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.

The History of Tai Chi and Health-Part III: Tai Chi’s Use for Health Promotion

When Mao Zedong took power of China in 1949, he outlawed all traditional practices, including TCM, Tai Chi, and Qigong, and viewed them as superstitious (Chen, 2004). However, during health reforms Mao and his advisors began to see Traditional Chinese Medicine, including Tai Chi and Qigong, as an opportunity to aid in primary healthcare (Xu, 2010). Mao saw individual physical fitness as a sign of a strong nation. Qigong and Tai Chi fit into his vision of active masses, and his efforts in primary care inspired much of the Alma Ata conference in 1978 (Janes, 1999; Xu, 2010). Because Mao was a modernist who believed in science, a tremendous research effort began to explore Tai Chi and Qigong. Thus, Tai Chi and Qigong had to prove not to be merely a mystical superstition through using tools of scientific observation, which at that time were mainly large case studies (Kaptchuk, 2000; Xu, 2010).

Today in North America, Tai Chi has a variable and intense research history. It has been used and studied as an intervention on AIDS patients, haemophiliacs and just about every type of disease imaginable. One search on Google Scholar using the search term “Tai Chi” yielded 24,700 hits, and a search of the Cochrane Library website brought up reviews on Tai Chi and hypertension, headaches, depression, rheumatoid arthritis, fall reduction, and dementia.

One of the first influential studies on Tai Chi in the US was in 1996, when a team of researchers received funding from the National Institutes of Health to study Tai Chi and fall reduction (Wolf et al., 1996). There have been many studies replicating its efficacy in fall reduction, and it is included in many recommended guidelines for that purpose, including those issued by the Canadian Society of Exercise Physiology (CSEP, 2008), the US Department of Health and Human Services (US DHHS, 2008) and the American Physical Therapy Association (APTA, 1999).

Not many studies have been conducted on exploring its potential use in primary prevention, meaning preventing disease before people get a disease. I think this lack of research has to do with many preconceived notions people have linking Tai Chi with elderly people or because it is slow. Also, there is some controversy in exercise science fields as to how much of a role VO2max plays in prevention of cardiovascular disease. Recently, there has been some research that suggests musculo-skeletal strength plays a larger role than previously thought. If that is the case Tai Chi can maybe a good exercise for the primary prevention of cardiovascular disease.

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

The History of Tai Chi and Health-Part II: The origin of Tai Chi

The origins of Tai Chi are rooted in mythical Chinese culture. The Chinese credit the celebrated hero Zhang San Feng with the creation of Tai Chi. Legend has it that he observed a hawk attacking a snake. As the battle between the two animals ensued, the snake repeatedly used relaxed evasive movements to elude the aggressive attacks of the hawk. Finally, the exhausted and frustrated hawk flew away. There are several versions, using different birds, but this is the basic myth (Frank, 2003). However, the true origins of Tai Chi are in dispute. The first historical record shows Tai Chi was developed in the 17th century in Chen Village (Yang, 2010). Later, Tai Chi was passed on to Yang Lu Chan, who developed the Yang style, which is now the most popular and most researched.

Yang Lu Chan’s grandson Yang Cheng Fu became the inheritor of the Yang tradition. He defined Tai Chi as “the art of concealing hardness within softness, like a needle in cotton” and asserted that “its technique, physiology, and mechanics all involve considerable philosophic principles” (Wile, 1983, p.3). He popularized Tai Chi for the masses and distinguished two levels, the civil and the martial (Wile, 1983). The civil is the “essence” and can be used for development of health, which is referred to as a type of gong, or practice or skill. In this way it falls under the umbrella of Qigong, a type of Qi-based exercise that literally means the practice (gong) of moving life’s vital energy (Qi) (Cohen, 1997). The martial is the “function,” which has the civil in mind but can be used for self-defense (Wile, 1983). Traditionally, Tai Chi is often taught in this martial manner, in which learning the form is not an end unto itself but a first step in which the basics are internalized. Then, after a year or so, the student learns push hands and sword practice. Thus, Tai Chi is a martial art that contains within it self-healing principles intertwined in martial movements.

As Tai Chi has developed through the centuries and through various schools of practice, it has become not one specific set of movements but can be practiced in different forms. Empty hand forms are usually the main focus of most Tai Chi classes. “Long forms” contain many more movements than “short forms,” which are not traditional but are modified to ease the learning curve. Different traditional styles are descended from the Chen but have evolved as various families transformed them, including the Yang, Wu, Sun, and Li styles. The variability of forms and intensities of physical activity among them is one of the challenges in understanding Tai Chi.

