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As I have identified before, I am a runner. I run to keep physically fit, to keep weight off (I am also an eater), and to clear my mind of extraneous materials as I dodge cracks in the sidewalk. I ran a race today and although it was unseasonably warm I did all right.

To set a race up takes a lot of effort and infrastructure. This particular race benefited the L’Arche community.  People volunteered willingly to help control traffic, hand out water, offer band aids and fruit to the runners, and in general make the runners feel welcome and supported. Turns out that racing itself is not nearly as important as training for a race. The act of training provides an opportunity to participate in “vigorous intensity aerobic activity.” For adults, in addition to strength training the CDC recommends:

2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week or 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week or an equivalent mix of moderate- and vigorous-intensity aerobic activity.

In addition the CDC points out the the more time you spend exercising, the greater the benefits are.

Human beings are designed to be physically active. People who are physically active get fewer heart attacks,have less hypertension, less diabetes, less colon cancer, less depression, and less anxiety. At these races, there are very few people who do not routinely participate in physical activity and they look healthy for the most part. In my clinical practice, on the other hand, I see a lot of folks who have led sedentary lives and are often afraid to begin exercising. The CDC recommends that those starting a program do so in doable chunks, 10 minutes or so at a time. In additions, they recommend a gradual increase over time:

If you want to do more vigorous-level activities, slowly replace those that take moderate effort like brisk walking, with more vigorous activities like jogging

For those of you who are physicians seeing patients with chronic illnesses, instead of adding another pill try an exercise prescription. Exercise prescription involves a planned or structured physical activity regimen given to an individual or group that includes specific recommendations for the frequency, intensity, and type of exercise. Write it out as you would a pill to lower cholesterol (it is almost as effective).

I often offer may patients the opportunity to begin a trial of exercise rather than adding another pill or potion and write them a prescription. Sometimes, it even works.

I live and practice in Mobile, Alabama. Alabama is ranked #2 in the supersizing of America with 31% of our adults in the obese range and 14% of our children. The Trust for America’s health, who compiled the above data, lists some policy opportunities to reverse the trend (should we in Alabama chose to). These include:

  • Support obesity- and disease-prevention programs through the new health reform law’s Prevention and Public Health Fund
  • Align federal policies and legislation with the goals of the forthcoming National Prevention and Health Promotion Strategy.
  • Expand the commitment to community-based prevention programs
  • Continue to invest in research and evaluation on nutrition, physical activity, obesity and obesity-related health outcomes and associated interventions.

I was reminded of the ranking of our state by a future medical student who is very interested in healthy eating and obesity prevention, and he met with me to call my attention to Wholesome Wave, a program designed to inexpensively deliver fruits and vegetables to low-income patients.

Obesity is a huge (no pun intended) problem without an easy fix. In my conversation with Will, we talked at length about how the problem is a mixture of diminished opportunity to purchase and eat healthful  foods combined with limited opportunities to participate in physical activities.Programs such as this are a start but need to be combined with biking, walking, and other means of burning calories.

US News and World Reports offers another opinion. They found 22 experts

including nutritionists and specialists in diabetes, heart health, human behavior, and weight loss

who reviewed and rated 25 diets in seven categories, including short- and long-term weight loss, ease of compliance, safety, and nutrition.

The winner, as identified by the experts, was the DASH diet, rated 4.1 out of 5 (lots of vegetables, fruits, low in fat). The loser, the Paleo diet (eat only what cave men eat) was only rated 2.0 out of 5. The website offers a feature where readers can identify with a YES or  NO whether or not the diet worked for them. Although liked by the experts, the DASH diet has only been tried by 1600 readers and only 24% found it effective. By contrast, the Paleo diet had been tried by 30,000 folks with roughly the same amount of weight loss. The winners, based on readers clicking YES were the Vegetarian, the Vegan, and the Eco-Atkins (#10, #14, and #17) which had 93% self reported success by over 40,000 readers.

Fad diets tend to work in the short run by limiting food choices and forcing participants to select lower calorie options. This is reflected in the number of people who reported losing weight with the “bad diets.” This weight tends to come back as people revert to old habits hence the ongoing problem of obesity. On the other hand, losing weight is more than choosing healthy foods. Losing weight is always ultimately about burning more calories than you take in. The DASH diet is a healthy long term diet and, for example, would work even better if it included actual dashes. The Paleo diet to be effective would have to include participation in activities only a cave man might do. As to what that might be, you’ll have to use your imagination.

