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Determination of Health- Redefining Lifestyle

Zeno Charles-Marcel
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The concept of "Health is a Choice" has benefits and limitations. Dr. Zeno discusses major determinants of health and how identifying and understanding these can improve patient care. 

Presenter

Zeno Charles-Marcel, MD, is a medical missionary physician, health educator, and academic and hospital administrator. His research interests include lifestyle medicine, and the connection between spirituality and health. He studied physics and physiology at McGill University, and zoology and medicine at Howard University. He specialized in internal medicine at Loma Linda University. He is currently the vice president for medical affairs at Wildwood Lifestyle Center and Hospital, and holds academic appointments at Montemorelos and Loma Linda Universities. He and his wife, Anita, have three sons.

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  • May 11, 2017
    7:00 PM
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Tonight we're going to talk about an expanded view of lifestyle who hears it about lifestyle medicine. OK Just about everybody of course you're seventy Adventist right. Though still medicine and who here has heard about choices making right choices and good choices. All right now tonight this this presentation has multiple different levels because we have to be able to get through some of the issues dealing with the continuing medical education for those of you who have signed up for continuing medical education and what we have said we would do we will do all right but we also are looking at things that other health professionals at that level might. Might need to engage with because the issues that are involved with that there are also things from personal life issues that we will be exploring some Christian life issues some human life issues and we'll be looking at some good science that deals with all of this and we'll be a little bit interactive at the beginning beginning because I want I want us all to feel comfortable as we go through so we start with a case study this is the case of Gina This is actually a real patient. You know is a nurse's aide who works on the night shift in a local nursing home she loves to eat and gets all tired and sleeps the whole day when she gets home. With over four hundred pounds multiple failed attempts to lose weight is seen by a doctor in San Diego and placed on a strict last regimen do you think she will lose weight why and why not I want you to talk to somebody next to you right and we have one minute you come to a conclusion based on this history whether you think she will lose weight yes or no why why not OK So it's you and I. All right OK let's see how many people think that yes she will she will be successful. She's going to lose weight on the short term. And so so most of you you guys are skeptics you're thinking she won't lose the weight you're real estate. Market So why don't you think you will be able to sustain this. She loves to eat. No tools All right. So. We have some things that kind of predict that you want and some that say yes what do you say. She's working nights that's going to be hard right yeah and you know when you're you're up at night we know about the circadian disruption and the increased weight due to hormonal changes in the individual All right so let's let's go and see what happened with her This is Gina she's a nurse's aid nature of local nursing home fifty one weeks after the first picture she controls portion sizes she exercises regulations less tired when she gets home and now she has a life she goes out and she goes to the mall during the day and she actually has a life. What do you think. Amazing Bryza Lauren. She made a lifestyle choice. She followed what she was being told and you know the doctor who saw her he thought this he was being very successful things were going along very well. And this is. Just regain thirty six bone in six weeks. And the doctor is seeing what is going on with this lady but you know at the same time that this is happening he is realizing that many of the people in. Clinic the other witless clinic at Kaiser Permanente down in San Diego and he was noticing that people who were losing weight were dropping out of the clinic. And he's thinking this is backwards is this does this is not right people who are not doing well he would expect them to drop out but people who are doing well they drop out of the clinic as a matter of fact in her case. In just a short space of time she was on this trajectory and she finally regained all of the weight in less time than it took her to then it took her to lose the weight. That situation. So question why do some people seem to make all the wrong lifestyle choices. I mean she was on a roll she could have kept it up right. What this guy when you think about him. Choices. Down that road. You know sometimes you might think that these people have nothing to worry about. But sometimes they do have a lot of worry about. What about this. Are we lacking any data that says that cigarette smoking may be good for something. Have you seen anything. And there are smoking even this little boy. Is becoming a man and this is what men do right. And then there are these. And we think why would anybody want to do this. When I was in school. We had there were people who hung around the hospital they were called hitmen anybody who. Worked in a large city. In. The E.R. would know about him and these guys were specialists at finding little the INS for the for the junkies they find a little vein so they could give a proper was back in those days as in the seventy's it was five dollars a pop right and most of the addicts that I know did not want to be addicts. And they hated needles. But they did this. Do you wonder what's going on with people like that. And then. Spousal and partner abuse. And people who they live in that situation. And then when you see you know you should press charges anybody has been there to witness this you say you should press charges what do they say no. In one situation this woman says this shows that my husband loves me. I can't imagine. That's love right. OK we're getting somewhere how about these people here. Now I don't know any of these people personally I got these pictures from the Internet. But I know people who whose pictures I could put up there. I've had patients over the years I could put their pictures up. They didn't give me permission. And then isn't this your patient. His cholesterol is here off the charts blood sugar is high he smoking and he says he's trying to start smoking his E.K.G. is abnormal