Archive for August, 2010

The Happy Meal Ban – Not So Happy, Not So Effective

August 20, 2010

By B Hannan and C Fernandez

In an attempt to reduce the growing obesity rate in Santa Clara county, the Santa Clara Board of Supervisors voted to ban restaurants from giving away toys with children’s meals that exceed set levels of calories, fat, salt and sugar. This translates into the banning of toys on meals with more than 485 calories, more than 600 mg of salt, and have more than 35 percent of their calories from fat or 10 percent from sweeteners . The nutritional standard is based on recommendations from the Institute of Medicine, a non-profit organization that published ground-breaking reports on preventing childhood obesity and U.S. Department of Health and Human Services .For example, a McDonald’s Happy Meal with Chicken McNuggets (4), small fries, and a 1% low-milk drink contains 520 calories and nearly 700 milligrams of sodium. The most popular Happy Meal: a cheeseburger, low fat milk, and apple caramel dippers have 500 calories and 15 grams of fat . Hence, a toy would not be offered with these meals. According to the measure, one in four 7th, 9th and 11th graders in Santa Clara County was either obese or overweight from 2007 to 2008 . The ban covers only unincorporated areas of the county. While the county has 151 restaurants, the ban directly affects 12 restaurants that offer children’s meals. Restaurants can be fined up to $1000 for violating the ban.
While this ban is certainly attention-grabbing and symbolic for the county, Santa Clara officials may be missing the mark on developing initiatives that truly reduce obesity. To date, there is no conclusive evidence linking the addition of toys in fast food meals to obesity levels. Obviously, it is the frequency of fast food consumption, quality of fast food and inactivity of children that are more direct contributors. Proponents for the ban argue that the addition of toys increase a child’s desire to demand a fast food meal. Yet, the point the board is missing is that children do not drive themselves to fast food restaurants and pay of their own meals: parents do. Santa Clara parents, like all parents, are challenged with getting their families quick and affordable meals. By only addressing toys, children may demand certain meal boxes less, but they will still be taken to fast food restaurants by parents seeking to feed their children in an affordable manner.

In an effort to de-link children’s association between fast food and prizes, the Board has managed to alienate important stakeholders such as parents and the Santa Clara fast food industry . The Board of Santa Clara have received letters and complaints from parents and restaurants alike. Some Santa Clara parents do not like the idea of local government choosing what meals their children can eat; others are indifferent. Restaurants in Santa Clara attest that they were not given any forewarning or opportunity to address their meal offerings. The 12 restaurants affected directly by the ban are the most discouraged by the new legislation. McDonalds restaurant have responded formally stating that they are “disappointed” by the decision and that “Happy Meals provide many of the important nutrients that children need .” The California Restaurant Association is watching the bill closely, nervous that this type of ban may be implemented in other parts of the state. Proponents of the ban such as the Santa Clara Public Health department and local health professionals have been virtually silent in the media regarding the issue.

While choosing to focus on fast foods to reduce childhood obesity is a worthy endeavor, by focusing on meal prizes the board is passing up opportunities to work with local fast food companies on other initiatives. Other initiatives could include:

– Finding more ways to post calorie and fat content on “meal boxes” or paper trays. We believe that parents should receive comparison meals so that parents understand the relative nutritional value of a meal versus an alternative meal.
– Giving incentives to fast foods companies to offer healthy alternative kids meals that are nutritious and affordable (incorporating more fruits and vegetables)
– Influencing restaurants to offer “healthy” toys that influence children to be active (ex. jump ropes, balls, etc.)
– Encouraging fast food restaurants to highlight their healthy choices of food when they advertise, which would be another means to market healthy choices to children

While the Board of Santa Clara attempts to de-link the association of prizes to fast food, they also may have enhanced the association of wanting fast food to punishment and denial. Better crafted initiatives for more positive associations are warranted.








New Washington law limits access to opioids

August 19, 2010

Washington lawmakers have taken new steps to limit access to prescription opioids, such as OxyContin.

Despite opposition, Washington state lawmakers have passed HB 2876, a bill which will restructure the way in which opioid pain medications are prescribed in the state.  Lawmakers cite increasing deaths due to prescription drug overdose as the catalyst for their action.  Washington State Department of Health reports that  from 2003 to 2008, the deaths from prescription medication overdose rose 90%, resulting in approximately 500 deaths in 2008 alone.  HB 2876 repeals the State’s current guidelines on pain management and replaces them will new rules for chronic pain management including dosing guidelines, indications for consultation with a pain specialist, and requirements for outcomes and opioid use tracking.  These new rules will apply only to chronic pain, and not pain resulting from acute injury or malignancy.   The Agency Medical Directors’ Group, the Department of Health, the University of Washington,  and the Washington State Medical Association will collaborate to develop the guidelines.   Several  public hearings will be held over the summer and early fall to discuss the elements of the proposed guidelines.

