I've built a healthcare practice by listening to my patients. More often than not, I've heard them express their appreciation. But like many of them, I've been to doctors who leave me scratching my head as to whether or not they heard a word I said. The difficulty in patient communication creates a considerable problem for both patients and doctors alike. This N.Y. Times article asks the question: "Can doctors be taught how to talk to patients?"

Doctors February 27, 2014, 11:05 am

Can Doctors Be Taught How to Talk to Patients?

By TIMOTHY D. GILLIGAN, MD. and MIKKAEL A. SEKERES, M.D.

 

 

iStock

Recently one of us attended a daylong retreat designed to help doctors communicate more effectively with patients. The course was taught by a colleague with whom we had consulted in the past on patient-related matters but who was known better by his reputation, which was almost laughably stereotypical: brilliant technically, but stunted when it came to interacting with people. 

A close family friend with cancer had gone to see him some years back. When the friend started asking questions about the treatment plan, the doctor had stopped him midsentence, glared at him and said, “If you ask one more question, I’ll refuse to treat you.”

“What could I do?” the friend later said. “He’s the best, and I wanted him to take care of me, so I shut up.”

Now that same doctor greeted us as we filtered into the conference room by looking us in the eyes, smiling and shaking our hands.

“Did you have any trouble finding the place?” he asked warmly, waiting for a response. Those of us who knew him were left speechless by his new demeanor. “Great! We’re going to have fun today. 

Why don’t you go get something to eat and grab a chair. I’m looking forward to working with you.”

A wealth of research suggests that physician communication about important topics like end-of-life care is associated with a better quality of life for patients, and a better quality of dying, with less intensive use of unnecessary tests and treatments. 

Teaching communication skills to doctors, though, isn’t easy. 

Physicians and medical students often have limited insight into how they come across when talking with patients, and little opportunity for formal feedback. While most doctors really are invested in their patients making the right decisions for their circumstances, many lack the skills to show that they care. 

After all, their admission to medical school was not based on a validated assessment of their ability to relate to other human beings. 

In response to the growing recognition that effective communication with patients is a basic competency of our profession, and that doctors often have inadequate training in it, medical schools and hospitals have invested substantial resources over the past decade to teaching communication skills.

But some place the blame for the stilted way we interact with patients squarely on the shoulders of our training, which teaches us methods for objectifying and quantifying symptoms. Prior to medical school, if we saw a neighbor fall and hurt their leg, we would likely run over and say. “Are you O.K? That looked painful. What can I do to help you?” As doctors, we ask, “On a scale of one to 10, how bad is your pain? What makes it worse? Does it radiate to your foot?” 

But can giving doctors a script for empathy actually make them more empathetic? Our patients know better.

A recent study published in JAMA highlights the difficulties of teaching effective communication. In the study, 472 internal medicine and nurse practitioner trainees were randomly assigned to either participate in an eight-session, simulation-based communications course, or to forgo communications training. Patients with end-stage cancer and other fatal illnesses or their families then evaluated the quality of their caregiver’s communication and their end-of-life care. Patients were also evaluated for signs of depression. 

The results? Physicians and nurse practitioners participating in the course were no better at communicating or providing end-of-life care than those who did not receive communications training. And patients cared for by health care providers receiving such training were more likely to be depressed. 

How could this occur? It is possible that those receiving advanced communications training spent more time talking about impending death in their end-stage patients, and that this was depressing. Perhaps those residents participating in the study were too early in their training to lead these sorts of difficult conversations and participation in the study emboldened them in inappropriate ways. 

It is also possible that, as we devote more time to teaching students and doctors effective communication techniques, we risk muting their authentic human voices, and instead of learning to connect they apply rote tools and scripts.

In the communications training course that one of us took, the doctor who at one time refused to take patient questions but who was now leading the course began speaking.

“Today we’re going to review some techniques to better communicate with our patients,” he said. “This has really helped me in my practice and has made me much happier at work. And believe me,” he paused and smiled, “if I can learn to do this, anyone can.” 

He then turned to a woman who sat beside him, an actor who had been hired to play the role of a patient for the day, asking the same question we had heard before — “Did you have any trouble finding the place?” – before asking her what brought her here today.

“I had a belly pain and my doctor told me I may need an operation,” she told him.

“Go on,” the doctor said.

“My doctor said I may have a tumor.”

“Go on.”

“But he said it’s curable with surgery.”

“Go on….”

It was hard to imagine relating to another human being like this. The doctor sounded stiff and his repetition of the phrase “go on” contrived, though he did encourage the patient to tell her story. And to ask questions.

It was hard not to wonder what might have motivated this doctor to change his ways. Did taking the course cause him to “see the light,” and now he was truly a changed man? Or was he pressured into taking and then leading the course because of patient complaints?

No communications course will magically transform lifelong introverts to hand-holders and huggers. At the same time, we must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care. Having physicians sound like customer service representatives is not the goal.

For those doctors who are emotionally challenged, communications courses can provide the basics of relating to other human beings in ways that, at the very least, won’t be offensive. But for the rest of us, we should take care to ensure the techniques and words we learn in such courses don’t end up creating a barrier to authentic human contact that, like the white coats we wear, make it even harder to truly touch another person. 

For some, exercising comes easily. But for many others, it's a matter of developing the routine and then, the rhythm. According to a Washington Post article, using music to enhance your workout may be the smart thing to do as it can serve to improve your speed and agility. Not to mention it helps make the time go by quickly.

Wellness

Music: Your best workout buddy

 

ZenGo Fitness - Indoor cycling bikes.

 

By Gabriella Boston, The Washington Post

 

You’re bundling up for a chilly morning run. Or about to climb on the elliptical for a high-energy workout. Or warming up before a weightlifting session.
What’s the first thing you reach for?

  

Your earbuds, naturally.

Studies have shown that listening to music that fits the cadence of what you’re doing — running, cycling, aerobics — makes you work harder.

“The metronome aspect, the synchronization of movement to music, is the most important,” says Carl Foster, director of the Human Performance Laboratory at the University of Wisconsin at Lacrosse.
The idea of synchronizing movement to a beat is nothing new, he points out: In Roman galleys, the drumbeat drove the pace of the rowers. “But there is also the distraction and arousal that music brings,” Foster says. They both matter, but it’s unclear how much. “There’s definitely more buried in music that affects us. But we don’t know exactly how to tease it out.”

Finding your pace
 
So, how to pick the “right” music?

If you want to make a workout mix based on tempo — or BPM, for beats per minute — various Web sites, including www.songbpm.com, can help you determine the tempo of your favorite music to see whether it fits your intended activity. Or you can go to sites such as www.motiontraxx.com that offer playlists at a certain BPM for running and cycling as well as other activities. Other sites include www.workoutmusic.com and www.powermusic.com.

