Beginnings Guides Blog
A body needs about 500 mg per day. The American Heart Association
recommends not more than 1500 mg per day.
The average American adult consumes
3400 mg per day. The average 4 year old consumes 2500 mg. More than 2300
linked to high blood pressure, hypertension, PMS, and kidney dysfunction. Can
you name it?
It's Na, sodium, soda—salt
If we reduced our average salt intake by 3g per day, strong and
clear scientific evidence says we'd have 60,000 to
120,000 fewer new cases of
heart disease annually, 32,000 to 66,000 fewer strokes and 44,000 to 92,000
deaths from any cause. All segments of the population would benefit,
particularly African Americans, women,
elderly, children. Even if we gradually
reduced salt intake by 1g per day over the next 10 years, that would be
more cost-effective than
using medications to lower blood pressure in all persons with hypertension.
The news release includes a link to a summary of the
The Health Literacy Challenge
The evidence is undeniable. We need to reduce salt intake. But
it's a strident challenge. The American Heart
Association offers some good
infographics advising us to "change our salty ways"; but the advice
is far from simple,
and likely to have limited effect.
your sodium palate. Hardly
plain language. The imperative assumes understanding that a body wants
is used to getting. So if you eat less salt, after a few weeks you lose your
taste for it. And if you feed a
toddler salty food, s/he develops a taste for
enjoying foods with less salt.
That means don't use the salt shaker at the table; but only about 6% of
our total salt intake comes from the shaker. About 75% comes from processed and
prepared foods. The rest is
naturally occurring in almost all foods. So the
message means eat fresh fruit, vegetables and meats. That works
if you can find
fresh food in your neighborhood, can afford to buy it and store it, and have
time and skills to
prepare it. But we average Americans eat at fast food
restaurants 4 to 5 times a week. We favor "The Salty 6":
rolls, cold cuts and cured meats, pizza, canned soup, sandwiches, poultry.
for lower sodium items. This directive assumes you know that salt and
sodium are the same thing and
items means food. Looking for such items
means reading food labels (about 48% say they do), and knowing to add
listed as Na, soda, baking soda, sodium, salt— all salt.
The Numeracy Challenge:
What's a mg?
Sodium content is listed in mg —milligrams or g —grams. This is not informative. Only
scientists talk about grams.
Here's translation: 500 mg, the daily amount of salt a body needs to
function, is 1/4 teaspoon (that's a measuring
spoon, not a spoon to stir tea)
or 3-4 shakes of the shaker. The recommended maximum intake is 1500mg or 3/4
tsp. The FDA wants the food industry to gradually reduce sodium in food
processing and preparation to get our
average daily intake down to 2300 mg,
about 1 tsp. One gram is about 1/5
tsp. Here is a converter
These challenges are part of the reason the FDA is working with
restaurants and food producers to lower the
amount of sodium in the food supply
over the next ten years. You can read the proposed guidelines
on them. For best consideration comment within 90 days. Meanwhile, health educators, any way a
person can reduce salt intake even a little is likely to enhance their health.
pregnant until 2018.
That is the
current public health message from El Salvador’s health minister. Colombian
women are warned to postpone pregnancy for 6 to 8 months. Jamaica just released
similar advice. The intent is to prevent mother-to-baby transmission of Zika.
known since 1947 as a rare mild disease limited to central Africa, is spreading
rapidly across dozens of countries in Latin America and the Caribbean. No one
knows why. The World Health Organization (WHO) warns Zika is likely to reach
every country in the Americas, except Canada and Chili. There is no treatment
or vaccine, largely because only about 20 percent of infected adults have any
symptoms. They might have a headache, body aches, a fever and red eyes for a
Here is the public health concern: in Brazil, since an outbreak of Zika
started there last May, more than 3800 babies have been born with microcephaly,
30 times the expected rate, according to WHO. Microcephaly is a rare birth
defect characterized by a very small head and incomplete brain development
leading to death or lifelong disability. There is little scientific evidence,
but the apparent association between Zika and microcephaly warrants public
health warnings, and delaying pregnancy seems wise. However…
The advice to women to avoid
pregnancy ignores the context in which they are expected to comply. In El Salvador and
Colombia there is little access to contraception, especially for poor rural
women. Abortion is illegal in all cases in El Salvador, where the teen
pregnancy rate is among the highest in Latin America accounting for a third of
all births. Abortion is illegal in
99% of cases in Colombia. In Jamaica, abortion is legal in some cases with the
approval of the father and two medical specialists. There is little or no sex
education in the schools. Sexual violence is prevalent. So women lack the
knowledge, services and power to heed the advice.
