Bad Bunny and Health

When Bad Bunny took the stage at the Super Bowl halftime show, the spectacle was undeniable. But beyond the lights and choreography, there was a message: unity across the Americas. It was deliberate, proud, and unmistakably cultural. Sitting beside me, a young woman sang every lyric with conviction — a reminder that while some of us may have aged out of pop culture’s center, its influence remains powerful and generational.

The reviews of the performance ran the full spectrum. Some praised it as groundbreaking. Others questioned its broader meaning and still others were appalled. For those of us working in health care, the more pressing question is not whether the show entertained it was what would be the implications as we work to meet our mission of best health for all.

While pop culture captures the spirit of the moment, the factors that drive how we provide health care requires a longer more measured horizon. Cultural visibility can shift narratives and foster pride, but it does not automatically become funding priorities, workforce investments, or accountability measures. While symbolism may open doors it is the systems designed by people that determines change.

Hispanic identity — rooted in Spanish heritage and sometimes interwoven with Indigenous, African, and other cultural influences — is not new or emerging but rather foundational to the hemisphere. Nevertheless, as the United States approaches its 250th anniversary, national celebrations often center on a narrow founding narrative. Spain, France, and Holland had established a presence on this continent centuries before 1776. Native American civilizations shaped this land long before European arrival. The story of America is broad and layered. The issue has never been presence; it has been recognition.

Recognition, however, must move beyond celebration. In health care especially, demographics are dynamic and reshape communities. If unity is to be more than a halftime theme, it must show up across everything we do in health— in policy alignment, funding commitments, workforce development, and long-term decisions.

Cultural moments can spark pride and visibility. Transformation requires policymakers and health system leaders to align with the communities they serve.

At the end of the performance, the message carried across the field was simple: “Together we are America”. The question is whether we are prepared to build systems that reflect that truth — not just during a halftime show, but in the everyday decisions that shape opportunity, health, and belonging.

Finally--- New Guidelines on Vitamin D Suggest Against What Many Have Been Told

"Vitamin D for the Prevention of Disease: An Endocrine Society Clinical Practice Guideline" [Link] is free and available. Please note that these guidelines are consistent with what many have been saying for years (see my blog on 8/21/18 and 2/6/20)...the routine screening for Vitamin D in healthy adults, the target levels for 25(OH)D and the need for taking Vitamin D supplements were not based on sound science. These new guidelines will save people from unnecessary testing and reduce the out-of-pocket costs for people. Some highlights:

General Recommendations: Suggest against routine screening for 25(OH)D levels in healthy adults, adults with dark complexion, and adults with obesity. Suggest daily, lower-dose vitamin D for those aged 50 years and older who have indications for vitamin D supplementation or treatment, rather than intermittent, higher-dose vitamin D.

Thresholds for Vitamin D: The panel did not establish specific 25(OH)D thresholds for disease prevention due to the lack of supporting clinical trial evidence. Previous target levels for 25(OH)D, such as 30 ng/mL (75 nmol/L), are no longer endorsed.

Nonpregnant Adults (<50 years): Suggest against empiric vitamin D supplementation above the Dietary Reference Intakes (DRI) established by the Institute of Medicine (IOM). Suggest against routine 25(OH)D testing in this population.

Adults (50-74 years): Suggest against routine vitamin D supplementation above the DRI.Suggest against routine 25(OH)D testing in this population.

 

What women want...information and no commercials

By listening to women and working with a fabulous group of experts we found that Latinas and their health care providers want information on how to be as healthy as possible that (1) does not have any commercial interest driving the message and (2) inspires and reinforces healthy behaviors. As a result we developed a three day seminar that includes the different systems in our bodies and how they interact, risk factors you can control, seeking well-being, importance of reading food and product labels, and much more.  Over 640 community health workers and community leaders have completed the three day seminar.  

We also recognize the limited time many of us have so we distilled the information to a two hour webinar that is self-paced. We released it today to celebrate International Women's Day. It is available in English Link and Spanish Link.

Let me know what you think.

Harmful Health Outcomes (HHO)— Are All About You

To have world class science and the best health outcomes means moving forward in bold ways that will improve the lives of scientists, health care providers, and people. 