“Music is positive energy,” says Deekron “the Fitness DJ” Krikorian, who produces fitness playlists for MotionTraxx. “So when I put together playlists, I look for intensity, positive feeling and cohesiveness.”

If he finds a song that feels right in terms of mood and intensity but has the wrong tempo, he might manipulate the BPM to fit the type of exercise intended.

“The beat becomes very important anytime there is repetitive movement,” Krikorian says. “Our instincts tell us to move to the beat. Our feet tell us to move to the beat.”

The ideal cadence for running is a hotly debated topic in the running world, and variations in stride length mean finding your ideal tempo could take a bit of experimentation. Some sources say an eight-minute mile corresponds with a BPM of 170; others go up to 200. Some suggest the ideal running cadence is in the 170s to 180s. And some studies show that faster may be better for injury prevention.
If that sounds like too much work, try a group fitness class; cycling, step and aerobics instructors have been leveraging the power of the beat for years.

Ingrid Nelson, a cycling instructor who packs her tempo-driven classes at Washington’s Biker Barre, says intensity, style and cadence are all important when putting together her playlists.

“I like a lot of ’90s hip-hop and usually stay in the range of 95 to 105 BPM,” Nelson says, aligning the beat to the cyclers’ revolutions per minute. But she might go as low as 80 or as high as 120 BPM for hills and sprints, respectively. When drills are aligned with the beat, she says, participants “connect with music” and “relax into the pulse.”

As for other fitness activities such as step aerobics, the tempo hovers around 130 BPM, says Harold Sanco, group fitness director and instructor at Results gym in the District. “You have to pick music that is both safe and effective,” he says. “If you are going too fast, you risk injury and you’re not working out effectively because you are not getting the full range of motion.”

But Sanco says music is important beyond tempo and genre; it also helps put participants in a lighter mood.

“Music can make people happy no matter what their day has been like,” he says. “It entertains and educates.”

A ‘holistic experience’
 
Rachel Goldberg, co-owner and instructor at Washington cycle studio Ride D.C., says her music choices go beyond BPM, style and genre. She uses the phrasing of the music to get the most out of her rides.

“When you marry your body’s movements with the music it’s a more holistic experience,” she says. “You start flowing with the music.” If there is a chorus or other recurring crescendos in the music, Goldberg might use those to increase the intensity.

“The music becomes your North Star — it guides you.”

It also distracts you — something many of us have relied on during a long treadmill workout. Cedric Bryant, chief science officer for the American Council on Exercise, says this is the aspect of music that resonates the most with him. “I enjoy using music as a distraction,” he says, adding that music can keep you going no matter how tired you are.

Distraction, whether it be music or even a comedy show, can be helpful in a workout — at least in the beginning, Foster says.

That’s where the importance of the beat and arousal come in. “After about 20 minutes or so, ‘Larry the Cable Guy’ is not enough to keep us going,” says Foster, who used comedy in one of his studies. “We need more than a joke to carry us.”

You eat right and exercise to stay healthy. Maybe you take vitamins too to improve your outcomes. If you thought taking anti-oxidants helped you recover from your exercise regimen, a new study indicates that doing so may inhibit the benefits provided by exercising.

Why Vitamins May Be Bad for Your Workout

 

By GRETCHEN REYNOLDS

 

 

Many people take vitamins as part of their daily fitness regimens, having heard that antioxidants aid physical recovery and amplify the impact of workouts. But in another example of science undercutting deeply held assumptions, several new experiments find that antioxidant supplements may actually reduce the benefits of training. 

Antioxidants became popular dietary supplements largely because they were said to sop up free radicals, the highly reactive oxygen molecules that are generated during daily activities. Physical exertion, through its breakdown of oxygen, results in the creation of large numbers of these molecules, which, in excess, can lead to cell death and tissue damage. So it seems logical that reducing the number of free radicals produced by exercise would be desirable. 

Enter antioxidants, which absorb and deactivate free radicals. While the body creates its own antioxidants, until recently many researchers believed that we produce too few natural antioxidants to counteract the depredations from free radicals created during exercise. So many people who exercise began downing large doses of antioxidants such as vitamins C and E, even though few experiments in people had actually examined the precise physiological impacts of antioxidant supplements in people who work out. 

For a study published last week in The Journal of Physiology, researchers with the Norwegian School of Sport Sciences in Oslo and other institutions gathered 54 healthy adult men and women, most of them recreational runners or cyclists, and conducted a series of tests, including muscle biopsies, blood draws and treadmill runs, to establish their baseline endurance capacity and the cellular health of their muscles. 

Then they divided the volunteers into two groups. Those in one group took four pills a day, delivering a total dose of 1,000 milligrams of vitamin C and 235 milligrams of vitamin E. Members of the second group got identical placebo pills. 

Finally, they asked all of the participants to complete a vigorous 11-week training program, consisting of increasingly intense interval sessions once or twice per week, together with two weekly sessions of moderately paced hour-long runs. By the end, all of the volunteers were more fit than they had been at the start, with their maximum endurance capacity increasing by an average of about 8 percent.

But their bodies had responded quite differently to the training. The runners who had swallowed the placebo pills showed robust increases of biochemical markers that are known to goose the creation of mitochondria, the tiny structures within cells that generate energy, in cells in their bloodstream and muscles. More mitochondria, especially in muscle cells, means more energy and, by and large, better health and fitness. The creation of new mitochondria is, in fact, generally held to be one of the most important effects of exercise. 

But the volunteers who had consumed the antioxidants had significantly lower levels of the markers related to mitochondrial creation. The researchers didn’t actually count the specific populations of mitochondria within their volunteers’ muscles cells, but presumably, over time, those taking the antioxidants would see a smaller uptick in mitochondrial density than among those not taking them.

That finding echoes the results of another study of antioxidant supplementation and exercise, also published last year in The Journal of Physiology, in which half of a group of older men downed 250 milligrams daily of the supplement resveratrol, an antioxidant famously found in red wine, and the other half took a placebo. After two months of exercising, the men taking the placebo showed significant and favorable changes in their blood pressure, cholesterol profiles and arteries, with fewer evident arterial plaques. 

The men taking the resveratrol were not as fortunate. They had exercised as much as the other men, but their blood pressures, cholesterol levels and arteries had remained stubbornly almost unchanged.

Why and how antioxidant supplements would blunt the effects of exercise is not altogether clear, said Goran Paulsen, a researcher at the Norwegian School of Sport Sciences, who led the vitamin C and E study. But he and many other physiologists have begun to suspect that free radicals may play a different role during and after exercise than previously thought. 

In this theory, free radicals are not villainous but serve as messengers, nudging genes and other bodily systems into starting the various biochemical reactions that end in stronger muscles and better metabolic health. Without free radicals, those reactions don’t begin. 

