Adding It Up: Hidden Lifetime Costs of Sexual Assault and Misconduct

Victims of sexual assault, violence, and misconduct suffer in multiple ways following the crimes committed against them. Liz Karns, professor from Cornell’s ILR School, has been following the lifetime costs for victims of these sexual crimes. As both a lawyer and an epidemiologist, she is tackling the data from an interesting perspective and sat down with eCornell’s Chris Wofford to discuss the lasting effects for survivors both on campus and in the workplace.

What follows is an abridged version of their conversation.

Wofford: You are an epidemiologist and also a lawyer, so you’re coming at this from two very interesting angles that together make for a really compelling story, so tell me a little bit about when you started looking at this and your experience.

Karns: As an epidemiologist, I started thinking about it just in terms of the types of data we would have, right? But it wasn’t until I went to law school like 13 years after being an epidemiologist that I started applying it to sexual assault, and in that context, I treated, and I continue to treat those cases just as I would any type of medical malpractice case or environmental harm case. They are the exact same set of ways that we assess damage. We need the studies, we need the research, we need the experts, and, it’s been a while coming that we got all of those things together. But at this point, we have so much research, so much information that makes it quite clear that the cost is a lifetime cost, and that currently it is usually the person, the victim, who pays for that – and that’s my interest, is to shift that.

In 2015 we had like a banner year of doing lots of different studies, and these studies were all essentially asking the same, which was ‘Have you been sexually assaulted while in college?’ And, there was some slight difference in terms of the phrasing. This was a study that was done by Kaiser and the Washington Post, and we have 25% of people who were assaulted since starting college, 20% for women, 5% for men. We see pretty similar pattern across all the different places, right? It never varies in a big way. The one that says 27 AAU, this was a study that Cornell was part of. We had 27 different colleges that did the same survey, and it’s important to have this information because it’s consistent across studies. There’s so many people who will say, ‘Oh, but people just make that up or it was dependent on the respondents.’ There’s been a lot of reliability and validity testing on this and this is solid data. The sad thing is that this the exact same data that we had in 1987. The numbers are the same since 1987 – roughly 20% is a consistent thing and it has not changed with anything.

Part of the reason that we add this up is that money matters. Somehow when we start attaching a price tag, people become more accountable, and the different systems that we look at are the legal systems. We’ve got the criminal and the civil system, and the financial obligation that arises out of that. Let’s imagine that a perpetrator is found guilty, and under the criminal system, ordered to pay restitution. That means they have to pay the victim money, and that is a contract now. That cannot be discharged, under a personal bankruptcy, so it is something that will stay with that perpetrator forever until they’ve paid it off.

Wofford: Wow.

Karns: That would change the world.

Wofford: I would imagine.

Karns: This is the standard approach to all injuries. This is exactly what’s used in your car accidents, your slip and falls, medical malpractice, everything else, so it’s interesting that people don’t think of it when it comes to sexual assault. So it’s part of my job, to articulate it, and make people think about that. If we assign dollars, we’ll get societal change. I’m quite sure about this one. The person initially talks to the psychiatrist, and then talks about different situations that this arises in, to figure out how invasive it is in their life. I have had people who could not go to covered parking lots ever again in their lives, and that meant that they would drive 50 miles out of the way to go to a different train station because they didn’t wanna use that one that had the covered parking lot. That meant that she couldn’t take certain jobs, so it’s got this sort of ripple effect.

Wofford: Yes, exactly. So what I’m getting at, or where I was going with that was, linking this particular diagnosis to these behaviors, and I wonder often how that plays out legally.

Karns: Yeah, well, I mean it’s absolutely part of the case because you’ve got, first the initial injury, which is the assault itself, and that doesn’t have a huge amount of value, obviously, like in terms of money, but the ways that it impairs one’s life after that are what get documented. That is the job of the lawyer to go through and describe the day and the life – you bring in different experts to say, this person will have a very predictable set of problems when they have their own children, so that’s a cost that you should be thinking about.

So the expert is who ties this person’s diagnosis and situation and then projects it forward, and when I’ve worked on medical malpractice cases where we had something happening to an infant, we would do the same thing. We’d say this is what their life looks like in the future.

Wofford: Yeah. Okay, behavioral health, again, this is not a big surprise, that they are more likely to be using alcohol or hard drugs, and they’re aware that they need to cut down, so they are aware that they’re using it as a substitute for treatment, if you will. And then this is the one that the insurance company knows is that they continually use more healthcare than non-victims, so whenever somebody discusses, gosh, maybe we should decide this is a preexisting condition, you can see why the insurance company is interested in that ’cause these are very costly, they have higher costs, 20% higher.

Karns: So, when people start acknowledging that the assault occurred, and that’s a process in itself, and realizing that they need counseling, it’s not unusual to have a diagnosis come up from that. They don’t have to go and seek a diagnosis to say, ‘mmm, boom, I have it.’ It’s going to evolve, and you have this statute of limitations, so you have so many years afterwards, that depends on your state, to file this case, and so, you don’t have to seek it right away. If you’re gonna build a case, and you’re talking to your lawyer, right, a lawyer, then they will very much ask you, ‘Are you in counseling? Do you have a diagnosis?’ Most of us have health insurance that would cover some aspect of that so there’s some record of that as well.

