In 2009, the Institute of Medicine (IOM) held its Summit on Integrative Medicine and the Health of the Public. To set the stage for this very important summit, David Katz, MD, MPH, and Ather Ali, ND, MPH, were commissioned by the IOM to develop a paper titled “Integrative Medicine and the Health of the Public.”1 The abstract of this very clear and provocative paper is as follows:
It is interesting that in the same year as the Summit, the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH)—on which I served along with 23 other global health scientists, from 2005 to 2009—presented its final report on the social determinants of health (SDH), Closing the Gap in a Generation: Health Equity Through Action2 to the WHO. In turn, the report was accepted and released by the WHO in 2009.
Thus, it is appropriate to ask the question, “How do social determinants of health interact with and impact integrative, preventive medicine?” My immediate reaction is that the SDH place preventive medicine in a broader context and require a focus on policy, which is critical for impacting SDH.
The term “social determinants of health” was defined by the CSDH thus: “The conditions in which people are born, grow, learn, work, and age.”2 In society, they are most influenced by the distribution of wealth and power. Thus, as a rule, changes in SDH require changes in policy.
Some of the best examples of the impact of SDH are found in the new approach that the Centers for Disease Control and Prevention (CDC) is taking in the prevention and control of HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis. Perhaps one of the most interesting and challenging examples of moving from a traditional approach to prevention to one that incorporates the SDH, is the CDC transition plan enunciated in 2010. In a series of articles in the July/August 2010 issue of Public Health Reports, Drs. Hazel Dean and Kevin Fenton outlined the important transition needed for HIV, sexually transmitted disease (STD), and tuberculosis (TB):3
Individual level determinants including high risk behaviors such as unsafe sex and drug injecting practices are major drivers of disease transmissions and acquisition risk. However, it is also clear that the pattern and distribution of these infectious diseases in the population are further influenced by the dynamic interplay among the prevalence of the infectious agents, the effectiveness of the prevention and control interventions, and an array of social and structural environmental factors.
Many of these conditions arise because of the circumstances in which people grow, live, work, socialize, and form relationships, and because of the system often put in place to deal with illness, all of which, in turn, are shaped by political, social, and economic factors. This means that behaviors do not occur in a vacuum with respect to sexually transmitted infections (STIs). Individual sexual risk behaviors occur within the context of a sexual partnership or partnerships, which are, in turn, part of a wider social network. For other infections, or infectious diseases, including TB, while physical environment can influence patterns and opportunities for interpersonal contact, social mixing, and the probability of onward transmission of infectious agents, all of these determinants of transmission risk also occur within the context of a wider social and structural network. The authors later discussed the social impact of stigma on the spread of a disease such as TB. This is interesting because of our work on mental health and how we noted and communicated the impact of stigma on health-seeking behaviors in individuals and families dealing with mental disorder.
Fenton and Dean point out how the growing recognition of the social and structural barriers to prevention and control efforts for HIV, viral hepatitis, STI, and TB have allowed prevention experts to employ more comprehensive approaches to these interventions. I find especially interesting programs of social mobilization to oppose harmful traditions of practice, which often interfere with good health practices.
But structural factors include those physical, social, cultural, organizational, community, or economic and legal policy aspects of the environment that impede or inform all efforts to avail disease transmission. Social factors are the economic and social conditions that influence the health of people and communities as a whole. They include conditions of early childhood development, education, employment, income and job security, as well as food security, health services, access to services, housing, social inclusion, and stigma. The stigma surrounding TB has become a major factor in the diagnosis and treatment of this disease.
In an article in the 2010 issue of Public Health Reports, “Prisons as Social Determinants of Hepatitis C Virus and Tuberculosis Infections” by Niyi Awofeso,4 a discussion takes place about the effects of prisons as social institutions that contribute to the health status and health outcomes of the incarcerated population. Sexual practices, often common in prison, dramatically increase the spread of HIV. In turn, the communities from which these prisoners come and to which they return, are impacted with an increased risk for the spread of HIV. Already the growing shortages of males in these communities lead to the potential for one male infecting several female sexual partners.
In the same issue of Public Health Reports, Anna Satcher Johnson and her colleagues examine and compare the patterns of infections and spread of HIV in native-born American blacks versus foreign-born American blacks.5 First, they found major differences in the modes of spread in foreign-born blacks versus native-born blacks (predominantly male to male sexual spread). Second, they found that the rate of diagnosis of HIV in foreign-born black women was nearly equal to that of men and considerably higher than in native-born black women. Third, they found that foreign-born blacks were more likely than native-born blacks to be diagnosed with AIDS within 1 year of the HIV diagnoses. These findings reflect historical social differences in these two populations, who end up together in this country—thus showing the impact of history and experience.