And large doses of antioxidant supplements absorb most of the free radicals produced by exercise.

Of course, that theory is still unsubstantiated and requires long-term testing in people, Dr. Paulsen said. It is possible, he said, that smaller doses of antioxidants or different formulations might be useful for athletes. Meanwhile, natural antioxidants from food sources, such as blueberries and red wine, are unlikely to be problematic, he said. “It’s probably only concentrated extracts that are potentially dangerous,” he said. It is also worth pointing out that the volunteers who took the concentrated extracts of vitamins C and E increased their endurance to the same extent as those taking a placebo. 

On the other hand, the supplements did not improve performance in comparison with a placebo, so why bother with them, Dr. Paulsen asked. “Personally, I would avoid high dosages” of antioxidants while training, he said. The science on the topic may not be complete, but the intimation of the recent studies is that by downing the supplements, “you risk losing some of the benefits of exercise.”

Do you own a FitBit or other exercise monitor? Does it motivate you to do more, meet goals, or put in the effort to stay healthy? A MedPage Today story questions if it's doing you any good, but is waiting for the results of a number of studies before declaring the devices a success...or just a fad.

Digital Health Devices Running on Questions

Published: Feb 13, 2014

By Crystal Phend, Senior Staff Writer, MedPage Today

Is that FitBit or FuelBand actually doing your patient or you any good? The first studies are gearing up to find out.

Such wirelessly-networked body sensor devices that connect via Bluetooth to a smartphone or tablet have seen an explosion in popularity such that the number manufactured is expected to well exceed the U.S. population within the year, based on data from the U.S. Census Bureau and market research firm ABI Research.

The idea is that the tracking and feedback motivates healthy behaviors and thus outcomes. Some devices are also billed as giving clinicians another tool to inform clinical management.

"There are a lot of good reasons to think mobile health devices will improve outcomes but the hard evidence to support that is for the most part lacking," explained Steven Steinhubl, MD, who studies mobile health devices and apps as director of the digital medicine program at Scripps Health in La Jolla, Calif.

What's to Prove?

The open question with most biometrics is whether the surrogate measures they track are actually meaningful, noted Euan Thomson, PhD, CEO of AliveCor, which makes an iPhone-linked, single-lead electrocardiogram (Heart Monitor).

Take for example activity trackers like the FitBit and FuelBand.

"If you count the number of steps, it doesn't tell you anything other than the number of steps," he told MedPage Today. "It doesn't tell you are you going to live longer, are you going to lose weight, are you going to get sick less?"

The ideal would be behavior modification to make people increase their physical activity, but there's a question of causality, Steinhubl added.

Studies have linked an increase in daily step counts to preservation of insulin sensitivity and to a small but significant reduction in cardiovascular events among individuals with type 2 diabetes.

But those studies weren't randomized comparisons of a pedometer or activity tracker versus none. All had their activity tracked the same way, but some were more motivated to make changes than others.
"Often the people who get FitBits and such are already motivated to be more active and would likely do it anyway," Steinhubl said.

For clinicians, reports and readouts of physical activity, ECGs, or home blood pressure are only useful if the data can be acted on in a meaningful way, he added.

"Taking it to the next level and creating real healthcare value is something I think people have to take quite seriously," Thomson agreed. "Otherwise all of these devices will really just be a fad."

More Is Better?

Beyond the unknown benefit, we shouldn't assume that all the extra data is benign either, cautioned H. Gilbert Welch, MD, MPH, an internist at Dartmouth University in Hanover, NH, and a vocal critic of overdiagnosis and overtreatment in medicine.

"We're at a place where we're often uncritical about the value of more data points," he explained. "Sometimes we respond to data in undesirable ways. It can be alarming and it can initiate unnecessary interventions."

That's especially true of chronic conditions, Steinhubl agreed.

In one study, more frequent home glucose monitoring not only didn't improve outcomes in diabetes, but increased depression and anxiety, he noted.

"I'm sure it would be the same if we ever did a study [in which] somebody with high blood pressure had to wear a blood pressure cuff everywhere they went and interrupt what they're doing," he explained. "In my experience as a clinician, people with chronic illnesses don't like being reminded that they have chronic illnesses."

On the other hand, Thomson noted that people using his company's iPhone ECG tend to say it's a tool for peace of mind.

"They want to know whether they have atrial fibrillation," he explained. "They are more likely to worry if they don't know than if they do."

Another concern is how to integrate the app and sensor data into clinical care.
Some mobile health devices allow a report to be sent to a clinician; others could be shown at office visits.

For clinicians, though, it's not an easy matter of how to incorporate that new data stream into patient care, Steinhubl noted.

Most clinicians "at face value look at mobile technology as more work with no reimbursement to the healthcare system," he said.

It could drive up healthcare costs too, Welch noted.

He pointed to research in heart failure patients attempting to use electrical impedance sensed by defibrillator leads in the heart as an early sign of fluid overload, but which didn't help survival but drove up clinic visits and hospitalizations.

Where's the Data?

One large-scale proving ground for mobile health devices and apps will be the Health eHeart study, with a planned 1 million participants. (See 'Big Data' No Small Challenge for Health eHeart Study.)
For example, a planned substudy will attempt to link activity levels measured by the FitBit before and after bladder cancer resection to patients' long-term outcomes, according to Carol Maguire, MSN, project director for the study from its headquarters at the University of California San Francisco.

A second would compare outcomes and lifestyle changes for participants given a bundle of devices -- a Bluetooth blood pressure cuff, a scale, a smartphone app for their diet and heart monitor -- for 6 months versus another group that doesn't get the bundle until later.

Another trial is Scripps' Wired for Health, testing whether a bundle of blood pressure cuff, glucose monitor, and heart monitor could cut unplanned healthcare visits among 200 chronic disease patients identified as high resource users.

Industry partnership studies are also underway, such as a collaboration between the Collaborative Chronic Care Network, ImproveCareNow, and Ginger.io using that company's app to passively monitor behavior via GPS, accelerometer, and text and voice call logs along with periodic surveys as measures of symptoms in adolescents with Crohn's disease and ulcerative colitis, with the hope of monitoring treatment effectiveness.

Ginger.io has its own similar study underway in diabetes.

With such research informing use, Steinhubl projected mobile health devices "will every year play a bigger and bigger role in helping us better understand the disease processes in individuals as well as better manage the health of those individuals."

In my practice, I listen to complaints of pain all day long...and most of my patients are women...and their pain is real. There are a lot of reasons why women have chronic pain but all to sadly, their complaints are too often ignored by their healthcare provider. In a Wall Street Journal article, an author details the clinical and socio-psychological aspects of pain and how she came to find the right doctor who listened.

