Speaking of suicide

April has been a cruel month here in southwestern Minnesota, where the lives of four teens were recently lost to suicide.

For their families, friends, classmates, teachers and others who knew them, the grief is deep and personal. For the community at large, it has focused attention on a mental health issue that needs to be named and recognized.

Somewhere in the middle of this is the uneasy presence of the news media. Which aspects of the story ought to be shared with readers and, by extension, the public? What should be left private? Should these kinds of stories not be covered at all, or do they represent an opportunity to educate the public about suicide prevention?

There’s in fact a sizable body of literature suggesting that the way suicide is portrayed in the print media, on television and in the movies can have an influence on how people behave. When the portrayal is handled well, it can counteract misinformation and encourage vulnerable individuals to seek help. When it’s not, it sometimes can result in copycat suicides or what behavioral scientists call “suicide contagion.”

More than 40 studies worldwide have examined the connection between media coverage and copycat suicides. The evidence is mostly indirect; indeed, it’s very difficult to accurately gauge the impact of media coverage on increased risk of suicide. It’s entirely possible that the real factor is heightened attention by the public overall, rather than media coverage per se. But at least one study, which analyzed 42 previous studies, found that news stories about entertainment or political celebrities who died by suicide were 14.3 times more likely to produce a copycat effect. Newspaper coverage also appeared to be more likely to produce this effect than television coverage.

How a death by suicide is covered in the media also seems to matter. In a report following a national workshop in the late 1980s, the U.S. Centers for Disease Control and Prevention identified several characteristics that appear to be linked to suicide contagion: offering overly simplified reasons for a suicide; coverage that’s excessive, repetitive or sensationalized; reporting details on how a suicide was carried out; idealizing or romanticizing suicide and individuals who die in this manner.

Several organizations have issued guidelines to help the media navigate this sensitive issue. The most recent recommendations come from the U.S. Substance Abuse and Mental Health Administration. They echo other recommendations from organizations such as the Suicide Prevention Resource Center, Suicide Prevention International and the World Health Organization.

By now, readers might be wondering what all of this has to do with them. After all, if you don’t report or produce the news, why would these guidelines matter to you?

But they do matter, in the sense that deaths due to suicide often lead to intense community discussions that may or may not be based on accurate information. Members of the public can be just as guilty as the media of oversimplifying suicide, downplaying the element of mental health or looking for an obvious answer to the question “why?”.

Some information and general guidelines from the Suicide Prevention Resource Center:

– Avoid using the terms “committed suicide” or “failed” or “successful” suicide attempt. The reasoning: the word “committed” carries moral or criminal overtones, and it’s more accurate to view suicide in the context of behavioral health. “Successful suicide” and “failed suicide” also imply judgment about the outcome. Experts recommend using the terms “death by suicide” or “non-fatal suicide attempt” instead.

– Avoid romanticizing someone who has died by suicide or glamorizing the suicide of a celebrity.

– Avoid oversimplifying the causes of suicide. Although it might appear as though a triggering event such as bullying, the end of a relationship or some other kind of loss is responsible, there usually are multiple and complex factors involved in a death by suicide. In the vast majority of cases, a mental health issue and/or substance abuse is involved.

– Avoid treating suicide as inexplicable or without warning. Many – although not all – individuals who attempt or complete suicide show warning signs ahead of time.

Finally, some statistics:

According to data from the U.S. Centers for Disease Control and Prevention for 2007, the most recent year for which complete numbers are available, suicide was the 11th leading overall cause of death in the United States.

Among the 15-to-24-year-old age group, it was the third leading cause of death. But the greatest number of suicide deaths per 100,000 isn’t among the young – it’s among the middle-aged and elderly. In 2007 there were 17.7 suicide deaths per capita among adults aged 45 to 54 – the highest rate per 100,000 of all age groups. The second highest? 16.3, among adults aged 75 to 84. In contrast, there were 9.7 suicide deaths per 100,000 among adolescents and young adults aged 15 to 24.

When communities talk about strategies for suicide prevention, the statistics make it clear that efforts need to extend beyond the young and to address what’s happening among the middle-aged and older population as well.

Fresh seedlings

If you pay any attention at all to the news about food, you’ve probably heard the word “fresh” over and over.

An emphasis on fresh food is one of the biggest things happening these days in U.S. food trends. It’s a wave that has been building for some time. In fact the Food Channel listed freshness as one of the top 10 food trends to watch in 2011, along with locally grown food, guys in aprons and a resurgence in home canning and preservation.

Here’s how the Food Channel editors describe the scene:

We see American food shoppers going about their marketing a bit more like our European counterparts in the coming year. People will be returning to the neighborhood butcher shop to pick up fresh meats and grabbing their specialty breads and pastries at the corner bakery or bakery-cafe, and shopping on nearly an everyday basis for the evening meal. Yes, the large supermarkets and everything-under-one-roof big box stores will still get the lion’s share of our grocery dollars, but the year-round availability of farmers markets has whetted our appetite for fresh, locally sourced foods and one-on-one personal attention.

