Saturday, December 31, 2011

Fiction and poetry are doses, medicines. What they heal is the rupture reality makes on the imagination.

(If you’re looking for the manifesto, please scroll down the page and there’ll be more soon)

‘Fiction and poetry are doses, medicines. What they heal is the rupture reality makes on the imagination.’ Jeanette Winterson 

Looking through the newspapers over the last few days, I’ve been overwhelmed by the usual round up of ‘highlights’ of 2011: successes, failures, deaths and revelations. I’m still surprised how little is reported on the on-going crisis resulting from the tsunami in Japan in March.
How is the health and well-being of the displaced people around Fukushima, now that the Japanese government has increased the levels of radiation it is permissible and ‘safe’ for its citizens to be exposed to? Although barely noticeable in the printed media in the UK, counterpunch have provided some compelling detail, exposing the very real and enduring plight of people in Japan. What is particularly poignant, is the focus on women's voices, reminiscent of Greenham Common in the early 80’s, when 30,000 women held hands and formed a human fence around nine miles of the US nuclear missile base, and sung They Shall Not Pass
The women of Japan sing a traditional song of remembrance and longing, Furosato:

Someday when I have done what I set out to do,
I will return to where I used to have my home.
Lush and green are the mountains of my homeland.
Pure and clear is the water of my old country home.

This year has also seen societal unrest on a scale unseen in a generation. Whilst focus in the UK media has been on the ‘Arab Spring’ and the unfolding crisis in Syria, the voices of school girls unbalanced the political system across Chile, resulting in a number of government resignations and questioning wider social inequalities. The voices of the young women of Chile cannot be ignored.
Closer to home, and less apparently sensational, the small print in the Guardian on 30th December revealed that antidepressant use in the England has risen by more than a quarter over the last 3 years. Prescriptions for anti-depressants rose from 34m in 2007/08 to 43.4m in 2010/11: an increase of 28%. Furthermore, in the North West we have the highest antidepressant use over 2010/11, with 7.2m prescriptions dispensed.
I have no doubt at all, that antidepressants offer critical respite from serious and debilitating depression, but we mustn't lose sight of some of the factors that impact on our mental health, and the current economic crisis plays a real part in this. Whilst counselling and talking therapies can help turn lives around, it is significant that as the government have increased their support for Cognitive Behavioral Therapy, this apparent treatment of choice is both time-limited and ‘measured’ in part, by the individuals’ ability to find employment/return to work. And we’re told that depression is costing the economy almost £11bn a year. I seem to remember the wonderful Dorothy Rowe telling the Un-Conference here at MMU in October, that guilt, blame and shame are all part of that complex baggage that erodes our well-being and can cause depression. (see Greenberg in recommended books for the big picture)

Doesn’t it seem like we’re in some horrible muddle, measuring our well-being...measuring our ‘happiness’ ad infinitum. The writer Jeanette Winterson sums it up perfectly, ‘...when money becomes the core value, then education drives towards utility...the life of the mind will not be counted as a good unless it produces measurable results.’
In her autobiography, Why Be Happy When You Could Be Normal? Jeanette Winterson paints a picture of her life, originally fictionalised in Oranges Are Not The Only Fruit. It’s an enthralling read and one that I won’t spoil, but one in which we are given some very strong ideas about the potential impact of the arts on our well-being, and how as ‘meaning-seeking creatures’ in an increasingly secular world, we need to find ‘new ways of finding meaning.’ She also succeeds in blowing the myth, that poetry and prose are luxuries for the educated middle classes, suggesting ‘a tough life needs a tough language - and that is what poetry is. That is what literature offers - a language powerful enough to say how it is.’


In his report to HM Treasury, didn’t Derek Wanless suggest that evidence showed that one of the strongest determinants of health impact, wasn’t in fact, the reach of health services, but the female literacy rate?

I wonder how the people of Japan will describe this experience of being; will the actions of the young women of Chile go down in song, and how will we make sense of the here-and-now on our increasingly depressed little island?   C.P

Thanks to Dr Nick Shimmin for sharing counterpunch; Professor Chris Williams of Pace University for his essay; the inspirational young people of Chile and Jeanette Winterson.

Thursday, December 29, 2011

Guest Commentary: Vaccine Hesitancy Leading to Lower Immunization Rates

Ruth S. Gubernick, MPH

I am the proud grandmother of a 5-month-old granddaughter whose parents are having her immunized by her pediatrician, according to the Recommended Immunization Schedule, approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).

Recent articles and a national survey are reporting, however, that at least one out of every 10 parents in this country are not following this recommended schedule and are opting out of immunizing their children either on time or at all. Most of these parents are college-educated professionals. Some of these children will be the playmates of my granddaughter.

Vaccine hesitancy is resulting in lower immunization rates in the U.S. today. This year alone, we've had outbreaks of whooping cough and measles in several U.S. communities. Those diseases are only a plane ride away. Several people incubating measles flew into Newark, NJ earlier this year coming in contact with young families in several communities. The un/under-protected infants and children in those communities without high immunization rates or community/herd immunity were especially at risk of disease.

Parents don't want the government or anyone else to make those decisions for their children. I get that. But the problem is where they are choosing to get their information about vaccine safety. It's often the talking heads on TV and Internet bloggers with misinformation, rather than science-based research. I'm in favor of individual rights but their decisions for their own children can adversely impact my granddaughter, who is not yet old enough to be protected against diseases such as measles or chickenpox.

As a public health professional, I see immunizations as a societal responsibility, to protect those who are too young or otherwise unable to receive these recommended childhood immunizations against 14 potentially life-threatening vaccine preventable diseases. Parents who hold "pox parties" or share "lolly-pox" with their infected child's saliva or swabs dabbed with fluid from their child's pox with other families, rather than have their children immunized, make me crazy. Natural disease is not less risky than a vaccine!