Wofford: So you’re recommending that the damages are then directed to the perpetrator, legally. What is the state of the law, what’s happening out there, as far as cases like this? Is this line of thinking adapted?

Karns: Yeah.

Wofford: Okay, so this is nothing new.

Karns: This is not, nothing I’m doing is new. All I’m doing is calling attention to it in a different way, and the way that I check myself, if you will, is that I look at what are called default cases – these are cases where the perpetrator, who then became a defendant in civil court, never showed up and the plaintiff, the person who experienced the assault, has the right to make the argument of, ‘What are the costs?’ And then the judge assesses those costs and decides whether or not they’re warranted.

This is all about true economic loss.

But, compensation funds will actually pay for things like therapy, so you could get that immediate counseling that you need, it’s just onerous to get there. Second one is – I mentioned this before – criminal restitution. This is part of any court process, that the criminal court can order the perpetrator to pay the victim. And then finally, civil damages, and this is the one I think most of us are familiar with, where we undertake legal action. The plaintiff, the person who is the victim, brings the case against that defendant, and everything I’ve talked to today goes into that damages number, and then that number gets used all the way through the civil court process, so demand letter, complaint, arguments.

So shifting the burden is what we need to do. That is absolutely what we’ll have to do. So things we can change. One, sexual assault happens in schools quite a lot, and we need to address the fact that it interrupts their education, and we need to think about a student loan deferral on this. It’s absolutely mandatory. The legal ones, holding the perpetrators responsible. And then finally, support, engaging survivors in discussions about the economic impact.

Want to hear more? Watch an excerpt of the live eCornell WebSeries event, Adding It Up: Hidden Lifetime Costs of Sexual Assault and Misconduct, and subscribe to future events.

New Certificate Program Teaches Dietitians Skills to Elicit Change

Cornell University’s director of wellness, Beth McKinney, has developed an online certificate program for registered dietitian nutritionists. The Nutrition Counseling certificate provides RDNs with client-directed counseling techniques they can use to elicit clients’ best thinking and results. Each course in the program provides six Continuing Professional Education (CPE) units for a total of 24 CPEs.

McKinney, a certified health education specialist and RDN who teaches an undergraduate course called Nutrition Communications and Counseling to upper level dietetics majors, has distilled her experience, and social cognitive learning theory, into an online program that allows RDNs to systematically learn, practice and hone their counseling skills.

“There’s a gap between the nutrition knowledge we learn in school and our ability to help clients make real changes. Even if most RDNs learned client-directed counseling, many haven’t had sufficient opportunities to practice it. These courses provide not only the techniques to transform behavior, but also videos in which practitioners can see counseling in action,” said McKinney, MSEd, RDN, CHES.

The Nutrition Counseling certificate, offered through eCornell, is comprised of four online courses that can be completed in three to five hours per week:

  • Getting into the client-directed counseling mindset with tools to develop self-awareness.
  • Mastering new, empathic ways to respond to clients that elicit more information and uncover problems from their perspective.
  • Motivational goal setting techniques that bring out clients’ best thinking.
  • Translating nutrition information to diverse clientele, using your authentic voice.

The program is open only to RDNs in the U.S. Students who complete all courses receive a Nutrition Counseling certificate from Cornell’s Division of Nutritional Sciences.

Want to Lose Weight? Drop the Diet and Get One of These.

The world is in the grips of an obesity epidemic. The UN’s Food and Agriculture Organization warned last year that “adult obesity is rising everywhere at an accelerated pace.” Some 640 million adults worldwide are now considered obese, or roughly 13 percent of the global adult population.  

As part of our Expanding Nutrition Frontiers webcast series, eCornell’s Chris Wofford was joined by professor David Levitsky from the Division of Nutritional Sciences at Cornell University to discuss why so many of us are putting on extra weight and what can be done about it.

Wofford: David, we’ll get into the solutions later but let’s start by talking about the problem. What is age-related weight gain? What is happening physiologically?

Levitsky: Well, I think age-related weight gain is perhaps the most serious medical problem in our country and maybe the world. Age-related weight gain is weight gain that occurs after you stop growing vertically. So after about 18 years of age, you continue to gain weight without growing taller. That age-related weight and the rate at which you gain the weight are the best predictors of whether you’re going to suffer from diabetes, hypertension, heart disease, stroke and many kinds of cancers.

Wofford: I was doing a little bit of research before this and I read that our muscle fiber tissues begin to disappear to some degree and get replaced with fat. Is there a biological reason for that?

Levitsky: Well, the decrease in muscle mass really doesn’t occur until middle age, your 50s or 60s. And it’s not that the muscle is replaced by fat, we’re just adding fat. Most of that weight gain is due to the fact we consume more calories than we expend. Simple as that. Despite all the hundreds of diet books out there teaching all kinds of magic, it is simple energetics.

Now we can ask why we are consuming more calories than we expend… My colleagues and I agree that we live in an environment in which we are surrounded by signals that make it easy. In psychology, we call this priming. So if we see food, it actually makes us want to eat. And we have experimental data showing that if you see people eating, you want to eat. When we see a television commercial containing food, we’ll get up and go to the refrigerator to get something to eat. We are totally surrounded by these stimuli and what is referred to as an obesogenic environment.