The trend appears to be at least partly driven by changing lifestyles and preferences. According to a study published in 2004 by the Center for Agricultural and Rural Development at the University of Iowa, the U.S. per capita consumption of fresh fruit rose 19 percent between 1980 and 2001, and the per capita consumption of fresh vegetables rose 29 percent. Consumers also want more variety and are increasingly willing to pay higher prices for what they perceive as quality, according to the report.

But there’s also another factor at work: increasing interest in the health benefits of fresh food.

When the U.S. government released its new dietary guidelines back in January, the key recommendations included consuming less sodium, which primarily is found in processed foods, and eating more fruits, vegetables and whole grains. Following these recommendations could help people cut down their risk of high blood pressure, heart disease and possibly some types of cancer, as well as avoid weight gain. Increased intake of fresh vegetables and fruit has even been linked to a lower risk of age-related macular degeneration leading to vision impairment.

When surveys are conducted, however, many Americans admit to falling short on the dietary front. There are probably many reasons for this: not enough time (or knowhow) to prepare meals using fresh food; cost; and, possibly most important of all, availability.

It’s encouraging, therefore, to see the growing number of community initiatives to promote fresh foods and to make fresh, locally grown food more readily available at affordable prices.

Here in Kandiyohi County, the Becker Market in downtown Willmar is heading into its fifth year. The response from customers and vendors has been so positive that an initiative is now under way to establish a community-owned grocery to make fresh local food available year round.

Since part of this effort involves community education, the organizers of the community-owned grocery are hosting a film screening in Willmar on Friday, featuring the documentary “Growing Healthy.” The filmmaker, Chris Bedford, has won numerous awards for his advocacy work – and he’ll be on hand to discuss the documentary afterwards with the audience. The free event, which is open to the public, will take place in the second-floor conference room at Christianson and Associates. It starts at 4 p.m. with a social hour, followed by the film screening at 4:30 and discussion at 5 p.m.

Although there’s a perception that everyone can adopt healthful eating habits if they just tried hard enough, the evidence suggests that the availability of fresh, quality food is one of the critical factors. Many inner-city neighborhoods, and even some rural communities, are food deserts – abundant in fast food, perhaps, but lacking in supermarkets with quality, affordable produce and fresh meat for residents to buy.

The evidence also is starting to build that when fresh food is made more readily available through farm-to-consumer initiatives or store development, people are more likely to buy it. One of the most recent studies was published in March in Preventing Chronic Disease, the journal of the U.S. Centers for Disease Control and Prevention. The researchers analyzed data from the National Cancer Institute’s Food Attitudes and Behaviors Survey and came up with some interesting findings: 27 percent of the survey respondents reported shopping at a farmers market or roadside stand at least once a week during the summer. Older adults also were more likely to shop at a farm-to-consumer venue. Ethnicity, gender, household income and education level didn’t seem to make a difference.

The study’s authors concluded, “Our findings suggest that farm-to-consumer venues have the potential to reach many Americans and can augment supermarkets and grocery stores as places to obtain fruits and vegetables.” They also shared some interesting data from the U.S. Department of Agriculture: The number of farmers markets in the U.S. has grown from 1,755 in 1994 to more than 5,700 in 2009. Furthermore, there’s evidence that participation in USDA farmers market programs results in an increase in fresh fruit and vegetable consumption.

If we are what we eat, it seems that it also matters where we eat. It doesn’t get much more local than the food supply that’s available at the markets where we shop every single week.

HealthBeat photo by Anne Polta

Our pets, ourselves

Those of us who are devoted to our animal companions – and there are lots of us in this category – generally regard our pets as full-fledged members of the family.

And rightly so because, as it turns out, pets and people have more in common than you’d think, at least when it comes to their health.

Banfield Pet Hospital, which operates nearly 800 veterinary hospitals in 43 states, has released its first-ever “State of Pet Health” report, outlining current trends in companion animal health and disease.

Guess what? Two of the top five conditions found among dogs and cats were dental disease and being overweight. The report also shows that diabetes has been on the rise in the past five years, probably due to the increasing incidence of pet obesity.

Sound familiar?

The Banfield report is one of the largest ever compiled on veterinary health. It contains medical data from 2.1 million dogs and 450,000 cats who were cared for last year within the Banfield Pet Hospital system. Banfield’s research team, known as Banfield Applied Research and Knowledge, or BARK for short, analyzed trends as well from the past five years to identify some of the most common and/or medically important diagnoses affecting companion dogs and cats.

Banfield officials hope the information will help veterinarians and pet owners in their goal of achieving longer, healthier and happier lives for pets.