Reed and colleagues examined the context of economic insecurity and debts among female sex workers in India.6 Economic status and debts were associated with experiences of violence and sexual risk factors for HIV in this population. As one would expect, this describes an association between education and STI diagnoses among young black and white women. They found an inverse relationship between education and STIs, with the association, however, modulated between racial groups. The authors suggest that other factors besides education play an intricate role in determining STI risk for young black women. Surely the plight of black men must be a factor in the risk, for even educated black women, as implied in looking at the high incarceration rates in communities and the return from incarceration by these men to communities where men are in short supply.
As former directors of the CDC, Bill Foege and I were asked to submit commentary (Satcher) and viewpoints (Foege) on this topic relative to actions that could be taken to address social determinants. In my commentary, I suggested four areas for interventions to successfully address SDH. I commented on (1) the importance of “health in all policies”7 and an approach recognizing that nearly all social determinants are outside the direct control of the health sector; (2) the need for public health to build stronger partnerships with nontraditional partners; (3) the need to conduct equity-effectiveness analyses along with cost-effectiveness analyses in all public health work; and (4) the need to expand resources to address all the SDH.
Bill Foege introduced his concept of “the last mile,” identifying the specific outcomes to be achieved by addressing SDH.8 He also proposed to develop a matrix for health and to incorporate prevention as part of medical practice allowing for reimbursements for preventive medicine.
During the development of the Affordable Care Act (ACA),9 a Prevention Council was assembled, from all agencies of the federal government, with a special focus on responding to the SDH and health in all policies. The Prevention Council, chaired by the then-surgeon-general Dr. Regina Benjamin, developed specific recommendations—a Prevention Agenda,10 as well as a budget, to be incorporated into the CDC budget going forward. The budget would start at 500 million dollars in 2011, and rise to two billion dollars per year by 2015, continuing at that level through 2020. This proposed budget has never been fully allocated as proposed, so the Prevention Council Proposal, for targeting the SDH, has not yet been realized.
In a 2009 article, “Don’t Forget About the Social Determinants of Health” in the Journal of Health Affairs,11 Gail Wilensky and I challenged the incoming Obama administration to respond to the CSDH’s report by promoting and implementing policies that will expedite healthy conditions for babies growing in the womb. We pointed out that maternal nutrition virtually sculpted the developing brain of the child in utero. We were pleased that the underfunded Prevention Agenda of the ACA built on this recommendation. However, the impact of social conditions on health does not end but instead escalates at birth and continues throughout life.
Targeting the SDH could be very helpful in the area of obesity and overweight. This problem and related conditions are responsible for a very large component of Medicare costs in this country.12 People who do not engage in adequate physical activity and practice good nutrition, will suffer from many chronic diseases, requiring care by the time they are eligible for Medicare.
In December 2001, The Surgeons General’s Call to Action to Prevent and Decrease Overweight and Obesity13 was released. We were especially concerned about how this condition was impacting children. It led us to refer to overweight and obesity as an “epidemic”—a term that had previously been reserved for infectious diseases. We found that, between 1980 and 2000, the problem of overweight and obesity in children had almost tripled in this country. Given that 80% of children who are obese at the age of 12, would be obese as adults, the Call to Action was long overdue. Thus, we attempted to clearly define those areas where action was both needed and feasible.
We first identified settings that could and should be targeted: (1) families and communities; (2) schools, where the average child spends eight or more hours a day, and where the health care system provides a powerful setting for intervention; (3) media and communications; and (4) worksites. In each of these settings, we applied the acronym “CARE” to define opportunities for intervention. The “C” stood for Communication, where we felt there were tremendous opportunities for improvement; “A” stood for Action that could be taken in the various settings; “R” for Research; and “E” for Evaluation.
Using this approach we were able to make specific recommendations for what could be done in these settings. Many of these recommendations have been implemented with some evidence of impact, especially for children under the age of 5. We have seen a stabilization of overweight and obesity, and in some states like Mississippi and Georgia, evidence of significant reductions.
However, The Call to Action was released before the World Health Organization’s Report on Social Determinants of Health. In 2001, the CSDH had not been formed to look at the impact of SDH, but many of the major barriers to progress were in the area of the SDH, which require in most cases changes in policy. For example, we recommended that Americans consume at least five servings of fruits and vegetables a day, but at the time, the Department of Agriculture’s “Free Breakfast and Lunch Program”14 did not comply with this recommendation. It was not until the “Child Nutrition Reauthorization Healthy, Hunger-Free Act of 2010”15 that this began to be corrected.
