AstroNutrition Health & Fitness Blog

When Robert E. Harrington, director of the Casper-Natrona County Health Dept. in Wyoming, started working in 2000 to steer his community toward meeting Healthy People 2010 goals, he knew he would have to pick and choose key priorities if any progress were to be achieved. Otherwise, the document -- a version of which has been issued by the Dept. of Health and Human Services at the beginning of each decade since 1980 to set national health objectives -- was just too overwhelming.

"We tried to use Healthy People 2010, but it was just too big of an elephant to swallow," he said.

The first edition of Healthy People laid out 226 objectives. Healthy People 2000 had 312. By the time Healthy People 2010 was issued, it attempted to tackle 467 objectives, with some items having as many as 28 parts. Subjects ranged from diabetes and mental health to health care access, along with myriad others. But, in recognition that the marching orders have become unwieldy, Healthy People 2020 is expected to be trimmed down.

"As the nation was developing the obesity epidemic, so was Healthy People. ... We need to be more focused to allocate our resources better," said Carter R. Blakey, HHS senior adviser and leader of the community strategies team. She spoke at an April 30 regional meeting in Chicago -- one of six across the country. The events are designed to gain input for the now-under-construction Healthy People 2020 from various health organizations as well as the general public. Comments also are being taken online (www.healthypeople.gov/hp2020/comments).

Officials say the push to streamline the document likely will be achieved by shifting away from disease-specific goals to those that affect risks for several medical conditions. For example, goals in Healthy People 2010 included reducing the rates of diabetes, end-stage renal disease and cardiovascular death, although some specific strategies overlapped.

Nonetheless, experts recognize that, because of how public health works, it will not be possible to pay attention exclusively to risk.

"Focusing on risk is a great idea, but we're not organized like that," said Blakey. "We're organized categorically. We're going to move in that direction, but at the same time we still recognize the need to pay attention to specific conditions."

Those involved in the revamp want to go beyond eliminating health disparities to achieving health equity and addressing environmental factors that may be interfering with the realization of some goals. Healthy People 2020 also is expected to establish objectives that take into account how the definition of health and wellness changes over a person's lifespan.

"My experience is that people often pay attention to specific populations -- children or adolescents or the elderly. We need to think about health across the life stages," said Patrick Remington, MD, MPH, professor of population health sciences at the University of Wisconsin School of Medicine and Public Health in Madison.

Gathering input

Officials are seeking input from more diverse sources than in previous editions. An interagency work group includes representatives from federal agencies both in and out of HHS.

While past editions have taken public comment into account, for the first time outside experts, including Dr. Remington and several other physicians, have been selected to form the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020.

"We have to do a better job of breaking down our silos, and, if we want people to work with us after the objectives are released, we need to work with them now," said Blakey.

At the Chicago meeting, those weighing in on the process expressed concern about impediments to achieving the initiative's goals. For example, an AMA representative testified about barriers to having physicians more involved in prevention.

"We need to look at a lot of the obstacles and how we can overcome them," said Richard A. Yoast, PhD, director of the AMA's Office of Alcohol and Other Drug Abuse.

For Healthy People 2010, the AMA had in place a memorandum of understanding with HHS to disseminate the document to physicians and to work toward implementation of interventions in the health care setting that would help achieve its goals.

Significant focus also surrounded the idea that a lack of access to care is hindering progress.

"Healthy People has set up some lofty goals, but they have no chance of being met unless we increase access," said Julia Olsta, a registered nurse and the health services community liaison for School District U-46 in suburban Chicago. In her 90-square-mile geographic area, for instance, no facilities were willing to provide eyeglasses to children who were unable to pay for them out of pocket or with private insurance. Also, only two dentists were willing to accept children on any form of public health insurance.

Minority health experts expressed an interest in developing goals specific to various races and ethnicities and not based on those set for Caucasians. They also wanted to better define the concept of health equity and to take into account genetic differences, such as the African-American predisposition for sickle cell anemia.