Among the highlights of the report:

– The single most common condition among dogs and cats seen at Banfield hospitals is dental disease, affecting 68 percent of cats and 78 percent of dogs over the age of 3. Just as with humans, oral health in pets is linked to overall health. Left untreated, dental disease in dogs and cats can affect the heart, kidneys, and liver, leading to chronic disease and, in some cases, to organ failure.

For reasons that aren’t entirely clear, Minnesota is one of the top five states in the U.S. in the prevalence of dental disease among both dogs and cats.

– The second most common diagnosis among dogs and cats: ear infections.

– Since 2006, the incidence of diabetes has risen by 32 percent in dogs and 16 percent in cats. Obesity was the major contributing risk factor.

– Flea infestations and internal parasites have been on the rise, with implications for human health if fleas, hookworms or tapeworms are transmitted from the family pet to others in the household.

The report notes a couple of important trends. First, the researchers saw an increase in the number of small-breed dogs seen at Banfield hospitals over the past five years. Labrador retrievers are still the most popular, but the rest of the top-10 profile has undergone a noticeable shift. In 2000, German shepherds and Rottweilers occupied second and third place in breed popularity; by 2010, they’d been replaced by Chihuahuas and Shih-tzus.

There could be several reasons for the growing dominance of little dogs. Perhaps more dog owners live in apartments or condos with no back yards, or older individuals are downsizing from suburban homes, making smaller breeds more desirable.

Whatever the explanation is for this trend, there are implications for veterinary care. Whereas large-breed dogs are more likely to have health problems such as arthritis, hip dysplasia and twisted stomachs, little dogs are more prone to diabetes, gum disease and dislocated kneecaps.

A second important trend noted in the report: When it comes to receiving veterinary care, cats are a significantly underserved population. Although they have a reputation for being self-sufficient, this doesn’t mean they never need to see a vet. In fact, the incidence of diabetes is higher among cats than among dogs. Their rates of dental disease and ear infections are high too.

One of the most noteworthy things about this entire report? Many of the most common health issues affecting companion dogs and cats in the U.S. are preventable or easily treated when they’re caught early.

Prevention and access to routine care are familiar messages these days in the world of human health. It seems the old saying “an ounce of prevention is worth a pound of cure” applies equally well when the patient is a dog or cat.

HealthBeat photo by Anne Polta.  Yes, that’s my cat finally making her blog debut.

Transparency: To tell or not to tell?

If hospital patients are harmed by their care and no one talks about it, does it mean there’s no medical harm done?

If a tree falls in the forest and no one hears it, does it still make a sound?

Paul Levy, former CEO of Beth Israel Deaconess Medical Center in Boston and a well-known advocate for patient safety and patient-driven care, has been musing lately about transparency in the hospital industry – or, to be more accurate, the lack of transparency.

On his blog, Not Running a Hospital, he points to discussions taking place in Canada and Denmark about whether to publicly disclose information such as medical errors, infection rates and mortality. Then he shares a summary of a book published in the Netherlands about the need for openness. He winds up this triple-header with some criticism of the Joint Commission, the main hospital accrediting body in the U.S., for its fuzziness and lack of leadership in making hospitals safer.

To the average person, these issues might seem rather esoteric. Most people, after all, aren’t in the habit of ardently discussing health care transparency over a cup of coffee or a beer or two. I’d argue, though, that it should matter a great deal to consumers, and here’s why: because you can’t have mutual trust or a level playing field when one of the parties unilaterally decides to hog vital information.

Several statements, both on Levy’s blog and in the comments, leaped out at me. Here’s one from a Danish newspaper account of a recent patient safety conference:

The director of the country’s largest hospital, Odense University Hospital, Jane Kraglund, believes that the hospitals already publish enough data about quality.

“Our quality is transparent, but we do not learn much by putting a malpractice on the website. When we make mistakes, we have a strict system where the error is systematically reviewed, but it will not necessarily come out to the public. Moreover, more information about risk would be more confusing for the patient,” says Jane Kraglund.

Another Danish hospital director worries that “our standing could be damaged if there are too many bad stories about a place where you expect to get the best treatment.”

OK, so this is Denmark. But are attitudes in the U.S. really all that different? A decade ago, when the American patient safety movement began to gather steam, there was considerable debate over whether providers should be required to report errors. Many in the industry were vehemently opposed to the idea. All these years later, there’s still only a handful of states – Minnesota among them – with mandatory reporting of serious events such as wrong-site surgeries.

Although most in the health care industry say reporting errors is the right and ethical thing to do, the available evidence suggests this doesn’t always happen and that errors in fact continue to be underreported.

Meaningful discussion about safety and transparency often is lacking as well at the top level: by hospital boards of directors and trustees.

