Revolution Foods

“Let’s look at the school lunch program…We are essentially feeding them fast food and teaching them how to eat it quickly… lunch should be educational. Right now the school lunch program is a disposal scheme for surplus agricultural commodities. When they have too much meat, when they have too much cheese, they send it to the schools, and they dispose it through our kids’ digestive systems. Let’s look at it in a different way. This should be about improving the health of our children.”

~ Michael Pollan (in an interview with Bill Moyers, November 28, 2008)

Check out this short video about a company called Revolution Foods, serving a new kind of school lunch:

The founders, Kristin Richmond and Kirsten Tobey, came up with the idea while in business school at Berkeley, motivated "by the idea of creating a healthier generation.”

Their company now serves almost 60,000 meals to mostly low-income students in 350 schools across the country!

The criteria for the food they serve:

• No high fructose corn syrup
• No trans fats 
• Antibiotic and hormone free meat and dairy 
• Local and organic foods preferred 
• No fried foods 

The challenge: healthy food is more expensive. These meals are $3-4/meal, while the government currently only reimburses schools up to $2.75 per meal. This is certainly worth the investment though, especially considering how much money this will save in medical bills down the road. 

How about also bringing this idea to hospital cafeterias?

Prescribing veggies

Doctors are now prescribing fruits and veggies at local farmers’ markets. Check out this article in the NY Times last week if you haven't seen it yet.

Doctors at three health centers in Massachusetts have begun advising patients to eat “prescription produce” from local farmers’ markets, in an effort to fight obesity in children of low-income families. Now they will give coupons amounting to $1 a day for each member of a patient’s family to promote healthy meals.

Farmers’ markets can be a “hub of preventive health.”

“Can we help people in low-income areas, who shop in the center of supermarkets for low-cost empty-calorie food, to shop at farmers’ markets by making fruit and vegetables more affordable?” said Gus Schumacher, the chairman of Wholesome Wave, a nonprofit group in Bridgeport, Conn., that supports family farmers and community access to locally grown produce.

If the pilot project is successful, Mr. Schumacher said, “farmers’ markets would become like a fruit and vegetable pharmacy for at-risk families.”

The key will be to make it easy for people by bringing farmers' markets into hospital cafeterias, doctors' offices, schools, and churches. Speaking of which, I was so happy to walk into our hospital cafeteria the other day and see this: A table dedicated to produce from local farms!

Perhaps one day doctors will even be able to prescribe farm shares, so that fresh fruits and vegetables can be directly delivered to people each week. 

Good news in the medical world

The Dean Ornish lifestyle change program will now be covered by Medicare (article here, CMS decision memo here). This hopefully means we'll be seeing more diet and exercise programs pop up around the nation, and people will be able to afford them.

Below (or link here) is a 3-minute Ted Talk where Dean Ornish talks about the pandemic of cardiovascular disease, diabetes, high blood pressure, and obesity, and how these diseases are reversible through diet and lifestyle in 95% of people. He also talks about how prostate cancer can be reserved or stopped through diet and lifestyle. 

Hospital food matters

Hospitals are meant to be places of healing, but it seems that the food we serve our there may have the opposite effect. I have a feeling that we will look back in 50 years and be shocked at the things we’ve been feeding people.

This NPR story talks about a pilot study done by the Johns Hopkins Center for a Livable Future: What happens when hospitals serve less meat on their menus? (And the meat that they do serve is bought from local, organic, and sustainable sources.)

They looked at 3 hospitals and found the following:

• A 28% decrease in meat and poultry purchases (translated to save $400,000/year)
• Reduction in meat-related greenhouse gases by 1,648 tons/year
• Reduction in CO2 emissions equivalent to burning 102,454 gallons of gasoline or sequestering carbon by growing 23,354 tree seedlings over 10 years 

Wow… how can hospitals not do this?! It would mean both healthier patients and a healthier planet.

3 simple things health providers/hospitals can do right now:

1. Buy & sell less meat
2. Buy food from local, organic, sustainable food sources
3. Participate in Meatless Mondays (also started by Johns Hopkins – go them!) 