The Saturday Essay

Why Women Are Living in the Discomfort Zone

More than 100 million American adults live with chronic pain—most of them women. What will it take to bring them relief?

By Judy Foreman

Several years ago, my neck suddenly went bonkers—bone spurs and a long-lurking arthritic problem probably exacerbated by too many hours spent hunching over a new laptop. On a subjective scale of zero to 10 (unfortunately, there is no simple objective test for pain), even the slightest wrong move—turning my head too fast or picking up a pen from the floor—would send my pain zooming from a zero to a gasping 10. 

Sitting in a restaurant was agony if the table was too high; it forced my arms and shoulders up. So was sitting in the movies, looking up to see the screen. Shifting from sitting to lying down in bed was excruciating; there is simply no way to do it with a bad neck. Even stupid little things like bending forward to paint my toenails became impossible. 

I had been inducted, apparently, into the growing army of American adults living in chronic pain. I discovered that there are 100 million of us, according to the Institute of Medicine. That was surprise No. 1. Surprise No. 2 was that most of us are women. Nobody really knows why. 

There are cultural factors, to be sure. Women are "allowed" to be emotional about their pain, and men often aren't, so perhaps women's pain gets noticed more. There are complicated hormonal factors too. There are research biases at work as well, including the absurd fact that most basic neuroscience work on pain pathways is done not only in rats but in male rats. Go figure.

What is clear is that women and men can react so differently to both pain and pain medications that, as the McGill University pain geneticist Jeffrey Mogil only half-jokingly puts it, we may someday have pink pills for women and blue pills for men. 

Here's what we do know. Clinically, women are both more likely to get chronic painful conditions that can afflict either sex and to report greater pain than men with the same condition, according to studies over the past 15 years. (Women also have more acute pain than men even after the same surgeries, such as wisdom tooth extraction, gall bladder removal, hernia repair and hip and knee surgery.)

In 2008, when researchers looked at prevalence rates in 10 developed and seven developing countries, in a sample that included more than 85,000 people, they discovered that the prevalence of any chronic pain condition was 45% among women, versus 31% among men.

In a 2009 review, researchers from the University of Florida found that, all over the world, women get more irritable bowel syndrome, more fibromyalgia, more headaches (especially migraines), more neuropathic pain (from damage to the nervous system itself), more osteoarthritis and more jaw problems such as TMD, as well as more musculoskeletal and back pain. In a large 2012 study (the biggest of its kind), Stanford University researchers confirmed this picture. 

And it isn't just clinical pain conditions that reveal an unequal burden of suffering. Sex differences have also shown up in lab experiments in which people voluntarily let scientists test their responses to pain stimuli, though recent research suggests that these differences are more complicated than once thought.

Historically, women have repeatedly been shown to be more sensitive to experimental pain stimuli than men—with lower pain thresholds (that is, they report pain at lower levels of stimulus intensity) and lower tolerance (they can't bear intense painful stimulation as long). More recent work shows that the type of pain stimulus—heat, cold, mechanical pressure, electrical stimulation, ischemic pain (from tourniquets cutting off blood supply) and other methods—matters a lot in the attempt to tease out gender differences. 

In a recent systematic review of 10 years' worth of data from pain labs, Canadian researchers found that men and women have comparable thresholds for cold and ischemic pain but that women have lower pain thresholds for pressure-induced pain than men. It's unclear why. With tolerance, there is strong evidence, the team found, that women tolerate less heat and cold pain than men, but that tolerance for ischemic pain is comparable in men and women. Again, it isn't clear why.

The more pressing question, of course, for millions of women in chronic pain is how well their pain will be managed once they seek help.

A few studies suggest that when women in chronic pain seek care in emergency rooms, they are offered comparable doses of opioids ("narcotics") as men and sometimes are actually offered more aggressive treatment. Chronic pain, by the way, isn't just acute pain that doesn't go away after a few months; it's a transformation of the nervous system that can literally shrink the brain.

But many other studies point to undertreatment of women's chronic pain—a pattern that fits an overall picture of differential care for men and women. With heart attacks, for instance, a team of Canadian researchers reviewed the charts of 142 men and 81 women with comparable symptoms and reported in 2002 that men were more likely to be given lipid-lowering drugs, to get angiograms (to detect potentially clogged blood vessels) and to have coronary-artery bypass surgery. 

Other data suggest that women are also less likely than men to be admitted to intensive care units and to get certain procedures, such as being put on a respirator, once they arrive there; they are also more likely to die in the ICU, in the hospital or within a year of admission. A 2007 Rhode Island study looked at 30 men and 30 women who had just had coronary-artery bypass surgery and tracked the medications they were given. The researchers were astonished to find that men got pain medications, while women got sedatives.

With chronic pain problems, women's symptoms are often minimized.

In a clever 1999 study, researchers from Georgetown University videotaped professional actors portraying people with chest pain. The researchers showed the videos to more than 700 primary care physicians and gave them data about each hypothetical patient. The doctors were much less likely to believe that the women with chest pain had heart disease. Similarly, when European researchers looked at the records of 3,779 heart patients, 42% of them women, they found that women weren't worked up as thoroughly. It was the same story in a 2000 Mayo Clinic of 2,271 men and women who went to the emergency room with chest pain. 

To be sure, chest pain and heart attacks can be especially tricky to diagnose because women and men tend to exhibit somewhat different symptoms. But less complicated medical problems, such as the knee pain of osteoarthritis, exhibit the same pattern of differential treatment.

Women are three times less likely to get the hip or knee replacement they need, according to Mary I. O'Connor, a former Olympic rower who now heads the orthopedic surgery department at the Mayo Clinic in Jacksonville, Fla. And when they do finally have the surgery, they often don't do as well as men, a problem she calls the "never-catch-up syndrome." 

Part of the problem is that women usually wait longer to have surgery, Dr. O'Connor has found, in contrast to men, who tend to seek surgery before their pain becomes extreme. The surgery itself is equally beneficial for both sexes, but because a woman typically has more advanced disease by the time she gets surgery, the result often isn't as good. 

Another factor may also be at work here: an unconscious bias that can make doctors less likely to recommend surgery to a woman with moderate knee arthritis. 

In a 2008 study, Canadian researchers looked into this very question, asking 38 family physicians and 33 orthopedic surgeons to evaluate one "standardized," or typical, male patient and one "standardized" female patient with moderate knee arthritis. ("Moderate" means a degree of arthritis in which it's a judgment call whether surgery is necessary or not.) 

The odds of a surgeon recommending knee replacement were 22 times higher for the male patient than the female, the Canadian team found. 