The bill passed despite intense opposition from local and national groups, including the Washington State Medical Association, American Society for Pain Management Nursing, American Academy of Pain Management, and American Pain Foundation.

The new law may limit access to medications necessary for adequate pain control.

Each has expressed concern about the potential for guidelines to result in decreased access to adequate pain control.  The groups are asking their membership to attend the hearings and advocate for guidelines that will minimize care access restrictions.   They cite the relative paucity of pain specialists, particularly in small and/or remote communities.  Like these groups, we urge clinicians and patients, particularly those in rural communities, to attend these meetings to ensure patients with chronic pain continue to have access to pain care.

For more information, please see:

Preventing Cervical Cancer in Islamic Countries

August 19, 2010

In the SBFPHC Policy Advocacy, an essay discusses cervical cancer in Islamic countries.  The article states that cancer is the 3rd leading cause of death in the UAE, and the WHO recommends the HPV vaccination as effective primary prevention.  The article goes on to say that that recent concerns have been raised about the vaccine, as well as the potential for encouraging sexual activity.  The article concludes by saying it is time to re-confirm the policy to administer HPV as an essential primary prevention of cervical cancer.  As health care advocates, we believe that not to continue the use of HPV would be detrimental to women’s health, and manifest itself in negative consequences for years to come.  We encourage women’s groups to speak out on this alarm.   The voice of women appears to be in danger of being stifled in this renewed debate.  While understanding that there are religios issues involved in any conservative religios state, the health of women is vital to the sustainability of a functioning society.  We are heartened by the stand here , and believe that a rollbacl in HPV administration would be a setback for female health, and a setback for the overall society in the UAE.  We urge a acknowledgement of religious beliefs and the understanding that this vaccine will help its society prosper and be viable .  Local customs should be heeded, but health care prevention not discontinued.

Bill Hannan , Christine Fernandez

A pragmatic approach to preventing cervical cancer in an Islamic country

August 19, 2010

Data from the Health Authority – Abu Dhabi (HAAD) shows cancer is the third leading cause of death in the emirate, and cervical cancer is the second leading cause female cancer death making its prevention a top 10 Public Health priority.

This confirms WHO data listing the UAE as intermediate in cervical cancer prevalence, and the continuing WHO recommendation that HPV vaccination is effective in primary prevention.  From 2007, HAAD has funded Gardasil within the Extended Programme of Immunisations (EPI) for UAE National and Non-National girls at the age of 17; the vaccine is given by school nurses as part of the school health programme with consent required from both the girls themselves and from their parent or legal guardian.

There has been persistent global concern about the vaccine, with some concerns about safety, although the US Food and Drug Administration and other regulators continue to consider the vaccine effective and safe.  Vaccine uptake remains constant at 54% of target girls taking-up the vaccine.

The decision to include Gardasil in Abu Dhabi’s EPI involved substantial stakeholder discussions, including with the Department of Religious Affairs (Al Awqaf), but there have been continuing concerns within the community.  Recently the Family Development Foundation has raised concerns regarding the suitability of the vaccine, citing concerns about the potential for the vaccine to encourage sexual activity.

Pragmatism and traditional values: A modern dilemma

Based on the unequivoval epidemiology of cervical cancer in the emirate, and three years of successful implementation, we believe now is the time to reconfirm the pragmatic decision to include this vaccine in the EPI, with two-layered consent to enable conscientious objection, and simultaneous education about sexual practice.

SMS (Save My Sanity)

August 19, 2010


To boost mental health, promising new programs will capitalize on the key role technology plays in teen’s lives – from SMS to facebook.

Mental health issues are alarmingly common among Australia’s youth in particular, with one in four aged 16-24 years affected. However, the latest Australian Bureau of Statistics research finds that only one quarter of the 671,000 sufferers used mental health services in the previous year. According to National Youth Mental Health organization, Headspace, there is a pressing need to do something more for young people.

It is imperative that we provide supportive solutions in the ways they like to communicate most.

One group from the Murdoch Children’s Research Institute is pioneering a program using cell phones – mobiletext. Teens taking part are texted questions designed to gauge their mood, feelings and emotions, ranging from how much alcohol they have consumed to how they coped with being stressed during the day. A software application on their phone allows their answers to be sent onto participating GPs for analysis. Of course financial supporters and telecommunications group, Telstra, have praised the innovation.