It’s obesogenic because simply responding to all the stimuli in the environment causes us to gain weight. And that’s the reason we’re gaining weight as we get older. We’re subjected to more and more of these stimuli and we’re going to respond by eating just a little bit more than we expend.

Wofford: Let’s back up a little bit and talk about your experience as it relates to psychology and nutrition, and the experiment that you conducted several years ago related to weight gain and how it might be prevented.

Levitsky: Okay. This all started for me when I was sitting in my office and I had someone pop in and say that they wanted to study “the freshman 15”, which is the idea that college students gain around 15 pounds during their first year. It turns out it’s less than that – more like 5 pounds – but the problem is real. Nobody was really studying it so I said, “Okay, go ahead and look at it.”

So we gave freshmen scales at the beginning of the semester, had them weigh themselves at the beginning the semester and again at the end of the semester, and by then they had gained about 5 pounds here at Cornell. We didn’t really believe it was real, so I got very excited about these findings because it represented an opportunity to study techniques to try and prevent that weight gain.

The most logical way to lose weight is to say, “I’m just going to reduce my calories by 200 per day.” Diets have been around forever, and forever they’ve shown that they don’t work for the vast majority of people.

They’re still responding to the stimuli in their environment and it gets more and more difficult the more weight you lose. So the traditional way of concentrating on caloric intake fails.

Wofford: Nothing new there. Okay, so you’re doing this study and discover that the freshman 15 – or maybe the freshman 5 – is real. What’s next?

Levitsky: My training is in psychology and it’s in a certain kind of psychology called behaviorism, which is a discipline that’s simply dedicated to your behavior in certain situations. In order to change behavior, you have to have some monitor of that behavior. When it comes to weight, that monitor can simply be stepping on a scale.

So the first thing we tried was to give freshmen scales and ask them to weigh themselves every day and keep a graph of their weight. We found that those who followed through and weighed themselves did not gain weight while those who didn’t follow through gained two and a half kilos. I did not believe it the first time we did the experiment so we replicated it the following year and the results were very clear: those who weighed themselves every day and had a record of their weight in the form of a graph do not gain weight.

But of course, college students do not represent the population so we then used older people at a health center for a two-year study and again, those who continually monitored themselves actually lost weight.

Now we have a project that we’ve just started here at Cornell, working with the staff because neither students nor people who belong to a health club are representative of the population. We’ve recruited staff from the groundskeepers to the police force here — wherever we could find real people who are more representative of the population — and half of them have scales and half of them do not. We weigh everybody at the beginning and we weigh everybody at the end. Our hypothesis is that people who weigh themselves regularly won’t see a weight gain. We’ll have to wait and see how it turns out.

Wofford: What is happening from a behavioral psychology standpoint? When they look at this weight graph, what is happening in their minds? How does that affect what they do?

Levitsky: Well, there are actually three hypotheses that we have been entertaining as to how this works. The first is that it is simply having the information. They look at the scale and say, “Oh, 155 pounds is too much for me.”

A second possibility is that it works as reinforcement. If you see yourself losing weight, you say, “Oh wow, that makes me feel good” and then you are going to reinforce those behaviors that made you lose weight. That is also a possibility but I’m not holding my breath that either one of these two hypotheses will work.

I prefer to consider the third hypothesis, which is based on priming. Just like when you see food and it makes you want to eat that food, we are working on a priming idea where just stepping on a scale is a primer for all the health information that you already know. You know what to eat, you know how you should behave but you need something to stimulate you. I think that is what happens on the scale.

We have done a number of studies in our laboratory where we bring people in for a focus group. Well, we tell them it is a focus group, but it’s not really. We put snack food in front of them and then sometimes we show them advertisements for cars or how beautiful it here is in the Finger Lakes and sometimes we show them food commercials. When we show them the food commercials, they consume considerably more than if we show them a food-neutral stimulus.

But when you have them weigh themselves just before they go in – we don’t tell them anything about why we’re weighing them, we just get their weight – they consumed considerably less.

Wofford: Even though they’re exposed to the same amount of stimuli.

Levitsky: Right, the stimuli is the same but stepping on that scale changes the way you react to things.

Wofford: I’d like to turn to the audience and get them involved. We have a question here from Christine, who says, “I have been stepping on the scale every day for years and I run three to four miles three times per week and yet I have gained at least 10 pounds.” Is this where we get into the issue of the quality of the calories?

Levitsky: Well, stepping on the scale does not produce magic. It should be a means of informing you of where you are. If she’s gained ten pounds over a few years, she can reverse it by making changes to her eating. You have to change something. If you can live without desserts, without snacks or with smaller portions, these are all good techniques to cause that negative energy balance to get you to lose weight. The only thing I would warn her is try not to lose that ten pounds overnight. She has to think of it in terms of a slow return back to her weight and she can do it. I mean, running 10 to 15 miles is no small thing.

Wofford: I’ve got a question here from Marsha. She says, “I weigh myself every day and work out at the gym every day but I could also use a calorie counter app on my phone. I feel like keeping track of the calories is the most influential in my weight control.”

Levitsky: Calorie trackers work but the problem with the trackers, whether it’s movement trackers or diet trackers, is that most people can’t keep that up for long periods of time. People don’t have room for extra things in their lives and inputting that information is an extra thing. That’s why I tell people in our studies to put their scale right by their bed. You get out of bed and step right on that scale and it takes two seconds to get a measurement, but it’s nothing extra you have to add into your life.

Wofford: Erica asks: “Do you believe that weight loss is about 80 percent of what you put in your mouth and 20 percent physical activities?” Is this a common metric?

Levitsky: There are a lot of reasons why people should exercise. However, and I hate to tell you this, exercise has very little effect on what you weigh. The reason is that the body is so efficient that when you go out and spend that energy and then come back and rest, your metabolic rate after you rest actually goes down lower than it would have had you not exercised. So, exercise doesn’t benefit your weight. It does, however, benefit your risk of heart disease, the prevention of diabetes, and the prevention of stroke and cancers.

Wofford: OK, so exercise isn’t going to get you there. It’s all about what you eat?

Levitsky: I strongly recommend that if you try to lose weight, it should be done very slowly. You should lose weight probably at no greater than one percent decrements. So you see what your weight is and then set a goal for a weight at no more than one percent lower than that for whatever time period you need. You need to take it one step at a time. Some people could do it immediately, while for others it will take them a while to figure out that maybe they can’t live without that afternoon snack. And that’s fine. You just try something else like lowering your portion sizes or skipping dessert. You figure out what works for you and then you try to get to that lower value. Once you discover you can live with whatever change you made, then you make another change. You go down another one percent.

I don’t recommend that anybody get below 10 percent weight loss. At 10 percent, you can reverse things like diabetes and lower blood pressure. All of the beneficial effects of weight loss occur at a maximum of about 10 percent weight loss. That’s all you need in order to improve your health. Now, if you want to lose it for other reasons, aesthetic reasons or whatever, that’s another matter.

Wofford: Another question from the audience focuses on so-called good calories versus bad ones. Do you have any thoughts on this?

Levitsky: Healthy food will do the most to reduce your caloric intake. Low fat foods will clearly decrease your caloric intake. If you reduce the portion size, you’ll be satisfied with less food. If you can do without the potatoes, without the the carbs, fine. Are there good carbs, bad carbs or good calories? It makes a great title for a book, but the nutritional science says that a calorie is a calorie.

Wofford: We’ve discussed weight solutions for individuals but is there anything we can do as a society to address this problem?

Levitsky: I think the scale is the most healthy tool that you can use, so why not give out scales? Let the government give out scales to those who want one. It will be cheap for them. It would cost them probably about $50 a scale and they could save millions if they could prevent you from getting diabetes or hypertension.

A number of my colleagues believe that the government should step in and curb food commercials, particularly ones targeting children. I mean, it sounds reasonable but I am very skeptical because the food industry is perhaps one of the most powerful lobbies in Washington.

Wofford: What’s next for you? Are there any new weight-related research projects you’re working on?

Levitsky: My dream experiment that I’ve been trying to do for a while is to work with obese children. We know that if you don’t do anything to help a pre-adolescent obese child, they will become an obese adolescent. We also know that if you do nothing once you’ve become an obese adolescent, you are going to maintain that obesity throughout your life. The chances aren’t just extremely high, it is almost a certainty.

So what I want to do is take these pre-obese children and give them and their family scales and see if we can we get these children to grow at a slightly reduced rate by watching their weight. Could that get them into their adolescence in a non-obese state? That’s where I would like to go but I’m still trying to get funds.

Wofford: That’s a noble cause. Isn’t the obesity rate among children something shocking – like over 20 percent?

Levitsky: It is and what is more shocking is the rate at which it’s increasing. The actual rate of child obesity is lower than adult obesity but the rate at which they’re getting fatter is what’s really threatening. And that’s what I want to prevent.

Wofford: We all wish you the best of luck with that. I want to thank the audience for coming today. And thank you David, this has been illuminating for me. I’ve learned a lot today in the short time that we’ve been together.

Levitsky: My pleasure. Thank you.


Want to hear more? This interview is based on David Levitsky’s live eCornell WebSeries event, The Only Weigh to Prevent Age-Related Weight GainSubscribe now to gain access to a recording of this event and other Expanding Nutrition Frontiers topics. 

Does Your Environment Impact What You Eat?

How to Improve Healthy Eating and Active Living in Rural Communities

America is in the grips of an obesity epidemic. While it may be tempting to lay the blame on personal choices, the reality is much more complicated. It’s hard to live healthily when you have limited nutritious food options nearby or if your community does not provide the types of environmental features that promote physical activity.

As part of our Expanding Nutrition Frontiers WebCast series, Chris Wofford was joined by Rebecca Seguin, an associate professor in Cornell University’s College of Human Ecology, to discuss healthy living in rural communities.

Wofford: Rebecca, what is the current state of affairs when it comes to healthy eating and active living? Why is this something we should be concerned about?

Seguin: I think everybody knows that we have a major problem with the number of overweight and obese Americans. Two out of three adults are overweight, and that is certainly problematic in and of itself. But it also carries all of these additional risks like cardiovascular disease, diabetes, and some types of cancer.

We also have a major epidemic of child obesity, with one in three children being overweight or obese and about one in five children qualifying as actually obese. We know that if individuals are overweight as children, they are more likely to be overweight or obese as adults and that will then carry through all these additional health risks. If current trends continue, the next generation will be the first to die younger and sicker than their parents.

