An Athlete By Any Other Name

A few weeks ago I was talking to a friend who was trying to convince me to sign up for my first triathlon with her. As I hesitated, considering my ability to prepare, she said, “Don’t worry. You’re in great shape. You can do it. Besides you’re an athlete.”

I was struck by that description. I think of athletes as people who excel at sports and bring home accolades for their athletic endeavors. They are the first ones picked for teams at gym and their names are emblazoned on school banners recording their feats. I was never one of those people. As a child, I didn’t excel in sports. I was known more for my academic achievements than my athletic pursuits.

As an adult, I took up running. That led to other pursuits in weight lifting, cycling and swimming. I do them all on occasion. But does that make me an athlete?

According to Webster’s, an athlete is a person who is trained in or good at sports, games, or exercises that require physical skill and strength. That definition suggests that one needs to excel to be considered an athlete. But then I remembered something I read in Runner’s World’s column. The writer said that being a runner was based on nothing more than an active pursuit of running, regardless of distance, pace or frequency. Based on that, I’m definitely a runner. Sometimes I run a lot. Sometimes I go a couple of weeks without running. But I always go back to it, remembering how good I feel after it. Does that make me an athlete?

I’ve run a mud-run, a few half-marathons and an ultra runners’ relay race. Each year, I looked for a new opportunity. Now I realize that it is that drive to do something new, to reach new heights and to challenge myself physically that makes me an athlete.

When I ran my first half marathon, I wore a pair of hemp gloves that read, “It’s not how fast you go. It’s that you go.” They were intended to be throwaway gloves to use at the beginning of the race when it was cold, but I have never gotten rid of them. They remind me that athletes are not just the stars of their sport. They are the individuals who find time on weekends and before or after work to physically push to new heights and challenge themselves to do better.

I started my journey to be an athlete to prove to myself that I could do it. Then it became about living a healthier lifestyle and setting an example for my daughters. Today I run, swim and bike for me. My athleticism has shown me what I’m capable of – both on a course and in life in general. It has given me greater confidence to try new pursuits and it has opened my heart to unconditionally support others doing the same.  I’m thrilled anytime someone starts this journey – and I hope they get as much out of it as I do.

As for my first triathlon, I started my training. I don’t know how it will go, but I’ve received lots of encouragement so far. And I will have my gloves to remind that it’s not how fast I go…

Mayor Booker, Here’s Some Help for Healthy Shopping

On Monday, Newark Mayor Cory Booker began a one-week food-stamp challenge that required him to live for the week on a food budget equal to that of a New Jersey resident of the Supplemental Nutrition Assistance Program (SNAP). The challenge stems from a Twitter exchange in which a follower argued with the mayor that nutrition is not the responsibility of the government. As a result, Mayor Booker challenged himself and the follower to live on a SNAP-equivalent budget for one week to document the experience, raise awareness of food insecurity issues and elevate food policy discussions.

Eating healthy is hard on any budget. We all know we need to do it, but so many factors impact our ability to eat well. Finances, stress, time, willpower and a host of other factors play a role in determining what we put in our mouths. But when you are on $30 per week budget, the challenge seems impossible. The average consumer has difficulty understanding what is healthy. Food labels are confusing. In fact, according to a recent study by the International Food Information Council, almost half of Americans think it is easier to do their own taxes than to figure out how to eat healthfully.

And many perceive that healthy eating is costly. A survey conducted for Share Our Strength’s Cooking Matters in 2011 shows that even though 85% of respondents say that eating healthy dinners is important to their families, one-quarter of families skip healthy purchases because they feel they cannot afford them.

But healthy eating doesn’t have to be expensive. Dr. Mehmet Oz recently argued in Time that we have many often-overlooked, affordable options in our supermarkets, such as frozen vegetables, canned salmon and tuna and peanut butter. Mayor Booker must have taken note. He bought several canned products and a few bags of frozen vegetables for the week.