This infusion of healing movements with martial movements signifies Tai Chi as a unique exercise. Many people compare it to Yoga but it is quite different because of this martial aspect. I know of many people who study Tai Chi solely for martial practices but predominantly Tai Chi is a healing exercise. This is especially the case in the US, where so many combative styles are promoted. Tai Chi has a comparative advantage in that it offers a mindfulness Qi-based exercise.

The next post will explore Tai Chi’s involvement in Health Promotion

The History of Tai Chi and Health-Part I: Tai Chi and Traditional Chinese Medicine

This series of blog posts will be in 5 parts. Hopefully providing a broad and in-depth picture of Tai Chi. For the first installment of The History of Tai Chi, we must explore its connection to traditional Chinese medicine or TCM.

Tai Chi is part of traditional Chinese medicine (TCM), both of which are indigenous practices from China. Because these holistic approaches are rooted in a time when doctors did not have today’s powerful medical and technological tools at their disposal, physicians tended to treat the whole person and the environment around them (Cohen, 1997; Kaptchuk, 2000). TCM, born thousands of years ago, epitomizes this approach (Hong, 2004; Kaptchuk, 2000). Health systems of that era were radically different from today, with no medical technology to speak of; secondary and tertiary prevention was not as efficient or effective. Consequently, people who lived prior to the advent of modern medicine had to be resourceful and devise systems of primary prevention, which were essential for survival.

At the basis of the TCM system stands Qi, which is often translated as a fundamental form of vital energy that animates all living things (Yang, 2009). Some scholars explain Qi’s place in Chinese thought as “a formless ‘reality,’ which, though not graspable by the senses, is immanent in all things” (Xu, 2010, p. 967). This belief in Qi is also essential to Tai Chi, which shares many principles with TCM and has been integrated into the TCM system.

Both Tai Chi and TCM are rooted in the Chinese philosophy called Taoism, which is based on intense observations of patterns in nature, such as the movement of water, wind, and rocks. Early Taoists developed treatises on longevity, hygiene, and immortality, and these ideas fuel much of Chinese culture. Feng Shui, dietetics, martial arts, painting, and TCM all use the same paradigm or explanatory model of how the universe works (Kaptchuk, 2000; Kohn, 1993; March, 1968). The individual is but a microcosm of the universe, and to achieve harmony or happiness, one should align himself or herself with Qi to stay in harmony with the melding of energy and matter (Kaptchuk, 2000). If an individual becomes un-aligned or a blockage occurs, then disharmony can fester and “dis-ease” or disease will result (Yang, 2009).

Taoism is represented graphically by the icon known in the west as the “yin-yang” symbol, which illustrates a balanced interrelationship of opposites—for example, night and day, and hot and cold, etc. (Frank, 2003; Kaptchuk, 2000). Embedded in its Taoist roots, Tai Chi literally means “grand ultimate point,” (Yang, 2008) the point of balance in the yin-yang. The oldest known writing that discusses yin-yang theory is the “I Ching,” or “The Book of Changes,” which describes the natural ebb and flow of energy in the universe and how that effects change, written during the Bronze Age, 1100 B.C. (Hong, 2004) (Yang, 2010). Tai Chi’s main aim, to harmonize or align oneself with Qi, was summed up by the Taoist sage Chuang Tzu in the 4th century B.C.: “Set your body straight, see everything as one, and natural harmony will be with you“ (Lan, 2002, p.217).

Next post will explore the beginnings of Tai Chi.

Alton Brown and the Science Behind Salt

For a few years in late 1990’s, I worked in a kitchen gadget store in Seattle. We made many product recommendations to our customers, and of all the celebrity chefs we touted, Alton Brown received the highest ratings. Unfortunately, he chose to use his celebrity status and reputation against the public health campaign for salt reduction.

Alton Brown is a successful author, television show chef, and TV show presenter who writes and produces many cooking shows on the Food Network. Brown’s main show, “Good Eats,” presents him as a culinary expert, and his television work has made him a very influential person in the food industry. That is why I was shocked and disappointed to see Brown adding his unique touch of comedy and science to the promotion of salt, sponsored by Cargill, a multinational corporation that produces salt and other food products. Cargill and many others in the processed food industry have been battling public health and its salt reduction campaigns since the 1970’s

Cargill’s latest crusade to promote salt includes an interactive website dedicated to Brown’s pitch: http://www.salt101.com/#/intro. The website features Brown as a tour guide/lecturer at Salt 101 Labs. In an extremely formal environment that screams power, he spouts about 10 facts about salt, such as “salt is goood!” “salt is a necessary component to the natural functioning of cells,” “sodium chloride, NaCl, is a compound all humans need to survive,” and “whoever controls salt is in power, and in my home it is me; I control the salt.” The message is clear, salt is not only tasty, but it is also good for you, life sustaining, and powerful. There are also interactive games where, for example, you can move Brown’s arm to season a meal with salt.