In addition, gay health advocates lobbied for the addition of questions about sexual orientation in the various survey tools public health officials use to assess progress. Questions about age, gender, race and ethnicity already are standard, and Healthy People 2010 was accompanied by the "Companion Document for Lesbian, Gay, Bisexual and Transgender Health." Those proposing this change say the information gleaned will increase the visibility of disparities associated with sexual orientation.

The framework and overarching goals for 2020 will be released by the beginning of next year. The full Healthy People 2020 will be published in 2010.

Washington -- With about half of the states exploring health system reform, now also is the time to address health care disparities, said researchers at a May 12 Capitol Hill briefing.

The event was sponsored by the Alliance for Health Reform, a nonprofit, nonpartisan group in Washington, D.C., and the Commonwealth Fund, a private foundation in New York City.

Inequities in the quality of care provided to minority patients have long been recognized. These differences were documented in two Institute of Medicine reports, "Crossing the Quality Chasm: A New Health System for the 21st Century," published in 2001, and "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," in 2002.

Since then, the elimination of these disparities has been the goal of several medical groups, including the AMA, which heads the Commission to End Health Care Disparities with the National Medical Assn.

Ensuring full access to health care means promoting the concept of a medical home, streamlining enrollment for public health insurance programs, promoting diversity among health care professionals and cultural and linguistic competence in health systems, said Brian D. Smedley, PhD, research director and co-founder of the Opportunity Agenda, an organization that addresses barriers to care. He was also the study director for the "Unequal Treatment" report.

Anne Beal, MD, MPH, assistant vice president of the Commonwealth Fund's Program on Quality of Care for Underserved Populations, noted that there are many causes of disparities, including genetic predispositions to diseases and patients who fail to follow treatment instructions. However, the "biggest bang for the buck" toward reducing disparities would be achieved if access to care is improved, adequate insurance coverage provided and the quality of care bolstered.

Luscious and wonderful images that spread like a virus to inoculate people against disease -- these are words curator Michael Sappol, PhD, used to describe the pictures included in the upcoming National Academies' exhibit, "An Iconography of Contagion: 20th-Century Health Posters and the Visual Representation of Infectious Disease." Dr. Sappol is a historian at the National Library of Medicine of the National Institutes of Health.

"These are rich, cultural documents," he said, and they provide insights into the interplay between the public understanding of disease and society's values.

The show, which will be on display beginning this month in Washington, D.C., explores the use of these images since the early 1900s.

Over the years, public health posters have focused on a range of new and old diseases -- from tuberculosis and syphilis to HIV/AIDS. They communicated messages about infection control and prevention and aimed to alter behavior and public perceptions. But these historic images become even more striking when considered in the context of the eras during which they first appeared.

"The posters reflect the fears and concerns of the time and also the knowledge that was available," explained Mary Wilson, MD, an associate clinical professor at Harvard Medical School and of population and international health at the Harvard School of Public Health, Boston.

This dynamic is evident in the portrayals of disease vectors. Some World War II-era posters warning of malaria depicted mosquitoes with Japanese features, "giving the illness the face of an enemy," Dr. Sappol said. Another example he offered is a syphilis poster from the same period. It featured an image of an alluring woman who also is scary in a sexually aggressive way, while ignoring the fact that men were equally culpable in spreading the disease, he said.

But the HIV/AIDS posters of the 1980s were an "enormous breakthrough," he added. They sought to destigmatize the disease carriers instead of making them the focus of wariness and caution.

The emergence of an art form

Posters as a form of mass communication first emerged in Western and Central Europe in the mid-1800s. Soon after, this approach became a cutting-edge form of advertising. Vibrant, eye-catching announcements publicizing everything from theatrical events to politics papered public spaces -- in part because of advancements in photography, color and design techniques, as well as mass production.

It was "a moment in visual culture when images began proliferating," Dr. Sappol said. "People were barraged by pictures trying to get them to do things. Public health crusaders at this time were also trying to mobilize the public. The two forces came together."

Ultimately, the use of posters became a mainstay of such efforts.

Whether urging people to carry handkerchiefs, use condoms, refrain from drinking unsanitary water or get vaccinated, through the years the posters have employed a mix of rational arguments and emotional images. To the extent that they tap into people's fears and belief systems, they can educate and change behavior -- but first they must get public attention, Dr. Wilson said.