In many communities, there was no easy access to fresh fruits and vegetables because there were no grocery stores nearby. Louisville, Kentucky, would pass zoning laws requiring that all communities have access to grocery stores, and thus fresh fruits and vegetables, clearly illustrating that change in the SDH almost requires a change in policy.
The Wellness Policy, as established by the Child Nutrition and WIC Reauthorization Act of 2004,16 requires that schools return to physical education K-12, and while many school boards have followed through, others have not. Some have pointed to their inability to employ physical education teachers, stating that funds were needed to teach science and math instead.
In 2005, when I was chair of the board for “Action for Healthy Kids,”17 we released a report that incorporated research showing that physically active children who ate a good breakfast performed better in school, including on standardized exams in science and math. So, hopefully in time, more schools will appreciate the value of regular physical activity and good nutrition to school performance, and the fact that children who are physically active and engaged in good nutrition exercise better discipline in class. As shown in the National Football League– and National Dairy Council–funded program Fuel Up to Play 60,18 some innovative approaches to achieving the goal have been implemented by schools, and even by some individual teachers in the schools.
While people realize the importance of regular physical activity, fear and threat of violence are and have been major barriers to walking and jogging programs in some communities. Notably, some communities have been innovative in creating safe environmental opportunities for physical activity. Again, the Prevention Agenda of the ACA included funding that provided for virtually every child to have access to safe places to be physically active. Unfortunately, as previously stated, those funds have not been sufficiently allocated through the CDC budget as was planned.
One of the early participants in the Satcher Health Leadership Institute Health Policy Fellowship Program moved into a nearby community, where she was told it was not safe to continue to go outside in the early mornings to walk or jog. She responded by developing a community walking group, and ultimately acquiring police support in making their walking path safer. Increasingly, churches are doing similar things.
The worksite may well present one of the greatest areas of success. Businesses/corporations that provide health insurance coverage for employees, have begun to provide incentives for employees to be healthy and to engage in healthy activities. They have supported smoking cessation and/or weight loss programs, and have rewarded those who have participated. The employees’ component of the premium has decreased where workers have quit smoking or lost weight. Of course, many businesses, such as Johnson and Johnson, which won a top national award in corporate health improvement in 2012,19 have also saved millions of dollars in their health plans by implementing these programs encouraging smoking cessation, weight loss, and physical activity.
Spelman College, whose campus I can see from my office window, a few years ago gave up competitive sports to focus on the need for all students to engage in regular physical activity versus the 5% or so who engaged in competitive sports. They have developed a campus wellness program that includes a state-of-the-art wellness center.20 Spelman has dramatically changed its social environment in favor of regular physical activity, for all students, providing both the opportunity and the incentive for such.
In the healthcare arena, many physicians have attempted to write prescriptions for food and physical activity where indicated, with varying degrees of success. As I discuss these issues with physicians, especially young physicians, the question that is asked over and over again is, “How do I, as a practicing physician, deal with and take into consideration the social determinants of health?” Through integrative, preventive medicine, physicians have worked to influence their patients’ behavior in the areas of physical activity, nutrition, and avoidance of toxins as well as their sexual behavior and sleep and relaxation routines. But now we are saying that physicians must go even further and work to influence their patients’ social conditions, as the conditions in which they live, work, and play. As I interact with young physicians around these questions, I suggest three areas of potential intervention to enhance social conditions impacting the health of patients and their families: (1) education of patients and their communities; (2) partnership with community institutions, especially those in the workforce, education, and government; and (3) interactions with policy and policy makers to ensure the support for these interactions.
Just as physicians can educate their patients about lifestyles that are best for their health, they are now called on to educate them about how the social environment can impact their health. We know there are social environments that are not conducive for people who suffer from addictions. And patients in recovery should avoid such social interactions. Likewise, there are social environments that enhance healthy behaviors. Clearly, there are children with asthma who thrive better in some environments than others. Sadly, some children still live in apartment buildings where they are exposed to tobacco smoke from neighbors.
Some community environments are not safe for either children or adults. Exposure to violence seems to increase the risk that children who grow up in these areas are themselves more prone to violence.21 This is in addition to the fact that such environments are not safe for families. From a positive perspective, children and families need safe places to get outdoors and be physically active, and patients need to be educated about this. By the same token, families need to live in areas where there is safe, clean water to drink. Exposure to lead is dangerous for any age group but especially so for the developing brain.
