A NEW debate in creating Health Care Efficiency?

I, like many, feel a little lost in connecting the dots when it comes to my current understanding of the inefficiencies in our health care system. Aside from the partisan debates, what are the facts in regards to cost reductions while improving delivery of care? Where do we find the unbiased, peer-reviewed sources, presenting balanced perspectives? We have all heard the adage - there are two side's to every store and then there is the truth. It takes a lot of endurance and patience to unravel the complexities and economics of the health care debate. Well, I was half asleep when my brain caught a few lines from Metro Morning at 5:30am, with Matt Galloway. I was desperate to turn a new chapter in my blogs and pursue something outside nutrition and labeling.

There are two sides to every story and then there is the truth.

Matt's opening remarks started with "Ontario spends 46 cents of every dollar on health care..." This was followed promptly with '...this could rise to 70 cents in twelve years according to the province, if changes to the health care system are not made." Wow, that is a pretty staggering figure and this introduction warranted my attention. Now before getting to the guest of the show, I realized that this topic touches on our earlier lectures and study, around the divergence of primary health care or population health and health promotion. We have already been introduced to Community Health Centres which provide both.

Ontario spends 46 cents of every dollar on health care..

Of interest to this blog post, their interdisciplinary team typically consists of at least a physician and/or nurse practitioner, but soon they could they see a new member - Physician Assistants? Yes, that's right, Ontario is monitoring a pilot project that could now see the introduction of a specialist that bridges the gap between nurse and physician? Do we need this, or do we have the right mix of specialists already? Is this new position going to create efficiencies, thereby reducing costs to deliver care, improve access to care, or both? To provide one perspective on this debate, Matt Galloway introduced Tom Closson, president and CEO of Ontario Hospital Association on his show. He has been interviewed by the CBC on several occasions before but today he was promoting a presentation he was making at the Toronto Sutton Place Hotel, on the challenges facing health care. His presentation was entitled "Major Opportunities: How to heal Ontario's Health System."
According to Tom, health care expenditures have been increasing over the past 10 years on average of 7.7% per year. Matt represented the voices of many Canadians, all of them wondering - how do we lower costs with an aging population, and one that appears to be getting sicker?
According to Tom the answer to this question not only has to do with improved efficiencies but also with following evidence. That definitely resonates for anyone in nutrition practice. We are accustom to thinking in terms of evidence-based research as it relates to our advancing knowledge, and provision of care. In reality, this is exactly what is not happening. Tom cites evidence provided by the Ontario Health Quality Council. In 2007, they published results that indicated that many patients living with diabetes, or those with heart disease, were not getting the right mix of drugs; nor were they following their regimes properly. One solution would be installing an electronic health records system so that practitioners know what conditions they are treating. Also, improvements in delivery of care can be made, by establishing best practices and offering the right incentives to the providers.

This appears to be commonsensical but the discussion isn't complete without understanding other programs which are not as clear cut. Take for instance the aforementioned role of Physicians Assistants. They have been used for decades in the military to provide care beyond what is typically delivered by a Registered Nurse (RN), in support of Physicians. However, the costs of having such a position has been contested, as has the pilot project underway in Ontario. According to an interview on February 10th, between Anna Maria Tremonti, host of the show "The Current," and Doris Grinspun, Executive Director of the Registered Nurses of Ontario, this new position, in it's current conception, has several flaws. Firstly, a Nurse Practitioner already delivers a level of care similar to that of the Physician Assistant, for less money; secondly, the current pilot project running does not stipulate that the Physician Assistant needs to have a scientific or medical degree prior to completing a two year Physician Assistant certification program. In other words, this new position could be filled by candidates that are being paid more and with less training. The whole point of of using Physician Assistants, as they have in other provinces, is to supplement the Physician, provide a more in depth assessment than a RN; complete diagnostic studies; conduct physical exams, etc. It appears to make sense but what if you just expanded the training of the Nurse Practitioners and save the additional cost of adding a new position to the mix of health care personnel. If not, the team of support personal to the physician or surgeon, would be bloated. See if you can determine where there is overlap in this following scenario. Your primary care or emergency department tier of personnel, under this new scheme, could be composed of:

Family Physician
Registered Nurse
Nurse Practitioner
Emergency Room Technician
Physician Assistant
Resident Intern
Surgeon

That's a lot of well-trained, highly skilled personnel; working under well-intentioned directives; all focused on delivering great care...but is it sustainable without reform?