it's blood pressure is up and he's looking at the scale but I tell you he gets big mac attacks or something. You have patients like those of you who are in practice you know and what do you think about these people. How do you respond to these lifestyle moments. Well. Unfortunately. Sometimes we do this and I say unfortunately not because sometimes it is not that person's fault. But the issue may not be for those what we're going to discuss is to not look at fault but actually look at determinants look at the things that actually. Inform and act to weed choices that people will make and actions that they take in the case of Jena. You know she chose the wrong path bad lifestyle she went back to what she shouldn't be doing and therefore she gained weight so the question would be what would we consider a lifestyle to be simply put it's the characteristic where the person lives his or her life. Or the habits that make up a person's daily life and the usual way always she or he spends his or her time and deals with situations that's it's the the stuff that we that we do we all have a lifestyle now if you were to go on the Internet and you type in my style this is not what you will get what you will get would be things about the gay life and that's what you will get that that has dominated the top of the of the lifestyle search but when you look for lifestyle medicine and things like that then you'll find definitions like this lifestyle involves habits beneficial or detrimental it doesn't matter it's just is what it is how we are what we do it involves eating sleeping recreation sitting or standing outdoor living physical activity oral hygiene body hygiene emotional hygiene religion work life sex. Practices risky behavior of sex stress called being health engagement chemical use the way we approach people and problems social connectedness isolation environmental exposures etc This is the stuff of everyday life our attitudes are motives our motivation our spirituality all of these make up our lifestyle and there's more I mean I could continue and would probably go use the all the time that we have just coming up with things that the constitute our lifestyle so it's all of these things put together that makes life so the question is do these things actually. Are they used for our benefit or are they used for our detriment and what are the things that informs the lifestyle that we actually have so information. What informs our lifestyle include things that we're taught. You know you're taught certain things and then you learn certain things and then that becomes part of what you do right it's what we believe becomes part of our lifestyle we believe it and therefore we act as if that is true and then that's it even if what we believe is a lie right what is modeled when we see people who are doing a certain thing and we and we say well that's how you do it then we follow it too and that's what we do what is a vailable you know you can't do something that is not available to be done. So that can't be part of your lives there but if it's available you might get involved and do what is normative whatever is normal we all have a sense of what is normal. Normal for us is our lifestyle. Right. What we are limited by what we're limited by actually tells us that we can't do certain things like you know I wanted to fly you know was going to fly. But I got word when I was a little boy that that is not. Really capacity that I have. I can't fly what you're exposed to what you're accustomed to what you're encouraged to do what you can physically do what you have a desire for what you are permitted to do what you're attracted to what you can afford to do what you get support for what you value all of these things constitute the things that that push us in one way or another to choose certain things and. That becomes our lives that. There are missing. A lot of stuff goes into it. So if we were to consider your life there now from a therapeutic standpoint and life then isn't your choices within the context of your real and your perceived world whatever it is that is real yes you can do it you can't do it you mean courage to do and you have access to it cetera but also your perceived world what's going on in your mind and therefore how you act in relation to what you believe what you value all of these things inform the lifestyle that you're going to choose right. Now many times. We see this chart being used as kind of the chart that shows what happens with lifestyle and it's looking at behavior the way we live it's the biggest driver of premature death and here is forty percent. What we do are we live our behaviors and therefore we see if we can change this. We can really make a dent in what happens to people as they go through their life and we can avoid or delay premature death. And that makes a lot of sense but that's this graph. Just to be sure we're also. The same thing forty percent then behavioral patterns. Thirty percent social circumstances. Ten percent health care. Sorry thirty percentage Anetta composition fifteen percent social circumstances and then five percent environmental exposures this is what. That is saying this was from work presented in two thousand and seven in the New England Journal of Medicine. But there's another chart that oftentimes doesn't get looked at and that is the one looking at things from a public health standpoint and then applying it back to individuals what are the determinants of health you're seeing here genes and biology even though people talk so much about their genetic make up it's only ten percent of what determines some what is health the physical environment ten percent clinical care only ten percent and so here we spend all our time as doctors and and practitioners and whatnot but we're only really impacting if we look at what access to the technology that we have or what we can do ten percent. OK health behaviors thirty percent so that's even more than all of those things. But then social and economic factors that takes up the big portion forty percent. And so the question that the Institute of Medicine has been looking at over the past several years is if this is really a big determinant of health how come we're not paying attention to that because when we look at what these social and economic factors are they actually play a very big part of the health behaviors that people will have. So rather than looking at my style as just being health behaviors. Lifestyle involves whether we take access or we appreciate. Make good use of the health care that's available. Whether within the context of our physical environment we choose the path that are better than the paths that are worst. We can't change biology but what