Colombia’s health minister explained that
his message to women is a good way to communicate risk. The minister seems to
forget that women do not become pregnant by themselves. No similar messages
have been directed to men. For sure, women who hear the warning will fear
pregnancy and birth defects more than they already do, but left to protect
themselves, this amounts to a “Just say No” campaign. It leaves women
vulnerable to blame for unplanned pregnancy and birth defects in their babies,
and to charges of non-compliance that could be misinterpreted as evidence of
low health literacy.
better message, free of gender bias, understandable and actionable, is to avoid
mosquito bites. CDC has issued Level 2 travel advisories (for all, not just pregnant women) for
the Caribbean, South and Central America, Puerto Rico, Cape Verde, Samoa and
Mexico. Travelers are advised to “practice enhanced precautions”.
In this case,
your doctor before and after travel to areas where Zika is active
insect repellant (safe and effective for pregnant women)
clothing to cover as much of your body as possible
under a mosquito net
doors and windows closed or screened
mosquitos bite in the morning, not just late afternoon and evening like other
lasts only a week or less. The danger is only to a current pregnancy. There is no danger to future
US Centers for
Disease Control and Prevention www.cdc.gov/zika
. Information is being updated
Can you name
It doubles+ the risk of eight of the ten leading causes of death,
which account for about 75% of the $3Trillion Americans spend on healthcare
annually. It explains half of learning and behavior problems in children. It is
prevalent in all sectors of society, at home and around the world. It meets the
criteria for a public health crisis. Can you name it?
It is ACEs — Adverse
I’ve written here
before about ACEs. I’ve said that anyone
working in maternal-child health, or early childhood education, K-12 education,
child care, chronic disease, or health literacy needs to know about the lasting
destructive power of ACEs.
participating in the 30th Zero To Three national conference held last week here
in Seattle, I understand ACEs are not just another related issue we should
be tracking. It is time to
acknowledge and address ACEs as the biggest barrier to personal and public
health, and to improving heath literacy. As keynote speaker, pediatrician
Nadine Burke Harris says, “ We — all of us — are the solution.”
Work in all
the many fields that aim to build a strong foundation for healthy child
development is futile where ACEs cause that foundation to crumble and leave
children physically, mentally, and emotionally predisposed to impaired
cognitive and emotional development, and to adulthood defined by diabetes,
obesity, heart and lung diseases, cancers. In the context of health literacy, unacknowledged
ACEs must be viewed as a looming barrier to health across the lifecourse, to
literacy, and to effective participation in healthcare and society. It is a
multigenerational problem. A mother with unaddressed ACEs cannot buffer her
child from ACEs.
last a lifetime, for
better or worse, by default or by design. ACEs are the worse-by-default
part that Zero To Three
mantra. By definition an Adverse
Childhood Experience occurs in childhood (< age 18) and the person remembers
it as an adult. Here are the nine
types of ACEs:
* physical abuse
* sexual abuse
* emotional abuse
* mental illness of a household member
* problematic drinking or alcoholism of a
* illegal street or prescription drug use by a
* divorce or separation of a parent
* domestic violence towards a parent
* incarceration of a household member
Why ACEs matter so much for so long
These are more
than unhappy memories. A baby’s brain is only partially (about 25%) developed
at birth so that it can be wired to enable the baby to survive in the
environment into which s/he is born.
Babies absorb everything they see, hear, feel and otherwise experience.
Those experiences tell the brain what to expect and how to be ready for it. By
Baby’s first birthday, brain wiring is 70% complete, by age 3, it’s 85% wired.