There are probably many consumers who would rather not know about errors. There seems to be a rising groundswell of sentiment, however, that transparency failures in health care don’t cut it anymore.

Here are some reactions from readers to Levy’s commentary:

– “Have you ever spoken with a mother whose baby was killed by a medical error? Do you think it’s ethical to hide that chance from the next parents? Do you consider a relationship built on false trust to be more important than finding and fixing the reasons those things happen?”

– “It’s not about quality of care for some hospitals, it’s about continuing to attract patients. Just the idea that the administrator would consider revealing information after someone has become a patient in the hospital but not before, so he could choose another hospital, says an awful lot.”

– “Ironically just yesterday I was wondering about how far we can get with transparency in U.S. medicine when the decisionmakers in medicine and safety continue to work more loyally to misguided clinicians than with devoted patient advocates.”

The health care industry’s ambivalence about transparency suggests several things: that the industry a) doesn’t trust the public to understand patient safety data and error rates; b) doesn’t trust what the public might do with this information; c) has difficulty giving up some of its control; d) places too much of a premium on market share and reputation; e) is focused primarily on the down side of transparency rather than on the benefits of being open.

Understandably, this is a difficult conversation to have. Whether you’re in health care or some other industry, it’s invariably painful to have to publicly own up to your shortcomings. The industry isn’t going to get past its ambivalence overnight. But health care has done the let’s-just-sweep-it-under-the-rug-so-no-one-will-notice approach for many years and it hasn’t worked very well, especially for patients. Hard as it may be, the movement needs to continue towards more transparency, rather than less.

Photo: Monkey carving at the Toshogu shrine, Nikko, Japan. Courtesy of Wikimedia Commons

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Privacy gaffe: Did the punishment fit the crime?

The health blogosphere has been in a tizzy this week over the story of a doctor from Rhode Island who was reprimanded by the state medical board for posting a patient anecdote on Facebook that inadvertently revealed enough information for a third party to identify the patient.

Here are the details, courtesy of the Providence Journal:

The board found Alexandra Thran, of Westerly Hospital, guilty of unprofessional conduct after she recounted some of her emergency-room experiences on Facebook, according to a news release by the state Department of Health. The board said she did not use the names of patients, and did not intend to disclose confidential information, but the nature of the injuries of one patient allowed an unauthorized third party to figure out who it was, the board ruled.

The panel said that Thran deleted her account as soon as she learned what had happened. The board issued a reprimand and told Thran to pay a $500 administrative fee.

Apparently Thran, 48, also has lost her privileges to practice at Westerly Hospital.

Was this a fair punishment or was it overkill?

The information contained in the news accounts is rather limited, so it’s difficult to do anything other than speculate. How did this incident come to the attention of the authorities? Who was the “unauthorized third party” and what was his/her relationship to the case? Did the hospital have a policy on the use of social media? Had there ever been any training for the medical staff on appropriate use of the social media?

The interface between medicine and Facebook, Twitter, blogging and the rest of the social media is ill-defined and wrought with uneasiness. Protecting patient privacy should be paramount, but it’s not always clear how far health organizations should go in ensuring that the boundaries aren’t overstepped.

It’s a fact that privacy breaches do occur – some of them far more blatant than an unintentionally revealing post on Facebook. Consider, for example, reported cases of unauthorized snooping into the medical records of Farrah Fawcett and Britney Spears by hospital workers who had nothing to do with either woman’s medical care.

Then there’s this whopper of a lapse in judgment: A surgeon in training at the Mayo Clinic in Phoenix, Ariz., brought a cell phone into the OR and took a picture of a patient’s penis tattooed with the words “hot rod.” The surgeon claimed he later erased the photo  – after first showing it to others on the surgical team.

Many clinicians blog about their work and about patient encounters. Some are anonymous; some are not. Most are respectful but some are not. Is it OK as long as no one recognizes the patient? Does it make a difference if the details are blurred so the story is a composite rather than the literal truth? Are unintentional breaches – which appears to be what happened in the Rhode Island case – more forgivable than other kinds of lapses?

The temptation might be for hospitals and clinics to ban the social media altogether. No Facebook, ergo no privacy disasters. I’d argue, however, that this is not the route to go.

For an industry in which privacy is so important, health care has been rather slow to address the issues inherent in social media use. I’ve been unable to find any figures on how many hospitals or clinics have formal policies on employee use of the social media, but I’d bet that many do not. I suspect many organizations haven’t even talked to their employees about what’s appropriate and what isn’t. Reacting on a case-by-case basis rather than creating clear expectations ahead of time doesn’t seem to be the best way of preventing the inevitable breach (and make no mistake, every organization at one time or another will face a privacy breach).

The industry needs to get with the program, Mike Morrison, a media relations officer at a Boston teaching hospital, argues on the Hospital Impact blog. “Having a clear understanding of social media at your hospital is important and may even preempt improper use,” he writes.