The Surgeon General’s Prescription, which I released in 1999 at the World Health Conference on Health Promotion and Disease Prevention, is a card that I always carry with me to pass out when I speak. In addition to encouraging people to avoid toxins, such as tobacco, and practice responsible sexual behavior, including abstinence as appropriate, it calls for moderate physical activity at least 5 days a week for at least 30 minutes per day. It also calls for good nutrition, especially 3–5 servings of fruits and vegetables per day. However, again, this will only happen if families have access to fresh fruits and vegetables. Some communities require innovation to compensate for the absence of grocery stores.
One of the most interesting and challenging leadership development programs at the Satcher Health Leadership Institute at the Morehouse School of Medicine (SHLI/MSM) is the Smart and Secure Children (SSC)/Quality Parenting Program. We believe that parents contribute the most important social environments for their children, and this begins with pregnancy. Because of this, we consider parents the most important leaders in the community. Each year, The SSC Program engages about 100 parents from low-income, predominately black communities, for a 12-week program dealing with child development from 0 to 5 years. We seek to measure developmental landmarks while influencing nutrition and early parent-to-child communication. The program was designed to measure changes in the children, not the parents; however, the parents expressed concern about any possible impact on them. Since depression has been increasing in black women in urban communities,22 we decided to measure the impact, if any, of program participation on depression in the female participants. We were pleased to find that the risk for depression went down among the women who participated in the program. Positive outcomes in the children, relative to developmental landmarks, have also been noted.
We have recommended that physicians should educate parents about improving the social conditions in which their children are developing, especially early communication with the children, including reading, singing, and other forms of communication. The National Institutes of Health (NIH) is now supporting the replication of the SSC Program in 12 states; we are already working in seven of them.
But education of patients about opportunities and dangers inherent in interaction with the social environment or social conditions of the environment is not the only contribution physicians can make relative to integrative prevention. Physicians can also partner with community institutions such as schools, churches, and workplaces to positively impact SDH. Pediatric residents, of which I was one, at Strong Memorial Hospital in Rochester, New York, in the early 1970s, were not allowed to make the diagnosis of attention deficit hyperactive disorder (ADHD), without having visited the home and school of the child to discuss the child’s behavior with its parents and teachers in different settings. This helped to create a more positive environment for the child and also improved the teacher’s level of comfort with the child. But it was also noted that some children who seemed hyperactive at home were not so at school.
Doctors, especially primary care physicians, are now partnering with teachers and parents for the early diagnosis of autism and autism spectrum disease. The Clinical Research Center of the Morehouse School of Medicine Transdisciplinary Collaborative Center (TCC), is working with a church in the Atlanta community, to help congregation members manage their diabetes. This effort is based on the theory and belief that a supportive environment expedites lifestyle/behavior changes of diabetic patients in a predominately black, low-income community and congregation. These kinds of social interactions seem to support both behavioral change and adherence to treatment plans in the patient population. So, clearly, there are opportunities for partnering with community institutions to improve the SDH.
Five years ago, at SHLI/MSM, we initiated a program in Community Health Leadership with a focus on health promotion and disease prevention. We invited community pastors, community businesses, county commissioners, city council members, and heads of nonprofit organizations to recommend people from their organizations who could spend 12 weeks (1 day/week) with us preparing to provide health promotion and disease prevention leadership in their communities. We felt we could also learn (shared learning) how to better interact with the community in our efforts to improve its health. So it was shared learning that took us from integrative prevention to integrative prevention in the context of SDH. When members of the CDC Reach Program (a national program to reduce racial and ethnic health disparities) heard about our program, they asked if they could participate. Since our program was local, it did not require travel or lodging costs, so we had no funds for the REACH program to participate. But in response, the CDC offered to fund lodging and travel, allowing members of their REACH Program, from 40 different communities, to participate. We have now graduated over 300 people from the Community Health Leadership Program, including more than 30 pastors who referred themselves, as opposed to, or in addition to, other members of their congregations. Many of the pastors have now developed positive programs in their churches and surrounding communities, including HIV/AIDS education and screening, violence prevention, and community safety for physical activity and community interaction.
Several county commissioners and at least 10 mayors have completed the Community Health Leadership Program, as well as several other people who are community leaders. We are now working with the mayors to develop a special program to support their involvement in this component of the program. The original director of this program was recently hired by the City of New Haven, Connecticut, in an effort to develop and expand the program throughout that city; we are anxious to see how this progresses.