But the mayor has already acknowledged that he made some mistakes. If he were to do it over again, he would have clipped coupons. But the challenge is that many of the coupons available are for unhealthy food. So what do you do – clip coupons for unhealthy food or pay full price for healthy options? There are better options. A new website called Everyday Healthy Values aggregates coupons for healthier product options. A collaboration between Coupons.com and Cigna, the health insurer, the site offers coupons for products that meet minimum nutritional guidelines aligned to federal standards for reducing fat, sodium and sugar levels.

We have become a culture of food snobs, focusing on labels such as organic and all-natural. But the reality is that our food supply provides healthy options for many budgets. If we can figure out how to purchase and cook healthier versions of the foods we love, we can make huge strides in the health and wellness of this nation. Everyday Healthy Values and Mayor Booker are both helping us all take that first step.

Using Social Determinants to Identify Dangers to Health

Over the years I have seen many people question the quantifiable effects of social determinants of health. I used to be one of them. I remember a colleague evangelizing the importance of understanding and considering factors such as income, geographical location and cultural norms in understanding health outcomes. I thought it was “nice to know” but not something we could actually fix. After all, where do you start? How does a health professional begin to understand and account for all the factors that could be impacting a person’s health?

Public health professionals play a significant role in this area. They have the ability to break society into smaller, more manageable bites and delve deeper into what is happening. A great example of this was documented in the a study published in the August 2012 Pediatrics about the increased rate of children admitted to hospitals for child abuse and its link to the housing mortgage crisis.

According to the New York Times report of the study, the rate of hospitalization for children suffering from physical abuse increased an average of 0.79 percent a year from 2000 to 2009. The researchers then linked the data to unemployment rates, mortgage delinquency and foreclosure statistics and found a correlation. For every 1 percent increase in the 90-day mortgage delinquency rate in a metropolitan area, there was a 3.09 percent increase in hospital admission rates for children and a 4.8 percent increase in high-risk brain injuries among children.

Clearly, the economic crisis has increased stress levels across the board. Research by the American Psychological Association (APA) shows work, money and the economy are the most frequently cited sources of stress, the same issues that have topped the list for the past five years.  And while we know that stress has a strong influence on our own health, we may not realize how it is impacting our children. This new research paints a picture. We get stressed. We lose our patience, and we inadvertently take it out on innocent victims in our lives.

As parents, we have all been guilty to some degree of letting stress impact our home lives. What parent has not scolded a child too quickly for doing something wrong simply because we had other things on our mind? If you are worried about how you are going to pay the mortgage next month, you may have less patience for a child who is jumping on the furniture pretending to fly. After all, the noise may be contributing to your headache, and you may worry that he or she may break something you can’t afford to replace.

There are no clear answers on how to fix the problem. But acute awareness is a good first step. Social determinants are the economic and social conditions that influence differences in health. It is most often associated with inequities in health, but – as in this case – it also helps shed a light on potential dangers to a population. Identifying and acknowledging issues like this will help us better address the health of the nation.

Why it is the way it is.

Recently I wrote about Joe Klein’s cover story in this week’s TIME magazine, chronicling the recent death of his parents. He eloquently describes the process of losing loved ones and making decisions to help them die with dignity. One of his biggest frustrations was with the health care system – from the lack of candor from health professionals to a system that lacks coordination. His piece helped expose the fragmented nature of our health system from the perspective of a caregiver.

During any health crisis, caregivers rely on the expertise of doctors and the effectiveness of the system to guide a patient through appropriate medical care. So when the guidance isn’t clear, the care ineffective, caregivers and health-care decision-makers can rightfully become frustrated, confused, desperate, angry, and emotional.

So why does this happen? I believe it is a combination of things. First of all, doctors are trained to save lives. It’s their very purpose to fight for a life. They are warriors in battle against disease and death. Sometimes, health professionals don’t have the courage to say there is nothing more that can (or should) be done. It may be that they are struggling with the failure of not saving a patient. Sometimes, the family isn’t ready to hear the truth – that the end is near. Mr. Klein interviewed a doctor who admitted, “Sometimes the family members don’t (get it). Sometimes they want us to do all sorts of things that just aren’t realistic, and we have to be very patient about walking them through the reality of the situation.,” said Dr. Victoria Devan of the Geisinger Health System. Basically, doctors are human – and imperfect like the rest of us.

