Food Reward Friday

This week's lucky "winner"... Oreo cookies!!!

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Launch: Effectiveness of Health Impact Assessment in New Zealand and Australia Report

The Centre for Health Equity Training, Research, and Evaluation invites you to attend the launch of The Effectiveness of Health Impact Assessment in New Zealand and Australia: 2005-2009 Report

Friday, 13 December, 2013

2 – 4 pm

Lavender Bay rooms 1&2,

North Sydney Harbourview Hotel

17 Blue Street, North Sydney

Flyer

Webinar facilities will be available for our interstate and international attendees. RSVP to Heike Schutze: h.schutze@unsw.edu.au

Beans, Lentils, and the Paleo Diet

As we continue to explore the foods our ancestors relied on during our evolutionary history, and what foods work best for us today, we come to legumes such as beans and lentils.  These are controversial foods within the Paleolithic diet community, while the broader nutrition community tends to view legumes as healthy.

Beans and lentils have a lot going for them.  They're one of the few foods that are simultaneously rich in protein and fiber, making them highly satiating and potentially good for the critters in our colon.  They're also relatively nutritious, delivering a hefty dose of vitamins and minerals.  The minerals are partially bound by the anti-nutrient phytic acid, but simply soaking and cooking beans and lentils typically degrades 30-70 percent of it, making the minerals more available for absorption (Food Phytates. Reddy and Sathe. 2002).  Omitting the soaking step greatly reduces the degradation of phytic acid (Food Phytates. Reddy and Sathe. 2002).

The only tangible downside to beans I can think of, from a nutritional standpoint, is that some people have a hard time with the large quantity of fermentable fiber they provide, particularly people who are sensitive to FODMAPs.  Thorough soaking prior to cooking can increase the digestibility of the "musical fruit" by activating the sprouting program and leaching out tannins and indigestible saccharides.  I soak all beans and lentils for 12-24 hours.

The canonical Paleolithic diet approach excludes legumes because they were supposedly not part of our ancestral dietary pattern.  I'm going to argue here that there is good evidence of widespread legume consumption by hunter-gatherers and archaic humans, and that beans and lentils are therefore an "ancestral" food that falls within the Paleo diet rubric.  Many species of edible legumes are common around the globe, including in Africa, and the high calorie and protein content of legume seeds would have made them prime targets for exploitation by ancestral humans after the development of cooking.  Below, I've compiled a few examples of legume consumption by hunter-gatherers and extinct archaic humans.  I didn't have to look very hard to find these, and there are probably many other examples available.  If you know of any, please share them in the comments.

To be clear, I would eat beans and lentils even if they weren't part of ancestral hunter-gatherer diets, because they're inexpensive, nutritious, I like the taste, and they were safely consumed by many traditional agricultural populations probably including my own ancestors.

Extensive "bean" consumption by the !Kung San of the Kalahari desert

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The Positive Power of Corporate Health and Wellness

Studies have shown the positive benefits of implementing corporate wellness programs, and Pacific Power Renewables in Auburn California has jumped on the band wagon of health for their employees in a BIG way! When CEO, Dan Powell contacted me to run the kick-off fitness challenge for Pacific Power, I was more than happy to oblige and over-the-top excited to be a part of bringing health into their work place in a fun, interactive way.  This was not going to be about anything generic, but I wanted to reach out to each individual employee and provide realistic goals and ideas on how to adapt a healthy lifestyle.  The PPR Ten-Week Fitness Challenge was going to run right through the holiday season…now talk about being serious…I was all in and motivated to MOTIVATE them!  Check out what Dan Powell, CEO Pacific Power Renewables had to say:

 

“When we first considered this fitness challenge, it was meant to be a general health improvement program.  It wasn’t about insurance premiums or anything else, we just care about our little family here and wanted them to be healthier.  We hoped a residual benefit would be some team building and bonding. We originally expected about a 50% participation level and about a 50% attrition rate from there. We were surprised that we originally had over 95% participation and only two people have dropped out.  On the flip side of that, we’ve had people from related companies, family members, etc. who’ve wanted to take part after we started. 

 

Now not even halfway through it, we have noticed a significant improvement in energy levels.  People seem happier, healthier, and are working together as a team to plan meals, exercise, even just daily walks.  We’ve all been having a lot of fun with it.  It’s a competition but a friendly one.

 

Our program was designed to have individual prizes for the greatest weight loss as well as group prizes for aggregate weight loss.  As well, we wanted to keep people motivated, so we offered individual awards for each significant milestone; running shoes, water bottles, exercise balls etc. 

