During this blizzard of 2010, I thought about the difficulties an ambulance would have reaching someone in need on an unplowed street—let alone if the person were significantly obese and hard to transport on even an ordinary day.  Then today I read an astounding Washington Post article that noted “a patient between 400 pounds and 600 pounds is part of every workweek for many crews throughout the [DC metro] region.”  Really? I thought this only happened on occasion in select areas shown on the Discovery Channel.  Apparently, not the case.

Emergency medical crews are making hefty investments (no pun intended) in super-sized, ambulatory equipment.   According to the article, “sales of stretchers designed specifically for very large patients were expected to reach $50 million in 2012, up from $29.6 million in 2004, while sales of specialized lift systems were projected to rise from $75 million to $193 million.”

And, it is interesting that just as healthcare spending is rising at a faster rate than the U.S. economy overall, the rate of morbidly obese patients who are at least 100 pounds overweight is increasing faster than obesity as whole, according to a RAND study.

What is more alarming is that, for the first time ever in U.S. history, children may have a shorter lifespan than their parents, and much of the reason is due to obesity and its related health problems.  More than 23 million children (one third of all children and adolescents in the country) are overweight or obese and at greater risk for Type II diabetes and other chronic, life-threatening health conditions.

So, how can we keep our children from ending up in super-sized stretchers one day?

In a previous post, I discussed environmental factors that hinder our ability as a nation to stay un-obese, so I’ll expand on that with some ideas I’ve heard in the classroom.

One suggested strategy has been a soda or sugar-sweetened beverage tax.

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Last term, my Program Planning for Health Behavior Change workgroup was charged with using theory to help explain a health behavior and design a targeted intervention.  With several MDs in my group, we chose improving warfarin adherence to reduce risk of stroke in elderly patients with atrial fibrillation.

2.2 million Americans suffer from AF, a condition that causes a 4 to 5 fold increased risk for stroke. What is worse is that 5% of those ages 65+ have AF.  Luckily, warfarin is an inexpensive, generic drug that, if taken consistently and with regular physician monitoring, can reduce the risk of stroke for AF patients.   However, compliance is a problem and as a result non-compliant AF patients remain at risk for stroke.

My group utilized a PRECEDE/PROCEED framework to conduct a hypothetical needs assessment and identify the underlying causes of the problem that our resulting intervention would address.  This framework provides a conceptual way of organizing multiple levels of factors that explain prescription regimen noncompliance and identify places where an intervention may be effective.  Utilizing our course textbook, Health Behavior and Health Education: Theory, Research, and Practice by Glanz, Rimer, and Viswanath, we found that examining the following factors was particularly important in explaining whether one is adherent:

• Predisposing factors – the motivation or rationale for behavior and include one’s attitudes, beliefs, preferences, skills
• Reinforcing factors – the reward or incentive for persistent behavior such as social support, modeling, peer influence
• Enabling factors – direct or indirect antecedents that allow motivation to be realized, including environmental and structural factors

We also used social cognitive theory, which focuses on the individual as a health behavior change agent, and its theoretical constructs.  In reviewing the literature, we found that elderly AF patients may:

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As this first full term at the Johns Hopkins Bloomberg School of Public Health has unraveled, I see how much they were prepping us during summer term.  My days have been filled with work, outside activity, caffeine, and a test of how long I can go without sleep and still be productive—similar to what I imagine the days are like for most of the Disruptive Women in Healthcare!  Classes this term included biostatistics, evolution of infectious diseases, program planning for health behavior change, health policy I, and public health economics seminar.  I chose the more rigorous biostatistics course (and will take others throughout the year) in an effort to become more quantitative and enhance my ability to analyze and conduct cost-effectiveness studies and economic evaluations in particular.  The course has its challenges, and there are certainly days when I wonder if I should have taken the other class, fondly known as “baby stats” to fulfill the requirement.  Health policy I: the social and economic determinants of health has been my favorite class, because not only have I learned about what the name of the course suggests (and health disparities is of great interest to me) but also how to develop a conceptual framework for a health policy problem and how to write testimony in an effort to get such an issue on a policymaker’s agenda.

In between classes, I have busied myself with all that the MPH program has to offer outside the classroom, as there is no shortage of activity competing for students’ every “free” moment.  For instance, I am part of a monthly health disparities journal club and am working with a professor on a book about Taiwan’s national health insurance system.  I am also now VP of Communications for Students Promoting HEalthcare REform (SPHERE), an organization spanning the school of public health and school of medicine whose goals are to assure that every person in the United States has the right to affordable, high-quality healthcare and to educate the Hopkins community.  So far the organization has had one event this year in which we heard from a panel that included representatives from Kaiser Family Foundation/The Commonwealth Fund, Johns Hopkins faculty, and local news radio, on the state of play in health reform.  We will be having other health reform educational events throughout the year and one major advocacy event in the spring.  As VP of Communications, I will be promoting events at the school, updating and enhancing our website, and possibly forming partnerships with other similar, local student groups.

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As I check Facebook before going to Program Planning for Health Behavior Change class, I can’t help but look at this pre-class behavior of mine in terms of some of the concepts I am learning in the classroom. We can keep in touch with all of our friends quickly and efficiently with the click of a button and thanks to the Internet, but on the whole we aren’t quite as compulsive about getting the recommended nutrition, exercise or health services upon which our livelihoods depend.

Much blame has been put on individuals for not exercising, eating properly, or managing their chronic conditions, thus burdening the healthcare delivery system. Some ask, if we have tons of healthcare literature out there and people know what is the ‘right’ thing to do—eat 3-5 fruits and vegetables a day, exercise for 30 minutes most days of the week, etc.—why aren’t people more adamant about taking care of themselves?

Sure, people are accountable for their actions. But I ask, what is it about the environment we live in that makes it so easy to instill the habit of checking Facebook constantly, yet so difficult to inspire people to take care of themselves? Why aren’t venues that sell fresh fruit and vegetables as abundant as fast food restaurants? Why has the food industry been able to sell us larger portion sizes that provide a bargain for our pocketbooks but make us chronically sick? Why are we so reliant on automobiles and don’t live closer to where we work, shop, go to school, etc.? And since we don’t walk or bike everywhere, why are our lives so demanding that we don’t have time to make moderate exercise part of our daily routines?

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Those who have spent their careers in the trenches of healthcare and are now reading the uncertain headlines in the news each day and fearing for the future of healthcare, fear not! There are fresh crops of enthusiastic students, eager to make a difference and keep the ball rolling in the quest to improve healthcare, sprouting up in graduate programs starting across the nation this summer.

Having started the Johns Hopkins Masters of Public Health (JHSPH) program in July, it has been a thrilling month and will no doubt be a fast year with many choices to make for classes, volunteer opportunities, and research projects. The plethora of options was described by one former student as “going to the grocery store when you’re hungry.” Not to mention, each student shopping in the “grocery store” is a Type A overachiever with diverse interests and remarkable accomplishments under their belts. It is no exaggeration that it is difficult to get a seat in the first few rows of the lecture halls—it is just that kind of crowd.

Each day has been a new adventure with exciting speakers further energizing us and spurring new thoughts and ideas, laying the groundwork for our future studies this year. Countless fliers for seminars to attend cover the bulletin boards week after week, and we each have several hundred courses for credit from which to choose during our 11-month program.

As the summer session comes to a close and I find myself in the throes of final exams, I not only have learned the principles of epidemiology and environmental health but also have taken away several overarching lessons with widespread implications:

• Change is possible, even if the odds are against you. Dr. D.A. Henderson, former Dean at JHSPH, spoke to our class about the global campaign he led to eradicate smallpox in the 1960s when no infectious disease had ever been eliminated on such a large scale.
• Even if wide scale change is not immediately plausible, something—no matter how small—can still be done. For instance, Howard County, Maryland took it upon itself to help its own uninsured residents by launching the Healthy Howard Access Plan to provide basic health services to those unable to obtain or afford health insurance.
• The American people can successfully unite to affect healthcare change. Polio: An American Story (required reading for incoming MPH-ers) by David Oshinsky, a Pulitzer Prize-winning historian, depicts the true story of Americans coming together despite socioeconomic class or political party to find a vaccine for polio.

Needless to say, with just one term under my belt, the JHSPH motto “protecting health, saving lives—millions at a time” doesn’t seem such a far-reaching feat after all. This thinking that is shared with my classmates is proof that midterms and finals have not tarnished our raring-to-go attitudes or deflated our ideas and dreams about improving the health and lives of many. And hopefully knowing this will help some of my more seasoned colleagues out there rest assured and sleep a little easier.