After viewing the intro, the user can click to enter the “lab” or the “kitchen.” Both links present authoritative information about salt with a bias towards using more. Brown is in his element explaining technical details to viewers. He excels at explaining the science of food, such as human taste, the chemical make-up of salt, and why it is so effective at enhancing flavor. The scientific facts sound reasonable and non-controversial, and it is unlikely there are factual errors in the science Brown presents. The real problem with the videos is not inaccuracies in scientific reporting but what information is omitted. In fact, there is only one potentially negative comment about salt: putting salt on snails will kill them because they are mostly made of water.

The one potentially redeemable aspect of the video is that they do recommend sea salt—Diamond Crystal sea salt to be precise—because sea salt has less sodium than regular salt. But this is still without much value because of the excessive promotion of adding salt to food.

While it is true that salt is necessary for sustaining life, the missing pieces of information are that humans only need a tiny amount (1,200 to 1,500 milligrams per day) and that excess salt consumption (above 2,300 mg per day) is strongly associated with serious health risks like hypertension, cardiovascular disease (CVD), and stomach cancer Cardiovascular disease is the number-one killer globally, and hypertension is one of the strongest predictors of CVD mortality. Brown’s salt industry presentation does damage to the health initiatives trying to reduce mortality.

There is no doubt that we as humans have cultivated a salt craving. Much of the world’s population consumes salt in quantities of greater than 6,000 milligrams per day, with Eastern European and Asian countries averaging higher than 12,000 milligrams per day. In 2004, the average Canadian daily salt consumption was 7,800 milligrams. Observational studies going back to the 60’s, conducted on indigenous peoples where salt consumption is low have shown that hypertension, the leading cause of CVD mortality, is extremely low there as well, making them a low-risk population. These groups of people had salt intake levels hovering around 1,000 milligrams per day.

Companies like Cargill make their money by “adding value” to food, which means they process it for the consumer. Processed foods account for 70% of the salt in the Canadian diet. For example, the label on a pack of Oreo cookies states that one serving (three cookies) has 160mg of sodium, which is 1/14th of the maximum recommended amount. To further encourage people to put additional salt on chocolate covered cookies and ice cream—a recipe proposed by Brown in the video--is nothing short of dangerous to public health.

Such companies have an incentive to promote salt content in foods, and consumers have built a taste for it. The taste for salt can be reduced, but it can be difficult to change, so any doubt cast on the evidence or authoritative messages proclaiming that salt sustains life make it that much harder for public health practitioners to protect consumers.

The exact pathogenesis of salt is not known, and that leads to the doubt exploited by industry. That is why an etiological understanding of salt’s effect in humans is an important step in regulating the processed food industry. Thus far, the most accepted explanation is that excess sodium in the human system can lead to decreased sodium excretion and water retention. This increases plasma volume and increases vascular tone and contractility, which increases blood pressure, resulting in hypertension.

The Salt 101 video portrays salt as healthful, nourishing, and empowering. By combining Brown’s comedic genius with the persuasive potential of social media, Cargill seduces viewers to ignore those charged with protecting the public health.

(References available upon request)

Vive L’amateur

In the mid 90’s I started taking an Aikido class in Seattle’s Chinatown. The crisp throws and graceful falls were all I needed to become hooked. The school advertised itself as “Aikido taught by professionals,” and was affiliated with a larger school north of the city. The instructor at the Chinatown dojo was a clean-cut young man, and as typical in martial arts school from Japan, he had a stern, militant voice.

I started the class because I needed to break a life pattern. The artist’s undisciplined lifestyle had been taking its toll, and I had had enough. Martial arts had saved me when I was a kid, and I knew it would do it again. As I began going to classes, first three days per week, then five, I became addicted, as did the other 20- and 30-somethings in the class. The class had a bunch of young men and women who bonded around Aikido’s unique philosophy of non-violence and non-aggression.

The students got along really well, and we thought we’d found the perfect school for us. Then, after about a year, these “professionals” started to make some changes to both the curriculum and, more significantly for me, to the payment plan. It was a time in the martial arts world when signing yearly contracts became popular, and the head instructors decided that was a good business model. In addition to requiring a contractual commitment with a lump sum up front, there were also tests fees, new uniforms, and other added expenses. It became a hefty sum of money, one that my wife and I could not comfortably afford.