we know is that we can actually alter what's going to happen to the next generation and the next generation in the next generation by how we live this life right if time should last. And the social economic factors this is what we're going to concentrate on for the next few minutes so this is the model that was. Presented by WHITEHEAD This year age gender constitutional factors the biology of the person that's at the core that's what you know we're a person and that's it but then we have individual lifestyle factors and these things play an important part but they are not the whole sum where we look outside of that we see social networks and community networks and then we see housing and health care services and water and sanitation and unemployment and work environment education i Reporter food production all of these things have an impact and the impact goes inward towards us and some of those things we cannot change. But they inform. Our lifestyle because they may limit the choices that we have or. They may open up new choices for us. And then general social economic cultural environmental conditions. You know the fact that you were born or you are living now in God's country. And you're not living in New Delhi. You didn't choose that. You know living. And you know you're living here. So there are things that that's just how it is. And there are some people who are living perhaps I don't know the area well enough to be able to see anything like this but the people who are living in cities and you say well we'll move out of the country. And it's like what. They don't they don't have the wherewithal to be able to move into the country they don't know how they can do that they don't know how to do that they won't even know how to survive if they were in the country the same way that some of us may not know how to survive if we go to the city. They don't know others of I'm a country. Here in Spokane County there was a study done and published in two thousand and twelve and this is available in P.D.F. and it's very informative and I have a bunch of slides that I made from from this I only show you a few of them. What they were looking at were the determinants of health for this county and comparing it with what was going on in the state of Washington altogether and basically what they found is if you were to look at the. Educational domain household income domain recent ethnicity domain and then the place a neighborhood them in they would be able to look at a wide cross-section of what's going on in this county as things that determine the health status of individuals and the characterization of the things that impact health. So in this one. Of these quickly just look at the top and get a glimpse of the other slide it later on you want to go back and look at it we can do that but as an adult level of education increases the likelihood of living in poverty significantly decreases so education is a key thing right getting a good education. Next one as appearance level of education increases the likelihood of their children living in poverty significantly decreases that should make sense. Adults with less education are less likely to have health insurance. OK. Adults with less education are more likely to have had several adverse childhood experiences that means that these adults actually have had things in their childhood like neglect and abandonment and emotional and physical abuse and somebody in the family being incarcerated or somebody with mental health issues or a significant person in the family dies all of these things impact the child's neuro development OK and so adults with less education are more likely to have had these adverse childhood events is insult on injury OK. Adults with less education are more likely to have had activity limited by chronic illnesses so you have a person with. An education issue and low and behold. Physical and mental issues are following with that adults with less education or more likely have had cardiovascular disease. The lower the adult income the more likely they are to have diabetes now you think about this in your practice somebody comes in and. Are you assessing the educational level are you assessing. Their income level are you really doing that or you're just asking the perfunctory questions or the person comes in and you know they have Medicare or they have private insurance or they have Medicaid or something and then you say OK and I assume what is going on but you know that that some of these some people the card that they carry may not really reflect what's going on in their real life. OK. So adults with less education are more likely to have that activity limited by chronic disease the law on adult income the more likely they are to have activity limited by chronic disease or education and income both affect chronic disease. The law of the adult income the more likely they are to be physically in active less money less physical activity why that correlation. The lower on adult income the more likely they are to experience poor mental health mental health by the way is a major major issue one in three to one in four people around the world has a mental health problem OK So in this room one two three. One two. No but we're not normal. We don't have a normal distribution of the law an income the more likely to cut or skip meals because there was not enough money to buy food and you know we tell people have a good breakfast and it's a choice that you make and what not and some people have to make a decision about eating food today or taking the bus to go to work. The lower an adult income the more likely they are to be obese. And you wonder how come well some of that work was done right here in Washington state at the University of Washington where they looked at. This was research done back in the one nine hundred eighty S. that people tend to choose what will fill their tummies. That's what they choose you want the cheapest thing that will fill your time. And those things are usually highly processed junk food. So in many communities we have the juxtaposition of poor nutrition or under-nutrition and all of our calories OK It's a strange combination but if you understand how people are making the choice you're get the the idea people don't want to go hungry I saw a very. I was in Abidjan a few weeks ago and we have an AIDS project going on in Africa in southern Africa. And I saw this like it that really it really affected me beautiful young lady. But she made this statement. Art rather. Have AIDS than die of hunger. This is what she had to choose. Because she had no income and the way to get income was to prostitution. Which means she was going to be exposing herself to AIDS. But she wanted