Are you a Difficult Parent?

A recent article in Pediatrics examines how pediatricians can manage their relationships with "difficult" patients and parents - those who are clingy, demanding, manipulative, or self-destructive ("Approaches to the Difficult Patient/Parent Encounter").

A litigious father, for example, complains angrily about the diagnosis for his 7-year-old son. A 15-year-old girl constantly challenges her pediatrician's advice. "Patient/parent issues can include psychiatric disorders, personality disorders, subclinical behavior traits, and information overload," the authors write. These patients and parents are no doubt difficult to handle.

But then the authors write that

Parents of children with chronic illnesses may be considered challenging; these parents are vulnerable or even frantic because they are coping day after day with an ill child. Despite recent clinical advances, many chronic diseases cause great suffering and uncertainty.

And I started to wonder whether some doctors simply had compassion fatigue. Often, it seems, patients (or their parents) are difficult because they don't think they are being heard or understood. Sometimes, being a good parent and means being a good advocate for your child's well-being - and therefore being difficult. 

Studies have shown, for example, that the most common type of medical error, medication mistakes, are especially common among pediatric patients. I've written before about radiation overdoses from CT scans that are not calibrated appropriately for children. Parents need to understand these problems and ask questions when their children need a medication or procedure. If they don't understand the answers, they need to ask more questions until they do - no matter how busy the doctor or nurse might be.

And so for 2011, I'm sending out good thoughts to all the parents out there. I hope they ask questions, get the answers they need, and participate actively in their children's health, in the doctor's office and at home. Because if your kids are doing well, you don't need much more than that.

Will Force or Favor Make People Buy Health Insurance?

The mandate that everyone buy health insurance by 2014 is facing a lot of legal challenges. Recently, a federal judge in Virginia decided that the mandate is unconstitutional. There are currently 24 lawsuits challenging various aspects of the Patient Protection and Affordable Care Act, according to a chart created by the Washington Post, with the insurance mandate a top source of friction.

Having both healthy and ill people purchase health insurance distributes the cost of care among both. A responsible society shares expenses for the common good. We don't expect children to pay for their public school education, for example, but expect that they will pay it back when they use their education to get jobs and become tax-paying adults themselves. Similarly, if we want to expand and secure access to health care, we need to all contribute to the expense - even if we are not deriving immediate benefits from our contributions. At some point in our lives, as injuries and illnesses occur, all of us will probably cost insurers more than we are currently contributing in premiums, and we will depend on the contributions of healthier people to cover the cost of our care.

But how do you make sure that enough healthy people purchase health insurance to adequately distribute these costs? Since legislation, now being challenged in the courts, might not work, Fierce Healthcare ran an article on some ways to pay for health care reform even without the individual mandate. Fierce Healthcare drew on a Kaiser Health News story ("Experts Ponder 'Plan B' Options For The Individual Mandate") for ideas, such as:

• Use taxes as an incentive. Raise taxes, then give tax breaks to people who have purchased health insurance.
• Use premium cost as an incentive, as suggested by former CMS director Gail Wilensky. Increase the cost of health insurance for several years for people who do not purchase it when they are first eligible. 
• Use a waiting period as an incentive, as suggested by sociologist and senior health advisor Paul Starr. Prevent those who opt out of insurance from purchasing subsidized insurance on the insurance exchange for several years. Insurers also would not be required to cover those who opt out if they had pre-existing conditions.

As these ideas demonstrate, where persuasion doesn't work, stricter financial penalties often do.

New Vitamin D Recommendations Include Surprising Changes

Last week, the Institute of Medicine (IOM) released new recommendations for Vitamin D and calcium intake that increase the amount of daily Vitamin D recommended for children and adults. Adequate Vitamin D intake is primarily linked to bone health, making it a vital nutrient as Americans age and diseases such as osteoporosis take hold.

The new IOM report, based on an scientific testimony as well as an analysis of almost 1,000 studies on Vitamin D and calcium, recommends 400 to 600 International Units (IU) of Vitamin D daily for everyone ages 1 through 70, and up to 800 IU daily for those over 70 (here is a chart with their recommendations). This is an increase over earlier recommendations of 200 to 400 IU per day for those 70 and under.

What else has changed in Vitamin D recommendations? The IOM found that most Americans do receive adequate amounts of Vitamin D, even though previous studies have shown that they did not. The IOM report stated that, in the past, inconsistent standards were used in blood tests that measured whether people had adequate Vitamin D in their bodies. As a result, many people studied were falsely labeled as Vitamin D deficient. The IOM considers over 20 nanograms of Vitamin D per milliliter of blood to be a healthy level.

Vitamin D might also help prevent serious health problems such as cancer and heart disease, although the IOM disputes these claims. With disease prevention in mind, though, some people recommend taking many times the recommended amount of Vitamin D daily.

The IOM, however, recommends upper level intake limits for Vitamin D. These limits range from 1,000 to 3,000 IU daily for children up to age 8 (depending on their age) to 4,000 IU daily for older children and adults. At these intake levels, kidney problems and other health issues can occur.

Another study of about 4,500 older women in the Journal of Clinical Endocrinology & Metabolism found that women 69 and older were more likely to be frail if they had either too little (less than 20 nanograms per milliliter) or too much (more than 30 nanograms per milliliter) Vitamin D in their blood. With Vitamin D, it looks like the middle path is best.

Food and Class in America

I'm interested in the locavore food movement, and agree with the principles of the slow food movement: think about where your food comes from, and how both the food sources and those who grow and pick the food are treated.

Finding, buying, and/or growing the freshest seasonal foods, however, can be both expensive and time-consuming. Because it takes time and money to be a foodie, the locavore and related foodie movements are class movements as well. Newsweek's November 29 cover article, "Divided We Eat," by Lisa Miller, explores the class divisions that food can create.

"Food has become the premier marker of social distinctions, that is to say - social class," epidemiologist Adam Drewnowski told Miller. "It used to be clothing and fashion, but no longer, now that 'luxury' has become affordable and available to all." Since the cost of nutritious food is rising faster than the cost of unhealthy food, wrote Miller, the poor often can't afford to eat healthy food. Wealthier (and subsequently healthier) families can.

It's clear from some of the content in the Newsweek article that some people are far more concerned about the quality of what they eat each day than about what - or whether - others in their community eat. Eating locally, for example, might be both high-status and tasty, but it doesn't solve the fundamental problems of our flawed food system.

The legislation that expands the FDA's powers to inspect food that passed in the Senate this week, on the other hand, might bring about more profound changes. The new legislation would let the FDA recall food, better access records at places where food is produced, increase the frequency of inspections of food facilities, and inspect a wider range of imported foods, explained Lyndsey Layton in the Washington Post ("Senate approves bill to require foodmakers to find ways to prevent contamination").

An overhaul of school lunch funding is also working its way through Congress now. The Healthy, Hunger-Free Kids Act would expand school lunch funding, increase the number of children who are eligible for the program, and encourage using local food sources for the lunches. The act would also encourage schools to create schoolyard gardens.

Class divisions have real consequences on people's lives. Analyses of health and life expectancy by neighborhood, such as one that a local county public health department conducted earlier this year, make it clear that where you can afford to live affects how long and how well you live. Health, wealth, and class are all related. Expanding access to safe and healthy food might help narrow the health gap between different classes, and perhaps budge some class divisions as well.