When I balked at the new expenses, asking if there was a way to avoid some of them, the instructor railed into me, saying I wasn’t serious about Aikido and questioning my priorities. His response made my next move easy. I never returned. I soon found another martial art and dreamed of opening my own school. But after much reflection, I realized that to be a “professional” means making money and capitalizing on the role as a respected teacher to persuade students to purchase contracts, uniforms, and anything else that can bring in a profit. This is not illegal in any way, but it doesn’t sit right with me for one reason: trust. At the end of the day, a professional’s job is to make sure he or she is in the black. So they have to devise ways to excite, inspire, and persuade students to invest in the school’s future and purchase things, things they might not actually need.

Since then, I have decided not to open a school for profit or to formally attend one. Instead, I occasionally visit teachers whose primary income is not from their martial arts classes. That squarely makes them “amateurs,” which gives me a sense of trust and passion—after all, amateur means “lover of.” The amateur passes on knowledge because it provides meaning to their lives and, they believe, to the lives of others. Long live the amateur!

Summary of the Canadian Health Care System

Canada is ranked as the second largest country in size but 39th in population (CIA, 2009). These two factors combine to make it quite unique. The Canadian health system is just as unique. Bordering the United States, which has the antithesis of a single payer health system, Canada has maintained one of the most successful health systems in the world for the past 40 years.

With more than 80% of the population living in urban areas, the health system can make primary and acute care accessible to a large population (CIA, 2008)(WHO, 1996). Life expectancy is among the highest in the world for both men and women at 79.6 (StatCan, 2001). The infant mortality rate (IMR) for 2005 was 5.4 per 1000 births, making it one of the lowest in the world (StatCan, 2005). Since life expectancy is so high and IMR is so low, 12% of the population is over the age of 65, a high percentage of older population. Added to the fact that fewer people are having children, this means that Canada is in the fourth stage of a demographic transition.

The Canadian health system has some of the best health outcomes in the world, with death and disease rates lower than most. Still, only 52% of Canadians say they are satisfied (Gallup, 2003). One of the major complaints is long wait times for special services such as MRIs and other high demand treatments.

In 1957, the Hospital Insurance and Diagnostic Services Act (HIDS Act) was passed, establishing single payer insurance that implemented universal coverage for inpatient hospital care. The HIDS Act set into motion a foundation on which the Canadian health system as we know it was built. It evolved into the national health system, which provides universal coverage to 10 geographically and culturally diverse provinces (WHO, 1996).

Funding and Spending

Many people call the Canadian system “socialized medicine” but actually it more closely resembles a Medicare system where the heath insurance is government sponsored. This means that physicians are not hired by the state but are privately employed and are paid fee-for-service by the government using taxpayer dollars (Davis, 1999). In 2006, Canada spent $3,672 per capita, and health costs were 10.0% of Gross Domestic Product (GDP). Seventy percent of total health costs are publically funded (WHO, 2006); thirty percent comes either from private insurance, employer insurance, or out-of-pocket (Davis, 1999).

Structure

The Canadian health care system has two main levels of power. The first is the provincial, in which the health ministries take on the day-to-day management of health services. The ministers of health plan, finance, and evaluate all types of care, e.g. hospital, physician, and public health. Provincial health ministries must also fund all public health activities and negotiate fees (WHO, 1996).

The second level of power is at the federal level. The federal government's role is to set and administer national standards for the health care system. Another federal responsibility is providing health care delivery to veterans, native Canadians living on reserves, military personnel, federal prisoners, and the police. The final function is disease surveillance, prevention, and health promotion (WHO, 1996).

Primary Health Care and Public Health

The lion’s share of primary health care is delivered by a general practitioner or a family doctor. Since they are the first point of contact in the health system they filter access to specialists, admission to hospitals, and other health professionals (WHO, 1996).

The original intent of public health was to control and prevent communicable disease. Since communicable diseases have mostly been ameliorated in Canada, public health has extended its mission to include health promotion and equitable distribution of health services to all members of society, as well as prevention of non-communicable disease and support for mental health services (WHO, 1996).

The Role of the Private Sector

Besides a single payer health system, there also exists a private sector. Canadians might opt to go to the private sector because of dissatisfaction with the public system or to seek an alternative and complementary treatment. The government is not responsible for payment of claims for those who elect to choose that option. There are many doctors, chiropractors, dentists, and such who operate outside of the government provided system. In addition, there are private insurance companies that can supply employers with supplementary health insurance (WHO,1996).