 

Only partway through our 10 week “fitness challenge”, we are declaring it an enormous success.  I attribute that to the following key factors:

1)  We hired a professional trainer in Darla Leal.  She assessed each person, set realistic goals and supported them throughout in uniquely individual ways.

2)  People here were on the verge of making these kind of life changes, they just lacked the motivation. 

3)  We went into this full bore, big prizes, professional trainer constant attention and motivation.

 

I have heard some touching stories come out of this.  People have made significant changes to their lives and we’re so glad we started this.  We’re having Darla give us a healthy cooking workshop in a couple weeks and people are really psyched about that.  Thank you for all your hard work Darla.  This has been fun!” Dan Powell (CEO Pacific Power Renewables Inc.)

 

 

 

 

Corporate wellness incentive plans are a great way to get employees started in a corporate health and wellness program.  Pacific Power has covered all bases with individual, group, and recognition awards throughout the program and the employees are definitely motivated.  I have seen excitement build over the weeks of working with each employee as weight has been lost, inches reduced, and overall health improved, but more than that, I have observed an improved mental outlook and happier person.

 

“I had been working out and eating somewhat healthy for months, but not losing the weight like I used to.  Darla offered lots of ways to make small changes that have really made a difference.  I’m finally on my journey in the right direction again!” Jennifer Goodwin

 

Most people spend more hours at work than anywhere else in addition to the time they spend commuting each day.  Taking that into consideration, it is easy to see why maintaining a healthy work and life balance has become increasingly important.  It is the caring employer that recognizes a corporate wellness program as an important tool to establish this balance.  The common goal of a workplace wellness program is to promote the well-being of the employees, employers and organization in general.  It is within such positive work environment that the morale is boosted overall, productivity is increased, and absenteeism is reduced as only a few benefits of a corporate wellness program.

 

“Darla is a very energetic, encouraging REAL trainer.  She listens to what your needs are and helps you find ways of success for your lifestyle.  Your encouragement and guidance got me started on the road to better health.  I am excited about losing weight and becoming healthier.  I am finding inner strength that I didn't realize I had and am now learning to control my weight instead of my weight controlling me.”Sarah Modgling

The bottom line is that Pacific Power Renewables has taken advantage of the benefits of corporate

wellness and has made it a goal to implement a program sooner than later, and not waiting until employees are stressed, sick or applying to other jobs.  I am touched each week by the care of the management and the response of the employees and have had the privilege to be a part of something very special within Pacific Power.  They have definitely set the bar high for other companies to follow suit in implementing a health and wellness program.  They realize that a healthy employee is a happy employee.

“I have really enjoyed this opportunity to work with Darla, and learn how to incorporate better, healthier choices into my life. Being accountable to another person has made it easier to stick to the program and keep up with my daily journal. Her enthusiasm is contagious and keeps me motivated to take my fitness to the next level.”

“Thank you so much for the nutrition work shop on Friday - it was a blast! The camaraderie that has developed from this program is really awesome!!”  Gina Herum

 

Stay Healthy Nutrition Workshop

 



 

Healthy Pizza Workshop

Another important and visible element of a corporate wellness program is setting up a fitness facility where employees can work-out.  Pacific Power Renewables has also answered that call and I have had the pleasure to conduct an interactive group exercise class as an intro to their new workout area.  This is definitely an added perk, free of cost, convenient and an investment that this company is willing to make for the health of their employees.  In addition to the fitness facility, Pacific Power has provided a Nutrition Workshop where I was able to teach not only the importance of eating healthy, but gave them a hands-on experience of cooking and tasting healthy foods.   When an organization invests in the health of their employees, the benefit is truly for the employer and employee as the quality of the workplace and the work through productivity and satisfaction are greatly improved in addition to overall health benefits for all.  Hats off to Pacific Power Renewables for making corporate health a priority!

 

It is time for all companies, large or small, to invest in the importance of health within their corporate environment.  I would be happy to consult with you to make this happen and I look forward to hearing from you.  Starting with a “Fun Fitness Challenge” to motivate and get people fired up for the program is a great start.  Give me a call today and StayHealthy!

 

 

Me with CEO Dan Powell and wife Karen

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

 

Stay Healthy~

Darla

 

 

 

Reminder: Important dates for IAIA14

IA14, the 34th annual IAIA conference, will be held 8-11 April 2014 in Viña del Mar, Chile.  For more information, visithttp://iaia.org/conferences/iaia14/.

Important Dates:
6 December:  Paper/Poster Abstract Submissions Due
6 December:  Student Fee Waiver Applications Due

Paper/Poster Abstracts Invited:  The online submission form for IAIA14 paper/poster abstracts is available on the conference website under the Submissions menu. The submission deadline is 6 December 2013.