Even Einstein agrees...

"Nothing will benefit human health, and increase the chances for survival of life on Earth, as much as the evolution to a Vegetarian Diet" ~Albert Einstein

Yoga in school

A few weeks ago, Caitlin and I started teaching Ashtanga twice a week at a local high school (thanks to Ty!). The students seem to like it and we've been brainstorming about how to bring more yoga into the school system. Part of gym class? Instead of detention? Early morning before school starts? During lunch? After-school program?

Here are some reasons why yoga, and Ashtanga in particular, seems to work well for high school kids (I'm sure there are many more so please add to this):

• Builds physical strength.
• Skill-building: Students learn and memorize the poses (and thus become potential future yoga teachers).
• Development of a self-practice: Students can practice at home on their own time (and teach their families/friends).
• Improves focus and concentration (as this school showed with their morning exercise program).
• Consistent: Students practice the same poses each class and know what to expect.
• Reproducible: Since all Ashtanga teachers teach the same practice, schools and students will not be dependent on one particular teacher.
• Cheap: No equipment or gym membership needed.
• Community-building: New people meet each other and practice next to one another, sharing vulnerability.
• Increases awareness of food and the body (brings more mindful eating)
• Pushes students to their edges: Helps overcome fear and mental limits. Love this quote: 

“It is a tremendous thing for a person to get, to realize, that the things that we set as extreme limits for ourselves are just in our mind, and we have to be careful of the limits that we impose on ourselves. As human beings it’s amazing how prevalent this is in our society."

~Chuck Miller

Morning mysore in schools

"I can't understand why people are frightened of new ideas. I'm frightened of the old ones." ~John Cage 

Roosevelt high school in Wyoming starts the day with a workout (and not just students… teachers join in as well). 15-20 minutes of sweat breaking exercise, then off to work (no time to shower).

Since starting this morning exercise routine, the school has seen reading performance improve dramatically.

This program was inspired by Dr. John Ratey and his book “Spark: The Revolutionary New Science of Exercise and the Brain,” where he talks about how exercise leads to the growth and remodeling of the brain.  

As one teacher said, “the culture at Roosevelt supports wellness and fitness… It’s not unusual now for a student to leave history class, run around the outside of the building and return to the classroom focused.”

We need more schools to follow their lead! 

How about morning mysore in schools? Everyone (teachers included) could grab a mat and pile into the gym for practice. I bet that would improve test scores!

Our brain on stress

Chronic stress can actually reshape and shrink the brain.

Studies have shown that mice living under chronic stress (confined in a wire cage) have “retraction in the projections, or dendrites, of some of the neurons in the hippocampus” and the hippocampus (an area of the brain important for mood, memory, and cognition) shrinks in overall volume.

A specific protein, called brain-derived neurotrophic factor (BDNF), has been found to mediate the growth and adaptability of neurons. The less BDNF, the less neurons can adapt and grow, and the more the brain shrinks.

So why should we care about this BDNF business?! Because exercise increases BDNF release! As The Ratey Institute* points out, exercise-induced BDNF release may make the brain more resistant to stress.

This study showed that just three months of endurance training significantly increased the release of BDNF. Wow! What might yoga does to BDNF levels?! Maybe we can test this on our Philadelphia ashtangis at some point… :)

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*The Ratey Institute is an organization dedicated to 1) the scientific study of the brain/body connection, and 2) improving educational and public policies to optimize physical and mental health… getting people moving and exercising. Dr. John Ratey, professor of psychiatry at Harvard Medical School, believes that: “The marriage of the brain and body bathed in the effects of exercise creates the essential environment for optimal mental and physical health.” 

Prescribing financial health

Another reason to eat right and exercise: Your financial health.

According to this article, “a growing number of advisors are encouraging clients to take better care of themselves because of the impact health has on insurance rates and retirement planning.”