Conclusion

One admirable aspect of the Canadian health system is that it doesn’t rest on its laurels. Building on its foundation of universal coverage, Canada strove even further to insure all of its people. Using the public health system to focus on health promotion and health equity, Canada has achieved some of the best health outcomes in the world. Today’s topsy-turvy economy raises many concerns regarding sustainability. Even in that arena, Canada has created many ways of cost containment, thus promising a continued healthy future for its healthcare system.

References

CIA , World FactBook. (2009). Canada: people.
Retrieved from
https://www.cia.gov/library/publications/the-world-factbook/geos/ca.html

Davis, J B.. (2001). Canada’s health system. Croatian Medical Journal 40(2).
Retrieved from
www.cmj.hr/1999/40/2/400221a.pdf

Gallup. (2009). Healthcare System Ratings: U.S., Great Britain, Canada.
Retrieved from
http://www.gallup.com/poll/8056/healthcare-system-ratings-us-great-britain-canada.aspx

Statistics Canada. (2001). Life expenctancy.
Retrieved from
http://cansim2.statcan.gc.ca/cgi-win/cnsmcgi.pgm

Statistics Canada. (2005). Infant mortality.
Retrieved from
http://cansim2.statcan.gc.ca/cgi-win/cnsmcgi.pgm

World Health Organization (1996). Health Care Systems in Transition: Canada.
Retrieved from
www.euro.who.int/document/e72450.pdf

World Health Organization (2006). Canada: statistics.
Retrieved from
http://www.who.int/countries/can/en/

The True Power in Tai Chi

Recently one of my martial arts friends asked me to work out, and I had to decline because of the broken scaphoid bone in my wrist—an old injury—and two other recent injuries. My knee most probably has a tear in a tendon from walking on the broken sidewalks in India with 100 lbs of luggage this summer, and my shoulder tendon has been burning every time I reach for something. Alas, the sounds of a wimp! But, hey, that is the true state of my body.

My friend’s response, “Very problematic, there are more than a few pro (motorcycle) racers who had to retire just because they broke that bone [the scaphoid]. It wouldn't heal and that was it. Such a small bone, but it can be such a bitch!”

After reading that email I immediately felt the loneliness of retirement and even more so, the loss of identity. I have been managing pain by rationing my martial arts workouts literally for 20 some-odd years. My wrist can only take so much activity. But maybe it is time to face facts. I am a type A personality and not the typical kind of person you find at a meditation class. I love sparring and getting hit and all that, but being type A means that I push it too far too often. Even my wife has been getting on me for instilling the martial ethic into my young son.

All my life I have been type A. When I was picked on in high school by the football team, I didn’t just rollover and take it like everyone else. I started to box, I ran 8 miles a day, punched the heavy bag for hours per day, and I did push-ups and sit-ups. My workouts lasted for hours. My work reaped the success I sought, and by the time I was a junior, I was no longer being picked on. Then when high school was over and I had to get serious about something society valued, I chose to be an artist. Of course in typical type A fashion I again went over the top with drugs, alcohol, and all that comes with that lifestyle. These activities led me to have some minor health issues.

This was the original push to get me to seek out Tai chi, because it is recommended for type A personalities. Many of my injuries and heath issues were linked to this type A drive. I changed many of my habits, like my expression of anger, slamming my fist on a desk, which took a toll on my body. But in time I gravitated back to the more martial aspects of Tai Chi and found a way to keep the martial artist in me alive. In Tai Chi Chin Na I found Jiu Jitsu correlates, and in Tai Chi sword I saw similar characteristics with Kali stick fighting. Again I was using Tai Chi as martial training, not solely as a health exercise, further exacerbating my wrist injuries.

Maybe because of this persistent injury, I am starting to see Tai Chi from a different perspective, as injuries always have a habit of inspiring. I used to think that a Tai Chi master could heal broken bones and beat a 25-year-old professional fighter. When I first started Tai Chi I believed that by simply practicing Qi gong and Tai Chi I could heal my body to a superhuman level. I thought by developing Qi, I would be able to throw a football player 10 feet and that I would never get sick. In my 12 years of serious Tai Chi practice I see that it is not the cultivation of a superhuman ability but some thing far more simplistic. It is the opposite of type A—it is about yielding control and letting things come to fruition on their own. Accomplishing that is harder than breaking coconuts and throwing heavier opponents to the ground.