From there, the reasons get more complicated. Our health care system is based on a fee-for-service payment system. Doctors get paid to do procedures – everything from administering a flu shot to removing an appendix. They don’t necessarily get paid to make a patient comfortable or advise that nothing more should be done. The system inevitably rewards physicians financially for doing more tests, procedures, and treatments. That explains why Medicare will pay for an elderly woman to have a heart valve operation to fix a condition she has had since birth. According to The New York Times, up to one-third of the $2 trillion of annual U.S. health care expenditure is spent on unnecessary hospitalizations and tests, ineffective new drugs and medical devices, unproven treatments, and unnecessary end of life care.

We also live in a litigious society where medical malpractice costs are huge. According to a Congressional Budget Office Report, the total direct costs to healthcare professionals resulting from medical malpractice liability (including malpractice insurance, settlements, awards, and administrative costs not covered by insurance) was $35 billion in 2009. [1] With that level of expense, who can blame health care professionals for being cautious and ordering extra tests or treatments to make sure they are making the right recommendations?

I’m not suggesting that doctors are scoundrels trying to make a buck off every sick patient by ordering unneeded tests. But as savvy consumers of health care, we need to be aware of the realities of the health care system. Part of being an advocate for your or someone else’s health is having the ability to question the value of certain tests and procedures, especially if they are invasive.

Estimates vary on the cost of end of life care. One report said in 2009 Medicare spent $55 billion on doctors and hospitals bills during the last two months of patients’ lives. That’s more than the budget for the Dept. of Homeland Security or the Department of Education. It’s estimated at 20 percent to 30 percent of the medical expenses had no meaningful impact. [2]

Realizing and accepting that the end is near is part of the circle of life. It’s a difficult stage that we will all face at some point. My only hope is that the health care system won’t make it harder on me and my loved ones when our time comes.


Healthy Way to Die

This week’s issue of TIME magazine (June 11, 2012) may go down as one of my favorite issues in a long time. It came in the mail on Friday and by Monday I had read it cover to cover.

The cover story is by Joe Klein, the well-known political reporter of Primary Colors fame. In his piece, he chronicles the recent death of his parents. The piece was insightful, honest and heartfelt. He talks about his mother’s ultimate demise from dementia and his stubborn, strong-willed, truculent father who challenged every professionals advice and resisted every attempt for help. As their health declined, Mr. Klein was faced with some of the most difficult decisions of his life, decisions about his parents care. He describes himself as his parents’ “death panel.” He talks about experiences he had with doctors who were not forthcoming with honest evaluations about his parents’ prognosis, unnecessary tests that wasted money and provided no helpful insight, lack of coordination between battalions of doctors, and the process of allowing loved ones to die with dignity.

No one wants to see a loved one die. And no one wants to see a loved on suffer. The process of witnessing the death of a loved one is painful. And we often follow the recommendations of doctors to engage in procedures that may extend a loved one’s life by a matter of days, weeks or even months. Its an unconscious way to show our love. But sometimes, while we may find comfort in that, we are only postponing the inevitable at the expense of the patient.

I believe we often act in an effort to keep someone alive because we want them with us. But sometimes the decisions we make prolong their life in a way that makes the patient suffer. Sometimes I wonder, will another round of dialysis help the patient markedly improve? What is the benefit of a surgical procedure on a sick, elderly patient? Is the recovery worse than the cure? By how much?

Living wills, advance directives DNRs and other documents are designed to help guide a patients family when the patient is incapable of communicating on his/her own. They are supposed to be the roadmap for care. Many people, like Mr. Kleins mother, give clear directions such as Let me die. I dont want to be a vegetable. They are hard directions to execute but they indicate a strong desire to not suffer and not be a burden.