Our neighborhood lost a local doughnut shop and I feel oddly compelled to “weigh” in. When we moved here 20 years ago, the local Krispy Kreme (built in the retail factory model of the 1960s) was a place to take the kids that served coffee and provided hours of entertainment as they (we) watched the yeasty donuts come out of the intricately timed warming component, move through the frying station (took about a minute a side) and through the glazing waterfall. As an added plus, a hot Krispy Kreme doughnut tastes like nothing else.

Why are they closing? Per their web site, they are going to a strategy of “factory stores, doughnut and coffee shops and satellite units.” I suspect they were unable to convert this to a coffee shop in a cost-effective manner, and with the construction of a new factory store in town the location is unneeded.The company has a growth strategy to bring doughnuts to multiple sites to an area through new technology that can create HOT DOUGHNUTS with minimal infrastructure and the company has an app to make consumption of HOT DOUGHNUTS even easier. From the web-site:

With Hot Light Online you can map your nearest Krispy Kreme location from your phone and get alerts when the neon glow of “Hot Now” is activated in your area. So look up, download or tweet your way to find a hot Krispy Kreme doughnut near you with any of the following free options.

Now the downside. Each of the tasty glazed morsels has 200 calories, 110 from fat (per the company’s nutritional info). Although the company reports a serving size of 1 (one) doughnut, they are most commonly purchased by the dozen meaning that the average consumer purchases between 24 and 36 hours worth of calories if you get the simple glazed. In addition to the 2400 calories you’ve consumed (after eating  “just one more” times 12), you will also get 72% of the day’s requirement of calcium and 48% of the iron.

Krispy Kreme expanded too rapidly in the early 2000s but has recently righted themselves financially and has turned a profit for 12 straight quarters. They have selected a new CEO, Kenneth May, who

…is a highly respected business leader with more than 25 years of operational, retail, supply chain and brand experience.  As part of a successful career with FedEx Corporation, he served as President and Chief Executive Officer of FedEx Kinko’s Office and Print Centers, and led the integration of Kinko’s into FedEx.

I should wish them the best, but won’t. It concerns me that to increase profit, they are looking to increase sales of these little fat bullets through innovative marketing techniques. For me, these were an annual treat and now they will be less so but then again, I am not in their target demographic. To be honest I would rather hang at a locally owned shop such as Serda’s, Cream and Sugar, or even a Starbucks and spend my money on good coffee and skim milk. I encourage you to do the same.

As I will be out for a few days visiting with family, I feel compelled to leave you information regarding the season. This information comes by way of the Washington Post. They have created a handy Holiday Calorie Counter. This counter allows you to put a calorie deposit onto your plate in order to count the calories  but also allows you to make a withdrawal in the way of activity. Use it to avoid having to let the belt out anouther notch.

Happy Thanksgiving, everyone.

On Sunday, All Saints Episcopal Church in our neighborhood is playing “In sickness and in wealth”  with a discussion to follow. This documentary uses people’s stories, people who work at the same company but have dramatically different lives, to illustrate the contribution to poverty and societal stress to the ill health of some Americans. The documentary makes the following point:

What needs to be done is to make sure that everyone is allowed access to the same opportunities even if they do not have the economic resources.  This would involve providing resources such as quality education, decent housing, access to affordable health care, and access to healthy food and safe places to exercise to everyone despite gaps in affluence.  Having access to such resources would simulate the control felt by the affluent when they come to make such choices regarding health.

The documentary was done in 2007. Things have not gotten much better. My friend Josh Freeman recently wrote about a presentation he saw by Stephen Woolf on the same topic done this year (found here). Josh reports that Stephen presented information familiar to those of us with an interest in public health but somehow lost in the debate over health insurance, such as that to truly improve health the practitioner needs to go outside the hospital or office to the community, where these causes of ill health are located.

Doctor Woolf advocates the use of “Health in All” policies.  These policies take into account the reality that decision-making regarding transportation, land use, built environment, taxes, housing, agriculture, and environmental justice, for example, affect health.  For example, the fact that  2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle should inform policies regarding public transportation and land use, among others.

Turns out, we can purchase better health. If we want to make improvements in the health of our citizens, we probably should focus as much on education and improving the overall living environment (including improvements in working conditions) as we focus on health care insurance. There is now a calculator that allows counties to compare where they are to where they could be if only their citizens were better educated. For Mobile County, for example, just by improving our educational status to that of Shelby County (Alabama’s best) we could avert 459 deaths in the county.