For more details read "To advance science we need to address 'otherness' " in Nature Human Behaviour published on 2/2/24. You can access the free online version here or for a free ePrint please click on this link.

Dear Patient---I Only Have Some of Your Health Record.

Most patients believe that once they grant permission that a health care provider has access to their full health history. In fact, what is shared is limited in many ways. Jack Lewin and I had our Commentary on Interoperability and the need for the full patient record published in StatNews.  

Some medical records are very lengthy and go back decades. Is all that information really necessary? It depends on the situation. One reader from Norway shared their story.

"This is interesting, since I recently witnessed how lack of available medical records may change a planned surgical procedure just minutes before an operation.

Norway has less inhabitants than Manhattan, but the principle of making medical records available to all medical health providers, is universal. Over here, Southern Norway has a system whereby all MDs and all hospitals may access any patient medical record, - if (note!) the patient has been treated in southern Norway. If a patient has had an operation in Northern Norway, a health provider in Southern Norway will not learn about this, unless the patient mentions it. And the same goes the other way around, - south vs. north. To my surprise this system has remained for the last 10 years, without health authorities doing anything about it.

On December 4 I was going to have a hernia operation in Bergen, - on the southwest coast of Norway. The hospital has a section specializing in hernia repair with 3 surgeons performing only this kind of operation. They have extensive experience with laparoscopy (lap), and as I met my surgeon on the morning of the operation, she told me that the lap method was their standard procedure, unless the patients' condition dictated otherwise. I then told her that I had been operated for intestinal loop (blockage) back in 1970 in Bodø (Northern Norway), and she was surprised. She had not read anything about that in my medical record, and I showed her the remaining sutures. That made her change her mind regarding her planned way of repairing my hernia just minutes before the operation as the 1970 operation had actually accessed both the stomach lining and cut a muscle. So she decided to make an open repair."

What do you think about the need for access to the full patient record? If AI is seen as the solution how can we expect AI to guide clinical decision making if the data on the patient are at best incomplete. 

We have a long way to go...and we need to get there soon.

View "Real or Synthetic" and Share the Wait2Click Challenge

Over the past year The Healthy Americas Foundation worked with The Carter Center and the creators of the comic strip "Baldo" to develop "Real or Synthetic?"  These materials explain how information people receive is meant to engage them quickly. These resources are available in English and Spanish. 

The challenge is not to click, especially when something quickly grabs your attention. Here are specific cues to look for. 

1. When you have a strong and immediate emotional response to the content or an image. False information often relies on strong emotional appeals, to get people to believe it and share it. A story or claiming vista is often specifically designed to make you angry, scared, or overly excited. Moreover, it is increasingly easy to create images that are not real and increasingly difficult to detect when they are not real. 

2. The sender asks for personal information or money. They may not ask the first time they contact you, but do so after a series of interactions when they have earned your confidence. 

3. The sender claims to have been referred by someone you know. Contact the person, preferably by phone, and check.

4. Promises a quick solution to a problem.

5. If it sounds too good to be true, it usually is not true. There are many fact-checking websites and organizations that verify the accuracy of claims and news stories. Websites like Snopes.com, FactCheck.org, and Politifact.com can help you determine if a piece of information is true. For Spanish go to https://factchequeado.com

Most important of all invest 30 minutes of time and watch the free webinar wait2click.org

New England Journal of Medicine and my article, "Beyond Diversity— Time for New Models of Health." It is all about leadership.

Although I had collected data for my dissertation in the US, Colombia, and Brazil, my committee told me not to use the word culture as culture was not a relevant variable. That was over 40 years ago. Fast forward to the summer of 2021 when I submitted an article to JAMA. One of the comments in the rejection was, "The section on cultural themes does not make sense."

It was not the first time I heard that comment so I submitted my article to New England Journal of Medicine (NEJM). The thoughtful editors had specific questions and very helpful, insightful suggestions. They accepted my article for publication and here is the link to the online version, "Beyond Diversity— Time for New Models of Health." The print version is in the New England Journal of Medicine, Volume 386:6, February 10, 2022, Pgs 503-505.