This makes me feel a little bit better about all the money I spend on yoga… if only insurance companies could be convinced that paying for yoga now will save them money later!

Meatless Mondays

San Francisco recently declared Mondays as “meat-free!” This is a nonbinding resolution to urge schools and restaurants to offer “plant-based” food options every Monday.

Meatless Monday is a non-profit initiative associated with the Johns Hopkins School of Public Health. Their goal is to reduce meat consumption by 15% in order to improve the health of people and the planet.

I’d love to see our hospital get in on this! 

Sin tax or bucks for broccoli

Interesting (and short ~3 minute) NPR news segment on structuring incentives to get people to eat better.

They talk about two methods to encourage healthier eating:

1.  Pay people to eat healthy food (“bucks for broccoli”)
2. Charge more for unhealthy food (“sin tax” on junk food)

Experiments have shown that with method #1, people buy more junk food (using money saved from the cheap healthy food). But when the junk food itself is more expensive (as in method #2), people actually buy less of it.

Why? Because people are more responsive to price increases than price decreases. It seems that charging more for junk food (i.e. tax on soda) will be more effective than subsidizing healthy food.

But then this article came out in the Wall Street Journal this week, reporting that there is no change in soda consumption in states with a soda tax compared to states without a soda tax. This could be explained by the fact that the soda tax was small and hidden... it might be a different story if the tax is large and noticeable.

This brings up some questions… should we pay people for their healthy habits and charge people for their unhealthy ones? Pay people to exercise? Subsidize yoga? Fine people for smoking? Charge people for unhealthy food choices? Apparently GE charges their employees who smoke an extra $625/year!

Health Reform: Prevention, Wellness, & Primary Care

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane."
~Martin Luther King, Jr

Health care reform passed in the House last night, and if all goes well will become final this week. Representative James E. Clyburn of South Carolina said, “This is the Civil Rights Act of the 21st century.”

With this reform, 32 million previously uninsured people will now be insured, health insurers will be unable to deny or drop coverage to the sick, small businesses will receive tax credits for buying employees’ health insurance, and the Medicare “doughnut hole” will be closed.

In addition to all of that, there are many exciting preventive/ wellness/ primary care changes worth highlighting.

The bill will:

• Establish a “Community-based Collaborative Care Network Program” for health care providers to create integrated health care services for low-income, uninsured, and underinsured populations.
• Establish “The National Prevention, Health Promotion and Public Health Council” to coordinate prevention, wellness, and public health interventions.
• Create a Medicare demonstration program called “Independence at Home” to provide primary care services in patients’ homes, allowing health professionals to share in savings from reduced hospitalizations, reduced health services, and improved health outcomes.
• Establish a grant program to support evidence-based and community-based prevention and wellness services that increase prevention, reduce chronic disease rates, and address health disparities.
• Provide free evidence-based preventive services (i.e. no cost-sharing).
• Provide grants for small employers to develop “wellness programs,” and establish pilot programs to financially reward employees for participating in these wellness programs.
• Require chain restaurants and vending machines to disclose nutritional content of each item sold. 
• Increase residency-training positions, prioritizing primary care and general surgery in areas with low physician-to-population ratios.
• Increase flexibility in laws regarding residency payment in order to promote training in outpatient settings.
• Ensure availability of residency programs in rural and underserved areas. 
• Increase workforce supply of health professionals by providing scholarships and loans for primary care training, providing grants to providers in medically undeserved areas, recruiting providers to rural areas, creating loan repayment programs, training residents in preventive medicine and public health.
• Support the development of training programs that focus on the primary care models of medical homes, team management of chronic diseases, and the integration of physical and mental services.
• Increase funding for community health centers. 
• Establish new programs for school-based health centers.

Innovation

It is rare for me to feel energized and inspired by a big medical school lecture... but yesterday was one of those days. 

Dr. David Brailer gave an excellent talk about innovation and entrepreneurship… and why they matter for health reform. 

Where we are now. 

“No other industry has an output that actually changes the human equation… that makes the human condition better.” 

• A child born today has >50% chance to living over 100. Over the past 100 years we’ve added 5 years to our life expectancy (in the past 30 years, we’ve added 1 extra year of life per year). 
• A lot of this increase in life expectancy is from living in a safer society – better public health, fewer homicides, fewer accidents. But a lot of this is also the result of innovation. Penicillin, Insulin, Antiretrovirals. These are the building blocks from which life expectancy grew. 
• Many inventions do not come out of laboratories, but rather they are concepts. The Framingham study (from which many cardiovascular and other treatments have stemmed), early cancer detection, evidence-based medicine. These are not treatments, but they make our treatments more effective. 
• As more and more companies suggest new products, he asks, “So what? What is this really going to contribute?” 

Health information technology.

“The great lifesaver of the 21st century will be health information technology.” 

• A patient needs to be able to go to the emergency room and have their medical records available right away – similar to how we can quickly get cash from an ATM.
• When a doctor uses a computer, they deliver better care (access to evidence-based medicine, health alerts, drug-dosing, drug-interactions, etc.) 
• The single largest growing item in federal budget is health information technology. We are living through this transition now. 
• Personal health records: Consumers thirst for being more involved in their care. They want to be more knowledgeable, more empowered. They want access to information. There is going to be a tremendous change in health literacy over time. 
• Where we are heading in terms of health information technology: 
• Telemedicine -- Getting specialists out to rural areas. 
• In-home monitoring -- Keeping a patient at home with an “electronic garden” rather than putting them into expensive skilled nursing facility. 
• Teleradiology. 
• "Autopilot" controls -- Just as planes have systems which don’t allow pilots to make unsafe maneuvers, this would similarly prevent physicians from cutting too close to vessels, etc. 
• Pharmacogenomics -- Looking at how genetic influences responses to drugs. 
• Data mining -- Sifting through clinical data to find powerful associations (this is how COX-2 inhibitors were taken off the market). 
• Real-time monitoring -- Of outbreaks, pandemics, etc. 

The culture of innovation. 

• We live in a “culture of health innovation.” 
• On one side, there are the inventors and entrepreneurs: 

“It is not usually that they have a new and different idea, but it is that they never give up on that idea. They push, break rules, frustrate conventions, risk careers, push push push. It’s not the discovery (though this happens as well), but it’s the hard work.” 

• On the other side, there is the more cautious, scientific discipline. The standards of conduct, inertia, status quo… all pushing back against ideas. 
• The purism and methodology of science lives in a messy and complicated real world, and it is the balance of these forces that creates our culture of innovation. 

How innovation happens. 

• Absolute persistence. Repeated failures, challenges, setbacks. This has been true for dialysis, organ transplant, the discovery of mRNA, the development of the CT scanner, etc.
• What IS innovation? It is when people work against norms and fears. It is relentlessness and not giving up. It is losing reputations. It is not working years, but working decades. 

Lessons from the arts: two types of geniuses (most innovators fall under category #2!). 

• One: The conceptual genius -- Picasso example. Picasso did his best work in his 20s. His earliest works are astronomically priced, while his works later in life are reasonable. His price curve goes down. As soon as he looked at the world, he knew. He painted each painting ONCE. He did not go back. 
• Two: The evolutionary genius -- Cezanne example. Cezanne did his best works in his late 50’s. His price curve goes up higher and higher. He went through iterative, exploratory processes. He repeated paintings, destroyed them, and painted them again 20 years later. It took him decades to evolve his style. He did not give up. 

What is holding back health reform. 

• The health system is protected. It is in the American psyche that we will find cures for diseases and live longer, healthier lives. People are scared that if we change policy too much, it will interfere with our system capable of discoveries and cures. 
• The health system is inertial. Current policy protects the status quo, even if it’s a bad status quo. For example, despite evidence on the dangers of tobacco, the federal government subsidized tobacco production until 2004. They subsidized the price per pack by more than half. Similar stories for getting insulin pumps, seatbelts, intensive care units into the system… the policy world is really hard to change. 

Protecting innovation.

• Americans have a depth of perseverance and relentlessness. No policy will change our culture of innovation. The innovation system works precisely because it goes against the status quo. 
• The question is: How can our health system encourage more innovation?

Bringing back house calls

Great NBC Nightly News “Making a difference” piece on doctors making house calls (thanks to Lizzie for sharing this!)

Each year, Medicare patients with multiple illnesses (3 million people) see an average of 13 different doctors, receive 50 different prescriptions, and account for 76% of hospital admissions.

House calls will help keep people OUT of the hospital, and save Medicare as much as $50 billion.

Let’s hope the health reform bill happens. Encouraging house calls has bipartisan support and will be beneficial for all involved...  patients, physicians, and the health system.

Real health reform (Part 4 or 4): Personal responsibility & Self-care

4) Personal responsibility & Self-care

• There needs to be a paradigm shift so that people start taking health into their own hands -- by practicing healthy habits like a plant-based diet, regular exercise, not smoking, positive relationships, less stress, etc. 

• Brian Berman, Director of the Center for Integrative Medicine at the University of Maryland, said: 

“About 40% of the illnesses that we have today are behaviorally based. How do we move toward more self-care?”  

Is it really only 40%? Thinking about the reasons patients are hospitalized, it seems like that number is much higher. 

• Christie Mack, cofounder and president of the Bravewell Collaborative, said: 

“[Patients need to] realize that they are the primary caregivers for themselves. And health care should provide the support systems to encourage behavior change toward healthier lifestyles.”

Real health reform (Part 3 of 4): Integrative care

3) Integrative care:

• As discussed in the earlier post on meditative medicine, we need to shift away from the division between “conventional” and “alternative” medicine. 

• There are cost-effective alternatives to expensive medications and interventions. Andrew Weil said: 

“As long as medicine remains this costly, it’s going to sabotage any system we create. You just can’t do statin therapy and stents and angioplasties on everybody; we can’t afford that. And there are low-cost alternatives to that kind of intervention.”  

The alternatives? Diet changes. Exercise. Stress reduction. 

• Unfortunately, these alternative approaches are often marginalized as “Complementary and Alternative Medicine (CAM),” when they are not complementary or alternative at all, but rather part of simple, fundamental health care. Mimi Guarneri said:

“I used to be called the ‘alternative cardiologist’ because I talked about nutrition, exercise, and stress relief. I thought, ‘Alternative to what? A bypass?’ [Nutrition, exercise, and stress relief] are not CAM, they’re not conventional, they’re basic health care, and they should be available to everybody.” 

• We need to stop calling basic health habits “CAM” when there is plenty of evidence behind them. Not to mention the fact that they are low-cost and have few, if any, side effects. 

• Integrative methods need to be part of medical school training in order to become part of our health system. James Gordon, MD, Director of the Center for Mind-Body Medicine, said: 

“When doctors, medical students, and residents experience these approaches themselves, then it will become part of practice.”

Real health reform (Part 2 of 4): Individualized Care

2) Individualized care

• Providers need to see each patient as a unique human being, not simply as a collection of symptoms.
• This approach requires time and a trusting patient-provider relationship. And, it requires more primary care physicians who are trained to look at the wider picture of a person.
• Brian Berman, Director of the Center for Integrative Medicine at the University of Maryland said: 

“Individualization – what’s appropriate for that person at that point in time – is what integrative medicine is really about. Someone may come in with a symptom, say, back pain. Perhaps as you start to talk with her, you realize she’s not satisfied with her job, which is a big predictor of continuing pain. Then you talk further and learn because she hasn’t been able to exercise and play with her children, her self-worth has taken a beating, and she’s been overeating. And because she’s gained weight, she has inflammation within the body that perpetuates that pain,"...  it’s really the whole person – mind, body, and spirit – that is out of balance.” 

Real health reform (Part 1 of 4): Health care, not disease care

I read a great article in Body & Soul magazine on the future of medicine, where they interviewed several leaders in the field of integrative medicine.

“Somewhere beyond the endless health-care debates could lie real reform: A future where we – an our doctors – will take a more balanced approach to keeping ourselves well...” 

There are 4 main parts to this, but today I’ll just address the first...

1) Health care, not disease care

“We don’t have health care: we have disease care.” ~ Mimi Guarneri, director of the Scripps Center for Integrative Medicine 

• Our health system is good for emergency care – heart attacks, strokes, trauma, and serious infections – but not great for keeping people healthy in the first place. 
• The preventive care provided is not really prevention. Guarneri said, “Prevention isn’t having a mammogram… Prevention is eating an anti-inflammatory diet rich in greens and whole grains and exercising.” 
• The current fee for service structure reimburses physicians for providing treatment. Physicians should be reimbursed for their time teaching about prevention and lifestyle change. 
• Medical schools need to expand their curriculum to teach about nutrition, exercise, and stress reduction. Andrew Weil, founder of the Arizona Center for Integrative Medicine, said: 

“There should be a course on the body’s healing system, on all the mechanisms from DNA on up, by which it can self-diagnose, repair, regenerate, and adapt… It seems odd to me, when you look at the NIH, that there’s really nothing there about health: it’s all about diseases… and that’s representative of what’s off in our whole way of thinking about the body.”

The cause of over half of our greenhouse gas emissions

In case the animal cruelty and health factors aren’t enough:

**Meat consumption causes more than half of our greenhouse gas emissions**

Health reform

The new director of the CDC, Tom Friedan, spoke to us about the CDC's priorities and challenges and gave us some insight into health reform. He said we are closer than ever to changing the health care system. He discussed the 3 main challenges in doing this:

1) Expanding access - to the millions of uninsured.
2) Reducing cost - we spend $2.5 trillion per year - every $1 out of $6 goes towards health care.
3) Improving the health value for the health dollar - currently if a doctor doesn't prevent illness, they make more money - the incentives are all wrong.

He then discussed some of the areas where CDC plays a role, including increasing the emphasis on prevention, creating community guides for preventive services, and helping create a "Prevention Trust" as part of health reform. The goal is to spend $10 per capita per year for prevention. Right now it's $0 per capita for prevention and $8,100 per capita per year for treatment. 

He quoted President Obama saying, "Facts and evidence must never be twisted or obscured by politics or ideology." 

The social determinants of health

I went to a talk at the Centers for Disease Control about the social determinants of health and the need to strengthen the evidence-base in order to address these issues. The speaker, from the Cochrane Group, emphasized the need to move away from simply describing/summarizing the social inequities and to begin intervening and taking action.

They discussed the World Health Organization (WHO) Commission on the Social Determinants of Health (2008) three recommendations:

1) Improve daily living conditions.
2) Tackle the inequitable distribution of power, money, and resources.
3) Measure and understand the problem and asses the impact of action.

Previously, recommendations such as these came from "expert committees" where the evidence was not always clear. Now, WHO is pushing for more real evidence in their guidelines.

Some interesting issues came up with regard this push towards evidence and "evidence-based medicine."

• If you do studies, yes you will find evidence... but funding is what controls the kinds of studies that are done. If there is no funding to look at certain issues, how will there ever be any evidence?
• Are under-served communities equitably represented in these studies?
• The scientific evidence and numbers are not always congruent with, or representative of, what is happening on the ground. Can qualitative analyses adequately capture issues of social injustice and social inequities?

The speaker then listed the areas where the Cochrane Group is doing systematic reviews and making policy recommendations: income distribution, education, public safety, housing, employment, social networks, food supply, natural environment, transport, health systems.

All important, but what about diet? exercise? preventive health measures? Their challenge is that the evidence does not exist for them to conduct their systematic reviews. So, they end up doing "empty reviews," which in themselves are a powerful indicator of the areas that need more attention and funding.

To me, all of this is even more reason to study lifestyle interventions and preventive health, especially in underserved populations.