So the earlier the experience, the greater and more lasting it’s impact.
repeated ACEs, four or more of the listed experiences, or the same experience
repeated frequently, the brain and all the body systems get stuck on high
alert; living in a crouch, always expecting something bad to happen. The Fight,
Flee or Freeze mechanism is designed as an emergency response system. When danger is past, it is supposed
to switch off so the body returns to a normal relaxed state. When it is stuck
in the On position, little energy and attention are available for learning and
cognitive development. Self-regulation becomes a strident challenge; behavioral
problems ensue. Eventually, the wear and tear of constant stress on the body’s
systems manifest as non-communicable adult disease. The leading causes of adult deaths worldwide have their
origins in early development. In ACEs.
Find your ACE Score:
See how ACEs have affected
you. Use the questions to generate
a reflective conversation with a mother about her ACEs and their impacts on her
life and parenting. Testing shows
the questions do not spur trauma or need for professional help. Download the questionnaire
View Dr. Burke
Harris’ TED Talk
childhood trauma affects health across a lifetime”
Next: How we can
use information about Adverse Childhood Experiences
Health Literacy: An economic issue
In the US, literacy has long been addressed as an economic issue, a pre-requisite for a
productive workforce in a competitive global economy. Some scholars argue that political campaigns to address
adult low literacy have been undertaken repeatedly in the US and elsewhere to
explain or distract from economic downturns, most recently in 1991 by GH Bush., That campaign produced the
the 1992 National Adult Literacy Survey. Results led academic medical
researchers to discover a glacier in their backyard — the
fact that few Americans understand information from doctors or insurers. The first health literacy studies in the medical literature
came out in 1993.
literacy as an explanation for national economic woes extended to patients' low
literacy as an explanation for low quality, high costs and inequities in
healthcare. Health literacy
was understood as low functional literacy (reading and numeracy) in a clinical
setting. The thinking went like this: if patients could read better, they would
better understand their disease and treatment instructions, and so comply.
Outcomes would improve and we would avoid unnecessary expenses like ED
visits, re-testing and
re-admissions. That thinking led to much needed information-improvement
High demands of complex systems increase negative impact of
Recent policy documents acknowledge patient's ability to
understand and use information for health is determined not only by their
personal skills (or lack of them) but also by the demands and complexities of
healthcare systems  . That recognition is leading to initiatives to redesign
services and remove barriers to access and participation.
Literacy: A health issue
In a new leap forward in thinking about HL, the National Academy
of Medicine (formerly IOM) has released a discussion paper suggesting that a
person's HL is also determined by the demands and complexities of their home
and social context.  This makes HL a public health issue, a pre-requisite
for an equitable health system, and
key to reducing health disparities.
Healthcare organizations should lead adult & family literacy efforts
It is becoming clear that literacy is not just an economic issue,
but a matter of personal and public health. There is no getting around the fact
that health and literacy are inextricably linked. More literacy — more health, and more health
literacy. In communities where low
literacy is the norm, where high school graduation rates are low and schools
are poorly funded —these are the same communities with
high incidence of asthma, diabetes, cancers—, healthcare
organizations should establish, house and and actively support adult literacy
and family literacy programs. High returns can be expected from a relatively
low investment. Such a program can make good use of facilities that typically
are vacant in the evenings and on weekends; and provide good marketing
opportunities while building the community's capacity for health and making
participants more prudent healthcare consumers. A healthcare-based literacy program that incorporates health education and
health literacy improvement can make everything easier and more efficient for
the participants and for the organization that provides their healthcare.
This question was
raised by Winston Wong, Director of Disparities Improvement and
Quality Initiatives at Kaiser
Permanente, during the Institute of Medicine's recent workshop,
Health Literacy: Past, Present and Future.
The workshop marked 10 years
since IOM released the landmark
report Health Literacy: A Prescription to End
A summary of the workshop
proceedings was released this month. Download a summary
free from National Academy of Sciences. Definitely
worth the read.
Here's the part
that made me stop and applaud
In a discussion about health literacy
and its role in achieving equity, Wong
recounted a conversation among
health plan leaders on patients'
non-medical needs (social determinants of health), that led to the question:
should be the core conversation between a doctor and an individual s/he sees
for 15 minutes per year?
“One interesting proposition is that we should start the
discussion with every person we come in contact with
by asking 'what does a
good day mean to you,’"
Wong said, "because that’s really a much more important
than ‘what hurts’ or ‘have you been
taking your medicine today.’”