But this is not about my article, it is about how an institution and its leadership leads. NEJM is an example of leading through words and actions.  The closing sentence of NEJM's October 7, 2021 editorial "Striving for Diversity in Research Studies" clearly stated, "From this perspective, diversity in research isn't simply a matter of social justice. It's a critical part of learning how to improve the health of every person." NEJM's actions were to outline new requirements for future submissions for publication that included a supplementary table on the representativeness of study participants. Words and actions. 

I am hopeful that my article will be widely read and stimulate healthy discussions. Consultant driven solutions, e.g., an organizational theory of change, setting up DEI committees, or appointing a Chief Diversity Officer, may create activities but are rarely the solution for meaningful outcomes.

Change happens through leadership and that starts with each one of us.

More on Sadness, Depression, and COVID

 Just want to share my two recent articles on depression that were published in The Hill.

Sadness is not Depression

Holidays and Stress

COVID-19 Vaccine Trials Need to Be Based on Good Science

It is 2020 and we still have to remind the health care decision makers that data need to be collected, analyzed, and reported by race, ethnicity, and gender. The reason behind this push to have meaningful inclusion of diverse population is that it is good science; and, to not do so may have dangerous consequences. This is especially true for clinical trials as they are meant to provide information that is useful about anyone who will use it or take it. Here is our OpEd piece on COVID-19 vaccine clinical trials that appeared in The Hill.

Buena Salud® Guide on Understanding Depression and Enjoying Life

As COVID-19 began to change our way of life I knew that this would be a hard time for most people and that many people would need support. I wrote the first edition in 2011 and because of how the science has advanced and how our expectations have changed what started as an update ended up being 90% new plus 92 endnotes. 

Life has changed and what is needed is a combination of science, clinical insights, and the lessons learned from many others. There is much that we can do on our own to make our lives better and when we cannot do it alone...there are many options for treatment.

The book is available at Amazon and at your local bookstores. 

Here is the link for English edition and for the Spanish edition

COVID-19 Requires Hospital to Rethink The Patient Experience

Keeping patients and health care workers safe is more than cleaning surfaces and having people tested for COVID-19 four days before they come from a procedure. It also means thinking about exposure, viral load, and ventilation. The time a patient spends in a hospital or health care facilities must be minimized for the health of the patient and all those who work in a health care setting. Procedures need to be recalibrated in real time to take into account the changing realities of COVID-19. It is not about having to wait; it is about the extra time spent possibly being exposed or exposing others.

For example, it is unconscionable that Georgetown University Hospital asks patients to check-in 2 hours before they are taken in to start the prep-op for a procedure. Good management practices would find it unacceptable that the process should take 2 hours. In the case that I witnessed the process actually took less than 20 minutes but the patient had to be there 2 hours before and then ended up waiting an additional hour because the other procedures were delayed. Of course there is paperwork that needs to be done, but much of that can be, and is often accomplished by phone or online.

I contacted the hospital by email about my concerns. The “Patient Advocate” responded in a way that made clear that they were an advocate for the hospital. I eventually called Dr. Michael Sachtleben, President, MedStar Georgetown University Hospital and Dr. Lisa Boyle, Vice President of Medical Affairs kindly returned the call. I emphasized that especially now, under the current circumstances, 2 hours should be unacceptable to all. For certain what is required is timely action and not the process of a committee to agree that 2 hours is too long. The goal must be to reduce time spent in the hospital as much as possible. No excuses. Following pre-COVID-19 standard operating procedures is dangerous to some and fatal to others.

I will see if there is any change as I will be taking my patient back for a repeat procedure. 

The Evidence on Vitamin D is Clear

In August 2018 I wrote my first blog on Vitamin D and wondered how long it would take for clinical practice to change. Much more has been documented since then to move prescribers to rethink and change what they recommend.

On August 27, 2019 JAMA published an original investigation, “Effect of High-Dose Vitamin D Supplementation on Volumetric Bone Density and Bone Strength: A Randomized Clinical Trial.” The September 3, 2019 NEJM Journal Watch comments on the study were succinct, “In any case, the findings point to no benefit for bone integrity — and even potential harm — with high-dose vitamin D supplementation in patients whose vitamin D levels are adequate.”  