to eat. So here is Gina. At age twenty eight here is Gina at age twenty nine and we heard her story. And we might say Dina made bad choices. But when Gina was being interviewed. The doctor made a mistake. And instead of asking her the question that he wanted to ask her he asked her instead. How much did she wear when she first was sexually active. And she said something like thirty eight pounds. And he stopped the whole thing No no she didn't understand and he said the wrong the wrong question. So he looked back at his notes. But he said the same question again. Inadvertently. And she said thirty eight pounds. My grandfather. And she burst into. Yes. When she was eight years old this is her picture she was a healthy. Normal weight girl. When she was eight years old her grandfather. Began. A different story in her life. And so. We have this and use it well how did that happen from that just because a grandpa. Well she had guilt. She had body image issues. She had cognitive dissonance this is a grandfather of his wasn't protecting her and said he was not. And then she phoned that when she looked like this. She was unattractive and she had no all more risk. No more risk. And you get the picture. So now she goes and she's in the clinic and she's lost weight and she looks like this. And you know what happens. Some guys begin to talk to her and make sexual innuendo. And her mind goes back to those. And therefore she makes a choice. I would prefer this. And not have to deal with that problem. Than this. Now when the doctor discovered that. He thought. I wonder how many patients. Have problems like this other. In missing. So he started to ask all of his obese patients. As a matter of fact he ran up a string. After he told his colleagues they were all looking for this. Two hundred and fifty six consecutive patients all had stories like this. Consecutive patients. Wow. He thought this is this is big. So he went to the. You know he's a preventive medicine dark the chief of remembers and then at the Kaiser Permanente clinic in southern in San Diego he goes and he presents a paper on this to the American Psychiatric Association. And he's laughed out of the room. They don't they don't believe him the thinking is. He's crazy they think he's crazy they didn't have a D.S.M. you know for classification very mother but they knew he was he was he was a this this couldn't be true but in the audience there was a doctor from an epidemiologist from the C.D.C. actually was he was from Emory University and he put him in touch with an epidemiologist from the C.D.C. and they did the definitive study it was called the adverse childhood experiences study they studied seventeen thousand people seventeen thousand and what they found. Shocked the entire world but it did not make any major newspaper it didn't make the television it didn't make a late night shows a didn't make any of those things you probably won't even hear it on N.P.R.. But we're going to talk about what that means now the issue is once you hear that ladies story. It doesn't matter who you are you have to have compassion. And this is the hallmark of Jesus's ministry Jesus when he saw people suffering he was moved with compassion. A seven there when this we should be moved with compassion with our patients we should see them and we should we should empathize with them. Compared to people with none of these adverse events adverse experiences those with four or more such events that is being neglected as a child or perceived neglect being abused as a child having one of the members of your family be incarcerated or die or someone with mental health issues. All of these if you had four or more right. These individuals are twice as likely to smoke. So now is it a choice to smoke or is it not a choice. It is but there are things that are pushing them in that direction right seven times more likely to be alcoholics. Six times more likely to have had sex before the age of fifteen as a matter of fact in this in the a study what they phone some of these young ladies. Within five years have more than fifty partners. They have holes in them that they are trying to fill. But they can fill it the way they were doing. The twice as likely to have cancer or heart disease twelve times more likely to have attempted suicide men with six or more aces were forty six times more likely to have injected drugs than men with no history of a server exposures. A person with four or more adverse childhood experiences in. Is two point two times as likely to have a scheme of heart disease so we have patients with heart disease and we say wait a minute we'll move your cholesterol is normal you exercise. You have no family history. But yet you have a heart attack. Or it must be genetics that's what we see right. We don't know because we don't ask about what's going on in that person's background that two point four times more likely to have had a stroke one point nine times more likely to have cancer one point six times as likely to have diabetes OK here are the things that are associated with Ace in every community that has been studied lack of physical activity is associated with having these this this in other words people who have adverse childhood experiences are less likely to enjoy physical activity. They're more likely to smoke the more likely to drink alcohol they're more likely to use drugs they're more likely to miss work they're more likely to have trouble at school they're more likely to have all of these negative they're more likely therefore to not have a job and therefore they're more likely to have an educational problem and a job problem and we just found out from the survey if you don't have a job. And you're not educated what happens to. All the health issues that go right and we see you in the emergency room and we see you in the clinic we see in the office we see in the hospital right severe obesity is part of the problem diabetes depression suicide attempts S.T.D. is heart disease cancer strokes your P.D. broken all of this associated with something that that individual did not have any. Control over. But has become part of their lifestyle because it is part of their life story. But it gets deeper. Time magazine but these are how the first nine months shaped the rest of your life you're not. I was in my mother's womb but I can't remember anything about what happened. I was when I was there but I wasn't there I don't know what happened I don't know how my mom was living when she was carrying me I have no idea but what mom even what she thought and how she was her attitude all of these things were affecting me. It was so interesting I. Am by choice I'm a dermatologist and so. I enjoy reading about diabetes and I