Like it or not, employees are using social media, Morrison writes. So are patients, families and the public. Rather than viewing it with distrust, health care leaders ought to realize that it’s here to stay and figure out how to use it wisely and appropriately. “No matter how you want your hospital to use social media, ignoring it altogether offers neither the opportunity to benefit from its power nor protection from improper use,” he writes.

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Driven to distraction

On your morning commute to work or school today, did you notice what the motorists around you were doing? Were they yakking on their cell phone while sipping coffee or eating breakfast? Were they fiddling with the GPS instead of keeping an eye on traffic?

Does any of this sound like your own behavior behind the wheel?

Welcome to the world of distracted driving.

We all do it from time to time and may think nothing of it. After all, it’s not the same as drunken driving, right? Wrong. The sobering reality is that when drivers are distracted and multi-tasking, they’re not paying attention to the road and the consequences can be deadly – not only to them but to others as well.

The U.S. Department of Transportation and law enforcement agencies are getting aggressive about increasing public awareness of the risks of distracted driving. This week a new national video, “Faces of Distracted Driving,” was released. Among the real-life stories: Eric Okerbloom, 19, who was killed when a texting truck driver slammed into his bicycle at 60 mph. Ashley Johnson, 16, who was texting behind the wheel when she crossed the center line and fatally crashed head-on into a pickup truck. Joe Teater, 12, who died when a driver talking on a cell phone ran a red light and crashed into the vehicle in which he was a passenger.

Similar safety messages are being shared all month long during April, Distracted Driving Awareness Month.

Here in Minnesota, the Department of Public Safety estimates that some form of distraction is a factor in at least 20 percent of crashes each year – the equivalent of 70 deaths and 350 injuries. It’s worth noting that these numbers are conservative, since it can be difficult to determine the extent to which distraction may have contributed to a crash.

Some facts to consider:

– There are three main types of driver distraction: visual, or taking your eyes off the road; manual, or taking your hands off the wheel; and cognitive, or taking your mind off the task at hand. Examples of distractions include the obvious – texting, talking on the phone, eating and drinking, talking to passengers – as well as the less obvious, such as daydreaming or driving while angry or upset.

– According to the National Highway Traffic Safety Administration, distracted driving was a factor in crashes that killed 5,474 people and injured 448,000 in the U.S. in 2009.

– Distracted driving appears to be increasing. The percentage of fatalities associated with distracted driving rose from 11 percent in 2005 to 16 percent in 2009.

– Drivers in their 20s and younger are the most likely to be involved in a fatal crash associated with distracted driving.

– Using a cell phone while driving is the single biggest source of driver distraction. Among drivers in their 20s or younger, however, texting is the main distraction. Some studies, in fact, have found that people who text while driving are up to 23 times more likely to be involved in a crash than drivers who aren’t texting. According to research carried out at the Virginia Tech Transportation Institute, drivers take their eyes off the road for an average of 4.6 seconds while sending or reading a text. At 55 mph, that’s long enough to travel the length of a football field.

Is it safer to use a hands-free device that allows you to keep both hands on the wheel? Studies have yielded somewhat conflicting results but the consensus seems to be that telephone conversations while driving, whether they involve a hand-held or hands-free device, can have significant potential for cognitive distraction. Some of the research has found that when drivers are talking on the phone, their reaction time is slowed to the same level as having a 0.08 blood alcohol concentration.

Although many of us are used to multi-tasking and might think we’re good enough or experienced enough to multi-task behind the wheel, the evidence suggests otherwise. Driving a car is multi-tasking, involving dozens of continuous micro-judgments and micro-decisions: What’s my speed? Am I staying in my lane? Why is the driver ahead of me slowing down? Is the traffic light about to turn red? Is that car or truck about to coast through a stop sign?

(If you really want to test your skills, try this interactive quiz from the New York Times. It was a lot more challenging than I ever thought it would be.)

It might seem quaint that years ago, there was debate about whether it was safe to install radios in cars so drivers could listen to the radio while on the road. These days, the radio is the least of it. Drivers in the 21st century have far more distractions than ever, from their navigation system to their mp3 player, video system and the Internet. In a hurry-up society that prizes speed and productivity, many drivers also have come to regard windshield time as wasted time and consequently try to fill it with tasks such as talking on the phone, rather than concentrating on their driving, the traffic and road conditions.

I don’t think I’d want to give up the sound system in my car, and I doubt most people are willing to throw away their cell phone or the electronic gadgets in their vehicle. There are ways, though, to use this technology that don’t interfere with the task of driving. Now put away that BlackBerry and pay attention to the road.

Photo: Wikimedia Commons

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The not-so-clean kitchen

If you changed your food preparation habits after a recent salmonella-related recall of frozen turkey burgers, raise your hand.