Why is this
question more important than typical problem-focused inquiries?
Wong said it
reflects the fact that medicine can help with some problems, but what ultimately
makes for a
good day for someone is determined by a constellation of actors
that foster good health. The question
recognizes that on average Americans
spend about one hour per year in a clinical setting; the healthcare
professional is just one actors; s/he marshals resources that account for about
10% of health. The other
are the people the individual is with the other 8764.81 hours per year. The
power to create health,
and to live well with disease, is with the patient.
What is a good day
like for you? addresses the person and
his/her "real life",
instead of focusing narrowly
on the patients' disease and
treatment. It suggests the patient's selfcare is achieving some good days,
than reducing the person to a medical problem and assuming that s/he has
failed to comply with the medication
What is a
good day like for you? is a good
> It cannot be
answered yes or no. It requires the respondent to think
critically about what matters to them,
to reflect on what they want from
medical care and how they will know they got it. It leads to conversation
what the person is able and willing to do now to achieve more good days.
> The response
serves the patient, rather than simply informing the clinician.
> The response
enables the clinician to hear and adopt the patient's words, so the patient is
to learn medical terminology, and the clinician is not expected to
check a glossary of simplified terms.
> The question allows the patient to
figure out and articulate what they want and need, making it easier
provider to achieve patient satisfaction.
> It shifts
thinking and conversation from what patient and clinician do not want — disease
how to get rid of it, to what they
do want —good days— and how to get more of them.
The hard part is
waiting for the response
Patients are not accustomed to being
asked reflective questions, especially by clinicians. Many, especially
who live in poverty and face daily discrimination, are rarely asked questions
and may be trained not
The reflexive first response is likely to be "I don't
know". They need a way to
think about it. Try
again; Can you remember a good day or a good
moment? Then the hard part:
wait. Let them be the one to
the silence. Ask follow up
questions to help the patient clarify what s/he wants, and what will tell her
that she got it; what has worked before and what is needed to achieve more good
days. An effective
conversation will end with the patient articulating the
action s/he will take and the clinician offering
supportive information and
More on reflective
McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active
disparities, low health literacy begin in poverty
Despite some encouraging news in the just-released annual
state rankings for child well-being, Annie E Casey Foundation reports large
numbers of children of all racial and ethnic groups are facing economic
conditions that can impede long-term success. In 2013 (latest figures) in the world's richest country, 22%
of all children
live below the poverty line —$24,250 annual
income for a family of 4. According to the Economic Policy Institute it takes
at least twice that amount to provide basic essentials. It's worse than the
average suggests. Here is where
health disparities begin: 39% of African American children, 37% of Native American children, 33% of Hispanic children
live in poverty. Compared to 14% of white children.
"When very young children experience poverty, particularly if that poverty is deep and persistent, they are at high risk of encountering difficulties later in life - having poorer adolescent health, becoming teen mothers, dropping out of school and facing poor employment outcomes."
Implications for health literacy improvement
These figures jumped out at me since preliminary findings
from my current research suggest that basic essentials —-
safe housing, adequate food, transportation, health insurance, and child care — are
prerequisites for developing maternal health literacy, mothers' ability to use
information and services to keep healthy and raise and healthy competent child.
It makes sense that no amount of reading skill, understanding of healthcare, or
knowledge of preventive practices can make those practices possible when
feeding the children necessarily takes priority. National and international
policy documents call for improving health literacy in parents to reduce health
disparities. Progress in unlikely until we provide health insurance and
economic supports to parents of very young children.
Cheers for the
Affordable Care Act
Thanks to Obamacare, the rate of insured kids improved 30%
leaving 7% or 5.2 million uninsured, most in states that declined to expand
Cheers for Alaska
Applause for Alaska governor Bill Walker. He announced last
week that he will use executive authority to expand Medicaid. That means nearly
30,000 Alaskans will soon be able obtain insurance. The annual Kids Count Datebook ranks Alaska 31 among the
states for child health. The governor's action bodes well for a higher ranking
in coming years.
Cheers for Minnesota
They're Number 1 overall in the Kids Count ratings, 2nd in
health behind Iowa.
Oh Mississippi! Worst place for kids. Still.