We have discussed the ongoing need for health care reform. Reasons include: population growth, diversity & aging population; societal expectations and economic conditions, such as what we are recovering from now. Also, there are new technologies, research and surgical procedures developed; staffing mix changes and new training programs. All of these are encouraging reform but the most current debate is improving efficiencies and reducing costs of providing care, while also improving access to care. Many would think that these concepts are dichotomous but many would argue they are not. It will take further debate; investigation and perhaps improving on what we already have; listening to those front-line staff that know what needs to be fixed.

References and Links:

Registered Nurses of Ontario
http://www.rnao.org/

Ontario Hospital Association (OHA)
http://www.oha.com/Pages/Default.aspx

CBC Metro Morning 99.1FM
5:30 am to 8:30 am
Host: Matt Galloway
Guest: Tim Closson from OHA
http://www.cbc.ca/metromorning/

CBC The Current 99.1FM
8:30am to 10 am
Host: Anna Maria Tremonti
Guest: Ian Jones, Doris Grinspun, Tom Closson
http://www.cbc.ca/thecurrent/2010/201002/20100210.html

Ontario Health Quality Council
http://www.ohqc.ca/en/index.php

Animals Fats: Are the Tides Turning?

Some of you may have read the recent article by Carly Weeks in the Globe and Mail: "Butter v. margarine - which is better?"

This is an age-old tug-of-war between margarine and butter. Both are jockeying for position as a healthier option. As an example, many of these margarines contain a lot of Omega-6 fatty acids and not all of them contain the same quality of Omega-3 fatty acids found in fatty fish. Is manipulating the properties of these oils safe...long-term? So is butter, in moderation, a healthier option? Many naysayers would point towards the saturated fat content of butter. In the article, they reference a meta-analysis study published in the March issue of the American Journal of Clinical Nutrition. Siri-Tarino and others found that intake of saturated fat was not associated with an increased risk of CHD, stroke, or CVD.

There appears to be a theme to the questions raised by this once, steadfast rule. I recall reviewing, with some intensity, reports recommending a maximum of 400 grams of red meat (uncooked), or less, per week. By contrast to the aforementioned study, there are a number of meta-analysis studies cited in support of reducing red meat consumption. However, the question constantly raised by proponents of consuming all meat in moderation, is that red meat is not all the same?

We understand the importance of controlling the multitude of compounding variables in these studies, but do we have all the science behind the inter and intra-variability of saturated fats. In other words, do all saturated fats get an "F" on their healthfulness report card? There is consensus within the nutrition research field, that the main culprit is processed meats - for reasons largely linked to preservation, and the science is pretty consistent there. However, there are only theories as to why red meat increases the risk of diseases such as bowel cancer. Some believe that it is the haemoglobin and myoglobin that trigger nitrosation in the gut. Or, it could be caused by heterocylcic amines, created during the cooking process. Maybe those that argue from an anthropological view in support of vegetarianism are right - our intestines are not short like a carnivore, therefore we were never meant to eat and digest meat. Perhaps it's environmental toxins, provided through feed. Maybe composition of the feed itself or how the animals were raised...can we say "Factory Farms and feedlots?" What's in the meat that increases the risk? I raise these last few points because this is exactly were research and public opinion are headed. The closer to the natural source (e.g., butter from organic, grass, fed, pasture raised, stress-free animals, living on small local farms) may not be the same as butter processed from dairy cows living in institutions. Margarine is so far removed from the original source that we don't know how many evolutions it will go threw, before those that originally abandoned butter realize, they would be better served having a 1/2 teaspoon of butter versus 1 tablespoon of margarine. Unfortunately, trying to pin down the exact variable responsible for these nutritional differences is a challenge. BUT, that is exactly where research is headed. In fact there is research studying the health properties of vaccenic acid...and yes, its a naturally occurring trans fat. This is one of the healthy conjugated linoleic acids and it's found at various concentrations in ruminant animals (e.g., cattle, deer, bison, goats, etc.). In fact, the type of feed provided directly impacts the formation of these healthy fats. Again, the closer to nature we get and the less technology applied, the healthier it is for us. Examples are abound on this topic, so maybe there are healthy reasons to ration, costly, leaner cuts of pasture raised organic beef and have organic butter on your toast.

If I look into my crystal ball, there are three changes on the horizon: first, Michael Schmidt is able to convince health authorities to exercise our right to purchase raw milk in major grocery stores; second, we will see the Heart and Stroke Foundation's Health Check seal on a variety of cuts of red meat; finally, when I Dietitian uses PEN, they will find well-vetted, peer-reviewed, longitudinal, meta-analysis studies all revealing the same evidence on the healthfulness of saturated fat and that it's not as negative as once thought.