To quote my friend, Josh, about the same observation in a Kansas comparison:

No drug comes close to this. No treatment of any kind comes close to this. If a new drug were shown to reduce mortality from a disease by 5%, or even 1%, it would get incredible advertising – hundreds of millions of dollars – and huge publicity, in both the scientific and lay press. But the simple fact that so many more deaths could be prevented, so many lives could be improved, by addressing the social determinants of health, is scarcely covered, and hardly funded at all.

The town in which I live has seen its share of trouble. Some of the trouble is caused by nature. As I sit here writing this, we are being visited by a violent thunderstorm, as we are almost every day during the summer. Not only do the thunderstorms sometimes cause damage, but the heavy rains provide an environment where mosquitoes (as well as other insects)  propagate at a level most people cannot even imagine. It was no accident that William Gorgas, E O Wilson, and others focused their great intellects on insects after growing up in Mobile. We got a lot of bugs, many of which cause diseases in humans. Oh yeah, and every couple of years we get hurricanes. Some, like Katrina, create enough of a stir that we forget about the bugs for a while.

As if this weren’t enough, humans seem intent on adding to our woes. Southern novelists have filled books on the theme of  “man’s inhumanity to man.” In one of the greatest ironies of all, America’s quest for cheap oil (drill, baby, drill) landed 4.9 million barrels of oil in the Gulf of Mexico. Much of this oil went on to disrupt the economy of Alabama either directly (can’t catch fish through oil) or indirectly (wanna drive 300 miles and see if the beaches are clean today?).

Given hurricanes, oil spills, lots of mosquitoes that might carry West Nile disease, not to mention the general hardships of living, life can be tough. This being the case, we on the coast should cultivate and value the ability to quickly recover from disasters and get back to status quo.

That is why I read with interest that a “Resilience Capacity Scale” has been developed. The initial story that I read (“What’s our resilience capacity?” Mobile Press-Register, link now available) did not lead me to believe this new scale would be useful. The article implied that the information used to create the scale was unfairly biased against Alabama and Mississippi. In searching for that article to link to, I found another article from an Alabama newspaper, with site comments that do seem to show anger at this perceived bias. Here is a representative response:

This study was funded by the John D. and Catherine T. MacArthur Foundation and administered by the University of California, Berkeley. No doubt the 12 economic, socio-demographic, and community connectivity indicators are from the perspective of the socialist mentality of the John D and Catherine T. MacArthur Foundation and their fellow travelers at the U of California at Berkely [sic].

I have subsequently spent a little time with the instrument, found here. The purpose, it turns out, is not to further the socialist agenda  but:

One way to assess a region’s resilience is by its qualities to cope with future challenges, a concept we label resilience capacity. Developed by Kathryn A. Foster, member of the BRR research network and director of the University at Buffalo Regional Institute, the Resilience Capacity Index (RCI) is a single statistic summarizing a region’s score on 12 equally weighted indicators—four indicators in each of three dimensions encompassing Regional Economic, Socio-Demographic, and Community Connectivity attributes. As a gauge of a region’s foundation for responding effectively to a future stress, the RCI reveals regional strengths and weaknesses, and allows regional leaders to compare their region’s capacity profile to that of other metropolitan areas.

The capacity is determined by an assessment of regional economic capacity (resilient communities have a narrow range of income across households, diversification of the  economy, affordable housing relative to income levels, and hospitable business environments as measured by business churn and access to venture capital and broadband), socio-demographic capacity (resilient communities have high levels of college-educated people and low levels of non-high school graduates, low proportions of the population with disabilities or living in poverty, and high proportions of people with health insurance) and community connectivity ((resilient communities have high rootedness and familiarity, with low in- and out-migration and high homeownership coupled with commitment to place demonstrated by the presence of civic organizations and high voter turnout). Mobile did not do badly in economic resilience (170/361) and community connectedness (171/361) but did very poorly in socio-demographic  (303/361).

So our global score of LOW (229/361) does not reflect the discounting of church membership (as was suggested in our local paper) but instead is reflective of our poorly educated populace who have a relatively high rate of disability, who are less likely to be employed and more likely to live in poverty, and who are less likely to have health insurance than all but 61 of the metropolitan areas assessed.