For now, the early 20th-century dream that the medium would be part of more coordinated and cumulative health campaigns seems far away. The crusaders at that time had hoped that visual representations would lead "the public to act to address the problems in their own bodies and their own communities, and to build political support for government action and medical intervention," Dr. Sappol said.

Still, Dr. Wilson noted that "images remain extremely powerful in shaping perceptions and actions, though now we receive more images through different media, including electronically. ... Cartoons, covers of magazines, brochures and certainly advertisements all shape our actions and beliefs in ways that we are often unaware of."

Though the posters included in the exhibit are entertaining to view, in their heyday they sought to complete serious educational missions that were matters of life and death.

"These [deal with] terrible diseases," Dr. Sappol said -- a fact he hopes people will keep in mind. Otherwise, he added, because of the interest and beauty of the posters, the exhibit could "just be too much fun."

A patient's health literacy can be measured quickly, according to a study published in the May-June Journal of the American Board of Family Medicine, but many experts question whether this information is necessary to guide medical care.

"This is fine for research, but it's not appropriate for clinical practice," said Joanne G. Schwartzberg, MD, director of aging and community health at the American Medical Association. "Clinicians can better spend their time ensuring that all their patients understand the medical information they need to know to care for themselves."

Researchers administered the tool that uses comprehension of an ice cream nutrition label to measure health literacy to 78 consecutive patients presenting at an outpatient primary care clinic. The activity took an average of 2.9 minutes per person to complete, and the authors suggest this may be a good way to perform literacy screening in clinical practice.

"As a physician, you want to know how much of what you are telling a patient is getting through. This gives some guidance on how to tailor your message," said Kristen Johnson, MD, lead author and a family physician at The Polyclinic in Seattle.

Those behind this tool add, however, that there is not enough evidence to support routine use. Rather, they would like to see physicians use it to raise their own awareness of health literacy in their practices.

"Some people are arguing with some justification that screening every patient really doesn't make sense," said Barry D. Weiss, MD, the paper's co-author and professor of family and community medicine at the University of Arizona College of Medicine in Tucson. "But, if physicians used this on the next 200 people in their practice, they would be universally surprised. There's a problem in everybody's practice because low literacy is very prevalent, and most clinicians don't know about it."

Only 12% of adults have the skills to proficiently manage their medical care.

Many experts, though, wondered if this kind of assessment should be performed. They cite concerns about stigmatizing patients and a lack of evidence that performing this screening affects outcomes. They also note that factors such as anxiety or information overload may be interfering with a patient's ability to understand.

"It has not been shown to benefit patients for doctors to know that they have limited literacy," said Michael Paasche-Orlow, MD, MPH, an internist and assistant professor of medicine at Boston University School of Medicine. "A fair portion of folks with limited literacy are ashamed when asked about this. And, even if the testing can be done in a nonjudgmental fashion, they would still very much not want this information included in their medical record."

In addition, many argue that since health literacy is problematic in many patients, a broad approach should be taken, with an across-the-board lowering of the level of education required to understand communication in a health setting.

"We don't insult people by doing that. All people are grateful for clarity," said Ruth Parker, MD, professor of medicine at Emory University School of Medicine in Atlanta and a member of the Institute of Medicine's Roundtable on Health Literacy.

For example, according to data released last month by the Agency for Healthcare Research and Quality, only 12% of adults have the skills to proficiently manage their own medical care. About 53% had intermediate skills and were able to determine the right time to take a medication based on label information. Another 22% had basic skills, meaning they could read a pamphlet and understand two reasons why a test might be appropriate despite a lack of symptoms. Lastly, 14% could only comprehend short sets of instructions, such as what they are allowed to drink before a medical test.

The AMA recognized low health literacy as barrier to effective medical diagnosis and treatment in 1998, and, through the AMA Foundation, has organized numerous educational opportunities for physicians, including videos, which are available online (www.ama-assn.org/go/amafoundation-healthliteracy).

A Foundation report, "Assessing the Nation's Health Literacy," is expected to be released in July.

