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Zika and Health Literacy. Advice ignores context
Parents’ “Health Learning Capacity” Are we moving beyond reading difficulties?
Health Empowerment: the act-ive ingredient health literacy
Time to Acknowledge our Biggest Barrier to Health & Health Literacy
Improve Health Literacy in Poor Communities: Start a literacy program

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Zika and Health Literacy. Advice ignores context

Don’t get 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.

The mosquito-borne virus 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 few days.

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.
 
Good risk communication?
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.

Don’t get bit
A 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,

•       see your doctor before and after travel to areas where Zika is active
•       Use insect repellant (safe and effective for pregnant women)
•       Wear clothing to cover as much of your body as possible
•       Sleep under a mosquito net
•       Keep doors and windows closed or screened
•       Avoid standing water 
 
Important Notes:
The offending mosquitos bite in the morning, not just late afternoon and evening like other skeeters. 
 
The infection lasts only a week or less. The danger is only to a current pregnancy.  There is no danger to future pregnancies.
 
 
Resources:

US Centers for Disease Control and Prevention www.cdc.gov/zika. Information is being updated regularly

Health Empowerment: the act-ive ingredient health literacy

Health literacy refers to a person’s ability to use information and services for health. (More definitions) 

Using information for health implies three steps: 
1) Understanding, that is, decoding the words
2) Making personal meaning, that is, reflecting on the question: What does this mean for me in my situation with my resources, my family, my beliefs, my values?
3) Acting, that is, making choices and turning those choices into desired actions and health outcomes.

These steps coincide with three steps in problem solving, 
which I’ve described previously as The Three-Step Dance

1) What do you want?  For example, a woman decodes information in Beginnings Pregnancy Guide. She understands smoking can harm an unborn baby.

2) What have you got?  She acknowledges that she has a pregnancy, and a smoking habit that she enjoys and that relieves stress. She has a husband who smokes and a mother-in-law who smoked through her pregnancy and has a son who turned out fine. She has a budget already stretched, a friend who’s been after her to quit, and a doctor who’s offered some aids.  Through self-reflection and discussion with family, friends, experts she makes personal meaning from the information.

3) What’s Next? She makes a choice (decision) not to act  or to take action — some small step that she is willing and able to do now to move toward her chosen outcome — a healthy baby, which she understands requires a smoke-free womb. 

It is the action (or inaction) that affects the outcome. 
The first two steps in using information for health, and in addressing a health problem, are “all in your head”, a purely cognitive exercise with no health effects. 

What’s empowerment got to do with it?
Take another look at Step 3 in using information for health:  making choices and turning those choices into desired actions and health outcomes.  This is the World Bank’s definition of empowerment.  And the “Three-Step Dance” is the process of empowerment described by David Emerald in his book The Power of TED* The Empowerment Dynamic.

Empowerment is the act-ive ingredient in health literacy.  Without it, it’s all in your head. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” ~Goethe    


Note the Goethe quote is typically featured in the front matter of reports from the Academy of Medicine (formerly the Institute of Medicine). It is often attributed to Bruce Lee, but  Goethe said it first)

Further Reading 
Alsop, R. & Heinsohn, N. (2005) Measuring Empowerment in Practice : Structuring Analysis and Framing Indicators. World Bank. Free online: https://openknowledge.worldbank.org/handle/10986/8856


The Power of TED by David Emerald - YouTube  https://www.youtube.com/watch?v=t5hSa16FX94

Time to Acknowledge our Biggest Barrier to Health & Health Literacy

Can you name it?
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 Childhood Experiences. 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. 
 
But, after 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. 
 
Early years 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 household member
* illegal street or prescription drug use by a household member
* 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.

With 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.
 
Resources & Reference:
 
This from Beginnings Guides Tools for Serving Families  http://www.beginningsguides.com/Tools-for-Serving-Families.html

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 
Read the research: www.acestudy.org
  
View Dr. Burke Harris’ TED Talk “How  childhood trauma affects health across a lifetime”

Next: How we can use information about Adverse Childhood Experiences

What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?

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 
Confusion.  A summary of the workshop proceedings was released this month. Download a summary of the 
workshop 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: 
What 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 
question than ‘what hurts’ or ‘have you been taking your medicine today.’”

Why is this question more important than typical problem-focused inquiries?

It's empowering.
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 
actors 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, rather 
than reducing the person to a medical problem and assuming that s/he has failed to comply with the medication
 regimen. 

What is a good day like for you? is a good reflective question.

> 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 
about 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 not expected 
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
 for the provider to achieve patient satisfaction.