Please note, predicting the future is not a strength of mine. Also, I don't advocate for the paleolithic diet, in fact my meat consumption is limited. My favorite meals are vegetarian, and this includes raw food.

Program Planning and Addressing Food Security

In 2002 FoodShare and others sent invitations to over thousand people and fifty organizations to a series of meetings to answer the question: "What would it take for everyone in Ontario to have access to affordable, nutritious food by the year 2002?"

Several of the recommendations that were summarized were included in a revised report entitled: "Food 2020." There are 28 recommendations but I have highlighted ones that are particularly relevant to my line of investigation with the Looking Project. They include:

• Encourage governments to examine licensing of community-run food discount stores which would assure that excess or dented foods would be managed to meet the industry's need for quality control, while creating a non-stigmatizing alternative to food banks.

• Governments and foundations should finance community-based food programs (community kitchens and gardens, cooking groups and classes).

• Policies should be implemented to allow for wholesale prices, encouraging fresh food consumption.

The establishment of several food cooperatives has been inspiring and would continue to improve access to affordable, locally grown and/or organic, food. Examples of these food coops include Kharma Coop and the future launch of the West End Food Coop. Improving access and affordability of these fresh foods is key in neighbourhoods such as Parkdale where I live. Several community kitchens are available to serve the marginalized population including homeless youth or those that live in shelters. At Sketch their community kitchen supports the nutritional needs and mental welfare of homeless youth. Paid Community Artists and volunteers come in three days of the week to prepare a tasty, nutritious and cost-effective meal, that utilizes both fresh ingredients- organic and local whenever possible. They have to make do with less, as many of the food donations from Second Harvest may not provide everything they need. Fortunately this can be supplemented with a weekly budget to purchase other ingredients including protein, when it can be found on sale. Initially my investigation was to assess the program planning, implementation and evaluation. Bhavana, a social work graduate, leads the food preparation, cooking and organization of staff and volunteers, to get these meals prepared within a short amount of time. Many days, they are feeding 60 to 70 people, ranging in age from 16 to 30 and sometimes older.

Project Management:
(Funds, support staff)

• Bhavana heads the kitchen.

• Community Artists assist and are paid.

• Volunteering e.g., currently they have a chef volunteering expertise

Situational Assessment:
(consultation and community stories, review of guidelines)

Many of the youth get their meals at local community kitchens and food banks but the meals are not always nutritious. It is quite common for them to go to local grocery store dumpsters to get their food...there's a lot of great food wasted. The other complication is that meal planning is difficult because of the lack of scheduled, consistent fresh produce and protein. Many of the youth are concerned about where their food comes from and are discerning consumers.

Goal:
(statement with overall direction)
The overall goal of Sketch is to create opportunities for street involved and homeless people ages 15-29, to engage in the arts in a cross-discipline studio environment or int he community. Although not formally drafted, I felt that the overall goal of the kitchen was to provide nourishment for the youth's mental and physical well-being.

Objectives:
(specific, measurable, attainable, realistic, and time-limited)

Provide a space for self-expression and skill building through self-directed time in studio or instructional workshops. Three days per week they will provide nutritious lunches. To support their service, they will establish relationships with local farmers and develop sustainable food systems throughout the community. To improve healthy food options they will create an exchange of food for service. As an example, they recently produced a bill board in exchange for food from a farmer. They have also established and maintain several community gardens throughout the city. A seed exchange has been initiated. They raise funds through: grant writing, promoting talent of artists; developing and sustaining community partnerships.

References and Links:

Sketch
http://www.sketch.ca/

Food Share
FOOD 2002 Grassroots Actions to Help Build Greater Food Security
http://www.foodshare.net/foodpolicy03.htm, accessed March 31, 2010.

