis can become their own barriers to equally valid insights and experience as well. With this respected such methods certainly have their use and place. As long as we remember to also release over attachment to them and allow for equal validity of so called right brain feeling, experiential, creative and perceptual capacities.
Even the short term effects of perceived stress with its effects of blood pressure, heart rate, adrenaline, fight or flight response can noticeably effect cardiovascular system unhealthfully to point of triggering angina, heart attacks and possibly strokes. Body sometimes overcompensates in its responses to perceived stressors by releasing, inhibiting or creating insulating fats, hormones or other chemicals which can have their own damaging effects.

Chris Aloia: Aaron, you bring up a great point. There is consensus that acute stress can induce a heart attack. However, short term stress does affect the cardiovascular system but to extrapolate that to CVD mortality is where things get VERY hazy.

And you are also right that individual perceptions of stress play major role, which again confounds the stress as direct causal agent theory because what triggers one person's stress response may not another.

Everyone is searching for hormones that are more stable markers for early stage CVD. Even Sapolsky has baboon blood in storage for the sole purpose of a discovery of a new hormones. Incredible! Thanks to all for posting. it helps me put this whole field into perspective.

Katherine Moss: Here's an idea for a study that doesn't involve torture. Put out a call for volunteers to participate in a study who describe themselves as "under severe stress". They would fill out a form describing their stressors: such as death in the family, job loss, divorce, child with medical issues, etc. Maybe they could be interviewed as well. Interview questions could include what level of social support people have, how often they see family and friends, if they feel comfortable discussing problems, if they belong to a church or other clubs, etc...Then they donate blood and it is examined. They have full cardiovascular workup. It could be a longitudinal study where they follow same subjects over time and ask about their stress levels and then compare results of heart tests? I realise that self selection isn't the best way to gather participants, BUT you would be getting people who subjectively see themselves as "stressed" which, as you say, varies from person to person even though they may be going through the same situations one person's stress might be greater than another. Just some thoughts. I'm sure someone is already doing this type of thing?

Chris Aloia: Yeah this has been done many times. The key is there is NO stable measure of stress. Self-reported stress can be confounded by lifestyle choices because people who report higher levels of stress are usually of low-income. low-education, they smoke more, etc etc. So no one knows which causes what. Does stress cause poor lifestyle choices? Do poor lifestyle choices create higher levels of stress? Is it education? Is it childhood SES? Crazy interwoven complexity and I love it.

Katherine Moss: What if the researchers eliminated those of low income or education or those who smoke from the pool?

Katherine Moss: I'm sure there are plenty of rich, well educated smokers who are stressed. In fact, they could use college professors as a start! LOL

Chris Aloia: Besides all these very interesting ideas above, there is also a political side. There is a mountain of evidence that shows a good chunk of the explanation for poor health outcomes are from social structures. The implication here is that what many call "human agency" is not as strong as some Republicans might argue. The pulling one up from the boot straps happens a lot a lot a lot less in low-income areas and even middle-income as well. This means the elites not only get the cash, the babes, the vacations, but they also live longer. Got to love that! Human civilization is more animal than human in my mind. I have no trouble with Darwin.

Katerine Moss: sad but true.

Sustainable Health Promotion

On February 2nd, Denise Stevens, the head of Matrix Public Health Solutions, the company that leads the Community Interventions for Health (CIH) project, was beamed into our classroom via Skype to present the CIH project strategy for chronic disease prevention. She laid out an extremely ambitious health promotion strategy that spanned 3 risk factors: tobacco, unhealthy diet, and physical activity; 3 countries: Mexico, India, and China; and 4 approaches: health education, social marketing, community mobilization, and structural change (Stevens, 2011).

The CIH intervention I think is the most emblematic of what it takes for sustainable health promotion is their tobacco reduction campaign in China, which has “smoking center inspectors” enforcing a city wide no-smoking ordinance. This one got my attention because not just anybody can waltz into China, a country that the WHO reports is “the world's largest producer and consumer of tobacco,” and establish an anti-smoking police force to enforce a CIH strategy. I had been studying sustainable health promotion for almost a decade, from WHO’s EPI to BRAC and including my own struggles with small-scale community health promotion. It seems I have never been able to grasp that elusive ingredient for sustainable health promotion. So here was someone drinking from the Holy Grail; I shot my hand up to ask, “how did you make that happen and who pays for it?”

It turned out that she knows the retired head of the Chinese version of the CDC and that the Pepsico foundation is a major funder behind CIH’s projects. She pointed out the prestige that comes from working with American partners is a bigger incentive for many of her international partners than money.

This funding and prestige revelation led me to research the Pepsico Foundation. Its goals and mission are in step with Pepsico’s own corporate mission and are found on the corporate website. CEO Indra Nooyi supports taking the lead in corporate responsibility and cultivating sustainability in the environment and health arenas (2010b). With Pepsico specifically in mind, I drew a concept map to illustrate the interaction between a corporation attempting to create a sustainable health promotion program in a globalized world and the communities it serves. With Pepsico’s war chest and corporate efficiency, they can fund community projects all over the world and gain access to academic and political elites “to help devise solutions to key global challenges” (Pepsico, 2010b). My map also shows the cycle of profits that fuel Pepsico, as their mission cannot be totally altruistic.