Student Fee Waivers: The Student Fee Waiver program allows up to ten students a waived conference registration fee in exchange for providing in-kind services on-site at the conference. For more information, contact Loreley Fortuny at IAIA HQ (impact@iaia.org) for program guidelines and an application form.  Completed forms are due 6 December.

Sponsorship opportunities:  IAIA is currently seeking sponsors for the IAIA14 conference.  Download the Sponsorship Opportunities brochure to find out the various ways your company can reach out to over 700 environmental professionals from 80+ nations.

Checking In & Melissa Bender Fitness

I was so pumped with the "finish the year healthy and strong" and have loved reading your comments about your plans to do the same.  Week one getting back to the gym was really tough, I was sore, sore, sore.  But, that's the pain that comes from being sedentary too long and it's a good sore- if you know what I mean.  Sitting in the steam room at my gym after a hard workout is on my thankful tree list this year. 

Week two, I started to feel like I was getting my groove back.  Don't get me wrong, it's still difficult getting into those workouts, but about 15-20 minutes in and the music is pumping on my iPod and something just clicks and the workouts start feeling GOOD!  Do you know what I mean?  That is the best.  And in just two weeks, I can see small changes to my body that are really inspiring.  

And now, week 3, I'm backing off because I'm not feeling too good- got run down, feeling sick, and have to listen to my body and take a little break for about a week.  I am just like you and I can't do everything all the time, and obviously I don't kill myself to post on both of my blogs daily, but just when I have something I want to share with you and can make the time to share.  I only want to write things here that you will find useful, beneficial, inspiring, or informational.  

So, today, I'm just saying, I'm not giving up, I'm not giving in.  I just needed a little break.  Back at it real soon.  Can't keep me down.  :)

How's it going for you?  

And I wanted to share a fitness blog I found that I was really impressed with- Melissa Bender Fitness.  This woman trained for a fitness competition without ever training in a gym- she did all her workouts at home. No excuses, right?!  I know getting to a gym is a struggle for a lot of people, so I thought you might want to check her site out.  She shares in great detail all her contest prep including food and workouts.  Let me know what you think and tell her I said hi!  

_________________________

MY INTENTION

 

 

"This really appealed to me in such a POSITIVE way. Life is about our journey, and the CHOICES that we make to become better people in ways that make sense to us. I think about the word "health" and what that really encompasses and it is not just a number on a scale but a combination of emotional, spiritual, physical and nutritional. I live my life the way I want to and some may like it and some may not, but it is MY LIFE, just as YOUR life belongs to YOU. We all have differing issues, possible medical problems and limitations, overwhelming life stresses, and those behind closed doors secrets that may greatly impact our life, and that we simply choose not to share with others. Those things belong to us, and sifting through and creating answers to our individual stories is what matters and doing so to become a healthier happier person in all areas of "health" is what counts. There is never a "one size fits all" answer to our fitness and nutrition programs, how we serve God, and how we choose to live our life. We are NOT generic people made to fit in some sort of "health" box coming out the other side all fixed. That is just not reality. What I enjoy may not be what you enjoy, what I eat may not be what you like to eat; the service I give to God may not be how you honor God...you get my point. I never fall for gimmicks that claim that this is the "only way" to achieve a healthy lifestyle. Really??? Based on what? When each of us walk a mile in each other's shoes, then we "might" have the ability to make such claim, but I will always be the type of MOTIVATOR that realizes that life and the journey to health is different for everyone, and I will do my best to provide the correct encouragement for YOU."

 

I shared the above post on my Facebook page last week as I was inspired after seeing a motivational poster and  reading several articles on the whole controversial “what’s your excuse” image that has been receiving both positive and negative feedback.  I am a believer of intention and positive messages shared through my life and stories.  I share because I am inspired to write and through that I am hopeful to help someone adapt a healthier lifestyle, whatever that may mean in a life and in that moment.  My intention is never to discourage, but to be a motivator through my passion of helping people.  Sometimes, images and statements can be miscommunicated which is why I am not a huge fan of texting as so many things can get lost in translation.  I believe that much misinterpretation occurred with the controversial image and that is one thing that a picture is unable to do…explain intention.  The originator intended one thing, the audience perceived something completely different.  The laughable part of the whole scenario is that all publicity is good publicity in the world of marketing, and one controversial image regardless of intention is now the beginning of either a great opportunity to further help people through the exposure, or a lost chance that will eventually fade due to inability to keep the audience captured.

