Culture of Health Blog

Providers need to be equipped with the tools to help patients make healthy choices. That’s why the Alliance for Healthier Generation is recognizing innovative training programs providing nutrition, physical activity and obesity counseling education to their students.

Even at the young age of four, Luke was overweight. In fifth grade, he tried out for the baseball team, and although he made it, he struggled that season. He was slower than the other kids as he rounded the bases, and he started having knee pain from the extra weight on his joints. Luke and his family knew they had to do something. But they dreaded going to the doctor, knowing he’d get weighed and then have to confront the escalating numbers on the scale. Year after year, the same thing would happen, and they’d have the same discussion with his doctor when they finally worked up the nerve to go. But the weight never came off.

Apprehension about a visit to the doctor is something we all face, no matter our age or health. Who among us doesn’t get a little nervous before our annual visit, knowing we might face a difficult conversation about losing weight, or flossing more, or stopping smoking? These are things we all know, but have a hard time talking about.

And even worse, if we do have these important conversations, they can lead to feelings of shame and disappointment.

But the reality is that it’s not necessarily your doctor’s fault. Even with the hundreds of thousands of hours of education your doctor gets in classrooms and hospitals, most receive little to no training in how to talk to patients about making healthy choices. In fact, fewer than 30 percent of medical schools meet the minimum number of hours of education in nutrition and exercise recommended by the National Academy of Sciences, Engineering and Medicine.

We’re all well aware that education leads to better jobs and higher income. Just as important, research also links education to reduced risk of illness, increased vitality, longevity and academic success that extends to future generations.

That’s why the situation for schools in Lawrence, Mass., was particularly concerning back in 2010. At the time, more than one out of every four Lawrence kids dropped out of high school. This led the Massachusetts Department of Education to put Lawrence’s schools into receivership by 2012, placing them under new management to safeguard state assets. The state-appointed “receiver,” was granted authority to develop an intervention plan to overhaul the schools through steps you might expect such as expanding the school day and replacing half the districts’ principals.

But the district also took one critical step by acknowledging that a family’s financial stability strongly influences how well children do in school—and whether they drop out.

Between 2000 and 2011, almost 1 million service members or former service members were diagnosed with at least one psychological disorder either during or after deployment, according to recent research by the Institute of Medicine (IOM). As a follow up, the U.S. Department of Defense (DOD) asked the IOM to evaluate the department’s efforts to prevent psychological disorders among active-duty service members and their families. That report was recently released.

The report includes recommendations on how the DOD can improve care.

Finding 1: DOD has implemented numerous resilience and prevention programs for service members and their families, but it faces a number of challenges, including an insufficient evidence base to support its interventions and a lack of systematic evaluation and performance measures.

Recommendation 1: By targeting resources to develop the evidence base and disseminate that evidence, DOD’s prevention efforts can be both more effective and cost effective.

Finding 2: There is a need for DOD to improve approaches for identifying and intervening with service members and their members who may already have or may be at risk for developing a psychological disorder.

Recommendation 2: DOD should dedicate funding, staffing and logistical support for data analysis and evaluation to support performance monitoring of programs for accountability and continuous improvement.

Finding 3: Screening, assessment and treatment approaches for psychological health problems are not always implemented between and within the DOD and the U.S. Department of Veterans Affairs (VA) in a consistent manner or aligned with the evidence base, which threatens the delivery of high-quality care and hampers evaluation efforts.

Recommendation 3:

• There are opportunities to improve processes of training and evaluating clinicians, including the incorporation of continuing education and supervision; standardized periodic evaluation; and a greater emphasis on coordination and interdisciplinary.
• The DOD and VA should invest in research to determine the efficacy of treatments that do not have a strong evidence base.
• Both departments should conduct systematic assessments to determine whether screening and treatment interventions are being implemented according to clinical guidelines and departmental policy.
• Accessible inter-department data systems should be developed to assess treatment outcomes, variations among treatment facilities and barriers to the use of evidence-based treatment.

This commentary originally appeared on the RWJF New Public Health blog.

Each year hundreds of public health researchers and practitioners meet to share research and best practices on creating a stronger public health system at the annual Keeneland Conference in Lexington, Ky. The conference, which will be held this year April 8-11, is sponsored by the National Coordinating Center for Public Health Services and Systems Research, based at the University of Kentucky.

Paul Kuehnert, MS, RN, senior program officer and director of the Public Health Team at the Robert Wood Johnson Foundation (RWJF), will speak at the opening lunch about threats and opportunities for public health, and how we can re-shape the system to create a healthier future for all. We caught up with him to get his insights before the conference on the evolving role of public health. Prior to joining the Foundation, he was county health officer and executive director for health for Kane County, Ill., where he led a partnership between the health department, hospitals and other partners to assess and address the community’s health needs. Kuehnert is a Pediatric Nurse Practitioner and worked as a primary care provider in schools and other community settings in Missouri and Illinois. 

NewPublicHealth: What are you going to talk about at Keeneland?