The SANE Mobile website is specifically optimised for the screen size and browsing capabilities of mobile devices and will a range of information and services including podcasts, video on-the-go and information for media, complementing SANE’s existing comprehensive services. People concerned about their own or a friend’s mental health can now send an enquiry to SANE from their cell phone, to get information, advice and referral from a health professional.

Another group, Youthlink are partnering with touch and interactive specialists, Enabled Solutions, to develop an assessment app for the iPad.

While these latest techno programs might engage teens with existing mental health problems, we should remain mindful of the importance of prevention. Positive psychology initiatives now in place in schools, such as the Bounce Back! Resilience Programs, promise to be helpful in this regard.

Controlling Malaria

August 19, 2010

Jhpiego , the non profit health organization  affiliated with John Hopkins commented on its web site about malaria prevention and the World Malaria Day on April 25, 2010.  It noted that most of malaria cases , and deaths occur in sub saharan Africa.  The good news is that it can be prevented and managed in low cost measures.   An example of such a low cost measure is the use of bed nets.   Jhpiego has been involved with WHO back to 1998 regarding iniatives to fight malaria.  While the promulgation of bed nets will work, the local population’s apprpriate utility has been a factor in the slowness of eliminating this problem.  Better solutions must come from a grass roots effort which must seek to engage local leaders and groups to better educate their residents about the need to combat malaria, that they can die from it , and the best and most practical appraoach each person to take to gain prevention.  Jhpiego has it right in that it understands the need to get in to local communites in this effort.  That bed net utility comes with a welcomed local knowledge that these nets are not for fishing , but for sleeping and saving lives.  Perhaps the WHO is too big of an organization to be able to drill down to the local level , and organizations like Jhpiego provide a superior bridge to the local level , given theoir expertise in  health care , and deep understanding that health care initiatives and choices are best met at the local level , with a strong consideration for local cultures and practices.  Their efforts against malaria should be applauded, and rewarded with more funding.

Bill Hannan,  Christine Fernandez

Addressing Patient Confusion in the Health Care Marketplace

August 19, 2010

Many types of health care professionals provide care to patients within the U.S. health care system.   However, differentiating among the qualifications of various health care providers can be difficult to do.  Complicating things even further are the numerous health professionals who are now earning doctorate degrees including: chiropractors, podiatrists, nurses, audiologists, physical therapists and naturopaths.  However, questions and concerns have been raised regarding these professionals referring to themselves as “doctor” in the health care setting.

Confusion among consumers about who is qualified to provide specific patient care undermines the reliability of the health care system. A 2008 survey conducted by Global Strategies demonstrated that consumers are indeed confused.  For example, 54% of consumers surveyed thought optometrists were medical doctors.

Legislation has been introduced at both the state and federal levels that would prohibit misleading and deceptive advertising in the provision of health care services and require health care providers to identify the license that they are practicing under. The goal of this legislation is to provide consumers with the information they need to make informed health care decisions.  A coalition of 14 medical associations, including the American Medical Association, have announced their support for HR 5295 The Health Care Truth and Transparency Act, which would prohibit deceptive advertising by health care providers.  The American Nurses Association opposes the Healthcare Truth and Transparency Act as “an unnecessary and dangerous imposition of trade restrictions on nursing practice.”

As advocates for the health of the public, we agree with the bill’s sponsor, Representative Sullivan, who stated that, “H.R. 5295 simply holds all health care providers to the same truth in advertising standards as every other provider of a good or service in the United States–that is something that will benefit anyone who seeks medical care.”

The Development of “Superbugs” through Meat Consumption

August 18, 2010

Would you eat antibiotics with each meal if you felt healthy? Of course not. But large agriculture companies supplement animal feed with sub-therapeutic doses of antibiotics such as penicillin to promote growth; according to the Pew Commission, 70% of antibiotics produced in the U.S. are administered in animal feed.

Bacteria exposed to antibiotics can evolve into antibiotic-resistant “superbugs” that cause difficult-to-treat infections. In humans, such infections result in $16 to $26 billion in additional medical costs annually due to additional hospitalizations and deaths mostly in infants and the elderly. Medical doctors are expected to judiciously use antibiotics, minimizing exposure of bacteria to these powerful drugs. However, farmers can buy antibiotics in bulk for their animal feed.