Common Areas and Food Security

The best method of learning for me, is relating the relevant theory from our current lecture and connecting it to the current issues. Recently I visited The Stop and spoke with someone at the food bank. We had a very enlightening conversation about the reality of running the food bank. Summer is the busiest time for them as volunteers go on vacation but the demand for food is great. Also, getting to a proper grocery store takes about $6 by transit or 15 to 20 minute walk from their location. You can imagine how hard it would be to hall 4 litres of milk home along with everything else, even if it is $2 less then the local corner variety store. What a stark contrast to my neighbourhood, 15 minutes away from The Stop by transit, where there are three fruit and vegetable vendors within 1 block. Most of this produce is 30 to 50% cheaper then at the larger grocery stores. I consider myself fortunate but there is more for me to learn about how those that are food insecure, find the services that can help them. How did such a disparity in food access manifest? I don't live in a food desert but if you travel North on Transit, within 10 minutes, there are no grocery stores within walking distance for those using the foodbank at The Stop. I also learned that once per month a family in need can receive 2 to 3 day supply of food from the food bank and then join the breakfast program run 4 days per week. This is not going to be enough for a single parent family who just found out that their rent is going up, or that they don't have as many hours at work. They may need food for the next 2 weeks. This stark reality means that many parents will go hungry so that their children will eat that day. Fortunately there are community advocates that come in to run information sessions about other financial aid services. Also, Food Share run the Foodlink hotline, which connects individuals in need to food programs within their neighbourhood. What's interesting is that citizens really only hear about theses services through word of mouth versus some other conventional channels of media. Reliable information can come from community centres, community papers and places of worship and non-governmental social saftey nets. These are all known as "the commons." This term was used in the 2001 report by Wayne Roberts at the Toronto Food Policy Council entitled " The Way to a City's Heart is Through its stomach: Putting Food Security on the Urban Planning Menu." In that report the author, argues that falling incomes and rising housing cost are responsible for the increase in hunger. Commons could be land, capital, tools or the culture and know-how (e.g., "common knowledge").

Community gardens become symbols of discovered commons. Low-income people can grow top quality food at minimal cost.

(Roberts, 2001)

Roberts highlights two things that we take for granted:

1) Food is assumed to be a commodity that can be bought - a logic we don't attach to doctors, parks, roads, schools, etc.
2) "The fallacy of misplaced concreteness," (borrowing from Alfred North Whitehead). In other words, kids think food comes from a store when it fact it comes from a farm.

The point being, maybe the assumption of food access is linked to income and not universal access, should be obsolete. This link is a result of public policy. Also, in regards to the second point, our food doesn't need to come from a farm or store. It can come from within our neighbourhoods, parks and backyards. Roberts reminds us that our self-reliance (e.g., traditions and capacities to grow our own food) was lost by the time of the big depressions of the 1980's and 1990's. It was this loss in traditions that reinforced the relationship between poverty and hunger. It is positive to see how there is a system in place for communities to receive support for starting a community garden but there needs to be a greater focus on public health reaching out to improve skills lost in food production and preparation. The same community coalition that established the Dufferin Grove park, is needed to press urban planners to include public spaces as the "foundation and precondition for the self-help skills that flourish outside a strictly cash economy" (Roberts, 2001).

Jutta brought to light the importance these collectivist movements, brought forth by the community, have on the health and well-being on the community. This is a bottom-up approach to enhancing community capacity, a piller to community development and generating solutions to common problems. This participatory approach is key to health promotion and is a far cry from the prescription-based, medical model, approach of population health. Perhaps further research could be conducted, with support of those living with food insecurity. If we study what the effective communication strategies are, promoting these various programs and services throughout the city, then perhaps we could identify needs and reduce poverty and hunger within our communities. This may be difficult to mobilize but a network, capacity and competence already exists in many communities such as Dufferin Grove Park.

References and Links:

Roberts, W. 2001. "The Way to a City's Heart is Through it's Stomach: Putting Food Security on the Urban Planning Menu." Available at <www.toronto.ca/health/tfpc_hs_report.pdf>
accessed March 2010.

Communicating Health for Student Decision Making

One of the articles that recently caught my attention was published under the The New York Times blog for Education. There was a lesson plan for grades 6 through 12 submitted, entitled:

The Care and Feeding of Kids: Finding Information on Nutrition and Fitness

By Catherine Hutchinson and Holly Epstein Ojalvo

Creating a lesson plan can be a user-friendly approach to communicating evidence. In this case, the lesson covers several components of the curriculum, including Health Education and Language Arts. This appears to be an effective communication strategy to support research in the area of obesity and is readily implemented into teaching.

As an example, the warm-up for this lesson instructs the teacher to make five bubbles or circles on the board, with the headings "health," "nutrition," "weight," "diet" and exercise." Students are then paired and asked to write those messages within their own journal. They will write one "lie" or myth about the statement e.g., a diet myth about saturated fat or cholesterol. Later, the students are invited to share their falsehoods, compare and react to others in the class.