Women are under-treated for abdominal pain, too, a 2008 study showed. In Philadelphia, emergency room doctors kept track of 981 men and women who arrived with acute abdominal pain. The men and women had similar pain scores, but women were significantly less likely to get any kind of pain medication and were 15% to 23% less likely than men to get opioids specifically. Women also had to wait longer before they got any pain medicine—65 minutes on average, compared with 49 for men. Cancer and AIDS patients have displayed the same pattern, with women much less likely than men to get adequate pain treatment.

And consider this: In Sweden, researchers used a modified version of a national exam for young doctors in which hypothetical patients with neck pain were described. Some of the hypothetical patients were male and some female; all were described as bus drivers who were living in tense family situations. The interns taking the exam were more likely to ask female patients psychosocial questions (implying a psychosomatic origin of the pain) and more likely to request lab tests in the males. Female interns were just as biased as males. 

So if women have more chronic pain than men—and they do—the obvious question becomes: Why?

At the most basic biological level—the expression (activation) of genes, including genes that control responses to pain stimulation—gender has a very significant effect. 

In fruit flies, for instance, researchers from North Carolina State University have shown that males and females are different in the expression of a whopping 90% of all their genes. In other words, for almost all the genes in the fly's genome, sex plays a significant role in how active a particular gene is—that is, how much it is "turned on" and how much of a role it plays in the animal's physiology and behavior. Exploring such sex differences in gene expression could help researchers understand sex-related differences in pain processing. 

Sex hormones also play a major role in the different ways men and women experience pain, though the hormonal connection is proving nightmarishly tricky to unravel. 

It's clear that, as young children, boys and girls show comparable patterns of pain—until puberty. Once puberty hits, certain types of pain are strikingly more common in girls. Even when the prevalence of a pain problem is the same in both sexes, pain severity is often more intense in girls than boys. That is especially true with migraines. Before puberty, boys and girls get roughly the same number. After puberty, the prevalence becomes 18% for women and 6% or 7% for men. A similar pattern holds for TMJ, temporomandibular joint disease (now called TMD), as University of Washington researchers have shown. 

Overall, many researchers think that testosterone generally protects against pain, an idea shown in some rat studies. If newborn male rats are castrated, they are unable to produce testosterone later, during puberty. The result? The animals become less sensitive to the pain-reducing effects of the opioid, morphine, and thus more susceptible to pain. If newborn female rats are given testosterone, they get better pain relief from morphine. (A word of caution, though: It isn't clear how well pain findings in rats translate to people.)

But if the role of testosterone in pain is relatively straightforward (more testosterone, less pain), the role of estrogen is anything but. 

Genetics research suggests that estrogen reduces the activity of one of the leading "pain genes," called COMT. The job of the COMT gene is to get rid of stress hormones such as epinephrine. That means that if COMT activity is too low, the body can't get rid of stress hormones as well. And since stress hormones act directly on nerves to rev up pain, the net result of estrogen acting on COMT is more pain, according to researchers at the University of North Carolina.

Other research, too, supports the "estrogen is bad " pain theory. Consider what happens when transsexuals take hormones to enhance the sexual characteristics of their new sex. In one preliminary study, Italian researchers tracked male-to-female human transsexuals, who must take estrogen to enhance female sex characteristics. They found that approximately one-third develop chronic pain, especially headaches. The researchers also looked at female-to-male transsexuals, who must take testosterone to enhance male characteristics; their chronic pain went down. 

But often, things aren't that simple. At menopause, for instance, women's ovaries stop pumping out estrogen. To combat the symptoms caused by this drop in estrogen, many women begin taking exogenous estrogen—that is, estrogen not made naturally in the body but taken as a drug. If the general theory—that estrogen increases pain—is true, you would expect that taking exogenous estrogen (hormone-replacement therapy) would make pain worse. But in truth, sometimes exogenous estrogen makes pain worse, sometimes it doesn't, and sometimes it makes it better. 

And then there is the "catastrophizing" problem. In general, studies suggest that women are more likely than men to catastrophize—that is, to imagine worst-case scenarios and to believe that the pain will be unending. The tendency to catastrophize even shows up on brain scans called fMRIs. In one University of Toronto study, for instance, researchers showed that while catastrophizing didn't affect how the brain processed the sensory aspect of experimental pain, it did make the emotional regions of the brain light up. 

Catastrophizing may actually be a learned behavior; girls, more than boys, seem to pick up verbal and nonverbal catastrophizing cues about pain from their mothers, says Lonnie Zeltzer, a pediatric anesthesiologist at University of California, Los Angeles. The good news here is that studies show that cognitive behavioral therapy can help reduce the tendency to catastrophize.

Where does all this leave women in pain?

To some extent, in the same boat as men in pain. Both men and women often have to be extremely persistent in the search for a physician who can help with their suffering. That is because most doctors don't get enough basic education about pain in medical school—a sad but well-documented fact.

But women, I believe, have to be extra-persistent, particularly if they feel their pain is being dismissed as emotional.

I know, because this happened to me with the first physician I went to for my neck pain. When she seemed to imply that there was an emotional trigger for my pain, it felt like she was literally adding insult to injury. I left that doctor and found another—a man, as it happened—who believed me and set me on a path of treatment that ultimately worked. Thankfully, I am much better now.

This essay is adapted from Ms. Foreman's new book, "A Nation in Pain: Healing Our Biggest Health Problem," published by Oxford University Press.

Most people are aware that obesity poses a health risk including diabetes, heart disease, musculoskeletal complications and more. But rather than waiting until later in life when these problems are finally being confronted, obesity needs to be addressed during childhood. A N.Y. Times article addresses a new study that examines the onset of obesity and how children as young as 5 who are overweight remain that way as adults.

 New York Times - 

 

Health

 

Obesity Is Found to Gain Its Hold in Earliest Years

By GINA KOLATA 

JAN. 29, 2014

For many obese adults, the die was cast by the time they were 5 years old. A major new study of more than 7,000 children has found that a third of children who were overweight in kindergarten were obese by eighth grade. And almost every child who was very obese remained that way.

Some obese or overweight kindergartners lost their excess weight, and some children of normal weight got fat over the years. But every year, the chances that a child would slide into or out of being overweight or obese diminished. By age 11, there were few additional changes: Those who were obese or overweight stayed that way, and those whose weight was normal did not become fat.

“The main message is that obesity is established very early in life, and that it basically tracks through adolescence to adulthood,” said Ruth Loos, a professor of preventive medicine at the Icahn School of Medicine at Mount Sinai in New York, who was not involved in the study.

These results, surprising to many experts, arose from a rare study that tracked children’s body weight for years, from kindergarten through eighth grade. Experts say they may reshape approaches to combating the nation’s obesity epidemic, suggesting that efforts must start much earlier and focus more on the children at greatest risk.