We know that while individuals make their own decisions about what they eat and what they do, they are part of social and physical environments that influence them both negatively and positively. So we need to better understand the features of those environments so we can help guide people towards making healthier living choices.

We can also influence policy at the local, state, and federal levels in terms of policies and guidelines that can help people make better choices and live healthier lives.

Wofford: Can you give us an example of how the physical environment in rural communities affects healthy living?

Seguin: There’s a town in Pennsylvania that we’ve worked with that’s fascinating. There’s a sort of a triangle in the middle of these two state highways and the community center and school are sandwiched in between. You have residential communities on each side of the highways and the children all get driven to school even though they only live a 16th of a mile away.

They have to be driven because there’s no safe way for them to get from their residences to the school or to the other side to the library, which is really the heart of this community. I myself took a walk through this area and it really felt dangerous. There weren’t sidewalks, there weren’t crosswalks. Cars were not looking for pedestrians at all.

So the question becomes whether you could build some structures and start changing social norms that would enable the kids to actually be more active in their daily lives. That’s what we really need. We don’t necessarily need people to be more active by going to gyms. They need ways to become more active in their daily routines.

Wofford: What’s the solution?

Seguin: A local policy might be to organize “walking school buses.” Parents could sign up to take one day a week in which they would help the kids safely walk to school. That’s an example of a residential policy initiative that could really help kids get active in their day-to-day lives.

Wofford: So that ties in to what’s known as the “built environment” concept, right? And doesn’t the same concept apply to things like the availability of healthy food?

Seguin: Absolutely. Something we have to think about, particularly in rural environments, are the small businesses. Small store owners, for instance, are often barely staying in business. So while you might want there to be healthier choices for people in those small town retail environments, in some cases healthier food choices are going to spoil because people aren’t buying enough of them. A local initiative that might actually help drive business would be to use local marketing to highlight some of these healthy options. If you can create enough demand within these small stores, the owners wouldn’t lose money and then they could stock more variety and higher quality products.

Wofford: As you said, the obesity epidemic is a national problem, not something that is confined to rural communities. What are some of the factors behind it?

Seguin: This is really simple stuff but I think it’s important to remind people that when we talk about obesity it is about energy in and energy out. What we want is for people to maintain an energy balance. Even if you are overweight, staying weight stable is a benefit compared to continuing to gain weight. And if you’re obese or overweight and want to lose weight, that means you have to expend a bit more energy and eat a bit less. If you just make those tiny shifts over time, you’ll get closer to a healthier body weight.

A lot of this has to do with sedentary behavior. We’ve built all of this efficiency into our lives and that efficiency has actually caused us to hold onto extra weight and not be as physically active or physically fit.

Two out of three people are not getting any daily physical activity. And at our schools, this number is a little out of date, but around 90 percent of children have no physical education classes. We need people to be more active. We want them to engage in vigorous physical activity. We want them to do a range of leisure activities and to simply sit less.

We’re all sitting down a lot but there are little things you can do to help: just getting up and moving around, parking a couple blocks away when you’re running errands, taking the stairs, that sort of thing. Those little bits of activity really add up throughout the day.

Wofford: Activity is one thing, but what about what people eat?

Seguin: We really need to see a shift in eating patterns, like eating more whole grains and having fruits and vegetables take up a much bigger bit of real estate on your plate, as well as having a variety of protein sources.

Let’s look at what Americans are eating. Too much in the way of refined grains, not enough in the way of whole grains. Too much in the way of added sugars and sodium. I don’t think people realize all of the foods that have added sugar. Bread and cereal are good examples. Both can have quite a lot of added sugar—more than people might realize.

Part of this is individual decision-making but part of it is also the social environment. And part of it is the built environment—financial access and physical access.

Wofford: Can you tell us about some of these environmental factors?

Seguin: When it comes to health in rural communities, there is a list of questions you need to look at. Is there a sidewalk? Are there crosswalks? Is there a restaurant there? Is it a fast food restaurant? Is there a grocery store? Is the only food store in town the gas station that sells convenience food? The built environment matters.

When people think about the environment, they think about things in nature but when we talk about the built environment, these are man-made features: streets, playgrounds, sidewalks, community centers, et cetera.

Wofford: So, making a community more walkable can help with obesity?

Seguin: Yes, but it really depends on a variety of factors. Part of it depends on how far people actually live from where they’re walking. There are also factors related to low-income neighborhoods and minority neighborhoods and there are safety and transportation factors. There’s not a clear answer but in general, community features that we consider to promote active living are associated with lower obesity rates.

Wofford: You mentioned earlier trying to walk a few blocks when out running errands, but in some rural communities the nearest market might be ten or more miles away.

Seguin: That’s right. For a lot of people the closest market is far from home and in a lot of cases it’s not even a good market in terms of healthy choices. That’s what people are faced with. They are basically forced to drive.

We did some work in rural Montana and, in some cases, people out there only shop once every three weeks or more because they are driving 100 miles to a mega-superstore and getting all this food.

Wofford: You hear a lot about “food deserts.” When it comes to access to food, what are we talking about?