When the term “death panel” entered our vernacular during the health care legislation debate, I was angry. It was such a blatant political ploy designed to distract voters from the real issues. As a society, we have to come to terms with death as part of the cycle of life. That’s not to say that we don’t fight illness with all our strength, but we need to come to terms with the fact that we cannot always win. Instead we had pundits claiming that death panels were tools to ration care and decide who was worthy of medical care.

Facing end-of-life issues is another phase of life that we all will face at some point. Our parents will age and will need our help to maneuver their final years. Joe Klein’s experience reminded us of the value of dying with dignity. The decisions he made and the candor and support he received from the medical staff that helped him through the process is a hopeful reminder that we can all get through these life challenges in a respectful way.

I know I started this story by saying I loved this issue of Time. Tomorrow I’ll be back to tell you why doctors arent always the best guides through these tough issues. And after that, Ill tell you why I am suddenly a Rick Warren fan.

Healthy on the Inside

Last night was the season finale of The Biggest Loser on NBC. If you have never seen it, the show centers on overweight contestants trying to lose weight to win a cash prize. The person who loses the highest percentage of weight loss over the course of the show wins. Many have criticized the show’s techniques as aggressive and unrealistic. After all, how many people can live on a ranch and dedicate themselves full-time to achieving their weight loss goal? How many people can realistically lose 15 pounds in a week?  And keep it off?

I don’t watch the show regularly but I catch an episode every once in while. And I think that the show’s editors often miss an opportunity to show deeper aspects of health. With its focus on last-chance workouts and weigh-ins, the show focuses on physical transformations only. But as these contestants lose weight, there seems to be something happening off camera where they are facing demons and dealing with issues that are affecting their personal happiness and causing them to engage in unhealthy activity, such as overeating. As a result, they are not just thinner at the end of the show. They are happy. They hint at their personal struggles in some off-camera interviews during the show, but we never really know what is affecting them on the inside that is causing them to reach these unhealthy states.

For example, take this season’s villainous character, Conda. Viewers reacted very negatively to her. There are even Facebook pages dedicated to get Conda off the show. She angered many with her attitude and attacks on other contestants. Yet, by the end of the season, she had toned down her acerbic style and smiled more. She transformed from an aggressive, angry woman to the persona of a young mom finding health for the future of her family.

Some may say this is reality television at work. But I think there is more to it than that. I think that through her Biggest Loser journey, she faced some demons that allowed her to lose weight, like herself and change her demeanor. I think all the contestants did. And that’s the part of health that few discuss.

The World Health Organization (WHO) defines health in a simple, yet powerful way. According to the WHO constitution:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

I think that is what’s missing in the show – the mental and social well-being part. These individuals change on the inside, and the show doesn’t explore their struggles. They have touched upon it in seasons, but the focus is on the physical transformation. I’m a big believer in fixing a problem by addressing the immediate need and also identifying the root cause of the problem and addressing that.

Health is more than the number on a scale. Health permeates every part of our being, so if we are struggling with trauma, overwhelmed by stress, feeling bullied or depressed or any number of other emotions, our health is impacted.  Wouldn’t it be helpful to understand why these contestants started making poor food choices in the first place? Wouldn’t it be powerful to address not the immediate need for better diet and exercise but also the underlying cause of the weight-gain? And by fixing the real problem, wouldn’t we all be healthier?

Why is Fixing Access So Hard?

An article in The Atlantic earlier this month discussed the New York City Department of Health’s Healthy Bodegas Initiative to increase nutritional offerings in at-risk neighborhoods. The logic is that low income neighborhoods have less access to quality food and that contributes to high levels of obesity.

Studies around the country have shown that less affluent communities tend to have high levels of obese and overweight residents. And New York City is no exception. According to the data, 60 percent of adults in East Harlem and Central Harlem are either overweight or obese. And less than 10 percent of Harlem residents eat the recommended servings of fruits and vegetables.