 

A third of children who are overweight in kindergarten are obese by eighth grade, a study says. Tim Boyle/Getty Images

The findings, to be published Thursday in The New England Journal of Medicine, do not explain why the effect occurs. Researchers say it may be a combination of genetic predispositions to being heavy and environments that encourage overeating in those prone to it. But the results do provide a possible explanation for why efforts to help children lose weight have often had disappointing results. The steps may have aimed too broadly at all schoolchildren, rather than starting before children enrolled in kindergarten and concentrating on those who were already fat at very young ages.

Previous studies established how many children were fat at each age but not whether their weight changed as they grew up. While valuable in documenting the extent of childhood obesity, they gave an incomplete picture of how the condition developed, researchers said.

“What is striking is the relative decrease in incidence after that initial blast” of obesity that occurs by age 5, said Dr. Jeffrey P. Koplan, the vice president of the Emory Global Health Institute in Atlanta. “It is almost as if, if you can make it to kindergarten without the weight, your chances are immensely better.”

Dr. Koplan, a former director of the Centers for Disease Control and Prevention, was not associated with the new study, although its lead author, Solveig A. Cunningham, is an assistant professor in the School of Public Health at Emory.

The study involved 7,738 children from a nationally representative sample. Researchers measured the children’s height and weight seven times from kindergarten to eighth grade.

When the children entered kindergarten, 12.4 percent were obese — defined as having a body mass index at or above the 95th percentile — and 14.9 percent were overweight, with a B.M.I. at or above the 85th percentile. By eighth grade, 20.8 percent were obese and 17 percent were overweight. Half of the obese kindergartners were obese when they were in eighth grade, and nearly three-quarters of the very obese kindergartners were obese in eighth grade. The risk that fat kindergartners would be obese in eighth grade was four to five times that of their thinner classmates, the study found.

Race, ethnicity and family income mattered in younger children, but by the time the overweight children were 5 years old, those factors no longer affected their risk of being fat in later years.

The study did not track the children before kindergarten, but the researchers had their birth weights. Overweight or obese children often were heavy babies, at least 8.8 pounds, something other studies have also found.

The study’s results, Dr. Koplan and others said, “help focus interventions.”

Most efforts to reduce childhood obesity concentrate on school-age children and apply the steps indiscriminately to all children, fat and thin — improving meals in schools, teaching nutrition and the importance of physical activity, getting rid of soda machines.

“This suggests that maybe one reason it didn’t work so well is that by the time kids are 5, the horse is out of the barn,” said Leann L. Birch, a professor in the department of foods and nutrition at the University of Georgia, who was not involved with the study.

The most rigorous studies of efforts for school-age children, conducted in the 1990s, randomly assigned thousands of children to either participate in intensive programs that encouraged them to exercise and improve their diets, or go on as usual.

One study involved 1,704 third graders in 41 elementary schools in the Southwest, where most of the students were Native Americans, a group that is at high risk for obesity. A second study included 5,106 children in 96 schools in California, Louisiana, Minnesota and Texas.

Neither study found any effect on children’s weights.

Some obesity researchers said the new study following kindergartners over the years also hinted at another factor: the powerful influence of genetics on obesity, something that can be a challenge to overcome.

Genetic influences tend to show up early in life, said Dr. Stephen O’Rahilly, an obesity researcher who is a professor of clinical biochemistry and medicine at the University of Cambridge.

“We have known for 50 years that B.M.I. is highly heritable,” he said. “Surprise, surprise, if you tend to be fat, you tend to be fat at an early age.”

Body mass index is not quite as heritable as height, Dr. Loos said. But genes are not necessarily destiny. Exercise and a healthy diet can often reduce, but not completely overcome, the effects of genes.

Steven L. Gortmaker, a professor of the practice of health sociology at the Harvard School of Public Health, said he saw a bright side to the findings. Young children, he said, can cross a line between being fat or normal weight by gaining or losing just a few pounds. For adults, it can be 20 to 30 pounds, or even 40 to 50 pounds.

“It can take a long time to turn that around,” said Dr. Gortmaker, who wrote an editorial accompanying the new study.

And, he said, a number of randomized studies involving young children have shown that it is possible to stop or reverse excess weight gain. One, for example, had some fat children ages 4 to 7 reduce their television and computer viewing time, and had others keep theirs the same. Children in the intervention group — especially those from poorer families — consumed fewer calories, and their body mass index fell.

But effective programs for young children involve time and effort, and the costs are not reimbursed by health insurers, said Denise Wilfley, an obesity researcher at Washington University in St. Louis.

“We can effectively treat these children,” Dr. Wilfley said. But other than entering children in research studies, parents can get help only by paying out of their pocket — about $1,500 to $3,000 for an intervention that usually lasts a year.

Advice offered by a family doctor — if it is given at all — is usually ineffective, Dr. Wilfley said. All too often, parents tell her, their worries about a child’s weight are dismissed.

“I just saw a mom who was in tears because her little girl, who is 11 years old, weighs 212 pounds,” Dr. Wilfley said. The child has been fat since she was a toddler, but, Dr. Wilfley said, “the provider told her mom she would outgrow it.”

With a background in the arts, healthcare, and urban development, I find that each are intrinsically tied to the health and well-being of the residents of a community. The overlay of each creates the expression of what is felt as a quality of life, and the following article from the APA demonstrates how it all serves as a catalyst to economic vitality.

From the American Planning Association -

How the Arts and Culture Sector Catalyzes Economic Vitality

Terms such as "creative economy," "creative class," and "cultural economy" are becoming more common among urban planners, arts administrators, economic developers, and business and municipal leaders.¹ These terms reference a variety of types of jobs, people, and industries, including the sectors of visual, performing, and literary arts, as well as applied fields like architecture, graphic design, and marketing. Whatever label is used, this use of terminology linking culture and the economy indicates recognition of the connections among the fields of planning, economic development, and arts and culture.

The activities of the arts and culture sector and local economic vitality are connected in many ways. Arts, culture, and creativity can

• improve a community's competitive edge
• create a foundation for defining a sense of place
• attract new and visiting populations
• integrate the visions of community and business leaders
• contribute to the development of a skilled workforce

To pursue economic development projects with a creative approach, there are four key points to consider:

Keypoint #1
Economic development is enhanced by concentrating creativity through both physical density and human capital. By locating firms, artists, and cultural facilities together, a multiplier effect can result.

Keypoint #2
The recognition of a community's arts and culture assets (and the marketing of them) is an important element of economic development. Creatively acknowledging and marketing community assets can attract a strong workforce and successful firms, as well as help sustain a positive quality of life.

Keypoint #3
Arts and cultural activities can draw crowds from within and around the community. Increasing the number of visitors as well as enhancing resident participation helps build economic and social capital.

Keypoint #4
Planners can make deliberate connections between the arts and culture sector and other sectors, such as tourism and manufacturing, to improve economic outcomes by capitalizing on local assets.

Keypoints

Competition, definition, attraction, integration, and continued development are all pivotal aims for economic development professionals. Traditional outcomes of economic development in planning include job creation, increased tax revenues, increased property values, increased retail activity, and more sustained economic vitality. These goals are often pursued through programs such as workforce development, recruitment, amenity packages for firms, local property investment, and policies that support business. When combined with creative approaches, these traditional programs can create a richer context for economic development.

Economic development approaches that integrate arts and culture are usually combinations of facility-centric, people-oriented, and program-based approaches. Development of an arena, cultural center, incubator space, or creative district is an example of a facility-centric method, while a people-oriented approach could include facilitating arts professionals' development by approving live-work spaces, supporting arts centers, creating cooperative marketing opportunities, or commissioning artworks.

Program-based approaches target a specific issue within a community, such as developing an arts program — whether gardening, mural making, or public art displaying — to address the issue of vacant property; promoting health education through a local arts festival, exhibitions, or performances or plays with health themes; or displaying artwork in vacant storefronts to attract passersby and enliven an area.

Whether targeting economic improvement through facilities, people, programs, or all three, creative strategies can strengthen economic vitality (Table 1). Each key point is explored in greater depth below, with examples and connections to the strategies in Table 1.

Table 1. Creative Strategies for Improving Economic Vitality

Strategy	Description
Promotion of Assets	Promoting cultural amenities for the purpose of attracting economic investment and skilled workers
Development	Promoting community development through artistic, cultural, or creative policies
Revitalization	Promoting community and neighborhood revitalization through artistic measures and strategies that emphasize creativity
Economic/Job Clusters	Creating economic or job clusters based on creative businesses, including linking those businesses with noncultural businesses
Education	Providing training, professional development, or other activities for arts, cultural, or creative entrepreneurs
Arts-Oriented Incubators	Creating arts-specific business incubators or dedicated low-cost space and services to support artistic, cultural, or creative professionals
Branding	Developing visual elements that communicate a community's character; using logo development and graphic design for advertising, marketing, and promoting a community
Districts Live-Work Projects	Creating arts, cultural, entertainment, historic, or heritage districts Providing economic or regulatory support for combined residential and  commercial space for artists
Arts-Specific and General Public Venues	Providing public or private economic or regulatory support for marketplaces, bazaars, arcades, community centers, public places, parks, and educational facilities of various types
Events	Using celebrations or festivals to highlight a community's cultural amenities
Urban Design and Reuse	Implementing the reuse of existing sites or buildings for arts and culture purposes
Public Art	Supporting temporary and permanent public-art projects

Keypoint #1

Economic development is enhanced by concentrating creativity through both physical density and human capital

Concentrations of cultural enterprises and creative workers in a geographic area provide a competitive edge, likely by elevating the quality of life, improving a community's ability to attract economic activity, and creating a climate in which innovation can flourish.

Concentration of culture-sector firms and highly skilled workers, along with related facilities and business, enables partnerships and cooperative projects to develop. Concentration also facilitates the marketing of skills and products. The physical density of creative and cultural firms promotes the sector's prosperity, which is in turn economically good for the local area as a whole.

Clusters of culturally oriented businesses and workers can breed innovation and new specializations. Places where innovation is prized are naturally attractive to innovators and conducive to creativity of all types, as the frequency of exchange promotes creative activity. Planners can develop projects that deliberately locate creative professionals in a facility or area. Density or concentration of creative facilities can occur on a range of scales, from a single building to a streetscape, neighborhood, or district.

The Crane Building in North Philadelphia is an example of a facility-centric redevelopment for creative businesses and artists. Originally built in 1905 as a plumbing warehouse, the building today houses Crane Arts (www.cranearts.com), with four floors of artist studios and suites and a variety of project spaces available for community programs and cultural development. Facilities include an art-restoration studio, a ceramics studio, a multimedia studio, and a printmaking, painting, and sculpting studio.

One of the office suites is a cultural coworking space opened by Peregrine Arts (www.peregrinearts.org) for entrepreneurs, consultants, artists, writers, visionaries, and anyone working in design, media, history, the arts, and cultural heritage. The building has been successful enough that Crane Arts is considering opening another building. As an economic development tool, the building is beneficial not only to the creative occupants but to adjacent communities and the design profession as a whole.

For example, during the recent economic recession, local architects with few or no incoming projects participated in a gallery exhibit at Crane Arts in an effort to "get back to the act of making things."² The exhibit was an effective tool for marketing and design. In Tampa, Florida, a local developer designed and created the Sanctuary Lofts (www.sanctuarylofts.com) as an urban revitalization project to concentrate creativity and attract residents back to the downtown. The project began with an early 20th-century Greek Revival church in the Tampa Heights historic district that was transformed into loft apartments with space for creative-studio rentals.

Many of the existing materials were salvaged, including doors, windows, pews, and hymnal racks. Sanctuary Lofts now serves as workspace for painters, artists, photographers, designers, and architects. This unique living space can assist in facilitating communication between creative organizations and the public and can create a stronger sense of identity for community residents.

Keypoint #2

The recognition of a community's arts and culture assets is an important element of economic development

Recognizing and strengthening existing assets are vital parts of community development and can contribute to economic development. Assets include those related to entertainment (e.g., theaters, performing groups), personal development (e.g., community centers, bookstores), and education (e.g., schools, museums), as well as more directly to job creation and industry (e.g., translators, designers).

Cultural and creative amenities are assets as well as excellent tools for identifying and promoting other community assets. Creative-class theory suggests that a high-tech, highly educated workforce prefers a location with creative amenities.³ A flourishing arts and culture sector can affect where workers in the information economy, especially younger ones, want to live and as such is important for workforce recruitment and retention strategies.⁴ To promote local culture and creativity, communities can deem an area or part of town as an arts, cultural, or creative district.

A district is technically a designation to name and centralize creative assets by locating and drawing attention to cultural assets throughout the community. There may be economic incentives to live or work in such a district.

For example, Taos, New Mexico, has a number of designations intended to promote it as an arts and culture magnet. The State of New Mexico has designated Taos an Arts and Cultural District.⁵ The New Mexico Arts and Cultural District Resource Team reviews the state of the creative economy and emphasizes building upon current assets to develop economic well-being. At the federal level, Taos is designated as part of the Northern Rio Grande National Heritage Area. Additionally, Taos is pursuing the New Mexico "Quality of Life" local option tax (a tax incentive to improve energy and water conservation, sustainable building, employment benefits such as job-training programs and employer-provided child care, and other quality of life factors) to support the continued formal existence of the Arts and Cultural District.