enjoy taking care of patients with diabetes. There's just no way we're going to stamp it out but I remember some years ago when I read a strange study. That showed that people who were. Low birth weight this was first done in an Asian population low birth weight. At age forty three to forty six had an increased risk of developing type two diabetes I thought this is amazing amazing Well guess what now we know now we know part of what happens in the uterus. Where Cindy is the sort that the mom has. OK the chemicals in the mom's body but the child and therefore that child was subjected to what mom was experiencing right and this increases the child's risk because IT programs the child. Now we know about. This is an interesting study that was done looking at people at women who were pregnant at the time the Twin Towers fell. Nine eleven they observed it and these people were followed. And we now even know all the markers the cellular markers that were affected if they were pregnant and they were in the third trimester what would happen to the children if they experience this trauma the child in and up with P.T.S.D. are you hearing me the mom has she experiences something and the child has a problem. Right. These babies will be more susceptible to anxiety depression even P.T.S.D. than those whose mothers did not experience the P.T.S.D. event we have issues with epigenetics preconceptions sperm and egg into your own life whether we're delivered by C. section or were delivered all of these things affect what goes on with a child when we have two people who are living in the same family two people same family as a matter of fact you can even say twins right and you say how come one is doing this and the other one is going a different path. We haven't the foggiest idea what's going on on the inside what happened on the inside. What happened when they were still being formed whether one got enough oxygen or enough food compared to the other you get the idea. All of these things affect the term metabolic programming food exercise sleep music attitudes beliefs fears joys all of these by the mother will affect what happens with that baby. OK. This doesn't want to stay on this ears so. All of this affects the baby. So when we talk about lifestyle we have to. We have to look at what informs the lifestyle not just the outward manifestation of what the person is actually doing. That's the point. So. So here's what's happening. Some people of gotten wise to this. This is a doctor Dr David shear He's at the corner health center. And. He has. Got a grant for an initiative Blue Cross Blue Shield of Michigan and has a one stop shop for addressing patients medical and social needs so he looks at some of these social issues and he has a team of social workers peer educators psychiatry's nutritionist as well as family doctors and there's a practitioner sort of a movement of ways and see as one stop shop he has a. Medical Home. Idea anybody here involved in medical home movement. No one OK I guess that hasn't come to Washington yet. All right he says there's no question about mind that if we didn't address psycho social needs we would put. On a lot of bandages and give immunizations but we wouldn't change the trajectory of our patients lives from a health and well being perspective we wouldn't be very effective. Because what he's trying to do and what I am suggesting that we all should do. Is we should be interested in not just what we see on the surface but trying to get to the root causes what is it it's informing this behavior why are you doing what you're doing now we can only go so far. And the reason for that is because we can see the issue is since Right I mean we know that sin is here OK but let's be let's be careful when we go that route because Adam and Eve. They didn't sin before they said. But you might say but sin was in the world. And that's true. But Lucifer. He had his problem in a sin less world. Right. So from the Biblical standpoint it's called the mystery of iniquity it's a mystery I can't get there but for human beings on this side we can get to some of these issues and the research is showing that when you address some of this you actually can make a big impact in that person's life. And there's this lady who wrote this stuff and said you know we should educate educate you for that stuff right. Well how would you know what to educate if you don't know what. Is going on with the individual. And then she says there's one method alone that will bring success in reaching the people you know one. Ministry of healing. The Savior mingle with men as one who desired their good mingled with them you know mingling is not just talking with them right. Right now I'm talking with you but we're not mingling yet. Where you're sitting you're with each other but you're not mingling right Jesus mingled with men as one who desired to can. I'm not he didn't pretend to desire. It's because he desired their good he mingled with them American sense. And in that context he was able to sympathize with them and he was able to meet the needs that they had now we can't meet all the needs that everybody has. But I want to suggest that we have opportunities to meet the needs and we have opportunities not just because we are practitioners but because we belong to a faith community. We have resources. Spiritual resources and we have physical resources called the church. And over the course of the weekend we'll be talking about about that how how we can how we can do this. I don't know this doctor I don't know if he's a Christian I have no idea what he's what he's into. But he's saying he wouldn't be very effective if he didn't take care of some of those issues. So when I look at. Kind of another way of dealing with lifestyle and making recommendations to people and to patients. I realize that where we live where we learn where we work where we play they have more to do with our health than going to the doctor. What's going on there that's where the that's where the action is in their life. And this is where the church is supposed to reside. And if we belong to if if. Community that's where in our other life OK our real life that's where we're supposed to reside to. So what is it that we recommend access to fresh fruits and vegetables. Right so what if the person doesn't have access to it. We have to look for a solution it's not enough to see you need to eat more more fruits and vegetables telling them that if they don't have access and that they have nowhere when we were in Mexico we went to this community the very little fruits and vegetables what they had were taught to years they had cheese and they had chicken and once in a while they'd have. Beef kind of mess our. Vegetables