There are many opportunities for physicians to partner with communities, to improve the social environment and the SDH, with tremendous impact on overall health and well-being. Physicians can also partner effectively with government to improve the social environment for the health of individuals and the community. Government, as represented by public health, is dependent on physicians and other healthcare providers for all three of the main functions of public health: assessment, assurance, and policy development.
For many years, from 1873 to 1954, the Public Health Service (PHS) was led by a physician. The surgeon general, who oversaw all aspects of the PHS, was trained in medicine until that time. During the period from 1873 to 1954, when the surgeon general had the major administrative responsibility of the PHS, there was very little direct communication between the surgeon general and the American people. However, in 1954, the function of the surgeon general changed when the position of head of the PHS was separated from the Office of the Surgeon General and the position of Secretary of Health, Education and Welfare was created and later became the Secretary of Health and Human Services.
This integration of health, education, and welfare, and later health and human services was in many ways a major step forward. It is perhaps no coincidence that 10 years later, the nation received its first direct and official report from the surgeon general, titled Smoking and Health.23 Since its release in 1964, this report and subsequent follow-ups are estimated to have saved almost 10 million lives—a period in which the percentage of Americans who smoke on a regular basis, has fallen from 43% to 16% today.
In 1987, recognizing smoking as a SDH, California became the first state to prohibit smoking in public places and now over half of the states in the country have such legislation.24 This is an excellent example of physicians partnering with government at the highest level, but there are opportunities for such partnerships at every level. Physicians certainly have the responsibility to help their patients quit smoking, but we get the biggest bang when physicians interact with government to impact the SDH.
At the local level, physicians have impacted educational policy, either by participating on school boards or serving as very credible advocates for local policies that are in the best interest of the health of children and the community. If we are ever to reach the goal of assuring that every child has a safe place to be physically active and have access to good nutrition, physicians in communities will have to get involved and to provide leadership where applicable. The most critical requirement for effective partnerships is the sharing of the community vision and goals. Physicians can also take the kind of social histories that will allow them to help patients deal better with their social environment.
Health equity will not be achieved until we work together to respond to the need, of all citizens, for access to quality healthcare and also quality living environments. The expertise of physicians committed to preventive medicine will be critical to reaching the goal of health equity. Furthermore, we must remember that access to healthcare is itself a SDH. When physicians and other health professionals choose to practice in underserved communities, they positively impact the SDH in that community. Though indirectly, when physicians live and/or work in a community, it raises income and even education levels—two major SDH. Conversely, it is difficult to get physicians to live or work in communities that are underserved, because environments of poverty and violence have such negative impacts on SDH, including income and education.
But wherever physicians live and/or practice, if they are practicing IPM, they must be concerned about the SDH that may be limiting factors for patients attempting to change their lifestyles. As we have noted, SDH may be rate-limiting factors in the motivation and/or ability of patients to lead healthy/healthful lifestyles. Income and education together impact the kinds of social environment that one can enjoy. Income and education can buy leisure time, into which can be built health-promoting activities including access to safe places to walk, run, bike, swim, play tennis, or other healthy behaviors. On the other hand, low-income and/or poverty greatly limit access to safe environments, as well as to fresh fruits and vegetables. At the same time, low income and poverty can enhance the risk of violence in communities.
Finally, and perhaps most importantly, we know that SDH can only be changed by changes in policy. Thus, physicians must partner with policy makers to help assure that the policies put in place are in the best interest of the health of the community. We often refer to the McKinlay Model,25 which is built on a model for improving the nutrition of children. It shows the points of intervention as: downstream, midstream, and upstream. In this model, downstream is where we deal with individuals, their health, and their behavior. Midstream is community, and it is where we come together in communities to improve the health of the community and the health-promoting environment of the community. And finally upstream is where we make policy, and physicians increasingly must be involved in informing policy and developing relationships with policy makers that would enhance communications around health promotion policies in the community. So upstream, ultimately, must be our target, and examples of that include the Surgeon General’s Report on Overweight and Obesity in 2001, which led to Congress passing the Child Nutrition and WIC Reauthorization Act, establishing the Wellness Policy in 2004. Then of course later, Congress passed the Child Nutrition Reauthorization Healthy, Hunger-Free Kids Act in 2010.
It must be pointed out that sometimes it is much easier to make policies than it is to implement them. The implementation of policy is the ultimate goal. We know, for example, that many schools that adopted the Wellness Policy, did not follow up and implement physical education K-12 accompanied by good nutrition. So, whether it is the making of policy or its implementation, when it comes to the social determinants of health, there is a role for physicians and other health professionals.