Mississippi ranked 50th overall as it has every year since
the rankings were first published in 1990. The state was last in economic
well-being, health, and family & community. It ranked 48th in education
ahead of New Mexico and Nevada.
See your state rankings here.
In Florida, if someone scares you
to death you can legally shoot them to death with your BLEEP. But your
family doctor or
pediatrician or health worker cannot legally ask you if a BLEEP is kept in your
house or how
it is stored.
Apparently even thinking about the
risk of unsecured BLEEPs to their children’s and
right to keep BLEEPs anywhere and any way
they want. This BLEEP has been
since 2011. (The part that made asking about BLEEPs a felony with
jail time and a $5 Million fine did not pass).
Physicians groups challenged the
law. It was upheld as constitutional in Florida since BLEEP ownership and
is a private matter unrelated to medical care.
BLEEPs and tobacco are the only
products on the market that when used correctly kill people; BLEEPS kill lots
of people, often children, in a seconds.
So BLEEPS can’t be a private matter.
Safety Checklist for a Crawler:
BLEEPS are unrelated to medical
care until a child -or some one
else- or the owner- is injured by the patients’ BLEEPs. Then
taxpayers fund emergency response and
medical care for totally
preventable horrific injury or death, and related
increased insurance premiums, and lost contributions to
And we live in fear…. Oh, I see, if you live in fear - get a BLEEP.
Texas legislature entertained a similar gag rule this month.
Death in the United States:
A Call to Action From 8 Health Professional Organizations and the American Bar Association.
Ann Intern Med. 2015 Feb 24. doi:
10.7326/M15-0337. [Epub ahead of print]
Ferrris S. Children’s Defense Fund report on Childs’ BLEEP deaths, new BLEEP laws Data analysis: More
preschool kids dead from BLEEPfire than
police. May 19, 2014
Walters, E. Bill Would Prohibit
Doctors From Asking About BLEEPs. The Texas Tribune March 18, 2015
Pitts, L. Republican list of things you cannot say.
Seattle Times March 19, 2015
I’m proud of my city. We are catching up
with the rest of the world.
Yesterday Mayor Ed Murray announced Seattle will provide paid
parental leave for City employees.
All parents — foster parents, adoptive parents,
mothers and fathers— will have the option to take four
weeks off —with pay— to bond with a new child. The mayor is encouraging other
employers in the state to offer similar benefits.
This should not be the surprise, the bold move, the
breakthrough that it is.
The US is the only developed country on the planet that does not
give new parents paid time off to support attachment and bonding and infant
brain development, and to put their newborns on a positive health trajectory.
President Obama announced a similar new
policy to provide six weeks paid parental leave to federal workers in
his State of the Union address.
A step toward gender equity in the workplace
I’m especially glad the paid leave
policy will apply to fathers as well as mothers. That presents child care as a
shared responsibility. It puts to rest arguments and unfair choices that have plagued so many women’s
career…You are on the mommy track, so you can’t
be on the partnership track. The paid leave policy protects mothers’ earning
potential, avoids unfair expectations and burdens and removes that awful choice
between career and family.
Most of all, this investment in parents shows we are a society
that values its children, including adopted children and those in foster care.
It shows respect for the role of fathers in raising children, and the role of
mothers in the workforce. It
acknowledges the contributions of
foster parents — special people who can love other
people’s children as their own, and encourages
foster parenting. Thank you Mr Mayor and Mr President for leadership toward a
stronger city, region and society.
US residents speak at least 329 languages. In some US cities less
than 60% of the population speaks English. About 32 million of us speak a
language other than English at home. If your service population is not diverse
now, it will be soon. Pew Research
projects the US Spanish speaking population will triple by 2050, and the Asian population will double. Success
in improving the health of ethnic populations will substantially influence the
future health of America as a whole.
Healthcare organizations have been working to develop their
capacity to address language barriers and cultural differences, but it’s
hard to make progress when the challenge is increasing along with the
complexity of treatments and healthcare delivery and financing systems. Non-English speakers still face substantial communication barriers at almost every
level of the health care system.
show that communication barriers have a negative impact on health, discourage
use of preventive services, and increase costs of treatment through unnecessary
testing, delayed diagnosis, extended treatment times, and misinterpreted
instructions. Without information that they can understand and use in their
everyday lives, patients cannot engage in self-care or self-management. In
short, they cannot take responsibility for their health and be partners in treatment,
as effective care now requires.