Now raise your hand if you’re still following those good habits two weeks later.

Uh huh, I thought so.

Anytime there’s news of salmonella in the turkey or E. coli in the alfalfa sprouts, there’s a flurry of advice and tips on what the public can do to reduce the likelihood of food poisoning. And for awhile, many people are probably heeding the advice. But once the latest food scare has faded from the headlines, folks often revert to their old ways.

Although it’s often assumed that careless handling by food processors or restaurant workers is to blame for the majority of food poisoning cases in the U.S., what we do at home in the familiarity of our own kitchen matters too.

Sometimes the picture ain’t pretty. A few years ago, researchers at Utah State University brought surveillance cameras into the homes of 100 middle-class families to observe their kitchen habits firsthand. To ensure that people would behave as they would in their natural habitat, the cooks didn’t know it was a study about food safety. Instead, they were told they were participating in a study about a new recipe.

The researchers then sat down to watch and analyze the footage and document their findings.

To be blunt about it, people were slobs. For starters, they weren’t careful about washing their hands. Two of the cooks didn’t wash their hands at all during the entire time they were preparing the food. Of those who did take the time to scrub in, one-third didn’t bother to use soap. One person dripped raw chicken juice onto a salad. Someone else gave her baby a bottle with unwashed hands after handling raw chicken. Many of the cooks used the dishcloth to wipe up spills or clean off countertops – and then dried their freshly washed hands with the same soiled cloth.

There was more. Although a meat thermometer is the best and most accurate way to gauge whether meat has been adequately cooked, only 5 percent of the study participants actually used one. More alarmingly, 82 percent of those who prepared a chicken recipe didn’t cook the chicken thoroughly enough to kill possible microbes. Nearly half of those who made a meatloaf recipe didn’t cook the meat long enough.

I’m guessing many of the study participants were shocked at the results. Most people, I suspect, aren’t deliberately trying to be careless. They simply aren’t mindful, or perhaps don’t have as much information as they should about safe food preparation.

In some ways, this isn’t surprising. After all, there’s a lot to keep in mind: clean hands, clean countertops, avoiding cross-contamination, cooking food thoroughly, thawing and cooling for the appropriate amount of time – the list goes on and on.

One important recommendation from food safety experts: Keep raw meat, poultry and fish and their juices away from other food, and wash your hands, the countertop, your cutting board and knife with hot soapy water after handling meat and fish. Raw meat and fish that’s stored in the refrigerator should be carefully wrapped so juices don’t come into contact with other food items.

Another important tip: Temperature matters. Perishable food and cooked leftovers should be refrigerated within two hours (or one hour if the room temperature is hotter than 90 degrees). Hot foods should be served hot and cold foods should be kept cold.

Although much of the food safety emphasis is on meat, other foods such as eggs, fruits and vegetables can be unsafe as well, especially if they’re not carefully washed or aren’t cooked thoroughly.

You can read many more details online from the USDA and Foodsafety.gov, including the answer to one of the questions I’ve always wondered about: Which type of cutting board is safer, wood or plastic? (Both are OK, as long as they’re kept clean. Food safety experts recommend having a cutting board that’s used for meat and nothing else.)

It shouldn’t have to take a food recall to jolt us into being more careful. Safe food handling and preparation is something we should all be doing anyway, 365 days a year.

Photo: Wikimedia Commons

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Paid to get healthy

In theory, everyone can be bought if the price is right. So would you stop smoking, lose weight or do something to lower your cholesterol if you knew there were an incentive involved?

Under the federal health care reform law, a $100 million grant opportunity is being offered to states, allowing them to experiment with a rewards system for Medicaid recipients who make health-related lifestyle changes. States have until May 2 to submit an application if they’re interested.

Kaiser Health News explains how the project is supposed to work:

Medicaid enrollees who demonstrate a commitment to improving their health will be eligible to receive financial rewards, such as coupons or gift certificates. For those who are overweight or trying to quit smoking, that commitment might take the form of weight management classes or tobacco cessation counseling. States are encouraged to provide rewards “on a tiered basis” for attempts at participation, “actual behavior change,” and “achievement of health goals.”

The idea is to try to reduce chronic disease among this low-income population, a move that presumably will help save money.

Sounds like a good idea, yes? But the big question is whether this approach actually works.

The concept isn’t exactly new. A handful of states are already using some form of incentive for Medicaid enrollees. Idaho, for instance, offers $200 worth of vouchers that someone on Medicaid can use to visit a doctor to discuss weight loss or smoking cessation. And in the private-sector business world, a number of corporations have tried a rewards system to encourage healthy behavior among their employees.