that was because here you know a little bit of tomato some onions that that's vegetables with it. So. In this particular town that's not how all of Mexico is what that's how this town was so we said how about having a garden right and after people Hamden hoard there's this one woman who had some property she said sure we can do the garden at my place so the women in the town right there about fifteen women the got together and so they were shown how to plant vegetables and they really really enjoyed this and the vegetables grew and it produced an abundant harvest OK and then it happened. The stuff was remaining on the plants and trees why they didn't know how to prepare them. They thought it looked good but what do you do with it so we have to teach them how to cook it how to cook these things how to prepare them how did some wrong etc right. And then it happened the woman whose land was being used she said this is my land I want it all. She took it over. So we had to start over again. But it worked out the other woman they said well that's all she is so we got another piece of land actually the mayor gave a plot of land and everybody had a little parcel but now they were experienced at things and I can tell you when last I heard which was a few years ago things were flourishing OK the community began with community gardens right. In another. Community were asking the kids about eating vegetables. Well they had only heard about broccoli they'd never seen a broccoli. So he asked Do you like broccoli they can tell you they've never tasted it. Carrots the only cars that they've seen were carrots that came canned with Chili Peppers. And so all they saw was a little piece of a carrot. They had never actually held a whole carrot. But I shouldn't be surprised that that in Mexico. When we were in in Pennsylvania some of the kids there had never been on a farm they didn't know where milk came from. And when they heard that it comes from the other about how they were saying you know. Rightly so. But they didn't know about the plants and they didn't know they didn't know they were living in the city and they didn't have access you for the what I'm trying to say when we we may believe that everybody understands things the way we do. But they may not. So access a fresh fruits of access to green spaces freedom to walk and play during the day there are some places where people have to be indoors and locked up because of crime and whatnot on the streets income levels low income three times the mortality before it's sixty five from those who are not low income education levels two and a half times what out to be void sixty five than those who have higher education in some states county residents and zipcode produced thirteen year difference in longevity if you have this is of course is that and this research was first done in Washington State. OK racial inequities and master status effect the master status effect just means in any kind of community there is some group that is considered That's the top group and then everybody else you're not going to fall into some hierarchical decline and this residence school high of a mother supply the chills this where you reside actually determines the school district right. And the school district may have good schools or bad schools right now the government may not tell you good schools and bad schools but we all know they're good schools and they're bad schools so where you reside determines the school and the school determines whether or not you're going to have higher education or not and that higher education is going to determine what kind of job you get in that job that you get or don't get will determine how much you get paid and that will determine where you live because if you don't have enough money you can't live in one of those neighborhoods that will help you get the idea you know this is called. A vicious cycle. Now our job if you. Will accept it you know Mission Impossible right. Is to be able to help people to get out of that cycle. And part of that getting out of that cycle is not just social and it's not just physical it actually happens to be spiritual. To have another view. Another way of looking at things and as doctors we have a unique opportunity and we have a responsibility for every patient that comes into our office and into our sphere of influence Here's an inconvenient truth. Dr John McCullough. Said life isn't just this is from. The state of. Why. In Spokane County Life isn't just better at the top it's longer and healthier at the top. The health. Iniquities and inequities. So what's the top. Everybody wants to be at the top Well here are some tips for staying healthier and having a fuller lifestyle approach. In your source you're going to make racial environmental context here it is don't smoke if you do stop if you don't don't start out that does that sound reasonable talking about this one eat a balanced diet whole foods fruits vegetables. As one author says. Eat wholesome food. Not too much. Mainly plants OK All right keep physically active if you drink stop if you don't drink don't start avoid excessive sun and protect your children practice safe sex mutually more Nagumo sex natural marital sex OK That's OK but dissipate in appropriate health screening and follow up right just getting a screen is not enough you have to follow up drive defensively don't drink and drive and don't drive with people who drink OK manage your stress practice physical mental and dental hygiene manage reciprocally supportive social ties maintain reciprocally supportive social ties and this want to go to church and go regularly you have a trusting relationship with God and love people OK. This advice to people How's that sound is that's not a good seven their business advice Yes But now let me make a twist. And show you what we have to do now that we have learned about the expanded social determinants. Recommend don't be poor. If you can stop me stop being poor if you can't try not to be poor for too long. Because the longer you're poor the worse off you're going to be next one don't have poor parents. You have poor parents you're more likely to be poor you're more likely to be sick you're more likely to have all kinds of problems you're more likely to live in a place that you would want to live. Don't live in poor or industrialized neighborhoods. Own a car but use it only on weekends and walk to work if you can. So your neighborhood can't be crime Laden right if because if it is then you can't walk to work. And if you leave the car is going to get stolen OK So practice not losing your job. And don't become unemployed and don't tell how much you made in the last job do you know why when you tell how