Paul Kuehnert: I think a lot of us are familiar with the data on our health care system, and the inter-twined issues of access, quality and cost. And the fact that younger Americans have a lower life expectancy than young people in other developed countries. We’re just not getting the health outcomes that one would expect from the amount we’re spending.

When you pit that against our legacy in public health, and what’s happening in the environment we operate in, I think there’s a real need to identify the threats and opportunities and re-imagine what we’re doing. We’re working from old models that need to be really questioned. What I’m hoping to do, and that others will do, is to provoke some creative thinking about where we need to go in public health to truly meet the challenges that face our communities and our nation.

NPH: What do you see as some of the major public health challenges today?

Kuehnert: For me, one of the first that comes to mind is that issue of life expectancy. With all the resources we have, we’re actually losing ground. It’s extremely concerning and has to do with a number of underlying dynamics—but particularly the epidemic of chronic disease, things such as obesity, heart disease, cancer, and all of those threats to our health. And there are also the incredible health disparities, the inequities that are reflected in our health across the country.

A group of professionally-attired policy-makers, influencers and public health professionals in Washington started their day this morning the way students at Namaste Charter School in Chicago do every day—doing upper and lower body exercises and stretches to make physical activity the first learning component of their school day. The Washingtonians—and some key education and health officials from around the country—were at the launch of “Health in Mind,” a project of the Healthy Schools Campaign and Trust for America’s Health (TFAH) that has released actionable recommendations focused on improving student learning and achievement through healthier schools. The recommendations were presented at today’s event to U.S. Department of Education Secretary Arne Duncan and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius.

“Unless we address health and wellness in schools, our nation’s efforts to close the achievement gap will be compromised,” said Rochelle Davis, president and CEO of the Healthy Schools Campaign, a national group that has focused on improving food and fitness in Chicago public schools.

Health in Mind aligns with the National Prevention Strategy introduced two years ago by the National Prevention and Health Promotion Council, which brings together 17 federal cabinet offices and agencies. The Strategy commits the entire federal government, not just the health agencies, to integrate health into their work and make a healthier nation a priority across sectors.

“The Strategy and these recommendations represent a major culture shift in how the nation views health—health will no longer be separated from education, transportation, housing and other clearly connected policies,” said Jeff Levi, executive director of TFAH and chair of the Advisory Group on Prevention, Health Promotion and Integrative and Public Health. “Health in Mind’s focus on students and schools promises to have a long-term payoff by improving education and quality of life for today’s kids as they grow up—they will do better in school and be healthier.”

The National Prevention and Health Promotion Strategy is about to celebrate its first anniversary. The Strategy offers a comprehensive plan aimed at increasing the number of Americans who are healthy at every stage of life. A cornerstone of the National Prevention Strategy is that it recognizes that good health comes not just from receiving quality medical care, but also from the conditions we face where we live, learn work and play such as clean water and air, safe worksites and healthy foods. The strategy was developed by the National Prevention Council, which is composed of 17 federal agencies including the Department of Agriculture, the Department of Education, the Department of Housing and Urban Development, the Office of National Drug Control Policy and others.

As the Strategy is rolled out, NewPublicHealth will be speaking with Cabinet Secretaries, Agency directors and their designees to the Prevention Council about the initiatives being introduced to help Americans work toward the goal of long and healthy lives.

This week, NewPublicHealth spoke with Mary Engle, Director of the Federal Trade Commission's (FTC) Division of Advertising Practices, and National Prevention Council designee.

NewPublicHealth: Why is health a priority for the FTC? Why was it important for FTC to be involved in the development of the National Prevention Strategy?

Mary Engle: When you think about our mission, which is to protect consumers and maintain competition in the marketplace, health is such an important part of that. We want to make sure consumers aren’t misled about health services and products marketed to them and that they don’t pay more than they need to.

Initiatives that are a priority for us include combating deceptive advertising of fraudulent cure-all claims for dietary supplements and weight loss products; monitoring and reporting on the marketing of food to children as well as alcohol and tobacco marketing practices; and developing consumer education materials designed to empower consumers to make informed health care decisions and to avoid fraud.

NPH: What FTC initiatives support the National Prevention Strategy?

The 2012 County Health Rankings, a joint project of the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute, were released this morning. For the third year in a row, the reports rank the health of nearly every county in the nation and show that much of what affects health occurs outside of the doctor’s office. The County Health Rankings confirm the critical role that factors such as education, jobs, income and environment play in how healthy people are and how long they live. NewPublicHealth spoke with Patrick Remington, MD, MPH, County Health Rankings Project Director and Associate Dean at the University of Wisconsin School of Medicine and Public Health, about this year’s release.

>>Join our Twitter Q&A TODAY, April 3, at 1 p.m. EST, and follow the rest of the NewPublicHealth coverage of the 2012 County Health Rankings launch.

NewPublicHealth: What’s new for the County Health Rankings this year?

Dr. Remington: The County Health Roadmaps are new. The County Health Roadmaps project includes several efforts to build connections with local communities and national partners and leaders, including grants to coalitions across the U.S. that are working to improve the health of people in their communities; grants to national organizations to activate local leaders and affiliates to improve health; a prize program to recognize communities taking action whose promising efforts will likely lead to better health; and tools and resources to help groups working to improve the health of people in their communities.