Unfortunately, there’s only limited evidence so far that this approach results in any sustained or long-term payoff. According to the Kaiser Health News article, participants in Idaho’s Preventive Health Assistance initiative seem to like the incentives but there’s been little indication they’ve led to changes in health-related behavior or lower Medicaid costs. In Florida, where a five-county program allows Medicaid enrollees to earn up to $125 in credits annually for getting flu shots and the like, most of these credits have been spent on immunizations and routine doctor visits that people would probably have sought anyway.

A rather interesting study that examined the impact of financial incentives on smoking cessation rates found that study participants who received money were much more likely to quit. The study, which appeared in February 2009 in the New England Journal of Medicine, tracked 878 employees of a multinational company who were randomized to simply receive information about smoking cessation or information plus money – $100 to complete a smoking cessation program, $250 if they weren’t smoking six months after enrolling in the study, and $400 if they remained abstinent six months after completing the cessation program.

Although this sounds promising, a couple of points are worth keeping in mind. First, this study was carried out in the corporate world and might not necessarily translate to the low-income Medicaid population. Second, smokers weren’t tracked long term, so there’s no way of knowing how many might have fallen off the wagon after the study ended.

Indeed, long-term sustainability appears to be one of the most challenging issues with health-related incentives. At the moment, there isn’t enough research to address this one way or the other. From the Kaiser Health News article:

Few behavioral studies have attempted to determine whether people who receive the incentives are able to maintain their short-term success long term – the ultimate goal of incentive-based prevention programs. Fewer attempts have been made to address how the design of an incentive program should be adjusted according to the demographics of the target population, such as [e]nsuring that low-income participants have transportation to get to appointments and classes.

The larger problem I see with incentives is that they tend to operate in isolation from other health-related factors such as the work and home environment, family dynamics and psychosocial stressors. Employers can offer their employees a $100 bonus to quit smoking, but if company policy continues to allow people to smoke outside the back door or on the loading dock, the environment isn’t exactly conducive to quitting. Low-income households can be given vouchers for fresh fruit and vegetables, but if there isn’t a neighborhood store with fresh produce or people don’t know how to properly store and prepare fresh produce, the vouchers are mostly a short-term, limited fix. Sustained behavior change generally needs to happen at a deep level, deeper than what a $100 bill or a handful of coupons can accomplish.

It’s entirely possible that some states will design an incentive program that leads to meaningful improvement in the health of the Medicaid population. But if I had $100 million in federal grant money to dole out, I’d rather see it spent on projects that improve social and community environments in ways that are sustainable and long-lasting.

Photo: Wikimedia Commons

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Food fights

Here’s a parenting dilemma:

Your child’s day care center provides a hot lunch of pizza every Friday. You don’t want him eating pizza every week. What should you do? Choose an alternate lunch that he can eat while everyone else has pizza? Try to prevail on the day care center to remove pizza from the menu? Cave in to peer pressure?

Karen Iracane of MedPage Today is taking a stand: no pizza. “Overdramatic? Perhaps,” she blogged last week. “But I had grown up with some non-negotiable rules when it came to the kinds of food I was allowed to eat, and to me, this was one of them.”

In fact, she plans to speak up and ask to have pizza removed from the menu altogether. “This may be an unrealistic request,” she writes. “I may be the only parent asking for such a change. But if I don’t speak up at all, then a change will never happen.”

I hope she follows up and blogs about the issue again, so we can all find out what happens.

This whole topic of food choices for children is a thorny one for many parents. It’s not easy to ensure your kids are getting the best nutrition. Often they’d rather have french fries and chicken nuggets than broccoli or apples. Even when parents try to set firm boundaries, mealtimes can turn into a battleground where the alternatives are to a) send a child away from the table hungry or b) give in, which defeats the whole purpose of having rules.

Then there are the many outside influences, from the school lunch menu to the fast-food commercials to the food your children see everyone else eating. How realistic is it for parents to remain principled about what they want their children to eat? The peer pressure can be intense, and it’s not just from other kids; it’s also from other parents. On the other hand, if you don’t lay down the law, you can end up with nutritional anarchy.

Gretchen Schlosser, one of my newsroom colleagues, is the mom of two preschool-aged children. Here’s her perspective on this issue:

Certainly, it can be a mother’s prerogative to take a stand over pizza served for Friday’s daycare lunch. But that choice must be well-founded and not based on the strict rules of your childhood, but rather the real expectations you as a parent have for your children and his health and well-being.

Questions for this mom: Why do you review the food menu? Do you not trust your child care provider to provide balanced meals that meet your children’s nutritional needs?

And, if you don’t trust the child care provider’s meal choices, why is your child in their care?

Part of being a modern-day parent is the ability to acquiesce control of your child’s care to his care provider. That includes his meals and snacks, along with his playtime, naps and the rest of his day.

It also includes pizza, but this blog really isn’t about pizza. It’s about control and a parent who is going to have to let go before she negatively impacts how her child learns to make his own food choices. Otherwise, that child will grow up to make less-than-positive food choices simply because of his mother’s control-freak attitude to food.