Even with critically ill patients the benefits were not evident. The December 26, 2019 NEJM original article “Early High-Dose Vitamin D3 for Critically Ill, Vitamin D–Deficient Patients” from The National Heart, Lung, and Blood Institute PETAL Clinical Trials Network concluded “Early administration of high-dose enteral vitamin D3 did not provide an advantage over placebo with respect to 90-day mortality or other, nonfatal outcomes among critically ill, vitamin D–deficient patients."

When it comes to recommending Vitamin D the willingness to change current prescribing behavior is still missing. The lag between the bench and clinical practice is not just a matter of communication; prescribers also have to be willing to change. 

High-fructose Corn Syrup (HFCS) and You

While the March 22, 2019  report in Science, "High-fructose corn syrup enhances intestinal tumor growth in mice," may need to be confirmed with humans, it is reasonable to expect that a similar effect will be found with people. At the very least each one of us who shops for food or beverages for ourselves and others should carefully read the ingredients that are listed on the label. And then what? When the product has HFCS...be proactive with your health and and the health of those you love and get something else.

Saving Money in Health Care

A good way to redirect the discussion on health care costs and savings is by reading our piece on clinical trials. We need to make sure that each person gets the medicines that we know will work for them. This is how to save lives and save money in our health care system.

Redo Recommendations Now: Vitamin D, Fake Data, and Hype

We all need Vitamin D, a hormone, but the challenge is in how to measure levels of Vitamin D, how to determine how much a person needs, and when necessary how to supplement it. Over the years it was difficult for me to reconcile how practically everyone I knew had a Vitamin D deficiency. Since we are not all part of one cohort and we are certainly a group that is diverse in many ways it seemed very odd that we all had the same deficiency.

An answer came in two recent articles. First and most concerning was the August 17, 2018 issue of Science article,"Tide of Lies— The researcher at the center of an epic scientific fraud remains an enigma to the scientists who exposed him."(DOI: 10.1126/science.361.6403.636). This analysis detailed that much of what we know about Vitamin D was based on Dr. Sato's fabricated studies. According to the article his work was "referenced more than 1,000 times, and 23 systematic reviews or meta-analyses have included one or more of the 12 trials." Second, on August 18, 2018 A Kaiser Health News investigation for The New York Times, "Vitamin D, the Sunshine Supplement, Has Shadowy Money Behind It," revealed the effect of one person on an entire field of practice.

Both are disturbing commentary on the state of our knowledge...and our sense of responsibility to one another. How fast will clinical practice change to take this fake data and hype into account? How long will it take to change the Recommendations for Vitamin D Supplementation, the Algorithms in medical decision making and AI, and all the other information that we give and have been giving. Given this evidence how do we answer the question, "Do I stop taking my Vitamin D?"

How Can We Do Better...

This has been a year of field research that evidenced that too often efforts to create a better situation ends up compromising a person's health and well-being. Here are three cases to consider.

Heathcare-associated Infections (HAIs)

Frank entered the hospital with pneumonia but upon returning home it seemed that while in the hospital he had contracted an infection of his foot. Several weeks later the infection was much worse and Frank was taken back to the hospital to determine how much of his leg would have to be amputated. There were no plans for rehab. 

In 2011 75,000 patients with HAIs died during their hospitalizations.

Best Practice

After Rosa’s stroke she was told that in order to prevent another stroke she needed to have the blockage in her artery cleared, i.e., carotid endarterectomy (CEA). Rosa knew the risks of the procedure but went through with it. Much to her disappointment, a few months later the blockage had reappeared. One year later she still has the blockage but no stroke.

Translational research is a step in the right direction but the continued lag from the bench (research) to the bedside (clinical practice) is unacceptable. At the same time evidence based medicine (EBM) continues to be undermined by the lack of inclusion and analysis by individual characteristics as well as the tendency of clinicians and insurers to apply a rigid set of procedures that are not nuanced to the person in front of you.