> It shifts thinking and conversation from what patient and clinician do not want — disease and suffering— 
and 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 
those who live in poverty and face daily discrimination, are rarely asked questions and may be trained not 
to think.  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
fill 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 services.

More on reflective questioning

Reference & further reading:
J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active Policy Attention
To Health Promotion Health Affairs, 21, no.2 (2002):78-93 doi: 10.1377/hlthaff.21.2.78   Full text online at http://content.healthaffairs.org/content/21/2/78.full.pdf
 

 

BLEEP Gag Rules Threaten Public Health, Child Health Protect right not to think

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 visitors’ safety threatens  
parents’ and patients’ right to keep BLEEPs anywhere and any way they want.  This BLEEP has been Florida law 
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 safety 
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 court costs, 
increased insurance premiums, and lost contributions to society. 
And we live in fear…. Oh, I see, if you live in fear - get a BLEEP. 
The Texas legislature entertained a similar gag rule this month. 
BLEEP  
 


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. Childrens Defense Fund report on ChildsBLEEP 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

New nutrition guidance from the FDA: Eat more fish! But avoid the big, long-lived ones.


 
In a reversal of its recommendations that have for years cautioned against children and pregnant or breastfeeding women eating fish, the Food and Drug Administration’s new guidelines reflect recognition that fish is a great source of protein and other essential nutrients. For the first time, the FDA has specified a minimum intake of fish and other seafood.
 
8 to 12 ounces per week— 2 or 3 servings
That’s the new minimum recommendation for a healthy diet. Beginnings Pregnancy Guide (2014) recommends 1 or 2 servings per week, the previous maximum recommendation, now considered overly cautious.
 
The warning to avoid large, long-lived fish like swordfish, mackerel and tile fish remains. Those big fish live long enough to build up organic mercury in their flesh. According to MedlinePlus, medical evidence suggests that being exposed to large amounts of the organic mercury called methylmercury while pregnant can permanently damage the baby’s developing brain. Small exposures are unlikely to cause any problems.
 
Choose canned light tuna
Salmon, shrimp. and other seafood that Beginnings lists as safe and healthy, are still safe and healthy.  It is important to caution mothers against canned white albacore tuna since it has three times the mercury of the recommended canned light tuna. The FDA suggests limiting tuna to 6 ounces a week.
 

Beginnings Pregnancy Guide (2014) pg. 13

Use the Fish Safety Hotline
Call 1-888-SAFEFOOD That’s 1-888-723-3366 to check the safety of fish in your area. This free 24 hour resource is listed on the Pregnancy Guide’s Key Messages Poster and on page 42.

Example from the field: Medication instructions show lots of room for improvement

My dad, age 86,  was hospitalized with arrhythmia. Hospital medical staff said his heart muscle looked strong and undamaged, but later another doctor said he had a minor heart attack. Dad was sent home with several medications with instructions to stop all his usual meds - including the multivitamin, and the stool softener prescribed by his internist. The hospital  nurses could not answer why those should be stopped…  Three days later Dad quit taking the new meds. He said they made him sleep 20 hours a day, and made him stupid when he was awake.  Worried, Mom set an appointment with his personal physician who adjusted the meds, lectured him about the danger of stopping them, and gave him this summary of new instructions.

 New Medications

 Medications to Continue Taking That Have Changed

     Other Medications
     START: amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) Oral, every day. Refills: 0
     STOP:  amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) 2 times a day. Refills: 0
 
 Medications to Continue with No Changes
     Other Medications

     aspirin (Aspirin Enteric Coated 325 mg oral delayed release tablet) 1 tab(s) Oral, every day, Refills: 0
    
     dufoxetine (Cynbalta 60 mg oral delayed release tablet) 1 cap(s) Oral, every day. (do not crush or chew). Refills:0

 No Longer Take the Following Medications

     digoxin 125 mcg (0.125mg) oral tablet) 1 tab(s) Oral, every day. Refills: 0

     metoprolol (Metoprolol Tartrate 25 mg oral tablet) 1 tab(s), Oral, 2 times a day. Refills: 0

 Contact your Physician Prior to Taking the Following Medications

     None

 Problem List
 No problem found

 Upcoming Appointments
 No appointment


While the summary shows good intent to inform the patient, it could be much easier to read, understand and act on.

1.     Delete the static 
Too many irrelevant words interfere with efforts to find the important information. The first heading  New Medications is meaningless. It amounts to static interference.  The information about meds to start and stop fits under the third heading:  Medications to Continue Taking That Have Changed; but an indented  subhead - Other Medications- is inserted between - more static. It’s another empty field on the form. These headings should automatically delete when the field is left empty.
 
2. Use upper and lower case. All the headings are in title case - all the words are capitalized. A capital letter signals the brain to stop and start something new. We recognize words by their shape. The cap changes the shape, and so slows reading and reduces comprehension.  It is odd that the proper names of the medications are not capitalized, but then in parentheses they are.
 
3. Use active voice and a verb in instructions. Medications to Continue with No Changes is a label.  A call to action is more understandable and actionable:   Keep taking these medications with no changes:
 
4. Make the changes clear. The information under START and STOP is very similar. It requires careful examination of every word and symbol to discern that the instruction is to take one a day instead of two. Few understand mg. Many do not understand oral, or tab(s), or the difference between cap(s) and tab(s),  or the meaning of delayed release.
 
5. Explain when to take the medication. What does 2 times a day mean? Before breakfast and after breakfast would comply with the instruction, but that might not be what the prescriber intends.
 
6.Use the Problem List (it’s a nice table on the form with cells for Onset and Comments). This would be a good place to give the patient and caregiver information about what these drugs are for.  The entry No problems found could leave one wondering why they are taking all this medication, and whether they should have seen the doctor.
 
7. Use the Upcoming Appointments form (another nice table with cells for date, time, location, appointment type(??) and provider.  The entry is No Appointment; but Mom has written in April 10, 1pm.
 
This form reflects an effort to be patient centered and improve compliance. But it is designed for ease and speed of entry by the provider, rather than for ease of understanding and right action by the patient and caregiver.  

 

Government shutdown is all FUD

FUD: Fear Uncertainty & Doubt. That is the foundation of the extreme House
Republican’ position on the Patient Protection and Affordable Care Act of 2010.
That’s why they call it Obamacare- in order not to say “protection” or “affordable”;
and  to hide the fact that the law was enacted 3 years ago, before the President
was soundly re-elected running against an opponent who vowed to repeal it.
 
FUD, initially an IBM strategy to eliminate market competitors by spreading fear
uncertainty and disinformation about their products, seems to be working for the
House Republicans. At least to some degree, for now. Polls and analyses of social
media suggest that some people favor the Affordable Care Act while opposing Obamacare.
 
Home visitors: “Obama snoopers” = FUD
I ignored the FUD like a parent ignoring a toddler’s temper tantrum until I saw
the Fox “news report” about the Affordable Care Act’s expansion of home visitation.
That’s  a preventive strategy in which public health nurses, social workers or trained
paraprofessionals connect families to healthcare and community resources and offer
health education and social support.  It’s origins date back to the 1800s. Programs
are run by county health departments, school districts, foundations, and private-public
partnerships. Home visiting programs are open to poor parents who request assistance.
 
It’s worth noting that in many countries, home visiting has long been standard for all
parents, because they acknowledge that parenting is a challenge and everyone can
use assistance. And because research shows it improves child developmental outcomes
and has immediate and long-term benefits that extend to entire families and to the
healthcare, education and justice systems. My researchshows that parents in home
visitation significantly improve their health literacy, capacity to manage personal and
child health and healthcare.
 
Pure FUD
A Fox announcer and a “business expert” called home visitors “Obama snoopers". 
They said  in this “brand new federal program”, “government home inspectors”
make random, unannounced  “forced home visits” to snoop on parents.  This is not
news. This is pure FUD - disinformation (lies) that specifically intends to instill fear,
uncertainty and doubt about the Affordable Care Act, to prevent people from learning
they can afford good healthcare coverage.
 
I have worked for decades with home visitors and know them to be among the most
caring, dedicated, respectful people on the planet, unlike the FUDders on Fox and in
the House.
 
FUD won’t work for long. Yesterday, the heart of the Affordable Care Act started
(keep saying the real name), opening access to healthcare for millions of poor and
uninsured citizens. Almost 3 million people visited www.heathcare.gov State exchanges
were similarly overwhelmed.  People are about to find out that the Affordable Care Act
makes good healthcare coverage affordable -for them. That will help them see through
the FUD.  Insurance companies are helping too. They are enrolling people they previously
rejected because, with the ACA, it’s good for business. Healthcare executives are calling
for more doctors, nurses and allied health professionals - doesn’t really sound like a
“job-killer” does it?
 
On the other hand, the House Republicans just put hundreds of thousands of people out of
work in hopes they can FUD us citizens of the richest country in the world into continuing
denying healthcare to poor people and sick people in order to preserve the freedom of
the rich to get richer.
 