As a parent of two children who attend day care full time, I am sometimes disappointed in the food choices offered to my children. But, I’ve given control of the meals to my day care provider, just as I will give control of the meals at school to the school.

Part of effective parenting is working on teaching children to make good food choices. That will not happen on one day, but it will happen. A child who is empowered to make his choices, and sometimes that’s getting to eat pizza like the rest of the daycare children, will eventually make the right food choices.

For the record, responses to Iracane’s blog fell into both camps. “Good for you, and keep it up!” one person wrote. “You might feel like you’re alone, but you’re not the only parent who cares about nutrition.”

Others thought she was being too rigid. “There is nothing unhealthy about having a slice of pizza a few times a month or even, on occasion, twice in one day. Everything in moderation,” wrote one of the commenters. Someone else pointed out that pizza isn’t automatically bad, and can actually be better than other choices if it contains healthful toppings such as low-fat cheese and extra vegetables.

What do readers think? Should kids be allowed to eat pizza (or other food that parents might frown upon) when it’s served at day care or school? How strict should parents be about household food rules? Should parents take a more active role in directing the menu at their child’s day care or school? Can parents become too uptight about what their child eats, and can this be to a child’s detriment? Share your thoughts in the comment section below.

West Central Tribune file photo by Ron Adams

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The new fat index

Move over, body mass index. There’s a new kid on the block: the body adiposity index.

The body adiposity index, or BAI, was recently introduced in a study, published in the Obesity journal, as a better and more accurate measure of body fat. Unlike the BMI, which is based on weight and height, the BAI uses height and hip circumference to determine where an individual falls on the weight spectrum.

One of the researchers talked to WebMD about why this method could be more helpful for assessing body fat:

The body mass index (BMI) does not accurately represent the amount of [body] fat,” researcher Richard N. Bergman, Keck Professor of Medicine at the University of California’s Keck School of Medicine, tells WebMD.

The new measure, called body adiposity index (BAI), does, he says. So far, he has validated the new measurement in Hispanic and African-American populations, and says more research is required to confirm how well it works in whites and other ethnic groups.

With BMI, he says, “you get a relative number” assessing body fat. With the new BAI, “you get a number which is the percent fat.” The new method, he says, is more accurate.

Here’s how it works: Take your hip measurement in centimeters and divide it by your height in meters times the square root of your height minus 18. The resulting number is your body adiposity index. The scale is the same as that for the body mass index – 18.4  or lower is underweight. between 18.5 and 24.9 is considered normal, 25 to 29.9 is overweight, anything over 30 is considered obese, and 40-plus is considered very obese.

The mathematics for the BAI seem rather complicated. Square root? I haven’t dealt with square roots since high school and I don’t like them any better now than I did back then. And the formula, or at least this early version of it, requires you to do the calculations in centimeters and meters rather than inches and feet. The body mass index, on the other hand, only requires you to divide your weight in kilograms by your height in meters squared – or cheat with one of the many handy online calculators that do it for you.

It has in fact been an ongoing academic challenge to come up with an accurate, consistent tool for assessing weight against the norm. The body mass index has been widely used for the past couple of decades and many Americans regard it as gospel, but it has its shortcomings. For one thing, it doesn’t account for individual variations in frame size. For another, it doesn’t distinguish between weight that can be attributed to muscularity vs. weight that’s due to fat. Nor does the adult BMI adjust for age.

The cutpoints are somewhat arbitrary as well. It’s not clear, for instance, the point at which women should be considered underweight. Varying expert opinions put the threshold at anywhere from 18.5 to 20. The division between normal and overweight also has been shifting. In 1985, the overweight threshold was 27.8 for men and 27.3 for women. In the late 1980s this was refined to allow slightly higher thresholds for people as they aged. The current cutoff point, however, is 25, which is stricter than the earlier criteria and has placed millions of Americans into the overweight category who weren’t previously considered so.

I suspect the new body adiposity index, while a useful tool, will have shortcomings of its own. Obtaining accurate hip measurements might be tricky, depending on where you hold the tape measure. For some people whose weight is carried primarily in their hips, the results could be somewhat skewed. The BAI also has been validated so far only among 1,700 people of Mexican-American and African-American background, so it’s premature to suggest it’s a good measurement for the population as a whole.

To complicate the picture, other research has found that the waist to hip ratio may be a better indicator of heart disease risk than the body mass index, at least among older adults.

So who’s right? All of these measures seem to be somewhat helpful for those who want to know where they are on the healthy weight spectrum. But it’s important to note that even the experts have yet to reach a consensus on what constitutes the ideal percentage of body fat for maximum health. Health encompasses more than what we weigh, and the numbers on the scale, the body mass index or the body adiposity index are only one piece of the whole story.

Photo: Wikimedia Commons

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