1. Katz DL, Ali A.Preventive Medicine, Integrative Medicine and the Health of the Public. Commissioned for IOM, February, 2009.Find this resource:
2. Commission on Social Determinants of Health (CSDH). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008.Find this resource:
3. Dean HD, Fenton KA. Addressing social determinants of health in the prevention and control of HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis. Public Health Rep 2010;125(Suppl 4):1–5.Find this resource:
4. Awofeso N. Prisons as social determinants of hepatitis C virus and tuberculosis infections. Public Health Rep 2010;125(Suppl 4):25–33.Find this resource:
5. Johnson-Satcher A, Hu X, Dean HD. Epidemiologic differences between native-born and foreign-born black people diagnosed with HIV infection in 33 U.S. states, 2001–2007. Public Health Rep 2010;125(Suppl 4):61–69.Find this resource:
6. Reed E, Gupta J, Biradavolu M, et al. The context of economic insecurity and its relation to violence and risk factors for HIV among female sex workers in Andhra Pradesh, India. Public Health Rep 2010;125(Suppl 4):81–89. Epub 2010/07/16.; PubMed Central PMCID: PMC2882978.Find this resource:
7. Rudolph L, Caplan J, Ben-Moshe K, et al. Health in All Policies: A Guide for State and Local Governments. Washington, DC, and Oakland, CA: American Public Health Association and Public Health Institute; 2013.Find this resource:
8. Nguyen J.The Task Force for Global Health: 2013 Annual Report. April 21, 2014.Find this resource:
9.Learn About the Affordable Care Act. http://www.hhs.gov/healthcare/.
10. Shearer G.APHA Issue Brief: Prevention Provisions in the Affordable Care Act. Washington, DC: American Public Health Association; 2010. https://www.apha.org/~/media/files/pdf/topics/aca/prevention_aca_final.ashx.Find this resource:
11. Wilensky G, Satcher D. Don’t forget about the social determinants of health. Health Affair 2009;28(2):194–198.Find this resource:
12. Lakdawalla DN, Dana P, Goldman DP, et al. The health and cost consequences of obesity among the future elderly. Health Affairs. Published online September 26, 2005.Find this resource:
13. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Washington, DC: US GPO; 2001.Find this resource:
14. US Department of Agriculture and Nutrition Service. National School Lunch Program (NSLP). http://www.fns.usda.gov/nslp/whats-new.
15. US Department of Agriculture and Nutrition Service. School Meals. HealthyHunger-Free Kids Act of 2010. http://www.fns.usda.gov/school-meals/healthy-hunger-free-kids-act.
16. US Department of Agriculture and Nutrition Service. Team Nutrition: Local School Wellness Policy. Available from http://www.fns.usda.gov/tn/local-school-wellness-policy.
17.Action for Healthy Kids Annual Report 2005–2006. http://www.actionforhealthykids.org/storage/documents/AFHK_Annual_Report_2005-2006_FINAL.pdf.
18.Fuel Up to Play 60. https://www.fueluptoplay60.com/about/about-the-program.
19. National Business Group on Health. Johnson & Johnson’s Fikry Isaac, MD, Honored with 2013 Global Leadership in Corporate Health Award. https://www.businessgrouphealth.org/pressroom/pressRelease.cfm?ID=215.
20. Spelman College Vision, Mission, and Goals. Our Vision: Embracing Wellness for the Health of It. http://www.spelman.edu/about-us/wellness-center/vision-and-mission.
21. Office of the Surgeon General (US); National Center for Injury Prevention and Control (US); National Institute of Mental Health (US); Center for Mental Health Services (US). Youth Violence: A Report of the Surgeon General. Rockville, MD: Office of the Surgeon General, 2001.Find this resource:
22. US Department of Health and Human Services. Office of Minority Affairs. Mental Health and African Americans. http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24.
23. US Department of Health, Education and Welfare. Public Health Service Office of the Assistant Secretary for Health. Office of Smoking and Health. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Publication No. (PHS) 79–50066. 1964.Find this resource:
24. American Nonsmokers’ Rights Foundation. US Tobacco Control Laws Database: Research Applications. http://www.no-smoke.org/goingsmokefree.php?id=519.
25. McKinlay JB. The new public health approach to improving physical activity and autonomy in older populations. In: Heikkinen E, ed. Preparation for Aging. New York: Plenum Press, 1995:87–103.Find this resource: