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E is for Empowerment
Health Literacy Challenge: How to Save 92,000 lives & $24 Billion in Healthcare Costs Annually
Promoting Health Literacy: Consider Access Needs
A New Improved Definition for Health Literacy: Rx to end confusion?
Interactive Health Literacy: under researched, unclear concept, measurement challenge


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E is for Empowerment

"Patients prescribe E5 for sustainable health systems"
That's the tagline for a year-long patient-empowerment campaign launched in May by the European 
Patients Forum, a coalition of organizations representing 150 million patients.
The Europeans, and the British, too, are looking at empowerment as a financial imperative. And we should, too. 
Here's the problem:  traditional healthcare systems were designed for infectious disease. Treatment fitting the 
disease was prescribed and managed by professionals while patients complied and were cured or died. That 
disease-focused model prevails but cannot sustain treatment of modern chronic conditions and aging populations 
where treatment needs differ, treatment options are complex, patients self-manage and live decades with their conditions. 
Health Literacy: an aspect of empowerment
The campaign defines patient empowerment as a process that helps people gain control over their own lives 
and increases their capacity to  act on issues that they themselves define as important.”   Heath literacy is 
considered an aspect of empowerment; it helps people gain control over their health and its determinants.  
Information and resources are considered tools for empowerment. If we consider information and services as 
tools for empowerment, how would we design them differently? What if the purpose of Informed Consent was
to empower patient choice rather than legally protect providers?
The five Es” of Empowerment:
Education: patients can make informed decisions about their health if they are able to access all the relevant information, in an easily understandable format.

Expertise: patients self-manage their condition every day so they have a unique expertise on healthcare 
which needs to be supported.

Equality: patients need support to become equal partners with health professionals in the management of their condition.

Experience: individual patients work with patient organizations to represent them, and channel their experience 
and collective voice.

Engagement: patients need to be involved in designing more effective healthcare for all, and in research to 
deliver new and better treatments and services  
Patient empowerment is a challenge for professionals, too
All the European stakeholders, including health professionals, agreed that a major barrier to achieving the five Es  
is health professionals' attitudes. This is not surprising, and it's likely the same in the US. Special  knowledge has 
been a source of power and status for physicians for centuries. Health education curricula is defined but de-funded 
in most schools so patients often lack essential knowledge.  Skills to collaborate with less knowledgeable patients 
as respected, equal partners with useful expertise are not developed in medical school. And there is never enough 
Content analysis of  US health literacy discourse suggests that here, as in Europe, professional attitudes inhibit 
patient empowerment.  The term empowerment is rarely mentioned. Patients are described' as "difficult", 
"hard-to-reach" or "illiterate", with "inadequate" or "marginal" skills, who "fail" to comply or "just don't care".  
If empowering the patient was part of every treatment plan, how would we describe patients differently?  
What would we do differently?
Learn more about the Patient Empowerment Campaign 
Follow them at @PatientsprescribE


Health Literacy Challenge: How to Save 92,000 lives & $24 Billion in Healthcare Costs Annually

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 
mg is 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 fewer 
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.
That's why the Food and Drug Administration just issued sodium reduction targets for the food industry. 
The news release includes a link to a summary of the evidence.
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.
1.     Change your sodium palate.  Hardly plain language. The imperative assumes understanding that a body wants 
what it 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 salt.
2.     Start 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": 
breads and rolls, cold cuts and cured meats, pizza, canned soup, sandwiches, poultry.
3.     Look 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
 up items 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 and comment 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.


Promoting Health Literacy: Consider Access Needs

Accessibility: A Universal Precaution
My dad states his age as older-than-dirt.  He's lost all hearing and has a bad back. He gets around with a walker. It's impossible for him to call the doctor to report an issue or schedule an appointment. He cannot drive or use public transportation. A routine office visit—getting dressed, out of the house, into the car, out of the car, into the office and onto the exam table, and then the whole process in reverse  — each step is an exhausting physical challenge and an assault on his pride. It's also exhausting and trying for Mom, his primary caregiver, driver and emotional compass.  A check-up takes most of a day. Nothing is simple.

Recently, Dad slipped off the edge of the bed and twisted his knee trying to get up. That led to four 911 calls: one to get him up (and discover he could not stand), and three "citizen assists"  to get him to the doctor's office, from there to the hospital, and after a night in the hospital, to get him home and into bed.  Thank you, my fellow tax payers.
He's not alone.
About 70 million of us Americans have such access needs that affect hearing, vision, or mobility and impair capacity to obtain heath information and services.  People with access needs contend with marked health disparities that may originate from the most fundamental  level —like inability to schedule an appointment, open a pill bottle, or read the fine print dosing instruction. Disparities also come from health professionals and researchers acting on assumption and stereotyping instead of data.
Access: first pre-requisite to health literacy
Access, the capacity to obtain…. information and services, is the first prerequisite to health literacy. And yet, several reviews report accessibility is not a topic of health literacy research and scholarly discussion.  Further, access needs is a missing demographic variable in most national databases.

Case in point: the 2003 National Assessment of Adult Literacy population sample included 30% with access needs; among them nearly half (48%) were deemed to have below basic health literacy. This is likely an underestimation since NAAL excluded those "who could not be interviewed due to cognitive or mental disabilities" and did not report demographics of those with access needs. A worldwide review of interventions to improve health literacy reports that research has, for the most part, followed NAAL's example and intentionally excluded people with mental or physical disabilities, along with other disadvantaged or "hard-to-reach" groups. Lumping together and then excluding "the disabled" from research causes disparities to persist; it's ethically questionable and alienating.  Reacting to a nurse who obviously assumed that his access needs indicated a cognitive deficit, Dad retorted, " I've got a little back problem. I can read."
Integrate accessibility into research, practice, policy
Health literacy standards should include accessibility and universal design approaches that make healthcare environments and information products usable to the greatest extent possible by everyone, regardless of their age, ability, or status in life.  Health literacy research should include accessibility, directly involve people with access needs, and report access-related demographics. To make the research process itself accessible to those with access needs, reports, like other health information,  should be available in multiple formats: standard, large print, Braile, text only electronic format, audiotape, sign language. 

Experts suggest we make greater use of access-enabling assistive technology to communicate with people with disabilities. The technologies show how universal design and commitment to accessibility help us all; email,  voice recognition, captioning, GPS — all were originally designed for those with access needs.
References & further reading
Perlow E. (2010). Accessibility: Global Gateway to Health Literacy. Health Promotion Practice 11 (1); 123-131.

Hollar DW & Rowland J. (2015). Promoting Health Literacy for People with Disabilities and Clinicians Through a Teamwork Model. Journal of Family Strengths 15 (2): article 5. Available at http://digitalcommons.library.tmc.edu.jfs/vol15/iss2/5

D'Eath M, Barry MM, & Sixsmith J.(2012)tera Rapid Evidence Review of Interventions for Improving Health Literacy. Stockholm: European Center for Disease Prevention and Control.


Zika prevention advice extends to men

Men, wear your rubbers. Even if you have no symptoms

If you have travelled to one of 25 countries where Zika virus is spreading rapidly, or if you are planning to attend the Summer Olympic Games in Rio, stock up on condoms.  Get any brand, style, size or type of condom,  plus cool posters, key chains and reminders at GlobalProtection.com
Consider visiting the Great Northwest instead of Rio
Public health warnings related to mosquito bites and birth defects intensified this week. Leading national and international health organizations now advise men possibly bit by mosquitos carrying the virus to use condoms.  At least three cases of sexual transmission have been confirmed. CDC says, so far, there is no evidence of transmission from an infected woman to a sexual partner. Zika virus has not spread to the US; but experts expect local transmission in southern states. The day-biting skeeters that spread Zika like tropical climates. Local spread is already reported in US territories — Puerto Rico. Virgin Islands, American Samoa. Health officials say there is virtually no risk of Zika coming to Washington state or Canada.
Zika is barely noticeable in adults, devastating to developing babies
Mounting evidence links the Zika virus to microcephaly, usually defined as head size two standard deviations smaller than the mean for age, size and gender.  Last week Brazilian researchers found evidence that the virus attacks developing babies in the womb. It seems to target nerve cells causing brain damage and developmental disabilities.  Seattle Times health reporter Jonel Aleccia interviewed Dr William Dobyns of Seattle Children’s Hospital after he reviewed brain scans from Brazilian babies. He found an “extremely rare, recognizable pattern” of severe cerebral palsy, epilepsy and feeding problems.
From a health literacy standpoint,  “Use a condom” is understandable and actionable. Condoms are inexpensive, readily available, and require no prescription. In some countries, governments are giving away condoms.  Earlier, still standing, advice telling women to avoid pregnancy, is understandable but not actionable in Zika-infected countries where women have very limited access to birth control and abortion and little protection from sexual violence.
What to tell a woman who travelled to a Zika-infected area,
or  had sex with a partner returning from a Zika-infected country:  “See your doctor right away.”  CDC recommends that women with symptoms get a blood test, but at this point only a few advanced labs can do the test.  It is not known whether babies of women with no symptoms become infected. Knowledge is advancing rapidly. Advice will continue to change. Stay tuned.
For up to the minute reliable information:http://www.cdc.gov/zika/pregnancy/index.html

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.

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

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. 

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.
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