It is also considering the construction of an arts-incubator space, to complement its affordable housing project, ArtSpace.⁶ Taos's approach to economic development is based on asset recognition and directly connected to the arts and culture sector. Another way to recognize assets and capitalize on them economically is to find ways to publicize and display the community's existing artistic talent and related amenities, such as ethnic foods, costumes, and visual arts and crafts.

For example, in New Orleans the cultural heritage of Louisiana is celebrated through the New Orleans Jazz and Heritage Festival. This festival increases tourism through a showcase of music of every kind — "jazz, gospel, Cajun, zydeco, blues, R&B, rock, funk, African, Latin, Caribbean, and folk to name a few."⁷

Keypoint #3

Arts and cultural activities in an area can draw crowds from within and around the community

Arts and cultural activity can increase attention and foot traffic to an area, including attracting visitors and increasing the length of time and money they spend, thereby contributing to continued development. Similarly, the presence of public art and related streetscape amenities such as artist designed lighting, signs, and benches is a way to attract pedestrians.

Arts and cultural activity often attracts attention, whether for casual perusal or artistic investment. Such activity can include events at culturally specific facilities such as theaters, museums, music clubs, and galleries, as well as cultural activity in venues such as arenas, public parks, community centers, and schools. Communities can also develop creative ways to make artistic activity happen in vacant or underutilized spaces.

Several communities have embraced the practice of promoting creative activity in vacant retail windows and storefronts as a revitalization tool. An economic redevelopment process can often last several years. In an attempt to temporarily transform a street scheduled for redevelopment in Brooklyn, New York, by the local BID, the local arts group Ad Hoc Art (http://adhocart.org/site) transformed a row of vacant stores into a street art gallery.

Known as Willoughby Windows, the block of Willoughby Street between Bridge and Duffield was turned into a temporary art exhibit, which included a photography-themed screenprint where a camera store used to be, woven paper maps, and a large cash register (representative of the perceived financial mistakes of Wall Street).⁸ This temporary, creative art exhibit transformed an otherwise vacant eyesore into an interesting space for pedestrians.

Boston Art Windows is a collaboration between the city and local artists aiming to fill vacant storefronts in the Downtown Crossing area with exhibits that draw pedestrians.⁹ The space is a streetside art gallery incorporating interactive video, lighting, and sound to encourage passersby to pause and enjoy the spectacle. One artist's camera records the movements of pedestrians and plays them back in time-delayed video loops that eventually cover a screen.

The redevelopment authority involves curators with the storefront show, seeing the exhibit as an opportunity to facilitate changes to Downtown Crossing as economic development continues.

In Grand Rapids, Michigan, local artists, business owners, and the public engage in an annual creative event called Art Prize (www.artprize.org/ home). Art Prize is an open contest in which any artist, established or emerging, can show work and any visitor can vote on it. In essence, Art Prize is the creation of a context for the city to become a temporary art gallery.

During this informal creative event, public participation, interaction, and economic development are strengthened as more than 100 venues open for it (including local retail and business spaces). More than 1,000 people volunteer. The resulting relationships extend beyond the boundaries of the competition to strengthen interaction among retail shops, business owners, and the art world. Economic benefits of the contest include increased traffic and improved business.

Keypoint #4

Planners can make deliberate connections between the arts and culture sector and other sectors

Establishing opportunities for partnerships among various economic sectors and creative professionals is a way to promote economic development. The talents of artists (especially related to design and communication) can enhance the value of local products and services and increase their dissemination. Partnerships often begin with economic clusters that are closely related to or dependent on the design field; examples include marketing, tourism, high-end manufacturing, and filmmaking. These economic clusters are groups of organizations with related producers, suppliers, distributors, and intermediaries. Proximate organizations can take advantage of shared interests, relationships, and economies.¹⁰

Deliberate team building by planners can help artists, designers, and people in related economic clusters to their shared advantage. Connecticut, for example, has recently instituted Cultural and Tourism Partnership Grants that encourage interdisciplinary collaborations among tourism, historical, film, and arts organizations.¹¹

The goal is to help localities develop relationships and strategies to improve tourism, an important goal in economic development.¹² The grants support projects such as film and arts festivals, development of garden and museum trails, seasonal crafts and events, and theater packages. Lead applicants must be nonprofit organizations, but they can partner to seek funding for both profit and nonprofit ventures.

Brooklyn, New York, is experiencing an economic transformation as a result of food. A growing gastronomical entrepreneurial energy is transforming once industrial, underutilized pockets of Brooklyn into culinary oases. Entrepreneurs in their 20s and 30s, who often have a strong sense of community and creativity, are opening restaurants, bars, pubs, specialty shops, butcheries, coffee shops, and other food production and processing facilities throughout the borough.

These businesses are not only meeting the growing local and regional demand for locally produced and wholesome foods but also creating an incubator for culinary quality, craftsmanship, and artistry. For example, the outputs of Cut Brooklyn, a knifemaking business, become the inputs for Brooklyn Kitchen, a specialty store; cacao nibs, a product of Mast Brothers Chocolate, and Ethiopian coffee beans from Gorilla Coffee are added to beer at Sixpoint Craft Ales; and root vegetables purchased from a nearby farmers market are combined with wort from Sixpoint to make relish at Wheelhouse Pickles.

This new collaboration between business owners is resulting in increased economic vitality and sense of community between merchants as well as residents.¹³ In February 2010, recognition of the economic, environmental, health, and social impacts of food production, processing, access, consumption, and waste disposal prompted residents of New York City and the Manhattan borough president to develop "FoodNYC: A Blueprint for a Sustainable Food System," a report that establishes goals and provides recommendations for improving and balancing the health, economic, and environmental needs of the city. This report recognizes the untapped economic potential of the region's food system, as well as the health, equity, and environmental challenges of this economic sector.

Conclusion

The economic development field has changed in the last decade from one that primarily emphasized location and firm-based approaches to one that more overtly acknowledges the development of human capital. Human capital refers to the sets of skills, knowledge, and value contributed by a population and has become a recognized asset as firms choose where to locate (and cities choose what to advertise and develop and whom to recruit) and entrepreneurs develop economic activity.

Members of some sectors of today's workforce seek certain characteristics in the places they choose to live. Places with entertainment options, public interaction, lively streets, and recreational and educational amenities are preferred, along with arts and culture activities and amenities. Leaders in the field of planning and economic development are developing noteworthy, creative approaches to making places of any scale more satisfying to this workforce, while increasing economic viability and competitiveness.

This briefing paper was written by M. Christine Dwyer (senior vice president, RMC Research Corporation) and Kelly Ann Beavers (PhD candidate, Virginia Tech, and American Planning Association arts and culture intern), and edited by Kimberley Hodgson, AICP (manager, Planning and Community Health Research Center, American Planning Association).