much you made in the last job that determines how much they're going to pay you in this job. Because people don't pay you based on what the job is worth they pay you based on giving you a little bit more than the last job but at the last job you were being underpaid guess what you're going to be paid in this one underpaid as well it's a cyclic thing. OK Don't be illiterate. This is of course a little tongue in cheek but this is this is really the issue don't be literate avoid it like the plague avoid social isolation but choose educated friends. Don't accumulate points. Choose your parents wisely try not to be part of a socially marginalized group and be born in a happiness index country. Well as I said it's done in cheek but actually all of these things have statistical significance and as as physicians in our practice we should be looking out for these things. But of course. It's ridiculous that somebody don't be poor. Choose your parents. Some of that really outside of their immediate control. But I remember some years ago a very interesting statistic. Looking at seven they're doing this are you aware that seven they're bent this as a group. Is poorer than the Mormons and the other religious groups are you aware of this more than the Baptists etc Oh you know Adventists are considered poor people but we believe the part of this was because the survey was not taken across the board because many of the professional seven their dentists did not turn in their surveys OK so we end up being poor but there is something very interesting that happens. When if the family becomes seven there Ventus within one generation the educational level of that family goes from. Three high school. To college and graduate school one generation. Right one generation educate. Educate educate. So here is what. Our church. Through our practice can be able to do this is that same graph and we're looking at. Individual lifestyle factors and social community networks etc. First of all. We can help patients even in our offices to. Develop is spiritual dimension a biblical world view because of how we talk to them the literature we have the the music that we play all of these things in our practice if we have control over those things OK. Next community. In our own practice is we can have we can form a community first of all with our staff. And them is there anyone here who has a group visit. Or you have to have a workshop on group visits it's the way to have a church in your office. Because the patients will come to a group visit and then they will learn to work with each other and pretty soon. Bible studies and all of those kinds of things can happen right there in your office. You know group visits right. OK All right so you can develop a community right in your office what else lifestyle we've talked about the expanded things we need to find out about. And then the things that we can intervene with we do age you know we can help people to grow younger. You know what the health age. Really age approach is you know over the Alameda study looking at different lifestyle factors and if you practice the more of these you you practice the lower your physiologic ages OK so I tell people I can help you to grow younger and I say Come on doctor we're going to be wrong we go through this stuff and we say you have to do this if you do these things right is it possible for you to do that which one's Can you do because if you don't ask that question it's all the yes yes yes yes yes but in reality it's going to be NO NO NO. OK education we can help people with that. And that's the interface with the church we can have all kinds of seminars and things like that in the church we can have homework helping for the kids. In the neighborhood. But we have a little issue I don't know if this is C M thing here but. Many of our churches are Sabbath only churches do you have that here too. Everybody lives far away from the church you come in on Sabbath you go to church you have Prata local whatever it is and you go back home in the church nobody lives around the church is that how it is here too. I don't know but anyway but that's how it is in many parts of the country actually and around the world I'm seeing the same thing so that becomes an issue and then agriculture and food production guess what we can teach this. Right even with our own members and then we spread it to the other people in the neighborhood nor problem no problem. OK unemployment we can get people to work if you have these things working together unemployment becomes less of an issue. Less of an issue. Does electronic health record capture these things well according to the Institute of Medicine they're trying to be able to incorporate this in just a few more slides to shew all those social and behavioral factors influence they held in mortality that often ignored him to make up practice a new set of standard measures will Social be able to diminish or help delineated by the Institute of Medicine committee should catalyzed action in this front now who should be leading this charge. I believe that seven there then they should be leading this charge but that's not necessarily the case here are some of the things that they they propose from the Institute of Medicine we should ask about your race we should ask about your ethnic origin why because these things are actually influencers of what the person will have access to and what they can do what they can't do and how they will be seen and in society and what etc Education highest level of school financial resources stress depression. Physical activity to back or use alcohol use we asked that for sure social connection isolation we usually don't ask that we don't ask how many friends you have do you have a social network of we don't ask those kinds of questions intimate partner violence. Residential address where is your current address I have some slides looking at different neighborhoods there's a place called I don't know Spokane so where's Riverside there's a downtown Riverside they seem to have the worst health indicators from everything just by looking at the data is it a bad place. Lower income OK. Anyway so you can find with US Census tractors if you have a patient you know where the person lives you can you can actually already begin to understand some of what that context might be and you might understand better what their lifestyle is as you're going to try to help them as an individual. Researchers have shown that there are three different levels of of social determinants that we can get into the health sector that means working with the hospitals working with the Health Department working with the insurance companies and so on so that you can get this used