 

I will share that I am a “NO EXCUSES” trainer when it comes to people giving me reasons why health is not a priority.  I do not hear that “my health is not a priority” stated in those words from people, but I hear it through the underlying messages of “I am too busy”, “I am unable to cook”, “I am unable to afford a trainer or membership”, “My kids need me, my husband or wife wants this kind of food”, “My work does not allow”, “I am on the road constantly”, “I have no time to shop”, and the list goes on and on.  The point is that I do not accept or believe that anyone is too busy to take care of their health. When I post an image of myself, it is not for the intention of saying “hey, check this out and you should look like this”, it is for motivation to share that I am almost 50, have gone through major physical and emotional adversity, and have come out the other side healthy and happy.  My career is my passion and I do walk the talk of consistent exercise and healthy eating, and I share that with my clients, family, friends, and anyone who will listen to me.  I will not tell anyone to implement a “my way is the only way” approach to health, fitness and overall wellness as that is not true.  I am confident in my teaching and my example, and know that it works, but intelligent enough to respect and research other avenues.  Shoot, I enjoy learning from my clients when they have researched a topic. In my book, we are in this world together, working together to be the best we can be.  I do not have the expectation that my clients or you will exercise like me, or maintain nutritional intake as I do.  I may make things look easy but I bet if I came to your job and I was able to watch what you do, I would think the same thing of you. The only expectation that I have is that healthier habits are formed and an eventual healthy LIFESTYLE is adapted and whatever that looks like to each person that I have had the opportunity to work with is an A+ in my book.  I always grade on a curve too as we are not perfect people, but always works in progress.   What it comes down to is that we all KNOW WHAT TO DO…right?  The problem lies in not accepting what we already know needs to be done to be healthier people.  It is my life, your life, our lives and how we CHOOSE to live each day is up to each and every one of us.  I do not want you to look like me, exercise like me, or eat like me because I am doing a great job living my life.  I am hopeful that you are sparked to make healthy choices for you, to implement exercise routines that you enjoy, to start cooking healthy foods that you like, and to look in your mirror and say I want to look like a healthy ME.

 

 

 

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

 

Stay Healthy~

Darla

Recent and Upcoming Appearances

Smarter Science of Slim

Jonathan Bailor recently released an interview we did a few months ago on the neurobiology of body fat regulation, and the implications for fat loss.  It's a good overview of the regulation of food intake and body fatness by the brain.  You can listen to it here.

Super Human Radio

Carl Lanore interviewed me about my lab's work on hypothalamic inflammation and obesity.  I'm currently wrapping up a postdoctoral fellowship with Dr. Michael Schwartz at the University of Washington, and the interview touches on our recent review paper "Hypothalamic Inflammation: Marker or Mechanism of Obesity Pathogenesis?"  Dan Pardi and I are frequent guests on Carl's show and I'm always impressed by how well Carl prepares prior to the interview.  You can listen to the interview here.

The Reality Check podcast

Pat Roach of the Reality Check podcast interviewed me about the scientific validity of the "carbohydrate-insulin hypothesis" of obesity.  The Reality Check podcast "explores a wide range of controversies and curiosities using science and critical thinking", and a dash of humor.  This one should be very informative for people who aren't sure what to believe and want a deeper perspective on the science of insulin and body weight regulation.  You can listen to it here.

Obesity Society conference

Next Thursday 11/9, I'll be speaking at the 2013 Obesity Society conference in Atlanta.  My talk is titled "The Glial Response to Obesity is Reversible", and it will be about my work on the reversibility of obesity-associated hypothalamic neuropathology in mice.  My talk will be part of the session "Neuronal Control of Satiety" between 3:00 and 4:30, specific time pending.  See you there!

WHO Urban HEART Consultation Day 3

I've been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 3 of the Consultation, there are also posts on Day 1 and Day 2.

Workshop 3: Review of Urban HEART guidance

There was a widespread view that the current Urban HEART guidance works quite well but that there are a few areas where it might be enhanced. There was discussion about the selection of interventions and responses being difficult in practice, and that it involves considerable negotiation. There wasn't agreement about the best ways to reflect this in the guidance but it was a recurrent theme, and one that's familiar in the context of HIA and negotiating recommendations.

Community participation is another aspect of Urban HEART that has been difficult to provide guidance on. Participatory rapid assessments, health assemblies, surveys, workshops, and the use of mobile and electronic engagement tools were all discussed as ways to involve communities in Urban HEART processes, though these were all recognised as having limitations.

There was quite a lot of discussion about the extent to which HIA might be integrated into Urban HEART, though it was agreed that Urban HEART and HIA are complementary rather than being processes that could be integrated. This is because Urban HEART helps to identify needs and areas for action at the city level, whereas HIA is most useful where there is a proposal or a limited set of options to assess. So whilst there are procedural similarities they serve quite different purposes and integrating them might complicate things rather than helping. The diagram below from the Urban HEART User Guide shows how WHO conceptualises Urban HEART's role in local planning cycles. Some related procedures like multi-criteria decision analysis and equity lenses were also discussed, and how they might be integrated into Urban HEART.