Seguin: I think people will often hear the term “food access” and they just think maybe there isn’t a store there. But it’s actually more than that. It’s proximity to the store—can you get there? There are many people, including a lot of the older adults whom I work with, who don’t have access to consistent or reliable transportation. And so, that Dollar Store or the local convenience store becomes their only food access point because they don’t have any other options.

Wofford: A big part of your work has been dealing with the local community members, whether that be in Pennsylvania or Montana or wherever. How did you get people engaged and did you meet with any resistance?

Seguin: We absolutely faced resistance. In food environments, the big issues are working in schools. There are huge barriers involved, like the food that the schools have access to, and time factors for the workers involved.

When it comes to the built environment and a focus on increasing physical activity, the biggest resistance is cost. How do you pay for all of this? It might sound great to build a bridge over those two busy roads to get the kids from the library to the school and then home again. But who’s going to pay for it?

There’s also the capacity issue. People have limited capacity and they’re busy, so how do you keep them engaged over time? That’s an ongoing challenge.

However, through some of the community work that we do, we can see that one of the key motivators for residents in the projects that we run is that they’re incredibly concerned about their children, their grandchildren, and future generations. That motivates them to get involved in changing community environments, because they want their grandchildren to be healthier.

Wofford: We’ve covered a lot of ground here today. Rebecca, thank you for joining us.

Seguin: Thank you, this has been great.


Want to hear more? This interview is based on Rebecca Seguin’s live eCornell WebSeries event, Improving Healthy Eating and Active Living in Rural Communities Through Citizen ScienceSubscribe now to gain access to a recording of this event and other Expanding Nutrition Frontiers topics. 

Hunger and Obesity from an Economic Perspective

A distinguished economics professor may not be the first person that comes to mind as an expert on global nutrition, but John Hoddinott has spent years at the intersection of the two fields, studying the consequences of poverty, hunger, and undernutrition in developing countries.

Hoddinott, the H.E. Babcock Professor of Food and Nutrition Economics and Policy at Cornell University, has conducted research in countries around the world, including Bangladesh, Ethiopia, Guatemala, Mali, Namibia, and Zimbabwe.

As part of Cornell’s Expanding Nutrition Frontiers WebCast Series, Hoddinott joined eCornell’s Chris Wofford to discuss chronic undernutrition in developing countries and the obesity epidemic in developed countries, as well as possible solutions to both issues.

Wofford: John, thanks for joining us. Let’s begin by defining our topic. What is chronic undernutrition?

Hoddinott: One way to think about this is to think about the nutrient content of foods, here being micronutrients and macronutrients. Micronutrients are things like iron, vitamin A, plus a ton of other things, but we’re not talking about those. We are going to talk both directly and indirectly about the macronutrients, which are calories, proteins, and fats.

Wofford: So we’re talking about a deficiency in calorie intake, right? Spending more than you’re taking in.

Hoddinott: That’s exactly right. We know that if children are not consuming enough of these calories or other macronutrients, they’re not going to grow as fast as they should. We can measure that in two ways: we can look at how much they weigh relative to their height or we could look at their height relative to their age and sex.

About 15 years ago, the World Health Organization commissioned a massive study in five or six different parts of the world in communities which were relatively resource rich. These were places where kids had adequate access to food and good access to health care, water, and sanitation. The WHO basically just followed these kids as they grew for the first two years of their lives and it turns out that well-nourished, healthy kids by and large grow at the same rate everywhere in the world. That is really useful for us because it gives us a reference standard.

So when we talk about a child who’s chronically undernourished, we are saying they are undernourished in terms of their height relative to the standard.

At the moment, there are about 160 million children in the world who are chronically undernourished. Most to those children live either in Sub-Saharan Africa or parts of South Asia.

Wofford: A cynic might ask, why we should care that little kids are a bit shorter than they should be?

Hoddinott: Well, the first part of the story is that people who are short when they are very young are more likely to be short when they are adults. And how might that actually matter for them in terms of how their lives turn out? Well, to give one example, women who are very short face a greater risk of obstetric difficulties when giving birth.

On the economic side of things, economists have looked at this and for every additional percent in height you have as an adult, your wages are higher by maybe one to three percent.

But there is something else that arises that is actually much more important. Children who are chronically undernourished suffer neurological damage in terms of the way their brains form and develop. We know that’s linked to how well they do in school.

I was part of a 40-year study that followed individuals from birth in rural Guatemala in the 1960s and 1970s through the early 2000s.

We’re actually just in the process of going back to find them and re-interview them again, but what showed up in this study is that people who are malnourished when they’re young didn’t go as far in school. They got less well-paying jobs. They also do worse on the marriage market. When you talk about marriage, for most people that involves thoughts of love and romance, but I’m an economist and we think of these things differently. Marriage is like a market in which you are looking for a match. The taller you are, the better educated you are, the better you are going to do in the marriage market. You are going to get a better partner.

What we found is that people who are chronically undernourished at the age of two are more likely to be poor when they’re adults between 25 and 40. This tells us that being chronically undernourished early in life carries long term consequences.

Wofford: The obvious question here is, what can we do to avoid those long-term consequences?