I recently piloted an online course that I designed and built for the JSPH Teaching/Learning Seminar required for my doctoral program. It is about immunizations and targets college-educated professionals who are new parents. My students reported that video clips of parents telling their own stories had the most impact on them. I introduced the course with How safe are we? The Role of Vaccines in Protecting your Community ( http://www.youtube.com/watch?v=hsDU35G477E&feature=youtu.be ). It opens with a mom sharing how she felt about unknowingly infecting her newborn with Pertussis. Share these stories with the families that you care for and care about who may be vaccine hesitant. As a grandparent and population health advocate and student, I thank you.

Ruth Gubernick is a JSPH doctoral student.

Wednesday, December 28, 2011

HHB New Year Resolutions!


What are your healthy hair and body resolutions for the New Year?  Mine are:

- get back to prepooing with coconut oil (I've been slacking)
- exercise more frequently
- grow my hair to waistlength
- stick to my hair care regimen
- be more diligent about taking my multivitamins

Monday, December 26, 2011

Ground meat treats: Zucchini and onion meatloaf

A cousin of the meatball (), the meatloaf is a traditional German dish. The recipe below is for a meal that feeds 4-8 people. The ground beef used has little fat, and thus a relatively low omega-6 content. Most of the fat comes from the 1 lb of ground grass-fed lamb in the recipe, which has a higher omega-3 to omega-6 ratio than the regular (i.e., non-grass-fed) ground beef. The egg acts as a binder. Leave the potato out if you want to decrease the carbohydrate content; it does not add much (nutrient numbers are provided at the end of the post).

- Prepare some dry seasoning powder by mixing salt, parsley flakes, garlic powder, chili powder, and a small amount of cayenne pepper.
- Grate one zucchini squash and one peeled potato. Cut half an onion into small pieces of similar size.
- Mix 2 lb of very lean ground beef (96/4) with 1 lb of ground grass-fed lamb.
- Add the dry seasoning, zucchini, potato, onion and a whole egg to the ground meat mix.
- Vigorously mix by hand until you get a homogeneous look.
- Place the mix into a buttered casserole dish with the shape of a loaf.
- Preheat the oven to 375 degrees Fahrenheit.
- Bake the meatloaf for about 1 hour and a half.


It is a good idea to place the casserole dish within a tray, as in the photo above. The meatloaf will give off some of its juices as it bakes, which may overflow from the casserole dish and make a mess in your oven. Below is a slice of meatloaf served with a side of vegetables. The green spots in the meatloaf are the baked zucchini squash pieces.


A thick slice like the one on the photo above will have about 52 g of protein, 15 g of fat, and 6 g of carbohydrates (mostly from the potato). That'll be about 1/5 of the whole meatloaf; the slice will weigh a little less then 1/2 lb (approximately 200 g). The fat will be primairly saturated and monounsaturated (both healthy), with a good balance of omega-3 and omega-6 fats. The slice of meatloaf will also be a good source of vitamins B12 and B6, niacin, zinc, selenium, and phosphorus.

Sunday, December 25, 2011

Days

What are days for?
Days are where we live.
They come, they wake us
Time and time over.
They are to be happy in:
Where can we live but days?

Ah, solving that question
Brings the priest and the doctor
In their long coats
Running over the fields.

Philip Larkin 1964

Thursday, December 22, 2011

Healthy Hair on Youtube: Sunshower143

I'm fan of Sunshower143 for her diligent twisting regimen and healthy hair.  Enjoy:

Wednesday, December 21, 2011

Best things...manifesto and first networking evening 2012

Just a couple of things for this last posting of 2011…

I want to give a big thanks to everyone who’s been supportive of Arts for Health over the last 12 months and wish you all the very best for whatever 2012 throws at us. On a personal note, it has been incredibly exciting to see people joining our supposedly ‘regional’ network from all areas of the globe! It’s wonderful to have lots of comments about the manifesto (part 1) too, some of which I will include in part 2 in January.
 
Work in progress from 1st session in Manchester...
If you haven’t sent thoughts or responses to me about the manifesto, but were involved in the process, I’d be really keen to hear your thoughts, or collect your comments before its next incarnation. So please send them to artsforhealth@mmu.ac.uk
I have collected some sharp, subtle and inspirational thoughts from people who were involved in the sessions, from those who weren’t but feel passionately, and from the wider world of Culture, Science, Politics and the Arts.

Dementia and Imagination evening
I’m thrilled that the artist Claire Ford will be sharing reflections of her Churchill Fellowship at our first network event of 2012 on Thursday January 26th between 6:00 and 8:00pm (venue to be confirmed at MMU). As usual the event is free to our members, and will be informal. Claire spent 10 weeks in the USA exploring different approaches to dementia and the arts, and will be sharing this experience, her findings and ideas about future developments in the field.


Final details of the venue and confirmation of places will be sent out one week prior to the event, but please drop an expression of interest in attending to artsforhealth@mmu.ac.uk before Thursday 19th January. Please enter Dementia and Imagination in the subject line of the email.

For now, my very best things to you...Clive

Monday, December 19, 2011

3in6: Prep Week #3

PREP WEEK #3: December 19-25.  To join the challenge, see this post.

Use this week to draft your healthy meal plan for 3in6:



For the challenge, we are to eat fruits/vegetables with each meal.

  1. Find or come up with recipes that incorporate fruits/vegetables
  2. Write your grocery list
  3. Set up a drinking plan for your water intake

REVIEW #12: Pura Naturals Cupuacu Hair Butter (Lemongrass)

NOTE:  I am not paid to review this product.

Purpose: Moisturizer

Ingredients: Theobroma grandiflorum (Cupuacu) Butter, Astrocaryum Murumuru Butter, Mangifera indica (Mango) Seed Butter, Shorea stenoptera (Illipe) Seed Butter, Organic Butyrospermum Parkii (Shea Butter) Fruit , Organic Olea Europaea (Olive) Oil, Cocos Nucifera (Coconut) Oil, Ricinus Communis (Castor) Seed Oil, Simmondsia Chinensis (Jojoba) Seed Oil, Organic Pouteria (sapote oil) Sapota, and Herbal extract blend (horsetail, nettles, and burdock root).  