An important issue that was discussed was that we need to focus on enhancing the equity focus of Urban HEART rather than simply improving the technical aspects of the process. The value of Urban HEART is its equity focus rather than its health focus, and we need to prioritise that in any revisions. This is something I hadn't really considered before and I think it poses a challenge to the HIA practitioners: beware focusing on improving technical aspects of the assessment process at the expense of an equity focus. Technically perfect assessments won't necessarily result in inequities being better addressed.

The need to demonstrate economic effectiveness/cost-benefit was also discussed. This is familiar territory for HIA practitioners! I confess that I have mixed feelings about this. Whilst I can see that there are benefits to even limited economic approaches to describing the economic benefits of HIA or Urban HEART (willingness to pay analyses, estimated savings based on case studies, etc), ultimately Urban HEART and HIA are about informing and improving planning and decision-making. They're not readily comparable to other health interventions because they're fundamentally different types of interventions.

The need for an online guide, repository and clearinghouse for evidence was discussed. We're very fortunate in HIA to have the HIA Gateway. The consensus was that something similar is required for Urban HEART.

City case presentations

Madeleine Ntetani-Nkoussou discussed the use of Urban HEART in Brazzaville, Congo. There's a number of issues in Brazzaville associated with informal settlement/slums and rapid urbanisation. The physical and service infrastructure has struggled to keep pace. Potable water access and access to water sealed toilets remain big issues, as is food security. urban HEART helped the city identify the four arrondissement that required greater activity, in particular around the provision of health services and prevention activities.

Plenary discussion: Next steps

One issue that was raised is whether there a need or mechanism to involve state and national governments in Urban HEART? Though this approach would have relevance to them, a big part of the appeal of Urban HEART is the clarity of the indicators and its applicability at the city level.

The distinction between Urban HEART as an indicator/diagnostic tool and a framework to guide implementation came up a few times. It's intended to be both, but there's a tension, which most HIA practitioners would have encountered as well

There was quite wide-ranging and detailed discussion about approaches to building capacity for Urban HEART, which I won't describe in detail here because I'm not able to do justice to the range of issues discussed. Some of the broad topics touched on included:

• capacity building
• sharing best practice, particularly in the form of brief case studies focused on key learning
• building Urban HEART into WHO and country-level work plans 
• linking to professional groups/associations
• ensuring the health sector comes along the journey and that Urban HEART doesn't become the sole responsibility of cities/other sectors
• how often does Urban HEART need to be revisited/redone
• how can we make Urban HEART sell itself, i.e. so it doesn't need much ongoing support
• compendiums of best practice and then thinking how some of these best practice cases might be synthesised
• how to advance an equity agenda in settings where it's not on the political agenda

These issues are all eerily familiar to people who've worked on HIA! It was an excellent Consultation with plenty of food for thought that also highlighted how well-designed Urban HEART is and how much work has gone into its development. I plan to do another post in a few days that brings together some of the critical points and what the implications might be for HIA.

WHO Urban HEART Consultation Day 2

I've been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 2 of the Consultation, there are also posts on Day 1 and Day 3.

Workshop 1: Review of Urban HEART concepts

The first workshop focused on factors affecting health equity that might be missing from or not sufficiently emphasised in Urban HEART. These include things like gender, food and nutrition, emergency preparedness, conflict and security, universal health coverage and environmental sustainability.

The issue of within-neighbourhood disaggregation was discussed, particularly in terms of age and gender, but there was a broad recognition that this data simply isn't available for most indicators and that this may add a layer complexity to an already imposing process. There was also a recognition that many indicators of health equity might not be sensitive enough, or may reflect structural or systemic inequalities, to change at the local or city level. These issues will be very familiar to those who have looked at equity and vulnerability within impact assessments.

There was quite a bit of discussion about the degree to which Urban HEART needs to be regarded as a standardised, readily-comprehensible approach or something that can be adapted to local needs. This is a debate I've encountered several times in relation to HIA and the answer seems to lie somewhere between those two extremes.

City case presentations

A presentation from Dr Oyelaran-Oyeyinka from UN-HABITAT emphasised the important role cities play as the engine rooms of economic development, though the challenge is to ensure that's inclusive development. Internationally the urban-rural divide is diminishing but the rich-poor divide is increasing.