The County Health Roadmaps is our response to the demand that has arisen by communities to help them find solutions. We were pretty good in the first two years at pointing out problems. Over the last year, we heard loud and clear that’s not good enough to just point out problems. The Roadmap is just one tool. It’s certainly not the automobile; it’s not the vacation plan. It is just a tool that communities need to use to come together and decide where they want to go and the Roadmap can tell you how to get there.

But an even better question is what is the same. We want the County Health Rankings to be an annual check-up that can be counted on by communities to provide residents with a way to compare the health of where they live to other counties in their state. Although we might add a measure or two each year, I think the most important message is that we’ve continued to use the same approach to measure and rank the health of counties.

NPH: What is that approach?

In Detroit, Michigan, the Joy-Southfield Community Development Corporation has developed a targeted approach to promoting health equity, based on the four factors measured by the County Health Rankings: health behaviors, clinical care, social and economic factors and physical environment. Despite its location in one of the most racially segregated cities in the country, with poor public transportation, high poverty and unemployment, and vast food deserts, the Joy-Southfield neighborhood has become a hub of partnerships and activities aimed at long-term health improvement. Several community groups and funders have collaborated to empower youth through mentoring and community garden projects; renovate vacant properties to attract new businesses; improve community safety; provide job training and foreclosure prevention services and more.

NewPublicHealth spoke with David Law, PhD, Executive Director at Joy-Southfield, about the program.

NewPublicHealth: Tell us about the Joy-Southfield Community Development Corporation. How did your priorities evolve, and how did the County Health Rankings help shape them?

To help public health officials and policy-makers better understand the opportunity around the community benefit requirements for nonprofit hospitals, the Robert Wood Johnson Foundation funded the The Hilltop Institute at UMBC – a research center that focuses on the needs of vulnerable populations – to publish a series of issue briefs on best practices, new laws and regulations, and study findings related to community benefit activities and reporting. The most recent Hilltop Institute brief on community benefit and partnerships between hospitals, public health agencies and the communities they serve includes a discussion of an innovative asthma management program created by Children’s Hospital Boston. Last week, new data was published in the journal Pediatrics showing that this program reduced hospitalizations and emergency room visits, improved patient outcomes and saved $1.46 for every dollar spent.

NewPublicHealth spoke with Laurie Cammisa, Vice President for Child Advocacy at the hospital, about the project and the hospital’s approach to community benefit.

>>Read more on community benefit and the Hilltop issue brief series in a Q&A with Abbey Cofsky, program officer at the Robert Wood Johnson Foundation.

NewPublicHealth: The new IRS regulations on community benefit begin in March, but you are far ahead of the game with some of your community benefit initiatives. How did that come about?

Laurie Cammisa: The State Attorney General called for voluntary community benefit guidelines beginning in the 1990s, so we have been thinking about our initiatives since then. Our community benefit initiatives have included programs on mental health, child development, fitness and asthma. We have programs in each area, in partnership with communities.

NPH: Why is asthma one of the focus programs?

John Buse, MD, PhD, director of the Diabetes Care Center and chief of the Division of Endocrinology at the University of North Carolina at Chapel Hill School of Medicine, was just recently named the new chair of the National Diabetes Education Program (NDEP), a joint program of the National Institutes of Health and the Centers for Disease Control and Prevention.

The role of NDEP, established in 1997, is to foster public and private partnerships to improve diabetes management and outcomes, to promote early diagnosis, and to prevent or delay the onset of type 2 diabetes in the U.S. Currently, nearly 26 million Americans have diabetes, and 79 million have prediabetes, which puts them at increased risk for developing type 2 diabetes and heart disease. Over the next decade, an estimated forty million more U.S. adults could develop the condition.

NewPublicHealth spoke with Dr. Buse recently about his new position at NDEP.

NewPublicHealth: What innovations might you like to try at NDEP?

Dr. Buse: I think the program has been remarkably successful over almost 15 years. NDEP has developed a lot of materials, and the focus now is on working through partnerships to get the materials out there to a greater extent. Our research unit at UNC has done a lot of work with the pharmaceutical industry and clinical trials in diabetes and cardiovascular disease and I do think there’s an opportunity to partner with industry. They provide materials to primary care doctors and health care systems to use in patient education. They generally develop those materials themselves. I think there’s potentially an opportunity to have them use the NDEP materials with the NDEP being sort of an honest broker in developing educational programs free of undue influence from the pharmaceutical industry. So I think that’s a potential opportunity. The resources of NDEP are pretty modest compared to the scope of the diabetes problem, so leveraging our little tiny budget through partnerships is really the way to have an impact.

And as universal health care coverage is slated to come into existence in 2014, the improved access to care will create lots of opportunities to improve diabetes care and the education is really critical in that process. Health care systems and insurance plans and legislatures are looking more and more carefully at diabetes and obesity as major areas of cost and expenditures.

NPH: Can you tell us the key mandates of NDEP?