 
 
 

Top Reasons to Promote Maternal Health Literacy #5 (#1 if you are talking to a legislator or business leader)

Skills beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
life across cultures. They are skills that empower people to  be what
they want to be, to make choices and transform those choices into desired
actions and outcomes. 
 
These life skills develop most easily in early childhood given a stable
supportive family environment. Disparity in brain development in children
growing in disadvantaged vs enriched environments becomes apparent in
the first year.  Quality of family life matters more than the number of
parents, their income or education. But poverty and accumulated disadvantage
prevent parents from doing their best to sustain the stimulating home
environments that support optimal development, especially when they
themselves lack skills, resources and role models. Early intervention ---
early childhood education, parenting training, family support and home
visitation programs--- can produce positive and lasting effects on children
in disadvantaged families.  
 
Nobel Laureate and economics professor James Heckman, makes the business
case for shifting public policy to support programs that offer parents information,
choices and assistance.  Promoting health literacy means providing direct
supplemental assistance that specifically and intentionally enables parents to
develop and hone the range of life skills used to participate in healthcare and
manage personal and family health at home.
 
Must read: Heckman,  James J. (2013) Giving Kids a Fair Chance (A Strategy
That Works) MIT Press, Cambridge, Mass.  ISBN 978-0-262-01913-2 
In addition to Heckman’s monograph, the book includes illuminating commentary
by 10 experts from multiple disciplines.

Pregnancy Guide Update: Obesity a disease?

The American Medical Association House of Delegates declared obesity a disease
last month. Is this good for maternal and child health?  For public health? 
 
It’s not new
In 1995 the National Heart Lung and Blood Institute called obesity a “complex
multifactoral chronic disease”. Ten years earlier, almost 30 years ago now,
NIH called prevention and treatment of obesity a national medical priority.
With 90 million Americans now officially obese, it seems few clinicians got the
memo.
 
Obesity prevention not a priority in maternity care
In researching issues of weight gain in pregnancy for  the update of the
Beginnings Pregnancy Guide, I found that weighing is still the only procedure in
early prenatal care that has shown any impact on outcomes. And yet it has
become uncommon for a pregnant woman to be weighed at prenatal visits or
when being admitted to a hospital for birth. Prenatal care providers have reported
they seldom weigh pregnant women or discuss weight for fear the conversation will
interfere with their patient/provider relationship. Others said they do not know how
to calculate BMI. They also must not know about the many BMI calculators that will
do it for them. One can only hope that calling obesity a disease will change these
attitudes. 
 
Healthy mothers, healthy babies. Fat mothers, fat babies
The issue in pregnancy is that a mother with an excess of fat cells produces a baby
with an excess of  fat cells. So we are building obesity and the attendant health issues
into the next generation.
 
ACEs -Adverse childhood experiences - witnessing or experiencing interpersonal violence
is closely related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical treatment,
many such women have lost weight, and gained it right back. That’s how the lifelong
effects of ACEs were discovered.
 
Other mothers have said it doesn’t matter if they gain too much in pregnancy since
they are just going to get pregnant again; the weight can come off after that.
Only it rarelydoes.
 
Turning people into patients
Google “obesity disease”. The first thing that pops up is ad ad for weight loss surgery.
This may be more telling than official statements.
 
Especially when we consider the Forbes June 28 report that the AMA’s Council on Science
and Public Health, the group appointed to address the question, advised against declaring
obesity a disease. But the delegates chose ignore their own advisors.
 
We have to ask, what was so compelling?
Perhaps it is the implementation of the Affordable Care Act that will bring healthcare
coverage to millions of Americans previously excluded from the healthcare system.
At least a third of them are obese. Now they can be patients.
 
According to CDC 35.7% of Americans are obese, 49.5% of African Americans, 40% of
Mexican Americans. Rates vary widely by state. Find your state rate at
http://www.cdc.gov/obesity/data/adult.html.  Now all those people are diseased
and in need of medical treatment.
 
Calling obesity a disease, again, could draw attention to related health issues, but it
hasn’t in 20 years.  It could result in better maternity care, but the declaration is
unlikely to improve clinicians communication and counseling skills.  It could spark a
Kennedy-style physical fitness craze, but that entails behavior change, and the same
communication issues.  It could increase research on obesity, but NIH already has a
Strategic Plan for Obesity Research and funds nearly a billion dollars worth of studies
annually. Grants.nih.gov lists 49 obesity-related research solicitations currently open
for submission of grant applications. 
 
Only one thing seems certain, making obesity a disease will increase medical treatments
and costs, and revenue to AMA constituents.
 
 
 
 
 
 
 
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