Kelly Murphy from St Michael's Hospital in Toronto presented on her work adapting Urban HEART for use in developed countries. The City of Toronto has adopted Urban HEART as a mechanism to guide funding of Neighbourhood Improvement Areas and Issue to 2020.


The difficulties encountered in Toronto include:

- working together (team changes, maintaining relationships, timelines, expectations)
-Urban HEART being easy to use but not easy to produce (the process is clear but the sources of data is not, potential misinterpretation of results, e.g. stigmatising areas or only focusing in "red" areas when gains could be made in "yellow" ones).

The facilitating factors in Toronto incude:

• WHO Brand associated with Urban HEART lent it credibility
• trusted convenor
• established relationships
• credible technical expertise (epidemiologist with recognised track record and relationships)
• senior champions (administrative rather than elected representatives)
• City's willingness to innovate
• lead partner providing secretariat support (so the process "belonged" to someone)
• community involvement
• specific funding from CIHR to get the ball rolling, though the City of Toronto has now adopted this as a process within its "Wellbeing Toronto" monitoring and reporting activities

Kelly spoke about the need to talk about equity for all sectors, as opposed to health equity, and responsiveness to policy processes. Urban HEART was regarded as a clear tool that "made sense". Despite being a developed city, Toronto found that Urban HEART was a useful approach and that the domains of the tool were still relevant.

Jose Velandia Rodriguez from Bogota, Columbia also spoke about his experience using Urban HEART in Bosa, a region within Bogota.

Workshop 2: Review of Urban HEART indicators

Most cities that have used Urban HEART have had to adapt the core indicators to some extent, or only use some of them. Most cities have also used secondary or suggested indicators as well, rather than solely the core indicators. The evaluations of city case studies so far have emphasised the need to integrate environmental and qualitative indicators/information to a greater extent.

There was a wide-ranging discussion of how and whether universal health coverage should be reflected in the Urban HEART indicators. There was a broad agreement that there should be at least one amongst the core indicator set that deals with universal health coverage, given the global focus on it, but it's hard to identify what the key domains of UHC are. It's generally regarded as having three dimensions - access to health services, utilisation of health services and financing of health services. There was recognition across the workshops that whilst UHC financing clearly has an impact, it often lies beyond the scope of local government to influence. They have a greater role in access and utilisation, often by providing co-funding or premises and in some cases payments to cover the direct health care costs of the poor.

The discussion on this was wide-ranging and quiet comprehensive. Rather than recapping it here I'll just note that WHO is currently developing a UHC indicator set, which will be drawn on in selecting the UHC indicators to be included in Urban HEART. The indicators will need to focus on access and quality and have some sensitivity to vulnerability and equity at the local level. In general, geographic distribution of services is an available indicator in many settings, but beyond that it's hard to say what will be available. Health care-related impoverishment (where people are pushed into greater poverty by healthcare costs) and catastrophic health expenditure were identified as important measures with clear equity implications, though it is unclear about how these can be turned into indicators reliably or meaningfully.

There was also discussion about how to incorporate ageing-related indicators into Urban Heart, though the consensus was that it may be more important to ensure there is disaggregation of other indicators by age rather than adding new indicators. It may be useful to refer people to WHO's guidance on age-friendly cities where appropriate.

Emergency management indicators have already been committed to in some form, following WHO discussions with other UN agencies. These might include existence of emergency standard operating procedure plans in local government agencies. Other indicators might include prevalence of disaster-resistant buildings, e.g. earthquake-resistant buildings, people trained in emergency response, presence of local emergency response groups/networks, etc.

Qualitative data may help to fill in gaps and supplement other indicators. There was some discussion about how to integrate and present qualitative data in Urban HEART.

A bigger issue is that there is a need to ensure Urban HEART has as few possible indicators as possible in order to enhance usability, and that the indicators included are all equity-sensitive and available. They also essentially need to be geo-coded, at least at a neighbourhood level, and very few indicators are in *any* setting. Addressing this will be no easy task.

WHO Urban HEART Consultation Day 1

I've been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on some of the issues discussed on Day 1, with some of my thoughts and reflections scattered throughout. There are also posts on Day 2 and Day 3.

Urban HEART grew out of the Commission on the Social Determinants of Health's work and dates back to 2007. Early activity on piloting and developing a tool were led by a few countries, notably Iran. The final report from the CSDOH gave further impetus and led to more piloting of Urban HEART in more cities. After piloting Urban HEART was extensively reviewed and Version 1 was published in 2010.