Number of trials: Numerous (until I finished the product)

How I used it:
Applied on freshly washed and conditioned hair.

_____________
THE REVIEW:

The cupuacu butter is divine.  It is really rich, thick, and moisturizing.  A little bit of the product certainly goes a long way; the sample lasted me much longer than I thought it would.  The lemongrass blend smell (while I like it) may be a bit strong for some, so I suggest trying the unscented version of this butter.

___________________
PROS: moisturizing, natural, a little goes a long way
CONS: a little expensive

RATING: Overall, I give the Pura Naturals Cupuacu Hair Butter 4.5 out of 5 stars.  

Protein powders before fasted weight training? Here is a more natural and cheaper alternative

The idea that protein powders should be consumed prior to weight training has been around for a while, and is very popular among bodybuilders. Something like 10 grams or so of branched-chain amino acids (BCAAs) is frequently recommended. More recently, with the increase in popularity of intermittent fasting, it has been strongly recommended prior to “fasted weight training”. The quotation marks here are because, obviously, if you are consuming anything that contains calories prior to weight training, the weight training is NOT being done in a fasted state.

(Source: Ecopaper.com)

Most of the evidence available suggests that intermittent fasting is generally healthy. In fact, being able to fast for 16 hours or more, particularly without craving sweet foods, is actually a sign of a healthy glucose metabolism; which may complicate a cause-and-effect analysis between intermittent fasting and general health. The opposite, craving sweet foods every few hours, is generally a bad sign.

One key aspect of intermittent fasting that needs to be highlighted is that it is also arguably a form of liberation ().

Now, doing weight training in the fasted state may or may not lead to muscle loss. It probably doesn’t, even after a 24-hour fast, for those who fast and replenish their glycogen stores on a regular basis ().

However, weight training in a fasted state frequently induces an exaggerated epinephrine-norepinephrine (i.e., adrenaline-noradrenaline) response, likely due to depletion of liver glycogen beyond a certain threshold (the threshold varies for different people). The same is true for prolonged or particularly intense weight training sessions, even if they are not done in the fasted state. The body wants to crank up consumption of fat and ketones, so that liver glycogen is spared to ensure that it can provide the brain with its glucose needs.

Exaggerated epinephrine-norepinephrine responses tend to cause a few sensations that are not very pleasant. One of the first noticeable ones is orthostatic hypotension; i.e., feeling dizzy when going from a sitting to a standing position. Other related feelings are light-headedness, and a “pins and needles” sensation in the limbs (typically the arms and hands). Many believe that they are having a heart attack whey they have this “pins and needles” sensation, which can progress to a stage that makes it impossible to continue exercising.

Breaking the fast prior to weight training with dietary fat or carbohydrates is problematic, because those nutrients tend to blunt the dramatic rise in growth hormone that is typically experienced in response to weight training (). This is not good because the growth hormone response is probably one of the main reasons why weight training can be so healthy ().

Dietary protein, however, does not seem to significantly blunt the growth hormone response to weight training; even though it doesn't seem to increase it either (). Dietary protein seems to also suppress the exaggerated epinephrine-norepinephrine response to fasted weight training. And, on top of all that, it appears to suppress muscle loss, which may well be due to a moderate increase in circulating insulin ().

So everything points at the possibility that the ingestion of some protein, without carbohydrates or fat, is a good idea prior to fasted weight training. Not too much protein though, because insulin beyond a certain threshold is also likely to suppress the growth hormone response.

Does the protein have to be in the form of a protein powder? No.

Supplements are made from food, and this is true of protein powders as well. If you hard-boil a couple of large eggs, and eat only the whites prior to weight training, you will be getting about 8-10 grams of one of the highest quality protein "supplements" you can possibly get. Included are BCAAs. You will get a few extra nutrients with that too, but virtually no fat or carbohydrates.

Saturday, December 17, 2011

What a year!!!

As I reflect on 2011, from a health policy perspective, it has been quite a year indeed. Berwick is out, ACOs are in, and costs continue to rise. Employers are trying everything and corporate wellness and prevention is the "new green". The lines separating payers, providers and purchasers are blurring every single day as insurance companies buy doctor practices and hospitals too!! The New England Journal says Disease Management doesn't work and everyone believes one study based on the sickest Medicare patients only. It is increasingly difficult to separate out the "truth" from the background noise, especially as the noise gets louder and louder.

Personally, I am really looking forward to 2012 and the ongoing struggle to make health care more accountable, transparent, safer and more cost effective. I am confident that the Jefferson School of Population Health will continue to provide leadership in its research, teaching and dissemination agenda. Our journals, this BLOG, our Medpages column, our national conferences, continue to resonate with the key opinion leaders in healthcare across the nation.

I hope that you will continue to turn to us for informed opinions and solid evidence too about what is working and what is not. One thing surely still remains the same regarding the reform efforts and that is of course " No Outcome--No Income". I am convinced that the future belongs to groups that can make this pithy statement a reality for everyday practice. We are always interested in your views too. DAVID NASH

Thursday, December 15, 2011

Guest Commentary: CMS Continues to Raise Stakes on Quality Measurement


This is the third in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Valerie P. Pracilio, MPH, Project Manager for Quality Improvement
and Bettina Berman, RN, Project Director for Quality Improvement

Measuring quality of care in the inpatient setting has been a staple of the healthcare environment for several years. Hospitals are penalized financially if they do not report data to the Centers for Medicare and Medicaid Services (CMS) on certain conditions, so solid measurement criteria is a necessity.