A famous Tai Chi master came up with a phrase that explains that the essence of Tai Chi; “invest in loss.” This simple concept has been a struggle for me since I began my practice. As a westerner in an eastern practice, I have a hard time reconciling the two approaches. The westerner in me asks, “how did the US become a superpower but by being type A?” Getting to shape the world in a major way is no small accomplishment. Eastern wisdom tells us this is short-term, it will pass. I wholeheartedly agree, but it is comfortable being on top even if it is for a relatively short period of time, like 500 to 1,000 years. Eastern wisdom is beautiful, and it is one of the best ways for all of us to coexist in a world that needs a way of curbing excessive human consumption. If we regulated our desires, many of the issues surrounding global warming could be attenuated.

Giving up martial arts is really hard. It is addictive for me because in martial arts you gain victory by defending against would-be attackers—and to give up creates a certain cognitive dissonance. The whole point of your martial life is to defend yourself. Not being able to do that is to deny everything that you worked so hard to acquire all your life. But just as a champion’s life is so short because there is always going to be someone younger and stronger willing to knock you down for the glory, one must eventually yield.

At this stage in the game for me, Tai Chi is not a miracle cure or a superhuman growth supplement but a form of exercise that can keep me active, which is a miracle in itself. It is also a means of managing pain and that translates directly into living an active life. As it is now with my wrist I could easily stop working out as working out brings pain. Tai chi allows me not to quit and to avoid that slippery slope of inactivity but instead to persevere.

The true power of Tai Chi is a far cry from the hype of internal martial arts promoters for one simple reason: there is no mysterious, esoteric secret. It is the practice of overcoming the part of you that looks for short-term victories and instant gratification. It helps you understand the bigger picture, but with that comes responsibilities and sacrifices. It comes by letting go of your desire to win.

Is there an inverse relationship between tradition and regulation? A Comparison between Canada and India

Indian culture is one of the oldest if not the oldest living culture still going strong. Without a doubt, one of the factors that generated that kind of longevity is tradition. Regardless of how we might judge tradition with a 21st century lens, a strict family structure with rigid social and cultural norms has got to be one of the reasons for India’s perseverance.

One of the hardest to understand cultural differences between India and Canada is the tradition of marriage. “Dr. Sanjay” (not his real name) is in his 30’s and a typical upper-caste Indian man. He is very handsome and tall but yet single. He is a senior resident doctor of community medicine at PGI. He led a tour of the community health center in Kheri for a group of doctors from North Koreans and myself. The North Koreans doctors, Dr. Sanjay, and I discussed each of our country’s courtship rituals on our way back to PGI medical center. The North Koreans asked if he was married. He said, “no.” As we were discussing this, a beautiful young rural woman passed by our van. I said, “in Canada, if we found her attractive we could approach her and ask her for a date, and if things worked out it is possible to get married. “ Dr. Sanjay said, “That would be next to impossible here.”

Another part of our tour was to observe a public health class. During the class discussion about private and public health, I was invited by the teacher to speak about the Canadian healthcare system. Being an American who lived without health insurance for many years and who now resides in Canada I had a pretty good personal perspective on each system. After sharing my experiences about the Canadian system, the students discussed the Indian health care system. I was impressed by their description of India’s far-reaching delivery of health to its people, but this interaction prompted me to ask an important question: why does Canada have generally very good health outcomes but India has some really poor outcomes?

I began to try to think of reasons and issues besides the obvious ones like population and colonization. This led me to a peculiar realization. India has one of the most rigid social structures on earth, yet the ability for the people to follow government regulations seems like a monumental task. And paradoxically Canada has very little real tradition, and there is no rigid social system. You can walk out of your house and marry anyone you please, and yet if you drive without a seatbelt or on the wrong side of the road you would be severely punished maybe even lose your license. To me the striking difference is a culture of safety—seemingly simple safety regulations that most people in Canada have no difficulty following are almost non-existent in India.

This difference makes me wonder if the health system is the most important way of preventing mortality. This question led me to develop four ideas that, in theory, could take the burden of prevention out of the hands of the health system. These include 1) a general culture of health awareness, 2) stronger regulations, 3) definite and immediate accountability for infractions, and 4) improved infrastructure like clean water, safer roads, sidewalks, etc.

While these are challenging and sometimes expensive endeavors, I have noticed an improvement in some of these areas since my last trip to India, in 2001, in things like public smoking restrictions and at least minimal seat-beat laws. Changing culture is rarely easy, but it won’t happen without starting somewhere. Public safety has to be assimilated into construction, food production, the work place, transportation and any business where people can be harmed by products.