Urban HEART is conceptualised by WHO as a tool for assessment and response to health equity issues at the city level. Urban HEART was designed to meet four criteria:

• ease of use
• comprehensive and inclusive
• feasible and sustainable
• links evidence to action

It's a stepwise process with a lot of similarities to HIA. In contrast to HIA it doesn't need a proposal (even a general one or options) to assess. Rather it allows municipalities to identify issues for action and responses at the city level, and in that way it's more like a needs assessment or planning activity. It's useful where some willingness to act on health already exists, so Healthy Cities is a useful basis for action. Higher-order support is always required (which may be less true for HIA?).

Data that informs Urban HEART is almost always spread across agencies - no single one holds or reports on even the core indicators. This means multiple permissions and interagency liaison is often required, which reiterates the need for higher-order permission and negotiation at the earliest stages. Whilst this is undoubtedly desirable for HIAs as well it hasn't always been possible in my experience and HIAs often fly under the radar, at least in the early stages. I'm not sure that would be possible for Urban HEART but I'm not sure that's a bad thing. The under-the-radar HIAs I've been involved in have often encountered resistance when their recommendations are presented. A clear, unambiguous mandate and imprimatur as a basis for proceeding isn't a bad thing.

A survey of Consultation participants that was conducted in advance found that most participants thought Urban HEART works well overall, is easy to use and successfully links evidence to action, but is less successful at being comprehensive and organisationally sustainable.

Case studies from the City of Paranaque in the Philippines, Tehran in Iran and Indore in India provided a range of useful, practical lessons on the use of Urban HEART (and they were quite inspirational). The Inore case in particular modified the indicators in a way to suit the local context, in their case by ensuring that the indicators were all meaningful and comprehensible to anyone, from residents to national bureaucrats. The case studies also highlighted the need for Urban HEART to not be a one-off activity but as an activity that needs to be revisited/undertaken semi-regularly.

Megumi Kano from the WHO Centre for Health Development gave an overview of the synthesis of evaluations of Urban HEART.  The synthesis was only of Kobe Centre-funded pilots in developing countries and may not reflect all use. The synthesis showed that "core indicators" (see Urban HEART User's Guide) were not used in all cases, in fact some of the "suggested indicators" were used as often. All case studies used the matrix, though data validation was rarely mentioned. Another difficulty was the lack of not only disaggregated sub-city level data but trend data over time. Interventions tended to focus on physical environment and infrastructure and social and human development, rather than economics or governance.

How should we stratify/disaggregate equity analyses?

One issue that was identified at the Consultation is whether looking at geography and sub-municipal spatial areas as the unit of analysis always appropriate? For example might gender, poverty or age at the city level be a more appropriate way of analysing health equity issues? This is a recognised tension because all health equity analyses should use gender and SES for stratification but cities are often focused on neighbourhoods and a spatial approach. In many ways it points to a bigger, perhaps more overtly political discussion about what do we mean by health equity?

Scaling up

It was noted that approaches scaling up Urban HEART might not be the same in all cases because it's so linked to the scope and role of government, so this will vary markedly. Encouraging progress has been made internationally, as the map below illustrates.

Map of countries who have built capacity to use Urban HEART, 2008-2011

Questions arising from Day 1

• How can we promote Urban HEART better?
• How can we involve NGOs or the private sector? Should we?

My general reflections

1. An issue I have encountered is the limited availability of *any* health indicators at the city/local government level, let alone sub-city levels, given that cities can be quite small in scale with limited resources in Federalist systems.
2. The health sector will always need to be involved in the use of Urban HEART in some capacity because they hold the data, or some of the data, but they needn't be a roadblock. A pragmatic approach to getting the best available data but to focus on response strategies and interventions helps.
3. In some ways the most useful thing that health systems can do is to regularly report on a broad range of health indicators at city and sub-city (disaggregated) levels, so cities can pick up Urban HEART and other related approaches and run with them.

Cross-posted on my HRH blog

Finishing the Year Strong Update & Tex Mex Casserole with Egg Noodles

We last talked about our goal of finishing 2013 healthy and strong and I so appreciate your feedback in the comments.  Your courage to share where you are in your journey helps me be transparent in mine too and I feel like we're in this together.  I got in 4 really great workouts last week, and I feel that that's a good fit for my current schedule through the end of the year.  It takes some planning and preparation to make sure to get to the gym, but if I workout hard for at least 50 minutes, I'm good with 4 days. 

Getting started back into a weight-lifting/workout routine is especially hard because you are so SORE for the first few days.  I had to take Advil a few times, but I'm already fine.  And isn't it funny how after just a few workouts you feel 5 pounds lighter?!  My scale says I'm down half a pound.  It's a start!

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On Halloween, I ate 2 chocolate chip cookies that a mom from my son's school made and a mini Reese's Peanut Butter cup.  To be honest, the cookies were delicious, but I should have just had one, and the Reese's didn't taste that good- probably because I'm a PB cup snob now, having fallen in love with the homemade variety.  The point is, if I'm going to "cheat" I want it to be worth it!  And I know that finishing the year strong requires some sacrifice and diligence with my food especially during the week.  So, I'm being more conscious of what foods I'm choosing and having something really good to look forward to on the weekend.  On Saturday night, we went out to a great restaurant and I ate oxtails and potatoes- so good, but really rich, so I only ate about 1/3 of what was on my plate.  I had 2 glasses of wine and for dessert, had a big ole ice cream cone that I really enjoyed.  Back on the wagon for Monday.   

My other tip for this week is to SHARE MEALS when you go out to eat, if possible.  I'm usually full after half my meal, but feel like I need to finish, so I'll end up eating too much.  Leftovers from restaurants usually end up in the trash and it's a shame to waste the food and money.  Sharing with someone eliminates that and you don't leave the table feeling so heavy from overeating.  

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I made a healthy meal last week that I think you might like too.  I warn you that it's not the prettiest dish, but very tasty and full of protein.  It's kind of a Tex-Mex casserole with egg noodles.  I really believe that "abs are made in the kitchen", which is why the eating portion is so crucial to seeing results.  My meals last week pretty much consisted of:

7am- oatmeal and coffee

10am- protein shake 

12pm- this casserole

3pm- tuna sandwich and Sun chips 

6pm- this casserole

8pm- Greek yogurt or hot cocoa

I also stopped in Starbucks a few times (which is a step back from my previous daily addiction).  

Ingredients

1 Jennie O- Extra Lean Ground Turkey

1 Laura's Lean Beef (94% Lean) - or go leaner

1 bag No Yolk Egg Noodles

1/2 container of Philadelphia Cream Cheese (1/3 less fat) - or use fat free

1 cup Shredded Mexican cheese (2%) - or use fat free

1 package Taco Seasoning (low sodium)

*Update 2/16/14:  add some minced parsley, chopped onion and garlic for added flavor

Directions

Preheat oven to 350 degrees.

Boil the egg noodles for about 8 minutes, then drain.

Meanwhile, (*Update 2/16/14, brown the onion and garlic) and then add the two meats until cooked though, add the seasoning mix with about a cup of water and let it boil until the water and seasoning is absorbed.  Then, I add the parsley.

Off the heat, add the cream cheese and the shredded cheese to the meat mixture and stir until all melted and mixed in.  Add in the noodles and stir until combined. 

Pour the entire thing into a 9x13 baking dish, top with remaining 1/2 cup of shredded cheese.  Bake for about 20 minutes.  *Update 2/16/14:  I'm not baking this dish anymore because I felt like that dried it out.  

I based this dish on a pin from Pinterest, but lightened it up.  To make it even lighter, use leaner beef and fat free cream cheese and fat free shredded cheese.  Some people may also like to add salsa to this for more flavor. 

If you portion this dish into 10 servings, below is the nutrition information.  I use myfitnesspal.com to calculate the nutrition- it's free and really user-friendly. 

So, how's it going for you?  If you've fallen off the wagon, just get back on!

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Buckwheat Crepes Revisited

One of my most popular posts of all time was a recipe I published in 2010 for sourdough buckwheat crepes (1).  I developed this recipe to provide an easy, nutritious, and gluten-free alternative to flour-based crepes.  It requires no equipment besides a blender.  It's totally different from the traditional buckwheat crepes that are eaten in Brittany, in part because it's not really a crepe (I don't know what else to call it, maybe a savory pancake?).  I find these very satisfying, and they're incredibly easy to make.  They're especially delicious with fresh goat cheese, or scrambled eggs with vegetables, but they go with almost anything.  Chris Kresser also developed his own version of the recipe, which is fluffier than mine, and more like a traditional pancake (2).

Buckwheat is an exceptionally nutritious pseudograin that's rich in complete protein and minerals.  In contrast to most whole grains, which have low mineral availability due to phytic acid, buckwheat contains a high level of the phytic acid-degrading enzyme phytase.  This makes buckwheat an excellent source of easily absorbed minerals, as long as you prepare it correctly!  Phytase enzyme works best in an acidic environment, which may be part of the reason why so many cultures use sour fermentation to prepare grain foods.  My original recipe included a sour fermentation step.

But there's a problem here.  Buckwheat doesn't ferment very well.  Whether it's because it doesn't contain the right carbohydrates, or the right bacteria, I don't know, but it spoils rapidly if you ferment it more than a little bit (using a strong sourdough starter helps though).  Others have told me the same.  So here's my confession: I stopped fermenting my buckwheat batter about a year ago.  And it tastes better.

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