CMS’s desire to increase accountability at the provider-level created a need to assess quality in outpatient settings. In 2006, a governmental mandate led to the establishment of the Physician Quality Reporting System (PQRS) to incent eligible professionals who satisfactorily report data on quality measures for services provided to Medicare beneficiaries. Since then, JSPH has been collaborating with Quality Insights of Pennsylvania (QIP) on the development and maintenance of the measures included in the PQRS program.

Measurement development is a rigorous process that must be supported by solid evidence and must also consider feasibility of application in practice. Through our engagement with the QIP, our team has supported this process through evidence gathering and grading. A Technical Expert Panel (TEP) established for each measure also works with QIP to discuss feasibility of measure application. JSPH plays a part in engaging relevant experts to serve on the panel and presents the evidence to support their decisions. Once the measure development process has concluded, the measures are submitted to the National Quality Forum (NQF) for endorsement and broadly disseminated.

At Thomas Jefferson University, the faculty practice plan, Jefferson University Physicians (JUP), has participated in the PQRS program since its inception. Under the leadership of Dr. David B. Nash, the committee that oversees JUP’s performance improvement activities, the JUP Clinical Care Subcommittee (CCS), decided that participation in this program would be valuable to advance quality of care. A strong collaboration between the JUP Performance Improvement Team and JUP administration led to successful implementation of the PQRS program in all practices. The team works closely with practice representatives to select measures for submission and provides ongoing education and support for the practices. As a result, JUP has successfully increased physician participation and incentive payments over the past four years since the start of the program.

More accountability is on the way. CMS plans to move from pay for reporting to pay for performance. Beginning in 2013, CMS will publish PQRS data on the Physician Compare website for providers who report on quality measures through the Group Practice Method (GPRO). In 2015, the stakes will be raised even higher when providers’ Medicare payments are adjusted downward if they do not participate in the PQRS program. The question remains – will demand for provider accountability benefit Medicare beneficiaries?

As always, we are interested in your comments.

Tuesday, December 13, 2011

Swap These Ingredients for Healthier Ones

For the full article, click here.  Share your own ingredient swaps below.

M A N I F E S T O and more...

M A N I F E S T O  Part ONE
Our manifesto is just as much about education as it is health; the arts as it is science, communities as it is the individual. Well-being is central to our vision. The arts are central to fulfilling our fundamental human rights.

  • this is not a quick fix
  • this is not about benign lumps of municipal sculpture
  • this is not about reducing the arts to a cost-effective prescription
  • this is about well-being
  • this is about democracy
  • this is about human flourishing
  • this is about new ways of understanding impact and value
  • this is about solidarity

Click on the image above to access full-colour, black and white and podcast versions. I'll be collating all comments and thoughts over the new-year.

NETWORKING EVENINGS at MMU
Please keep your eye on the blog for updates on three very special networking events over winter/spring 2012:
  • Stroke and the Arts
  • Dementia and Imagination
  • Fourth Culture
Response to the European Review Consultation
For those of you who were interested in the response to the European Review Consultation lead by Sir Michael Marmot for the World Health Organisation, emphasising the importance of creativity, culture and the arts in relationship to social determinants of health and health inequalities, please see the co-ordinated response from Stephen Clift, to whom I extend my thanks.
(Click on image below)

 Experience of Creativity Questionnaire
Elaine McNeill from Liverpool John Moores University is undertaking a study that network members may want to contribute to.
The purpose of the study
This study is part of MSc in Consciousness and transpersonal Psychology and will look toward developing an understanding of personal transformation as an outcome of creative practice.  As a participant you may benefit by gaining a deeper understanding of your creative practice. 
Taking part
It is entirely up to you to decide whether or not to take part. If you do you will be asked to complete a 10-15min questionnaire online. You are still free to withdraw at any time and without giving a reason. A decision to withdraw will not affect your rights. The online questionnaire requires you to consider a time when you were being creative. The questionnaire should take approx 10-15mins. You may be asked to take part in an in-depth interview which will take 20-30mins, please leave a contact email address at the end of the survey. The interview will be exploring the aspects of the creative process discussed in the questionnaire.
The possible benefits include:
A greater understanding of creativity which could inform your studies/practice.
Confidentiality
As a participant you will have access to the final report and you may be quoted verbatim in future publications. However, your participation and contribution to this research will be kept confidential as you will remain anonymous in all information/data. 
Please click on this link to access the questionnaire:  http://www.survey.ljmu.ac.uk/ecq

The Two Wheeled Key to Better Health and a Better World
Thanks again to Cheryl G for another excellent info-graphic. Click on the graphic to go to the full document.

Monday, December 12, 2011

3in6: Prep Week #2

PREP WEEK #2: December 11-18.  To join the challenge, see this post.

Use this week to adjust your regimen for 3in6:


  1. Determine what protective style you'll wear for 3in6
  2. Choose whether you'll style for 2, 3, or 4 weeks at a time
  3. Purchase products you will need to maintain your hair
  4. "Practice" your new regimen
  5. Up your water intake gradually




Finding your sweet spot for muscle gain with HCE

In order to achieve muscle gain, one has to repeatedly hit the “supercompensation” window, which is a fleeting period of time occurring at some point in the muscle recovery phase after an intense anaerobic exercise session. The figure below, from Vladimir Zatsiorsky’s and William Kraemer’s outstanding book Science and Practice of Strength Training () provides an illustration of the supercompensation idea. Supercompensation is covered in more detail in a previous post ().


Trying to hit the supercompensation window is a common denominator among HealthCorrelator for Excel (HCE) users who employ the software () to maximize muscle gain. (That is, among those who know and subscribe to the theory of supercompensation.) This post outlines what I believe is a good way of doing that while avoiding some pitfalls. The data used in the example that follows has been created by me, and is based on a real case. I disguised the data, simplified it, added error etc. to make the underlying method relatively easy to understand, and so that the data cannot be traced back to its “real case” user (for privacy).