Canada has great infrastructure. Water for human use is filtered and treated to a high degree of purity, roads are safe, and building construction is highly regulated for safety. Contractors and developers can get arrested if they cut corners on building codes, there are elected officials in charge of checking on zoning and building codes of safety, and they have the authority to stop construction or penalize a contractor if unsafe construction practices are used. These regulations are designed for both the construction phase, to protect workers and the public, and for the completed phase, to ensure that buildings don’t collapse or require nearly immediate repairs.

In addition, driving in India is a high-risk activity. On the 5-hour drive from Chandigarh to the Delhi airport, I saw two immediate wrecks probably involving fatalities, three trucks overturned, and numerous automobiles driving on the wrong side of the road. To a North American observer, this disregard of road safety seems to be a point of pride with many Indians, as if they see any demonstration of fear about daily driving habits to be a sign of weakness. This type of cultural myopia is hard to change. When I discussed road safety with many people, they often laughed at our concern and shrugged off the seriousness of accidents. But road accidents in India are extremely high.

According to a Boston Globe article using World Health Organization statistics, “road accidents now are the number two killer of young people age 5 to 29 worldwide…. [In India], an estimated 270 people die each day from road accidents, and specialists predict that will increase by roughly 5 percent a year.”

Many cars do not have operable seat belts, and children ride on motorcycles and scooters without any protection. In Canada this practice is illegal. In fact, it is also so culturally abhorrent that people would call the police and look down on such a person. Because I am a cultural relativist, I don’t judge Indian people who chose to ride a motorcycle with a child, as I understand there are many factors that influence behaviors. But I am concerned about safety. My biggest fear in India is seeing an accident involving a child being slammed onto the asphalt—if I witnessed such an incident I would never forget it.

Much of India’s charm is its stalwart retention of its culture, even in the face of westernization. In Canada, without the long tradition and strong culture, sometimes there is a loss of identity, as people seem to be grasping for something to believe in. Also, such stringent regulations can sometimes be claustrophobic and create a backlash. It is precisely in this dilemma where the public health worker inside me, who believes in safety and longevity as a human right, and the dedicated traveler, who believes that culture is what makes us unique, collide. But I do think a happy medium can be achieved slowly.

Personal Paradigm Shift

Spending 11 weeks this summer in India, where the heat is 109 degrees and walking 4 days per week, administering surveys door-to-door, negatively affects my daily routine of Tai Chi. It is simply too hot to move. I have been doing some Chi Gung at night before bed. But I still feel like I am missing my daily one-hour routine of Tai Chi. I have felt jealous of my friends back in the US who aren’t missing a beat in their own practice. Then I had an epiphany that led to my own personal paradigm shift.

My choice of going into health research as opposed to acupuncture or some other health care delivery was just the beginning of incorporating my research into my life. Scientific research is a systematic method of adding knowledge about the world around us by collecting data, lots of data. My research here in India is trying to ascertain how people’s dietary habits impact their physiology. What I am finding thus far is that small, simple choices in an individual’s and a culture’s diet can negatively impact their life span. In short, people’s cultures are killing them slowly.

My research in India takes me door-to-door asking people in their homes about their lifestyle choices. Everyday I meet people who are overweight, with high blood pressure, not exercising, making poor dietary choices and of the age where their first MI (myocardial infarction, or heart attack) is not far off. So many of them think that they are healthy and that they are eating just fine. They truly are in a state of denial. The stats tell another story: About 17.5 million people die from cardiovascular related deaths every year. That is 30% of all deaths in the world, which means that CVD kills more people than any other disease.

Although I haven’t been doing as much Tai Chi as I like, I am seeing first hand through a scientific lens that, overwhelmingly, lifespan is determined by the choices people make day in, day out, many of them based on cultural norms. The average life span in India is 64 years of age. The people I meet here are creating a pattern of behavior that will affect their child’s life span as well. Science has given me the tools to see this. By collecting data from hundreds of people I can infer whether a certain behavior is rampant or not. If you just follow a tradition or culture that is orally interpreted or passed down in books you might not notice what is actually happening on the ground. A state of denial is created because tradition is kind of like a rule book or a map following it confirms you are doing well. Unfortunately, many of the directions are flat out wrong or not appropriate to the present time frame. I am finding that the people of India follow their traditions and are very devout, much like people of other places, but unfortunately without that scientific lens they can’t see where the health outcome of their tradition leads. The Hindu religion states the eating of meat is forbidden, with beef strictly taboo. Although the attitude toward chicken is more casual, many people proudly don’t consume it for religious reasons. However, chicken is a more efficient protein, with less fat, than the daily consumption of whole milk (in tea and drunk plain), paneer (a type of cheese), and whole milk yogurt that makes up a big part of the Indian diet.