medical assistance to refer food insecure patients to food benefits program provide legal services through medical legal partnerships these are things that you may have access to an influence over that will benefit your patients OK. OK. I recommend this article for anyone Steve Schroeder wrote this we can do better improving the health of American people since the actionable deterrence of health personal behavior social factors health care and environment disproportionately affect the poor strategies to improve national health rankings must focus on this population this is what he said this is Dr shares looking at his his people. Again in the one one stop shop This is from. From the north of here in Canada they were looking at what's going on in their community and these are some of the issues that they have as social issues affecting the health. Of their population so what can we do first of all we can be aware and screen for Social Determinants of Health and Barrister health in our offices in our practice is legal is legitimate and there are there are questionnaires a few questions five ten eleven questions right that will give you part of that profile and the one that the Institute of Medicine had today just showed you is a good place to start train or send your staff or training in other words the staff. Is also part of this. They also should be sensitive to this in corporate wellness and preventive services into your practice consider a home visit. To one. Of your geriatric patients. Periodically go and see. How they live. You know you send them home with a prescription or with good advice and what you have no idea how they're going to do this when they get home. So go by and see something. Explore the full medical ministry angle and engage your patients and engage your community engage a church people in meaningful health ministry with your patients permission this some people all they need is somebody to call them and see how they're doing. And there are people in the church will say I'm looking for missionary and ministry opportunities. You link one with the other somebody calls how we're doing the next thing you know to develop a friendship next you know. Have dinner together. Next thing you know they're coming to church. Now here's what Dr Gordon Schiff said he's a doctor bring in women's in Boston for many of us particularly primary care physicians more than anything. Financial incentives etc Our more fulfilling rewards and professional satisfactions come from having meaningful relationships with our patients as well as our ability to broadly a million rate their problems and suffering. This is what this Harvard guy says. And I have to ask the question and I'm asking it to you. Is that really what satisfies you in your practice. I can tell you I know some doctors this is the furthest thing from the truth. And they're seven they're going to this. But here's this guy saying here at Harvard here the Brigham. This is this is it. And we know that Christ method alone. So part of my recommendation and we're going to talk about this over the course of the weekend is what I call. The. Dark orgy. It doesn't exist OK. It doesn't exist but you know when somebody is looking for a doctor and they say I want it Dr who is not going to treat me as a piece of meat. But somebody who is going to treat me as a person. Somebody who really cares about me and what I'm going through somebody who's willing to take a little extra time. Somebody who was willing to see me. Within the context of an add on today. Somebody who was compassionate. And kind. And. Who will say hi to the kids who come to the office. Who are they looking for. I think they should be able to go on a website called W W W S D A dark dot org. And find you or find me what you think. Now what are the characteristics of people who sign up to be part of this network. Competency I tell you there is no excuse for being incompetent right. Highly competent individuals so competency excellent conviviality meaning they can mix and mingle with people outstanding. I want this one conscientiousness over the top. How about character Christ like integrity and a Christ like Christian worldview like that. And of course compassion out of this world. Actually described as being heavenly. Would you want to be a doctor like that would you want to be able to go to a doctor like. This is what seven dead and his doctors were supposed to be like. Following the pattern of the Great Physician. The principles Matthew seven in as much as you have done it under the least of these my brother also Matthew seven Let your light so shine you know it before men that they might see what your good works and pay you a lot of money is that what it says. No and glorify your Father which is in heaven Matthew twenty five sheep and goat right which which side do you want to be on. Isaiah fifty eight. Being a Good Samaritan. Consider Joseph through whom all the world was blessed you know. Part of us house was blessed not because of part of. It wasn't even because of Joseph's ability the Bible says it's because of who Joseph was. That everything he touched was successful. Is in Spokane. Successful. Because you were here. I'm assuming you are from Spokane of course that may not be true but is your town is your neighborhood better because you are there. I hope over this weekend you have a chance to examine that question. And we remember the Christ method alone is what will bring true success. For the patient who says But doctor I have all these negatives all these social things all my baggage all these East cores. How am I ever. Going to get out of this broken cycle. Trust in the Lord with all your heart lean not to your own understanding in all your ways acknowledge Him and He will direct your path God doesn't have to take that history he knows it he knows our frame he knows where dust and he is able to do for us far beyond what we can even ask or think. But this advice is. For the physician to. How can you do this how can you transform your practice how can you be able to take care of people with all these needs a doctor you you must be crazy how I can hardly keep up with what I already have FAR want to get the social history and find out about whether I can do about. Advice trust in the Lord with all your heart lean not to your own understanding. In order always acknowledge and he said there in your prayer thank you very much this media was brought to you by audio verse a website dedicated to spreading God's word through free sermon audio and much more if you would like to know more about audio verse if you would like to listen to more sermons lead to visit W W W audio verse or.

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