Hoddinott: You might think there is a simple thing you can do, which is to just make sure there’s more food, right? The simple solution is saying, “Look, kids need to grow, so if we grow more food, kids will grow faster.” But say you’re living in a country where food production is already growing really fast. Bangladesh, for example, has gone from a country that was famine prone in the 1970s to one which is self sufficient in terms of food production. You’d think we would see the nutritional status of kids actually improving really dramatically. But there is no correlation whatsoever.

So then you say, “Okay, well maybe it’s not so much about food, but more about income.” With greater incomes, people could buy more food for their kids, receive better healthcare, that kind of stuff. But income doesn’t have a direct correlation either.

Wofford: Is the problem the quality of nutrition?

Hoddinott: Yes. There has been work done by nutritionists, particularly nutritionists at Johns Hopkins University, where they have gone around and analyzed the blood of chronically undernourished kids in Africa, particularly in Malawi. One of the things they found in those kids is that they have very low levels of essential amino acids.

Researchers have identified something called an mTOR and there’s a particular type of mTOR that signals the body to create growth. And what does an mTOR need to work? It’s essential amino acids.

So everytime someone suggests that the solution is just to produce more food and produce more calories, well, maybe it’s not just calories you need.

When you see that big increases in income aren’t having such a big effect on nutrition, you think that while people may be buying stuff they need, maybe they’re not quite buying the right stuff.

There is an experiment I’ve been working on with some colleagues I’d like to share.

Wofford: Please do.

Hoddinott: Okay, so we take a group of people and we’re going to randomly assign them to different treatment groups. Some people, and this is specifically related to mothers, get a cash transfer every month for two years. So that’s group number one.

Group number two consists of households where we’re going to give those mothers a food basket that consists of cereal and a lot of calorie-based food.

Then we’re going to have a third group that will get the cash transfer but they’ll also get nutrition counseling on what their kids eat. Another group will get the food baskets plus the nutrition counseling and finally we’ll have a control group. This goes on for two years and we look to see what happens to the kids.

Wofford: What were your findings?

Hoddinott: The cash transfer group—and, remember, this is a significant amount of money—had a little bit of an effect on what the kids ate but no effect on their height. There was also no effect whatsoever in the food basket group. It didn’t matter what they ate, even though it was stuffed full of calories. The same was true for the group that got the food baskets and the nutrition education: no effect whatsoever.

Wofford: This isn’t looking great. What about the cash and education group?

Hoddinott: That’s where you see growth that is large enough to be meaningful. To put it in context, the prevalence of chronic undernutrition falls by seven percent over two years in the group that gets the cash and the nutrition training. That’s the equivalent of three and a half percent per year. At the moment in Bangladesh, the rate of chronic undernutrition amongst kids is falling at the rate of about one percent per year and that’s one of the fastest reductions in the world. We’re seeing results that are triple the national rate, which is already excellent by international standards. So what’s going on? Why does the cash and nutrition training make the difference? Well, they used the money to buy extra calories but because of the training they were also much more likely to buy animals or soups, milk, eggs and a little bit of fish—that kind of stuff.

Wofford: What are the next steps? What do you do with that kind of information?

Hoddinott: What it suggests is a very large shift away from worrying about the amount of calories to worrying more about their quality.

There are things that point in the direction of there being something about animal source foods that is really important for child growth. So what should we be doing about that?

You might suggest that everybody gets chickens, but for most people they’d probably either die or run off. We could give everybody a cow, but that’s also really expensive and most people are probably not that great at raising livestock. A real constraint on these animal source foods is that they’re really expensive, particularly in poor populations. If we can’t get the price of those things down, it’s very hard to increase consumption levels. We need to look at both the supply and the demand for quality food products and then think about how that is best attained.

Wofford: Speaking of animals, there is a trend here in the United States in which people are eating far less meat than they used to. There’s a focus on eating fewer processed foods and so on. There are also a lot of people worried about the environmental impacts of meat production as it relates to land and water degradation and the emission of greenhouse gases. How do you weigh the benefits of an animal-based diet against some of the drawbacks?

Hoddinott: I think the answer is not so much to think about the total level of production and consumption but to think about how it’s distributed globally. North Americans and Europeans probably consume more than they should, while we have very poor populations in developing countries that aren’t consuming enough.

Wofford: How about calorie intake, obesity rates, things along those lines?

Hoddinott: Again, I’m an economist, not a nutritionist, but I think there are a couple of really interesting and important issues, one of which is the significant health costs to the U.S. economy. Certainly the overweight and obesity problems represent a significant drain on the market economy.

Globally, the prevalence of overweight and obesity are rising dramatically. For every person in the world who is considered hungry, there are two and a half people who are overweight. What that means is that designing policies and interventions becomes much, much harder, in the sense that if you are worried about the undernutrition part, you can’t just say, “Well, I think we can actually address the undernutrition part by making calories really cheap.” That might help one part of your population, but it might be somewhat detrimental to another part. So trying to get the balance right becomes really tricky.

Wofford: You said a moment ago that there’s no silver bullet solution, but are there any shining examples of economic policy or prescriptions that you think might work in one place versus another?

Hoddinott: If you’re concerned about the hunger and nutrition part, then you want to make sure that economic growth is concentrated at the bottom. In the context of chronic undernutrition, you also want to align it with work in other areas. You’ve got the nutrition education part to encourage people, for example, to have their kids consume more diverse healthy foods. You want to work on things like improving water quality. You want to improve the sanitation infrastructure, all that stuff.