This exercise also encourages critical thinking skills through investigation and disseminating of the evidence to stakeholders, including teachers, parents and students. Ultimately, these formats for engaging students, communicating current health topics, that affect government policy (e.g., Michelle Obama's program to reduce childhood obesity) are effective in that they make the search findings actionable. Teachers have a unique set of skills and contribute significantly to the health mindedness of students; helping to shape their opinions and make informed decisions. Finally, the teachers will be able to measure some element of learning through the lesson plan, with the ultimate goal of improving the student decision making.

Nutrition labeling...moving forward?

In our class the other day, we were discussing some of the limitations with nutrition labeling. Several important points were made, including:

• Lack of standardized serving sizes
• The health or nutrition literacy varies among the general population
  
• Values and calculations can be confusing
  
• Doesn't cover ready-made or processed food, etc.
  

In regards to the last point, there has been a lot of attention in several U.S. cities over the past couple of years in regards to developing new laws enforcing restaurant chains to post nutrition labels on their menus. The City of Philadelphia council introduced February 14th, 2008 a new ordinance requiring the chain restaurants and retail food establishments make available certain nutrition information. The enforcement of that ordinance began February 1st of this year. In one of their consumer information sheets, the Department of Public Health announced:

"Menu labeling would allow Americans to exercise personal responsibility and make informed choices for a growing part of their diets"

They cited some shocking statistics including:

• Average American eats out 4 meals a week
• American adults and children consume on average 1/3 of their calories from eating out

Equally shocking, in 1970 Americans spent just 26% of their food dollars on restaurant meals and other foods prepared outside their homes. Today, they spend 46% (Centre for Science in the Public Interest, 2003). I would love to insert some current Canadian data here. Let me know if you have reviewed any literature on the topic.

Nutrition information is also becoming more readily available online. Bing, Microsoft's search engine, just announced that this information will be available along with recipes. So when you type in "apple pie nutrition," within seconds there is a link on the left-hand side of the screen with a full breakdown. Give it a try.

The Centre for Science in Public Interest has been in the news more than once around the topic of nutrition labeling. Recently they released on updated version of a more consumer friendly label. This proposed revision reflects new research in nutrition and addresses the proliferation of novel packaged goods displaying contentious health claims. See: "Food Label Makeovers Proposed by CSPI". Their December '09 issue has a great "before" and "after" graphic illustrating how particular ingredients and nutrient values, can be misunderstood. I appreciate the strategic use of typefaces and fonts on a small label, to improve legibility. Also, I like the breakdown of sweeteners the CSPI is proposing.

In the Public Health Nutrition journal (2005), Cowburn and Stockley completed a review of published and unpublished research into consumer understanding and use of nutrition labeling. They cited one Canadian study along with several from the UK and U.S. Although the paper addressed limitations with their review, there is some excellent tables summarizing research gaps in consumer use and understanding of nutrition labels. Also, there are a few sample tables from other countries.

A few key findings:

• Although consumers understood terms like "fat," "calories/kilocalories," "sugar," etc., they had difficulty understanding the role that different nutrients played in their diets
• Serving size information was difficult to interpret
• Older consumers and people of lower income levels of education or income were likely to have the most difficulty understanding the labels
  

(Gill Cowburn and Lynn Stockley. Consumer understanding and use of nutrition labelling: a systematic review. Public Health Nutrition, 8, pp 21-28 doi:10.1079/PHN2004666)

Fireside Chats

I have been part of several fireside chats at work over the years. They are positioned as an informal meetings designed to exchange ideas, deliver feedback, discuss topics inside and outside of work...pretty much an open ended meeting with your direct report. I have always enjoyed this format as its less formal then a performance review. How encouraging to see a similar, informal web-based setting, for relevant health promotion topics within Ontario. Check out some of the free webinar sessions coming up, hosted by CHNET:

"Getting Lost in the Evidence - Part 2 - Collecting, Synthesizing & Applying Evidence in Practice"

Visit:

http://www.chnet-works.ca/index.php

Great forum for professionals and those concerned with issues in community health.

Nate

Lot's of Possibilities

Finally...my first blog! This is a very exciting opportunity. Who know's what this blog will look like a few years from now, or where it might take me. Maybe this site will become my new online home but it is a little too early to tell. There is a little trepidation as I take my first steps.

Who is going to find my internal musings of interest? I look forward to sharing ideas, as well as discussing topics of health, philosophy and art. Most importantly, I want to learn more about myself; read and appreciate a diversity of perspectives; contribute to my community in a meaningful way; develop intellectually and creatively. In other words, I need to continue to learn, grow and have an impact. Also, I look forward to eventually developing this blog into a outlet for my creative work - a forum to nurture my passion for health promotion and graphic communication.

...we will see.