This concept of low access to healthy food options in low socio-economic communities led to the term “food desert.” A food dessert is defined by the U.S. government as “a low-income census tract where a substantial number or share of residents has low access to a supermarket or large grocery store.” There are more than 6,500 food deserts in the continental U.S. (food desserts are not yet defined for Hawaii and Alaska) and 75 percent of them are in urban areas. Some studies have correlated low access to healthy food options to higher obesity rates.

So the solution should be simple. Let’s work with grocery store and supermarket chains to open more retail locations in these food deserts. Once residents of food deserts have healthier options, they will surely eat better. Right?

Again, the solution is not that easy. According to the New York Times two new studies are challenging the notion of lack of access to fresh food in low-income neighborhoods.  The studies show that while poor, urban neighborhoods have a higher concentration of fast-food restaurants and convenience stores, they also have more grocery stores, supermarkets and full-serve restaurants. They don’t lack access to healthy options. The study concludes there is no relationship between the type of food available in a neighborhood and obesity rates among its children and adolescents.

So what does it all mean? Like an economic model, we need to look at the supply and demand side of the equation. In this case, the Field of Dreams approach of “build it and they will come” isn’t the solution. Building fresh food stores only addresses the supply portion of the equation – and the recent studies are calling into question whether supply is even an issue. We need to look closely at the demand side.  If it were a matter of supply only, the New York bodegas wouldn’t be able to keep their small supply of fruits and vegetables in stock. Instead, they are throwing out half their stock. Why aren’t consumers in poor, urban neighborhoods buying produce when it is available? Is it too expensive? Is it difficult or time-consuming to prepare? Are the fruits and vegetables available not part of a community’s culinary culture? For example, communities whose heritage comes from warm weather climates (such as the Caribbean) may be less familiar with fruits and vegetables grown and consumed in more temperate climates (such as North America and Europe). What factors are impacting the demand side of the equation?

There are many variables impacting eating behaviors that we need to consider in the fight for healthier eating habits. Prescriptive supply-side solutions won’t fix the obesity crisis.  Shaming the food industry or overweight people won’t do it either.  The answer lies on the demand side of the equation. And that’s the hard part of the equation. If the demand is there, the supply will follow. The overweight and obesity issue in this country requires comprehensive, societal change, one that impacts body, mind, soul and environment. It’s pretty daunting to think about it that way, but then again, so is the problem.

Be Careful with Labels in the Fight against Child Obesity

A couple of months ago, Disney quietly launched a new attraction at Epcot’s Innoventions called “Habit Heroes.” The attraction was intended to be an interactive exhibit to combat childhood obesity and encourage healthy habits.

The opening was a soft launch to get feedback before formally launching in early March, and they received quite a bit of criticism. The National Association to Advance Fat Acceptance (NAAFA) felt the attraction stigmatized being overweight because all the villains in the attraction were portly. It criticized the attraction for its negativity and even accused Disney of “taking the side of the bullies.” I read one account by a Canadian blogger who wrote, ”

“So thanks for being so helpful Disney – I mean if your kid’s not overweight or obese, here’s to Disney reinforcing society’s most hateful negative obesity stereotyping, and if they are overweight or obese – what kid doesn’t want to be made to feel like a personal failure while on a Disney family vacation?”

Disney has since closed the exhibit for re-tooling.

I have not seen the exhibit so I can’t speak to its appropriateness. I’m also not familiar with the NAAFA, so I looked at their website. The purpose of the organization is to protect the rights and improve the quality of life for fat people. “NAAFA works to eliminate discrimination based on body size and provide fat people with the tools for self-empowerment through advocacy, public education, and support.” I’m not sure I can support an organization for fat acceptance, but they do make a valid point in their criticism of how the attraction can make overweight children feel.

As the nation has tried to tackle childhood obesity, it has created a stigma against being overweight. If you are fat, you are bad. And why not? According to the Centers for Disease Control (CDC), the medical cost of obesity in the U.S. totaled $147 billion in 2008.