Wofford: Let me ask you this. How does everything that we’ve described here translate to your work at Cornell?

Hoddinott: I actually teach a course called The Economics of Food and Malnutrition. The philosophy of the course is that it’s open to both economists and nutritionists. The idea is that if you are an economist, we’ll teach you about the nutrition, and you’ll see how the two link together. For the nutritionists who come to the course, we’ll teach you the economics and you can see how the two link.

We start off with the big picture type statistics and we drill down to ultimately, why farmers grow what they grow, particularly in developing countries. Then we move on to talk about dimensions of undernutrition, some of the things we’ve been talking about here. We talk a little bit about acute undernutrition and micronutrient deficiencies and various ways it can be addressed. Then we round that off by talking about issues around overweight and obesity, and some of the trends and economics behind that.

And that takes us back to where we began, which is the somewhat amazing factoid about the numbers of people who are hungry on the one side and overweight or obese on the other.

Wofford: This concludes our latest Expanding Nutrition Frontiers WebCast. John, thanks for making yourself available and thanks to the audience for tuning in.

Hoddinott: Thank you.


Want to hear more? This interview is based on John Hoddinott’s live eCornell WebSeries event, Chronic Undernutrition in Developing Countries: Retrospect and ProspectsSubscribe now to gain access to a recording of this event and other Expanding Nutrition Frontiers topics. 

Learn How and Why to Eat a Plant-Based Diet

The Government Office of Disease Prevention and Health Promotion, the nation’s top nutritional panel, released a 571-page report with their dietary guidelines for Americans. Their top finding? That Americans need to consider the environment when planning out their diet.

According to the group, two-thirds of American adults are overweight or obese. About half of American adults, or roughly 117 million people, have preventable chronic diseases related to poor diet and physical inactivity. They best way to combat this is a diet rich in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts.

Converting to a diet that limits or cuts out meat seems daunting. However, eCornell’s Plant-Based Nutrition certificate can walk you through how and why to make this transition.

eCornell partnered with the T. Colin Campbell Center for Nutrition Studies to create this certificate program. In it, you’ll learn about nutrition science and the role diet plays in maintaining health or creating disease.  Explore some of the ways a “wholistic” approach to nutrition might inform our approach to scientific and medical practice, healthcare in general, and even education and the environment. Interact with students from around the world, get great recipes and learn how to optimize your nutritional health for a long and healthy life.

Learn about our Plant-Based Nutrition program here or check out our downloadable flyer.

Giving the Gift of Good Health

eCornell’s online Plant-based Nutrition Certificate was offered in VegNews’ Holiday Gift Guide for 2011.

No matter the time of year, good health is always in season. In addition to the Certificate in Plant Based Nutrition from the T. Colin Campbell Foundation and eCornell, healthcare practitioners and nutritionists may receive CME, CEU or CECH credits upon completion of the certificate program.

Interior Designers in Healthcare Get Certified @ eCornell

The web-based, instructor-led courses were authored by Cornell University’s College of Human Ecology. Participants who complete the 6-course certificate will be awarded 1.8 AAHID continuing education units (CEUs), or can take one of three approved individual courses for 0.6 CEU hours each: Planning & Designing a Healing Environment, Basic Tools for Facility Planning and Practice-Based Research.

A highlight of the program is the evidence-based design course with Cornell University Professor Frank Becker, Department Chair of Design & Environmental Analysis. Participants explore the dynamic relationships between nursing unit design, the interaction of patient care teams and the cumulative effects on quality of care.

The certificate further positions AAHID as the industry’s primary healthcare interior design credentialing organization, and demonstrates the real value it brings to Board-certified designers by offering opportunities for career advancement and greater job fulfillment. Professionals who complete the six-course certificate will gain competence in facilities planning, strategic expansion and organizational decision-making processes.

“At the AAHID, we are careful to ensure that every decision we make ties directly back to our mission: the credentialing of healthcare interior designers,” says Jocelyn Stroupe, President of AAHID “Continuing education is vital to our membership, and we strive to ensure that everyone has the opportunity for professional growth and career advancement. The AAHID board found that eCornell’s online certificate programs and courses were a solid fit for our organization and will be instrumental in serving our members and helping us realize our mission.”

eCornell’s unique approach to e-learning combines the most effective elements of an Ivy League classroom with the flexibility of an online learning environment. eCornell courses—while self-paced and 100% online—are “instructor-facilitated” to help guide a cohort of 20 to 30 participants through challenging, real-world exercises with practical application on the job. Built-in collaboration features enable learners to share experiences, best practices and discuss on-the-job application attempts while immersed in learning that fosters collaboration, interaction and networking amongst the cohort.

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Students in the T. Colin Campbell online courses create Yahoo Group

A new Yahoo group is available for students who have taken the online courses in plant-based nutrition as an informal way to continue to keep in touch after the completion of coursework.

The Certificate in Plant-Based Nutrition offered through the T. Colin Campbell Foundation and eCornell is an innovative online three-course program designed to help understand the role of diet in healing and managing disease. It expands upon the ground-breaking book The China Study, by T.Colin Campbell with each course providing approximately six hours of learning based on the lectures and research of Dr. Campbell along with a variety of other experts in the nutrition and medical fields.