Let us assume that John Doe is an intermediate weight training practitioner. That is, he has already gone through the beginning stage where most gains come from neural adaptation. For him, new gains in strength are a reflection of gains in muscle mass. The table below summarizes the data John obtained when he decided to vary the following variables in order to see what effects they have on his ability to increase the weight with which he conducted the deadlift () in successive exercise sessions:
    - Number of rest days in between exercise sessions (“Days of rest”).
    - The amount of weight he used in each deadlift session (“Deadlift weight”).
    - The amount of weight he was able to add to the bar each session (“Delta weight”).
    - The number of deadlift sets and reps (“Deadlift sets” and “Deadlift reps”, respectively).
    - The total exercise volume in each session (“Deadlift volume”). This was calculated as follows: “Deadlift weight” x “Deadlift sets” x “Deadlift reps”.


John’s ability to increase the weight with which he conducted the deadlift in each session is measured as “Delta weight”. That was his main variable of interest. This may not look like an ideal choice at first glance, as arguably “Deadlift volume” is a better measure of total effort and thus actual muscle gain. The reality is that this does not matter much in his case, because: John had long rest periods within sets, of around 5 minutes; and he made sure to increase the weight in each successive session as soon as he felt he could, and by as much as he could, thus never doing more than 24 reps. If you think that the number of reps employed by John is too high, take a look at a post in which I talk about Doug Miller and his ideas on weight training ().

Below are three figures, with outputs from HCE: a table showing the coefficients of association between “Delta weight” and the other variables, and two graphs showing the variation of “Delta weight” against “Deadlift volume” and “Days of rest”. As you can see, nothing seems to be influencing “Delta weight” strongly enough to reach the 0.6 level that I recommend as the threshold for a “real effect” to be used in HCE analyses. There are two possibilities here: it is what it looks it is, that is, none of the variables influence “Delta weight”; or there are effects, but they do not show up in the associations table (as associations equal to or greater than 0.6) because of nonlinearity.




The graph of “Delta weight” against “Deadlift volume” is all over the place, suggesting a lack of association. This is true for the other variables as well, except “Days of rest”; the last graph above. That graph, of “Delta weight” against “Days of rest”, suggests the existence of a nonlinear association with the shape of an inverted J curve. This type of association is fairly common. In this case, it seems that “Delta weight” is maximized in the 6-7 range of “Days of rest”. Still, even varying things almost randomly, John achieved a solid gain over the time period. That was a 33 percent gain from the baseline “Deadlift weight”, a gain calculated as: (285-215)/215.

HCE, unlike WarpPLS (), does not take nonlinear relationships into consideration in the estimation of coefficients of association. In order to discover nonlinear associations, users have to inspect the graphs generated by HCE, as John did. Based on his inspection, John decided to changes things a bit, now working out on the right side of the J curve, with 6 or more “Days of rest”. That was difficult for John at first, as he was addicted to exercising at a much higher frequency; but after a while he became a “minimalist”, even trying very long rest periods.

Below are four figures. The first is a table summarizing the data John obtained for his second trial. The other three are outputs from HCE, analogous to those obtained in the first trial: a table showing the coefficients of association between “Delta weight” and the other variables, two graphs (side-by-side) showing “Delta weight” against “Deadlift sets” and “Deadlift reps”, and one graph of “Delta weight” against “Days of rest”. As you can see, “Days of rest” now influences “Delta weight” very strongly. The corresponding association is a very high -0.981! The negative sign means that “Delta weight” decreases as “Days of rest” increase. This does NOT mean that rest is not important; remember, John is now operating on the right side of the J curve, with 6 or more “Days of rest”.





The last graph above suggests that taking 12 or more “Days of rest” shifted things toward the end of the supercompensation window, in fact placing John almost outside of that window at 13 “Days of rest”. Even so, there was no loss of strength, and thus probably no muscle loss. Loss of strength would be suggested by a negative “Delta weight”, which did not occur (the “Delta weight” went down to zero, at 13 “Days of rest”). The two graphs shown side-by-side suggest that 2 “Deadlift sets” seem to work just as well for John as 3 or 4, and that “Deadlift reps” in the 18-24 range also work well for John.

In this second trial, John achieved a better gain over a similar time period than in the first trial. That was a 36 percent gain from the baseline “Deadlift weight”, a gain calculated as: (355-260)/260. John started with a lower baseline than in the end of the first trial period, probably due to detraining, but achieved a final “Deadlift weight” that was likely very close to his maximum potential (at the reps used). Because of this, the 36 percent gain in the period is a lot more impressive than it looks, as it happened toward the end of a saturation curve (e.g., the far right end of a logarithmic curve).

One important thing to keep in mind is that if an HCE user identifies a nonlinear relationship of the J-curve type by inspecting the graphs like John did, in further analyses the focus should be on the right or left side of the curve by either: splitting the dataset into two, and running a separate analysis for each new dataset; or running a new trial, now sticking with a range of variation on the right or left side of the curve, as John did. The reason is that nonlinear relationships tend to distort the linear coefficients calculated by HCE, hiding a real relationship between two variables.

This is a very simplified example. Most serious bodybuilders will measure variations in a number of variables at the same time, for a number of different exercise types and formats, and for longer periods. That is, their “HealthData” sheet in HCE will be a lot more complex. They will also have multiple instances of HCE running on their computer. HCE is a collection of sheets and code that can be copied, and saved with different names. The default is “HCE_1_0.xls” or “HCE_1_0.xlsm”, depending on which version you are using. Each new instance of HCE may contain a different dataset for analysis, stored in the “HealthData” sheet.

It is strongly recommended that you keep your data in a separate set of sheets, as a backup. That is, do not store all your data in the “HealthData” sheets in different HCE instances. Also, when you copy your data into the “HealthData” sheet in HCE, copy only the values and formats, and NOT the formulas. If you copy the formulas, you may end up having some problems, as some of the cells in the “HealthData” sheet will not be storing values. I also recommend storing values for other types variables, particularly perception-based variables.