The hard truth is that health systems all over the world struggle to deliver primary care or health promotion, especially to the least fortunate (Frownfelter and Dean, 2006; Holman and Lorig, 2004). One of the main reasons for this is that the demand for secondary and tertiary care is less affected by price (Roberts et al, 2004). This means that when people are sick they are willing to pay whatever it costs to save their own life. This high demand creates a stable need for professionals and thus status becomes attached.

“Basic food” is another high demand commodity (Roberts et al., 2004 p. 164). There will always be a demand for food, and companies that control the food market are some of the richest and most powerful. Ironically, many of their products are partly responsible for exacerbating the prevalence of some chronic diseases.

In contrast, health promotion, and even primary care are extremely price sensitive and do not generate the high revenues like acute care services (Roberts et al., 2004). Simply put, people in general don’t value something that may prevent possible future costs and are less willing to create a demand for those services. This is why I believe that corporations are better poised to deliver health promotion. The new trend in corporate responsibility and sustainability provides the funding, visibility, and sustainability for health promotion in ways that other entities cannot support. Thus, it is important that we in public health can see this as an opportunity to develop public-private partnerships to ensure that such corporate campaigns deliver the right information.


References

Frownfelter, D., Dean, E. (2006). Cardiovascular and pulmonary physical therapy evidence and practice. St. Louis, Missouri: Mosby Inc.

Holman, H., Lorig, K. (2004). Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119:239-243.

Pepisco. (2010a). Corporate fact sheet. Retreived on . Retrieved on February 6, 2011 from www.pepsico.com/Download/PepsiCoCorporateFactSheet.pdf

Pepisco. (2010b). Letter from Indra Nooyi. Retrieved on February 6, 2011 from http://www.pepsico.com/Purpose/Performance-with-Purpose/Letter-from-Indra-Nooyi.html

Roberts, M. J., Hsiao, W., Berman, P., Reich, M.R. (2004). Getting Health Reform Right: A Guide to Improving Perfomance and Equity. New York, Oxford University Press.

Stevens, D. (2011). A systems oriented solution to a complex public health problem. [PowerPoint slides] Retrieved on February 19, 2011 from Simon Fraser University webct http://webct.sfu.ca/webct/cobaltMainFrame.dowebct?appforward=/webct/viewMyWebCT.dowebct

WHO. Towards a tobacco-free China. Retrieved on February 16, 2011 from http://www.wpro.who.int/china/sites/tfi/

The History of Tai Chi and Health-Part V: Tai Chi in Western Culture

This is the last article in the history of Tai Chi and Health series

The current view of Tai Chi in Western popular culture is that it is primarily a Chinese exercise for elderly people, and not one particularly ideal for cardiorespiratory fitness. Some people who are interested in martial arts see Tai Chi as a viable form of martial arts training. The definition used commonly by both Western and Eastern researchers is that “Tai Chi is a low impact, low to moderate intensity exercise incorporating elements of balance, strength, flexibility, relaxation, and body alignment” (Taylor-Piliae and Froelicher, 2004, p.49).

A broader view, however, is presented in a 2002 demographic survey done in the United States, which found that more than 2.5 million people practiced Tai Chi and 500,000 practiced Qigong (Birdee et al., 2009). The age range was evenly split throughout all age groups, countering the stereotype that Tai Chi is primarily for older adults. Birdee et al. posit that because Tai Chi has roots in martial arts, it increasingly may be viewed as masculine and attractive to younger people (2009). The majority of the Tai Chi and Qigong users was Caucasian, but proportionately there was no difference in race or ethnicity; most had a healthy BMI and self-reported good health. The authors also found that 11.4% of the users practiced Tai Chi for a cardiovascular workout. From this study, it would appear that a large number of people perceive Tai Chi as a cardiovascular workout and good for health maintenance.



It is really important to stay open and re-invent yourself and re-invent Tai Chi. Many people, especially physical activity researchers want to place activities into categories. As a researcher myself, I understand the rationale for this. There has to be some kind of standardization so other researchers can test hypotheses. The problem is then the practice becomes limited. As a Tai Chi practitioner and someone who wants their life to be a work of art, I seek to be unlimited. Tai Chi is fresh and new NOT only an ancient exercise for elderly people.

The History of Tai Chi and Health-Part IV: Tai Chi and Chronic Disease

In 1973 in Hunan Province, an archaeologist unearthed a silk scroll dating back to c. 168 B.C., which depicted exercise postures. Below each embroidered pictograph was a written “exercise prescription” for different types of diseases, many of which were chronic conditions (Cohen, 1997). This evidence suggests that long before this recent surge in research, early Taoists had devised a method of self-care in the form of exercise to manage chronic conditions. Today, a growing body of evidence suggests that Tai Chi may be an efficacious intervention for the primary, secondary and tertiary prevention of CVD, diabetes, and the determinants of those diseases (Kaptchuk, 2000; Taylor-Piliae and Froelicher, 2004; Thornton, 2008; Yeh et al., 2008). However, of all the studies conducted on a broad variety of diseases, the literature on Tai Chi for the primary prevention of CVD is one of the least explored.