The problem is that obesity is not a health issue we can fix with a simple solution. A few years ago, we targeted smokers as the health issue to fix. Health campaigns around the country encouraged smokers to stop cold turkey, and that action removed the negative label. That same standard doesn’t apply to people who are overweight. First of all, we can ask them to stop eating. Food is a necessity. Second, changing your diet does not automatically fix the problem. Weight loss takes time and is often impacted by other social and environmental factors. We eat for more than just sustenance. After all, we have all heard terms like  “comfort food” and “stress eating.” So to address obesity, we need to look at the social and environmental factors impacting weight gain — the “why” people eat.

A few days ago, the New York Times published an op-ed by Frank Bruni where he explored our country’s expanding waistline, the reasons behind it and the toll it takes. He sums up the point well with the following:

“If we’re going to wage a successful war against unhealthy weight gain and obesity, we need to understand all of that. We need to stop vilifying obese people, who aren’t likely to be helped by it.”

This is even more important when we talk about kids. When we target overweight kids, we risk labeling them during a critical period in their development. Studies have shown there is a developmental association between obesity and rates of self-esteem in children and adolescents. Overweight children are at greater risk of lower self-esteem. This can result in social isolation, bullying and other issues.

Bottom line, we have to tackle childhood obesity. It’s critical for the future health of our country. But we have to be careful about labeling overweight kids as bad or deficient in the process. Positive social support has to be part of the equation. So how do we do it?

Eating Healthy — if you can

We all know we need to eat healthy. Just turn on the TV or open a magazine. From the “Eat This, Not That” guy to the glut of health reporters, dietitians and celebrity chefs trying to help us all figure it out, we know healthy eating is important. After all, three-quarters of American adults are overweight or obese. So this should be easy, right?

Not necessarily. Access to food and hunger is a big issue in this country. More than 16 million children in America are at risk of hunger. That’s more than one in five children who are not sure where their next meal is coming from. Child hunger is not just a health issue. It’s a social and developmental issue. Children who are hungry are often more prone to illness, more like to ultimately be obese later in life and more likely to have highly levels of behavioral, emotional and academic problems. How can we expect to raise the next generation of confident, strong, successful Americans when as children, they are not getting their basic food needs during their developmental years?

The Food Network has partnered with Share Our Strength, an organization dedicated to eradicating childhood hunger. On April 14th, the Food Network aired a documentary about childhood hunger in America through the eyes of three families in Texas, Virginia and New York City. If you missed it, you can watch it online. It will air again on the Food Network on April 21st at 6:00 p.m. EDT/5:00 p.m. CDT and April 23rd at 10:00 a.m. EDT/9:00 a.m. CDT.

Eradicating childhood hunger is an investment in our future. Our children need to be strong of mind and body to compete in the global economy. So look at it as a future investment.

But let’s also look at it in more immediate terms. We tend think of food insecurity as an inner city problem or a rural issue. But food insecurity abounds in well-to-do, suburban communities. It can be someone in your child’s classroom. We know the health implications. Children who struggle with hunger are more likely experience headaches, stomachaches, colds, ear infections and fatigue. But the emotional and social impact is much deeper. As the documentary showed, children at risk of hunger feel shame and insecurity. According to Share Our Strength, children who regularly do not get enough nutritious food to eat can be more aggressive and anxious. Teens who regularly do not get enough to eat have difficulty getting along with other kids.

This is a community issue. Let’s look at it from the perspective of one child in one class. Have you ever wondered about the root cause of a child’s behavior? The disruptive child in your son’s class may not be a bad kid. He may be hungry and struggling to concentrate. He may be anxious, reflecting his parents’ anxiety about being unable to provide nutritious food at home. Imagine the positive impact — if this one child could become food secure, he/she could thrive in school, improve social ties and the entire class can benefit. Now replace the word “classroom” for “community” and the possibilities grow exponentially.

Health is a group effort that directly impacts the happiness and productivity of a community. It’s a daunting challenge to tackle. But I’m going to start by picking up some extra food at the supermarket today for my church’s food pantry.