Examples of perception-based variables are: “Perceived stress”, “Perceived delayed onset muscle soreness (DOMS)”, and “Perceived non-DOMS pain”. These can be answered on Likert-type scales, such as scales going from 1 (very strongly disagree) to 7 (very strongly agree) in response to self-prepared question-statements like “I feel stressed out” (for “Perceived stress”). If you find that a variable like “Perceived non-DOMS pain” is associated with working out at a particular volume range, that may help you avoid serious injury in the future, as non-DOMS pain is not a very good sign (). You also may find that working out in the volume range that is associated with non-DOMS pain adds nothing in terms of muscle gain.

Generally speaking, I think that many people will find out that their sweet spot for muscle gain involves less frequent exercise at lower volumes than they think. Still, each individual is unique; there is no one quite like John. The relationship between “Delta weight” and “Days of rest” varies from person to person based on age; older folks generally require more rest. It also varies based on whether the person is dieting or not; less food intake leads to longer recovery periods. Women will probably see visible lower-body muscle gain, but very little visible upper-body muscle gain (in the absence of steroid use), even as they experience upper-body strength gains. Other variables of interest for both men and women may be body weight, body fat percentage, and perceived muscle tone.

Thursday, December 8, 2011

Thursday Tips!

*Check your hair scissors periodically.  Dull scissors can contribute to split ends.

*Mix one part of pure honey with two parts conditioner for an extra punch of moisture.  Use the concoction after a fresh wash, leave it on for 20 minutes, and then rinse.

*Donate unused hair products that you have in overstock, or give them away as gifts this holiday season.  Swap used hair products with friends or family.

Wednesday, December 7, 2011

Guest Commentary: Physician Profiling in Emilia-Romagna Italy: A Tool for Quality Improvement



Vittorio Maio, PharmD, MS, MSPH,
Associate Professor
and Valerie Pracilio, MPH, Project Manager
for Quality Improvemement
Jefferson School of Population Health

This is the second in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Assessment is part of our daily lives. In school, we apply for admittance; in employment, we are screened before being hired, and once we’re “in,” we are regularly evaluated to ensure that we are performing at a level deemed appropriate. In the Italian Healthcare System a similar approach is being used to engage primary care physicians in quality. Performance data presented to physician teams is the first step in a profiling process. Not only does this help raise their awareness about the level of care they are providing, but it also engages them in discussions with their peers about what they can do to improve.

By definition, physician profiling is an analytic tool used to compare physician practice patterns across quality of care dimensions (American Academy of Family Physicians). The benefit is that it raises provider awareness of quality through feedback to stimulate improvement.

In Italy, primary care, provided by general practitioners (GPs), is the foundation of the Italian National Health Service, which maintains universal coverage to all citizens either free or at minimal charge at the point of service. Traditionally, GPs have worked in solo practices. However, in the last ten years, in an effort to increase coordination of care, the Italian National Health Service has introduced substantial reforms seeking to encourage collaborative arrangements among GPs. In order to build on earlier national reform, the Emilia-Romagna region (a large region located in northern Italy with a population of about 4.6 million inhabitants) passed a law in 2004 that required GPs to join a Primary Care Team (PCT).

In a PCT, GPs, many of whom are in solo practice, act in full autonomy, but are part of clinical networks designed to provide patients with integrated delivery of healthcare. Specifically, in a PCT, GPs are mandated to collaborate and share information, and by means of clinical governance, to engage in improving the quality of healthcare services provided to patients.

To this end, using the regional healthcare administrative database, the Emilia-Romagna region and Thomas Jefferson University began a collaboration to provide PCTs with information about the quality of services delivered to their patients via PCT profiles. GPs discuss the PCT profile data they are presented with their colleagues in their PCT and initiate PDSA cycles of improvement to make changes to their practice accordingly. Through a collective agreement with the region, GPs receive incentives to participate in the activity.

In the U.S., where the mission is not unified as it is in Italy, the focus has been on paying for performance rather than participation. There is something to be said for the focus on participation that has been demonstrated in Italy to invite physicians into the conversation about quality and actively engage in improvement. In the current U.S. healthcare environment, the stakes are being raised and soon the incentives for improving will turn into disincentives for not meeting standards.

Should we be focused on engaging physicians in quality through a non-punitive approach such as the one our colleagues in Italy are using, or continue to expect physicians will meet quality goals if incentivized? We’re interested in your thoughts.

Is a Pizza a vegetable?

Thank you SO MUCH for all the thoughts and comments on the manifesto part 1. Everything is valid and will be thrown in the mix for part 2. Sorry for my slow response if you've emailed me whilst I've been in Australia. I am back in the UK now and will be updating this blog in the manner in which you are accustomed to.

So for now, and to get us in the mood for all that 2012 offers, a question.
IS A PIZZA A VEGETABLE?
It appears that congress thinks so. Read on by clicking on the pizza!
Best things, Clive

Monday, December 5, 2011

The Truth about Probiotics

With the increasing interest in probiotics (bacteria that help maintain the natural balance of organisms in the intestines), it is important to know the facts.  Check out the following overview on WebMD.

Want to make coffee less acidic? Add cream to it

The table below is from a 2008 article by Ehlen and colleagues (), showing the amount of erosion caused by various types of beverages, when teeth were exposed to them for 25 h in vitro. Erosion depth is measured in microns. The third row shows the chance probabilities (i.e., P values) associated with the differences in erosion of enamel and root.


As you can see, even diet drinks may cause tooth erosion. That is not to say that if you drink a diet soda occasionally you will destroy your teeth, but regular drinking may be a problem. I discussed this study in a previous post (). After that post was published here some folks asked me about coffee, so I decided to do some research.

Unfortunately coffee by itself can also cause some erosion, primarily because of its acidity. Generally speaking, you want a liquid substance that you are interested in drinking to have a pH as close to 7 as possible, as this pH is neutral (). Tap and mineral water have a pH that is very close to 7. Black coffee seems to have a pH of about 4.8.