Defining Comfort

Agnes was having difficulty breathing and was taken to the hospital. Her initial diagnosis was pneumonia and a UTI; then, suddenly while at the hospital she had two heart attacks. Her family was told that (1) her heart had stopped working and was severely damaged, (2) there were no treatments available, and (3) diagnostic procedures that were invasive were not possible given her age and fragility. Agnes' family was also told that she would die that night in the ICU. Agnes's family decided that given the damage to her heart that "palliative or comfort" care was the best option for her. Somehow Agnes got through the night and after two more nights in the ICU Agnes was moved to a private room. The family was told she could not go home because the levels of oxygen given were higher than allowed in a home setting.

Comfort care what does that mean? How do we know?

Statement on CBO Estimates of Better Care Reconciliation Act

22 million people losing health insurance is unconscionable

“The CBO estimate of 22 million people losing health insurance should be a bill stopper.  This bill was supposed to increase the number of people who have health insurance.  As it stands the legislation is unconscionable,” said Jane L. Delgado, PhD, MS, President and CEO of the National Alliance for Hispanic Health, the nation’s leading Hispanic health advocacy group.

“It’s time for legislators to go back to the drafting table.  The American people deserve bipartisan legislation that will deliver on the promise of insurance for everybody.  Congress must (1) ensure access for people with pre-existing conditions instead of enacting barriers to access that may be a death sentence; (2) roll back Medicaid cuts and allow for rates of growth that reflect the reality of an aging population; (3) ensure an orderly transition that does not disrupt care and ensures states can respond to changes in a way that reduces cost growth without compromising quality and access; and, (4) strengthen and expand the network of community health centers that have a proven capacity to deliver quality services,” emphasized Dr. Delgado.

“The one thing that everybody agrees on is that our system is not perfect, so it is time to start working in a bipartisan fashion and serve the interests of the nation.  The American people deserve better,” concluded Dr. Delgado.

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About the National Alliance for Hispanic Health (The Alliance) 
The Alliance is the nation's foremost science-based source of information and trusted advocate for the best health outcomes for all. For more information, visit: http://www.healthyamericas.org or call the Alliance's Su Familia National Hispanic Family Health Helpline at 1-866-783-2645.

The New No Gimmick Diet— 
The Buena Salud® Guide to Losing Weight and Keeping It Off

I am thrilled by the review and recommendation by Redbook for the latest book in the Buena Salud® Series. You can order the book from Amazon in English or Spanish or through your local bookstore. Let me know what you think. The process of writing and living the book has been quite a journey.

The other books in the Buena Salud series include:
The Buena Salud® Guide for a Healthy Heart
The Buena Salud® Guide to Diabetes and Your Life
The Buena Salud® Guide to Arthritis & Your Life
The Buena Salud® Guide to Overcoming Depression and Enjoying Life

Considering Arthroscopic Surgery for Your Degenerative Knee Disease?

According to the most recent recommendations published in BMJ it seems that your answer should be,"No." The exceptions are young patients with sports-related injuries, patients with major trauma, and those with a true locked knee. This is a huge concern as according to the article 25% of people 50+ years old have degenerative knee disease. 

While a health care provider may be an expert on this procedure and may have been doing it for years...the time has come to rethink when to do it or have it done. The evidence is that in most cases arthroscopic surgery for degenerative knee disease does not produce the desired outcome.

There will be more research to come...in the meantime the challenge is to develop new interventions which are truly helpful. 

Back Pain

The data indicate that most people with back pain that lasts less than 12 weeks get better regardless of the treatment. Some people get better even without treatment. Taking all this into consideration as well as all the available evidence, the American College of Physicians recently published new guidelines for the treatment of back pain. This was the first revision since 2007 and what is recommended is a departure from past practice. 

There are surprises in the new guidelines, e.g., for acute back pain the recommendations include superficial heat, massage, and acupuncture. There are also very specific guidelines as to the medicines a person should take. Take a look at the recommendations and share them with a friend. 

The science behind wellness is growing. To make the best decisions for our health and the health of those we care for, we each need to know the latest science based information.