The FDA’s draft guidance, released in June, suggests limiting antibiotics to sick animals only, under the supervision of veterinarians. While agricultural companies such as Hormel Foods argue that antibiotics are necessary to prevent infections in animal herds and promote growth, the USDA recently admitted that this practice poses a health risk to humans. Scientific evidence suggests that antibiotic resistance in animal bacteria can be passed on to human bacteria, leading the CDC and the Union for concerned scientists to encourage the restrictions on antibiotic use.

As health professionals, we oppose indiscriminate use of antibiotics in animals and support regulations that restrict its use to only sick animals with a prescription. To support this position, please comment on the draft FDA guidance document and contact your Senator or Representative about this critical food safety issue.

For a Healthier America, Demand Marriage Equality

August 18, 2010

Reducing health disparities is a moral imperative.  The $2.3 trillion dollars spent every year on health care in the U.S. makes it a financial imperative, as well. One way to improve the health of our nation, reduce health disparities, and save precious health care dollars is to allow same sex marriage throughout the United States. In the interest of the public health, we call for repealing the Defense of Marriage Act (DOMA) and re-defining the federal definition of marriage as a legal union between two consenting adults.

Health professionals recognize the link between same sex marriage and health. The American Medical Association, the largest organization of US physicians, recently made it their official policy to promote marriage equality because bans on same-sex marriage contribute to health care disparities for LGBT Americans and their children.  The American Academy of Pediatrics adopted a similar stand because children fair better when their parents are permitted the 1138 rights afforded by civil marriage.  The American Psychological Association has long argued for marriage equality because denying marriage to American citizens undercuts their mental health.

The data on marriage is clear: married people live longer, happier and healthier lives.  Individuals denied marriage rights are less likely to afford health coverage, more likely to incur severe illness when hospitalized, and more likely to need costlier care.  That said, because same sex marriage is only permitted in 5 states (and the District of Columbia) and explicitly banned in 39 states, many individuals are denied the opportunity to realize the benefits of married life.

As public health advocates, it is our responsibility to improve the health of all citizens and to work towards the elimination of state sanctioned health disparities.  For the health of our nation, we demand the repeal of DOMA and the sanctioning of same sex marriage.

We need increased federal and state funds to reduce racial/ethnic disparities in healthcare

August 18, 2010

The state of racial and ethnic disparities in health care continues to be problem for the U.S., and as such, federal and state funding is needed for targeted education, outreach, prevention and testing campaigns, and getting patients into treatment in a timely manner.

In 2000, Healthy People 2010 was published to provide a health prevention framework for the U.S., as a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. Addressing health disparities was the 2nd overarching goal of the report. But sadly, here in August 2010, we have fallen short of the goal, as Healthy People is being updated for 2020.

Today, minority populations are still disproportionately affected by many diseases including:

• Cancer – 50-200% greater mortality for “treatable” cancers if not detected early
• Chronic Kidney Disease – 200-400% greater prevalence
• Diabetes
• Heart Disease
• HIV/AIDS – 200-400% greater mortality rates
• Immunization gaps
• Mental health issues
• Obesity

(according to the Alliance of Minority Medical Associations)

According to the 2009 Congress-mandated annual quality and disparities reports issued by the Agency for Healthcare Research and Quality , “…we are not achieving the more substantial strides that are needed to address persistent gaps in quality and access.”

The drivers behind racial and ethnic disparities in health care and outcomes are varied, stemming from long-term socioeconomic disparities, access to care and language and cultural barriers. There are even environmental pollution/contamination effects that have been noted, as many landfills and other contaminating sites tend to be concentrated in areas populated by the poor and disenfranchised. An overview of the drivers and impact of disparities can be reviewed via a brief video from Kaiser Permanente.

Many believe that access to health care is the primary determinant of disparities. However, I believe that with increased access to care for all U.S. citizens, there is the possibility that with more Americans participating in the system and a predicted shortage in primary care physicians, there may actually be an decrease in the available health care for minorities. Given the expected growth in minority populations over the coming years, disparities will become a more critical issue. As such, federal and state funding should be increased to support & expand initiatives specifically targeted at reducing disparities.

The Congressional Black Caucus Health Braintrust posits that increased expenditures to achieve health equity represent “good” debt, in that it adds value for individuals, communities, the U.S. workforce, defense and the nation as a whole. Especially as compared to the “bad” debt of the current Iraq war investment (of $9 million/month).

Even a small percentage of the funds spent on the war overseas could have an impact on health disparities. The U.S. needs to wage battle on the variety of chronic and acute conditions that affect everyday Americans, but especially minority groups that suffer disproportionately. So all people are encouraged to contact their state and federal legislators regarding policies and state budgetary items that can reduce disparities, and call for increased investment in this area that will affect all Americans in the years to come.