Also problematic are drinks containing fermentable carbohydrates, such as sucrose, fructose, glucose, and lactose. These are fermented by acid-producing bacteria. Interestingly, when fermentable carbohydrates are consumed as part of foods that require chewing, such as fruits, acidity is either neutralized or significantly reduced by large amounts of saliva being secreted as a result of the chewing process.

So what to do about coffee?

One possible solution is to add heavy cream to it. A small amount, such as a teaspoon, appears to bring the pH in a cup of coffee to a little over 6. Another advantage of heavy cream is that it has no fermentable carbohydrates; it has no carbohydrates, period. You will have to get over the habit of drinking sweet beverages, including sweet coffee, if you were unfortunate enough to develop that habit (like so many people living in cities today).

It is not easy to find reliable pH values for various foods. I guess dentistry researchers are more interested in ways of repairing damage already done, and there doesn't seem to be much funding available for preventive dentistry research. Some pH testing results from a University of Cincinnati college biology page were available at the time of this writing; they appeared to be reasonably reliable the last time I checked them ().

Saturday, December 3, 2011

3in6: Prep Week #1

PREP WEEK #1: December 4-10.  To join the challenge, see this post.

Use this week to get a fresh trim or cut.  The following reasons are why:


  1. The goal of the challenge is to retain length, and there is no better way to do it than with healthy ends from the start.
  2. Trimming or cutting throughout the challenge is a no-no.  It will defeat the purpose of retaining length.


How should one trim/cut her hair?  It depends on your preference.  A trim can be done on dry or wet hair, and straight or coily hair.  I prefer to trim in twists.

Read this post about trimming.

Friday, December 2, 2011

3in6 is Back!

Just in time for the New Year!  This challenge will run from January 1 - July 1 2012.  Below are the details.  Are you in?  Mark your spot in the comment section.


Purpose of this challenge: To retain 2-3 inches of growth in 6 months.

Challenge period: January 1 - July 1 2012

Guidelines:
1. Eat fresh vegetables or fruits with each meal.
2. Take a daily multivitamin.
3. Drink sufficient water.
(Amt of water in oz. = Your weight in lbs * 0.5)
4. Wear twists or braids 2-4 weeks at a time.
5. No direct heat.
6. Absolutely no trimming.  (Start with a fresh cut now if need be.)


Allowances:
Each challenger is allowed two 1-week periods of styling her hair as she pleases (e.g., puff, rollerset, etc.).

Tips on wearing twists/braids long term:
- Do not twist/braid too tightly
- Redo the perimeter weekly or biweekly.
- Deep condition & detangle thoroughly prior to twisting or braiding.
- For more tips, check out posts in the twist series

Monday, November 28, 2011

Trim & Regimen Experiment

TRIM: 
I'm trimming 3/4" of an inch.  My method is to put my hair in jumbo twists and trim the ends of the twists.  (I recommend doing smaller twists for a more accurate trim.)  This is my first trim in months.

REGIMEN EXPERIMENT:
Normally, I twist my hair for 3-4 weeks at a time during the cooler months.  This time, I'll maintain my summer regimen and twist biweekly.  My hair is getting harder to detangle (as it grows), so doing so 1x every 2 weeks instead of 4 weeks will make life easier.  It'll also be easier on my hair.

Guest Commentary: Translational Research for Actuaries





This is the first of a series of four blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11, 2012 with more details of the Center’s work.

Rob Lieberthal, PhD
Faculty, Jefferson School of Population Health

I will be talking about my research project funded by the Society of Actuaries (SOA) at the JSPH Center for Value in Healthcare Forum on January 11, 2012. The project is “Validating the PRIDIT method for determining hospital quality with outcomes data.” The goal of our project is to determine hospital quality using publicly available Hospital Compare data.

After funding the project, the SOA organized a project oversight group, comprised of practicing actuaries volunteering to serve the profession by supervising our research project. Actuaries are the professionals who are responsible for calculating and managing the cost of health insurance. They have always played a crucial role in benefit design. In the era of managed care, that has meant more and more involvement in creating and managing provider networks.

Given their professional interest, the oversight group was intrigued by my prior findings and was interested in using these findings to reduce cost and increase quality. I explained that, from my perspective, one of the barriers to putting my results into practice was that healthcare professionals did not seem interested in using my results. Their feedback was that my method might be inaccessible, even to a group as mathematically inclined as actuaries.

As a result of our discussions, our work has become literally translational: they are helping me translate my work from my language into theirs. If we can pair actionable results on hospital quality with an instruction book for how to use the PRIDIT method, we can increase the chance that actuaries put our findings and our methodology into practice.

I have previously noted that actuaries could be the ideal group to bridge healthcare quality and safety data with financial and nonfinancial incentives. This could drive patient behavior and improve population health. This is very much a work in progress, so stay tuned for an update from me on January 11, 2012!

Triglycerides, VLDL, and industrial carbohydrate-rich foods

Below are the coefficients of association calculated by HealthCorrelator for Excel (HCE) for user John Doe. The coefficients of association are calculated as linear correlations in HCE (). The focus here is on the associations between fasting triglycerides and various other variables. Take a look at the coefficient of association at the top, with VLDL cholesterol, indicated with a red arrow. It is a very high 0.999.


Whoa! What is this – 0.999! Is John Doe a unique case? No, this strong association between fasting triglycerides and VLDL cholesterol is a very common pattern among HCE users. The reason is simple. VLDL cholesterol is not normally measured directly, but typically calculated based on fasting triglycerides, by dividing the fasting triglycerides measurement by 5. And there is an underlying reason for that - fasting triglycerides and VLDL cholesterol are actually very highly correlated, based on direct measurements of these two variables.