With more influenza vaccine than ever before likely available in the upcoming season, public health officials and physicians are faced with countering the aftershocks of last season's flu-strain mismatch and implementing new recommendations regarding who should receive the preventive.

These issues were among the topics addressed at the National Influenza Vaccine Summit in Atlanta last month. The summit is an annual event co-sponsored by the American Medical Association and the Centers for Disease Control and Prevention.

"There looks to be a plentiful supply. What we need to do now is determine how to most wisely and equitably distribute and use it so that it makes it into noses and arms," said Gina Mootrey, DO, MPH, the summit's co-chair and associate director for adult immunization at the CDC.

Approximately 143 million to 145 million doses are predicted for next season, and, with five vaccine manufacturers in the game, the supply chain is more stable than ever. Advocates want to close the growing gap between what is manufactured and what is used. Out of the 140 million doses produced last year, about 113 million were distributed. This amount is more than ever before, but approximately 27 million doses remained on the shelves.

"We have to keep chipping away until we get these numbers up," said Nancy Hughes, RN, director of the American Nurses Assn.'s Center for Occupational and Environmental Health. "We've got to overcome the myths and the barriers."

One of those barriers is the findings earlier this year about the vaccine's effectiveness. A paper in the April 18 Morbidity and Mortality Weekly Report reported that the strains selected for last season's vaccine were not a good match for the strains that actually circulated. The vaccine was 58% effective against the most common one, and overall effectiveness was 44%. Also, the preventive may have reduced the severity of illness for strains not included. Still, the message many patients heard was that the vaccine didn't work.

"The concern is that, because the so-called mismatch received so much attention, there will be difficulty in recruiting physicians and the general public to take advantage of the vaccine abundance. There may be some merit to that concern," said William Schaffner, MD, who represented the National Foundation for Infectious Diseases at the summit. He also is the chair of the Dept. of Preventive Medicine at Vanderbilt University School of Medicine in Nashville, Tenn.

Looking forward

For next season, a key test will involve how easily new recommendations from the Advisory Committee on Immunization Practices are adopted. In February, ACIP added all children 6 months to 18 years to the list of people designated to receive this vaccine. The panel wants full implementation by the 2009-10 season.

Physicians welcomed the simplification of the recommendations. But those who will be giving the shots also noted the difficulties involved in adding 30 million children to the list. This circumstance is especially acute, since those younger than 9 who are receiving it for the first time need two doses at least four weeks apart.

27 million doses of flu vaccine remained unused in the 2007-08 flu season.

"It does make it less confusing, but some people feel that the increase in volume of vaccines given to children is an extra burden on the medical home," said Jennifer Shu, MD, an Atlanta-based pediatrician who represented the American Academy of Pediatrics at the meeting.

Flu vaccine, for the most part, also lacks a regulatory mandate linking it to school attendance. Only New Jersey currently requires it of children attending preschool and licensed day-care centers. That state legislation was enacted in December 2007 and takes effect in September. Supporters say the dictate should make vaccination more likely, although not necessarily a done deal.

"The challenge will be to make sure that the day care centers and preschools know of this requirement and that physicians, health care providers and clinics are aware that this is in fact a requirement," said Eddy Bresnitz, MD, state epidemiologist at the New Jersey Dept. of Health and Senior Services. "We're not expecting perfect implementation, but we think we'll get reasonable rates."

Also, while the supply has been fairly stable and growing for several years, the effect of previous unstable seasons continues to be felt among physicians providing vaccines to this age group. For example, surveys of members of the American Academy of Family Physicians have found that the number saying that they plan to order vaccine dropped from 94% in 2005 to nearly 90%in 2007.

"We know that the vast majority are giving immunizations for influenza. [It's] not a statistically significant decline but it got our attention," said Herbert Young, MD, director of the AAFP's scientific activities division.

The first supplies of the intranasal version are expected to arrive in physicians' offices as early as August. The injectable will be available in September. Meanwhile, the AMA continues efforts to communicate with those involved in vaccine distribution so that physicians who serve populations at high risk of complications receive supplies in a timely manner. The AMA also encourages physicians and other medical workers to be vaccinated themselves.