Following the Gulf Oil Spill, a leadership driven process produced a report entitled A Roadmap to Resilience. In this process, several hundred community leaders came together to “Build regional capacity for long term resilience.” They pledged to “Keep it simple.” This report is 194 pages and includes everything from drug education to building a $500,000,000 bridge with federal funds. Turns out, they could have greatly increased the resilience of Mobilians by focusing on three things:

  • An education system second to none from K-graduate school
  • Universal access to healthcare
  • Full employment

I think for those of us down here on the mosquito coast, that’s not too much to ask.

The Robert Wood Johnson Foundation and the University of Wisconsin have put together a web site which compares the health status of counties within states. Originally done by the University of Wisconsin for Wisconsinites, last year they expanded it to all (well, all but 115) counties in the United States. The local paper dutifully published an article, identifying Mobile County as a low performing county (#46, down from #43 last year) and the neighboring county of Baldwin as a high performing county (#3). The next day, the paper decided to get serious, publishing an editorial identifying what was measured

Social factors and health habits are taken into account in the health rankings, including obesity, smoking, high school graduation rates, air pollution, access to health care, access to exercise and life expectancy.

and pointed out that perhaps building a walking trail would solve all of our problems

From a health standpoint, trails offer cheap and easy opportunities for exercise. Families can walk together; those beginning an exercise program can try a one- or two-mile stretch of trail and improve.

In reality, being third in the 45th ranked state is nothing to brag about. Anyone who knows anything about who lives in cities as opposed to who lives in suburbs likely can make an educated guess as to why Baldwin (suburbs) has better health statistics than Mobile (city) and it has little to do with a 2 mile walking trail.

A more interesting comparison tool, found here, compares counties against others of similar demographics and economics. In this comparison Mobile County still doesn’t fare very well (average life expectancy 73.6 years, peers 73.5-77.8 years, every marker worse than peers except immunization rates and prenatal care access) but Baldwin is no great shakes either (average life expectancy 76.6 years, peers 75.5-78.2 years, worse than peers except in breast cancer survival, infant mortality, and suicide rates).

The purpose of the rankings is not, or so says the University of Wisconsin, to facilitate boosterism but in the hopes that communities will use this information to work towards improving the health of the citizens. I hope that the local paper (as well as the media outlet of any communities whose “rankings” were not what they would like) will look at this page where action steps are discussed. These action steps include working together as a community, finding programs and policies that work, implementing strategies, assessing needs and resources, evaluating efforts, and picking priorities. Additionally, they have targeted advice for community leaders, educators, health professionals, and government officials, and public health officials.

Here is the advice for the community leaders, in case anyone from the local paper is paying attention

  • Get the word out. Reach out to people you know and see every day about the County Health Rankings report, e.g., at a local Chamber of Commerce breakfast or at an urban planning meeting. Post information about the report on a listserv, website, or e-newsletter.
  • Organize. Meet with local leaders and community residents to discuss barriers to health and ways to overcome them. Host a town hall meeting or invite people to one.
  • Get policymakers to pay attention. Tell them about how their county or counties ranked and open a dialogue about ways to improve health in your community.
  • Be an advocate. Step out as a spokesperson about the rankings and the health issues you care about and rally other community leaders to take action.
  • Contact your local public health department about participating in a local task force or, if none exists, organize one to tackle these pressing issues in your community.
  • Ask your local or state health department about what they’re doing in response to the report to make sure you aren’t duplicating efforts.
  • Share your resources. Offer your time, staff, and/or funding with community partners. These are resources that can go toward community plans and programs aimed at tackling factors that affect health.
  • Communicate your message. Write an op-ed or talk to local media about the rankings and what needs to be done to improve the health of your community.
  • Start a conversation. Talk to your friends, colleagues, neighbors, and family members about the health of your community and what everyone collectively can do to make it healthier.

Now that the word is out in Mobile, I hope we’re able to make the rest happen here.

Josh Freeman points out that my last post was not only a comparison of  health planning to community planning but it was an especially apt comparison because healthy communities are needed to facilitate human health. This is something we have known for a while. Suburban living left unchecked contributes to obesity, respiratory problems, mood and affect disorders, and limited access to health resources to those who need it most.

The CDC has put together a web site to help guide us to making healthy choices and to help developers create a healthier living environment. In their words:

Healthy community design can improve people’s health by:

I encourage you to take a look.