But if VLDL cholesterol is calculated based on fasting triglycerides (VLDL cholesterol  = fasting triglycerides / 5), how come the correlation is 0.999, and not a perfect 1? The reason is the rounding error in the measurements. Whenever you see a correlation this high (i.e., 0.999), it is reasonable to suspect that the source is an underlying linear relationship disturbed by rounding error.

Fasting triglycerides are probably the most useful measures on standard lipid panels. For example, fasting triglycerides below 70 mg/dl suggest a pattern of LDL particles that is predominantly of large and buoyant particles. This pattern is associated with a low incidence of cardiovascular disease (). Also, chronically high fasting triglycerides are a well known marker of the metabolic syndrome, and a harbinger of type 2 diabetes.

Where do large and buoyant LDL particles come from? They frequently start as "big" (relatively speaking) blobs of fat, which are actually VLDL particles. The photo is from the excellent book by Elliott & Elliott (); it shows, on the same scale: (a) VLDL particles, (b) chylomicrons, (c) LDL particles, and (d) HDL particles. The dark bar at the bottom of each shot is 1000 A in length, or 100 nm (A = angstrom; nm = nanometer; 1 nm = 10 A).


If you consume an excessive amount of carbohydrates, my theory is that your liver will produce an abnormally large number of small VLDL particles (also shown on the photo above), a proportion of which will end up as small and dense LDL particles. The liver will do that relatively quickly, probably as a short-term compensatory mechanism to avoid glucose toxicity. It will essentially turn excess glucose, from excess carbohydrates, into fat. The VLDL particles carrying that fat in the form of triglycerides will be small because the liver will be in a hurry to clear the excess glucose in circulation, and will have no time to produce large particles, which take longer to produce individually.

This will end up leading to excess triglycerides hanging around in circulation, long after they should have been used as sources of energy. High fasting triglycerides will be a reflection of that. The graphs below, also generated by HCE for John Doe, show how fasting triglycerides and VLDL cholesterol vary in relation to refined carbohydrate consumption. Again, the graphs are not identical in shape because of rounding error; the shapes are almost identical.



Small and dense LDL particles, in the presence of other factors such as systemic inflammation, will contribute to the formation of atherosclerotic plaques. Again, the main source of these particles would be an excessive amount of carbohydrates. What is an excessive amount of carbohydrates? Generally speaking, it is an amount beyond your liver’s capacity to convert the resulting digestion byproducts, fructose and glucose, into liver glycogen. This may come from spaced consumption throughout the day, or acute consumption in an unnatural form (a can of regular coke), or both.

Liver glycogen is sugar stored in the liver. This is the main source of sugar for your brain. If your blood sugar levels become too low, your brain will get angry. Eventually it will go from angry to dead, and you will finally find out what awaits you in the afterlife.

Should you be a healthy athlete who severely depletes liver glycogen stores on a regular basis, you will probably have an above average liver glycogen storage and production capacity. That will be a result of long-term compensatory adaptation to glycogen depleting exercise (). As such, you may be able to consume large amounts of carbohydrates, and you will still not have high fasting triglycerides. You will not carry a lot of body fat either, because the carbohydrates will not be converted to fat and sent into circulation in VLDL particles. They will be used to make liver glycogen.

In fact, if you are a healthy athlete who severely depletes liver glycogen stores on a regular basis, excess calories will be just about the only thing that will contribute to body fat gain. Your threshold for “excess” carbohydrates will be so high that you will feel like the whole low carbohydrate community is not only misguided but also part of a conspiracy against people like you. If you are also an aggressive blog writer, you may feel compelled to tell the world something like this: “Here, I can eat 300 g of carbohydrates per day and maintain single-digit body fat levels! Take that you low carbohydrate idiots!”

Let us say you do not consume an excessive amount of carbohydrates; again, what is excessive or not varies, probably dramatically, from individual to individual. In this case your liver will produce a relatively small number of fat VLDL particles, which will end up as large and buoyant LDL particles. The fat in these large VLDL particles will likely not come primarily from conversion of glucose and/or fructose into fat (i.e., de novo lipogenesis), but from dietary sources of fat.

How do you avoid consuming excess carbohydrates? A good way of achieving that is to avoid man-made carbohydrate-rich foods. Another is adopting a low carbohydrate diet. Yet another is to become a healthy athlete who severely depletes liver glycogen stores on a regular basis; then you can eat a lot of bread, pasta, doughnuts and so on, and keep your fingers crossed for the future.

Either way, fasting triglycerides will be strongly correlated with VLDL cholesterol, because VLDL particles contain both triglycerides (“encapsulated” fat, not to be confused with “free” fatty acids) and cholesterol. If a large number of VLDL particles are produced by one’s liver, the person’s fasting triglycerides reading will be high. If a small number of VLDL particles are produced, even if they are fat particles, the fasting triglycerides reading will be relatively low. Neither VLDL cholesterol nor fasting triglycerides will be zero though.

Now, you may be wondering, how come a small number of fat VLDL particles will eventually lead to low fasting triglycerides? After all, they are fat particles, even though they occur in fewer numbers. My hypothesis is that having a large number of small-dense VLDL particles in circulation is an abnormal, unnatural state, and that our body is not well designed to deal with that state. Use of lipoprotein-bound fat as a source of energy in this state becomes somewhat less efficient, leading to high triglycerides in circulation; and also to hunger, as our mitochondria like fat.

This hypothesis, and the theory outlined above, fit well with the numbers I have been seeing for quite some time from HCE users. Note that it is a bit different from the more popular theory, particularly among low carbohydrate writers, that fat is force-stored in adipocytes (fat cells) by insulin and not released for use as energy, also leading to hunger. What I am saying here, which is compatible with this more popular theory, is that lipoproteins, like adipocytes, also end up holding more fat than they should if you consume excess carbohydrates, and for longer.

Want to improve your health? Consider replacing things like bread and cereal with butter and eggs in your diet (). And also go see you doctor (); if he disagrees with this recommendation, ask him to read this post and explain why he disagrees.