Even in my beloved Tai Chi there is very little information on dietary behaviors. There is some wisdom on the balancing of the 5 elements and their dietary correlates: sweet, sour, salty, pungent, and bitter. Unfortunately, it doesn’t give any measurements or of course the wise sages could not fore see the transition from a rural old world diet rich in whole grains to a modern diet full of processed refined grains heavy in salt and sugar. Consequently, Tai Chi instructors without training in western science do not pass on that kind of wisdom. The Tai Chi literature also says to avoid any type of cardio activity. Although there is some wisdom within those words when applied to elderly people but it is poor advice for middle-aged adults who are in need a cardiovascular exercise for their heart.

Absorb what is useful, discard the rest

It is difficult not to be influenced by cultural traditions. Tradition gives many of us meaning in life and even makes us aware of many positive activities as well. The Tai Chi literature is full of all kinds of awesome behaviors to follow, that is why I love it and read so much of it but there is a fundamental lack of precision. Following the scientific method gives me the insight of what is actually happening on the ground from the data collected. The choices I make of which many come from the Tai Chi literature are tempered and corrected by the large body of literature amassed by the western science paradigm. So I can as Bruce Lee has advised, “absorb what is useful, and discard the rest.”

IS there such a force as CHI, QI, or PRANA?

At the very end of the day, this is what we know: physical activity is one of the best activities for preventing a whole array of diseases. Greeks, Indians and Chinese knew this but did NOT or could not empirically prove it. They all created an energetic system of healing. Greeks had Pneuma, Indians have Prana and the Chinese, Chi. But we also know it is it is really hard to exercise everyday, maybe those ancient teachers knew this too?

Until someone actually does a study like one I have designed which isolates Chi practice from physical activity then there can be NO proof of any single activity that people claim cultivate Chi is valid. In other words, all the positive effects of 'Chi' could easily be explained by physical activity. My study would not prove the existence of Chi itself but it could prove that activities which claim to cultivate Chi are more efficacious than running on a trend mill. Maybe one day I will find myself in a situation where I could run that experiment. Or maybe a new technology will come along that measures Chi?

One of the biggest issues in discussing, explaining or even harder, proving Chi is that we have to fuse together two explanatory models about the world. An explanatory model is a structured thought or diagram or paradigm, which attempts to make sense of our world in a simplified way. Hence the only way to explain Chi must be in terms of physics and biophysics. The Chinese had no knowledge of what we would call modern physics but they did understand how to make use of it. This is where we run into problems, I could say Chi is energy but there is a whole field called thermodynamics that also deals with energy. I could say, Chi is the movement of neurotransmitters in the body; again there is a whole field of science that researches this. Unfortunately by applying an old language to a new science much gets lost in translation. Then why use Chi at all? Part of me thinks it is not necessary and part of me thinks that the concept of Chi gives us something to grab onto when explaining complex bodily functions. While leading a lesson on Tai Chi I can’t say, "now let’s feel the release of dopamine and serotonin." It is so much more convenient and accessible to say, "let the Chi sink into your belly." But I also feel it serves another purpose.

The activity of learning and exploring through being thoughtful or mindful is also extremely beneficial towards living a long and healthy life. Many cognitive psychologists are finding that if humans learn something new and complex they are less likely to suffer severe memory loss. Being thoughtful about Chi and its interactions with the complexities of our physiology serves two purposes. One, it keeps my mind active reading higher level material instead of playing video games, which have not proved to prolong memory and two, it motivates me to return to practice, day in and day out. The outcome of which is a highly functional system of cognitive and physiological benefits both inspiring each other. If the mystery of Chi keeps me practicing for 50, 60 or more years than that is quite an achievement by itself.

The paradox of physical exercise is that our minds know it is good for us but the mind has to motivate the body to get up and do it consistently for there to be any benefit. What if the mystery of Chi Gong is so complex that is can not be empirically 'figured out' as so many of us try? That makes it the ultimate cliffhanger created by a most wise sifu. If you ever have a chance to meet one of these people after-death or otherwise, and you finally get to ask that one burning question that has been tugging at you for years, "is Chi real?" Sifu would say, "the mind is dumb and the body is the smart." "Ah ha," you say, "I knew it was a trick all along." And before that smugness has a chance to settle, the sifu responds, "But the mind always has to be right."