In most cases, provider
organizations and insurers have the means to overcome language barriers. But
current practice in most communities still reflects an assumption that it is
the patients' obligation to make themselves understood, to ask appropriate
questions and to correctly interpret and comply with instructions. In most
instances, this assumption is wrong as a matter of law. Federal and state civil
rights laws and Medicaid regulations require access to linguistically
appropriate care. These laws are the basis for accreditation standards that
require providers and insurers to position themselves for our multicultural future.
Studies show that print
materials, particularly in combination with brief counseling, can increase
recall, compliance, and behavior changes; and reduce consultations regarding discomforts
that could be self-managed. Health information is increasingly available and
accessed online, through mobile devices and virtual patient educators. Still a
clear message from research participants
is that written information should always be available, even in the
presence of multiple other media.
While they are not a total
solution, CLAMs remain the necessary foundation for a comprehensive
communication effort, and an obvious starting place to promote health literacy.
Organizations serving diverse populations will need to hone a process to
develop and test English language materials, and to adapt essential proven
materials for non-English speakers.
More on that next time. Stay tuned.
Let’s welcome the new year with some new
thinking about measuring health literacy.
It’s hard to say exactly what electricity
is, but if the lights are on, we know we’ve got it. And we
measure electricity by the light it produces. So it is with health literacy. It
is hard to say just what health literacy is, but we know it by its
consequences, and we can measure those consequences.
Services utilization, behaviors, self-care
Two recent systematic reviews and concept analyses (Sykes 2013,
Sorenson 2012) identified the consequences of health literacy. Both studies found the most frequently
reported consequences of health literacy are improved use of services,
behaviors, and self-care. These consequences reflect how people use their
health literacy skills in everyday life and what they actually do for health with the information and
support available to them.
Although these consequences are supposed or anticipated rather than
evidence-based (Sykes 2013), the documented presence of these consequences
would indicate that the person possesses and has used health literacy skills to
produce them. Studies using the Life Skills Progression instrument to assess
maternal heath literacy are building the evidence base.
The LSP Maternal
Health Literacy Scales rate mothers health literacy by their health and
healthcare-related actions practices and behaviors. Sequential measures show
change —improvement or regression. The LSP Healthcare Literacy Scale uses 9 items to rate
mothers’ use of information, emergency services, medical and dental
care and preventive services for herself and her child. The Selfcare Literacy
Scale uses five items to assess risk behaviors and selfcare practices. Three published studies using LSP data on three different cohorts
of mother-child dyads provide
evidence that mothers supported by home visitors trained to promote maternal
heath literacy produced the consequences of health literacy at increasing levels
over 12-18 months. So the recent
analyses of the consequences of health literacy confirm earlier findings that
the LSP can be used as meaningful
measure of MHL.
Next: the recently identified unique consequences of critical
health literacy add weight to our theory that critical thinking skill,
particularly reflection, is the active ingredient in health literacy that enables mothers (and others) to
transform their decisions into health promoting actions and outcomes. Stay
K. Van den Broucke S, Fullam J,
Doyle G, Pelikan J, et. al. (2012). Health Literacy and Public Health: A
systematic review and integration of definitions and models. BMC Public
S, Willis J, Rowlands G & Popple K. (2013). Understanding critical
literacy: a concept analysis. Biomed Central Public Health:13:150.
Smith, S. A., & Moore, E. J. (2012). Health literacy and depression in the context of home visitation. Maternal and Child Health Journal, 16, 1500-1508.
Carroll LN, Smith SA & Thomson NR. (2014). The Parents as Teachers Health Literacy Demonstration Project: Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice
pii: 1524839914538968. [Epub ahead of print]. Available on Internet at: http://hpp.sagepub.com/content/early/2014/06/23/1524839914538968.abstract
Mobley S, Thomas S, Sutherland D, Hudgins, J, Ange B & Johnson M. (2014) Maternal Health Literacy Progression Among Rural Perinatal Women. Maternal Child Health J 18: 1881-1892.