Tag Archives: health

Price Policies to Promote Healthy Eating: Missing the Forest for the Trees

Champagne wine and fruit salad coctail in a glassAmerican anxiety over healthcare costs and obesity continues to fuel public health advocacy for increased taxes on sugar-sweetened beverages and other unhealthy foods. Proponents of imposing higher taxes on unhealthy food products, such as soda, claim they are a necessary and effective strategy for modifying consumption behaviors and improving health outcomes. The logic is that a tax will make unhealthy foods more expensive, thereby deterring people from consuming them in excess. Advocates argue that excessive consumption of sugar-sweetened beverages not only harms individual health, but also induces increased healthcare costs that cause societal harm. Since rising healthcare costs negatively affects the public, they propose that governments are justified using fiscal policies to intervene to nudge individuals to change their dietary choices. This logic has persuaded residents of Berkeley, Seattle, and Philadelphia to vote in favor of implementing a sugar-sweetened beverage excise tax. Despite fervent support from public health advocates many people remain skeptical of imposing excise taxes on sugar-sweetened beverages as a public health solution.

I have to admit, when I was first exposed to the concept of “nudging” and soda taxes, I found them appealing. However, after in depth reflection about my values as a public health scholar, my perspective has shifted.

In late 2017, Cook County repealed its sugar-sweetened beverage tax due to intense opposition after the tax failed to live up to expectations. A major concern of using taxes to shift dietary choices is their disproportionate impact on low-income households. Higher prices on consumer goods disproportionately affect households of lower socio-economic status than wealthier households. This concern for equity was explored in a recent Lancet article, which has been touted as “a new weapon in their battle against sugar” by a review published in Fortune. The authors of the Lancet article conclude that although price policies DO often bear the largest tax burden, governments can justify this burden if the estimated health benefits of decreased consumption are likely to disproportionately benefit poorer households. This moral trade-off assumes that sugar-sweetened beverage taxes are effective at improving diet patterns and health. However, this assumption is just that-an assumption- since the evidence in support of substantial behavior changes or health impacts is weak. Even so, when it comes to public health, debating the equity of excise taxes of unhealthy food products misses the forest for trees.

The Big Neoliberal Distraction

Taxing unhealthy food items to modify individual behavior is part of a neoliberal trajectory in public health discourse. Neoliberalism is the prevailing political-economy paradigm that emphasizes free-market consumerism, individual responsibility, and minimal government spending. A variant of neoliberalsim, referred to as libertarian paternalism, legitimizes the role of private and public institutions in using market-based strategies to influence private behavior so that an individual’s freedom of choice is maintained. Fiscal policies, such as excise taxes, are a market-based strategy that nudge individuals into taking responsibility for their health are a form of libertarian paternalism in public health.

The push for increasing taxes on food items deemed unhealthy is occurring in midst of a larger political-economic wave of tax cuts for wealthy households and corporations, increased corporate consolidation, decreased public investment in education, calls to cut investment in Medicaid and privatize Medicare, restrict SNAP eligibility, threats to environmental regulations, and persecution of labor rights–all policies that contribute to increased economic insecurity that leads to stress (weight gain) and decreased ability to purchase adequate healthy food. This neoliberal agenda erodes an institutional environment that provides the greatest support for health while painting soda-drinkers as social deviants. It is within this context that The Lancet article argues that even though increased price of soda disproportionately affects people of low socioeconomic status, soda taxes may be just because these same people may realize greater health benefits than people from higher socioeconomic statuses. But is the fact that low-income individuals might benefit more in terms of health from this policy enough to claim that the policy is just?

Neoliberal public health strategies that aim to “fix” a single behavior (drinking soda or eating junk food) are reductionist in nature and ignore the underlying socio-cultural determinants of behavior and health. This paradigm of public health views solutions to complex phenomenon like health in terms of singular components isolated from the larger socio-political context. It penalizes people for “what they do wrong and what they fail to do right” while conceptualizing health as an individual responsibility rather than a right or public good. Conceptualizing health as an individual responsibility that governments can encourage through taxation distracts the public health discourse from advocating for strategies such as investment universal healthcare, public education, and living wages. Unhealthy diet patterns and poor health outcomes are in part a symptom of deeper structural factors exacerbated by neoliberal policies and cannot be resolved simply by taxing “bad” food items.

When arguing in support of increased soda taxes, public health advocates often lament the power of “Big Sugar” or “Big Soda” and suggest that the increased cost to consumers, and theoretical decrease in purchases, will shift enough revenue away from large beverage corporations to curb their control over people’s dietary choices. Again, this deflects the public health discourse away from more effective strategies for curbing corporate power like enforcement of anti-trust laws or support for labor rights and casts the individual in the role of starving the beast. It also overlooks the role crop subsidy policies play in making sugar so cheap to begin with. Focusing attention on taxing soda instead of the root causes of extreme corporate power feeds into the neoliberal agenda of deregulation at the macro level that further increases concentration and power in the food industry. The exact opposite of what public health advocates claim they are fighting for.

Beyond Soda Taxes: Seeing the Public Health Forest

Wellness, and not the individualized form of it popularized by self-help health gurus, offers an alternative paradigm through which to think about public health policy. It is a holistic and affirming process that focuses on cultivating factors that support human health and well-being, rather than on just preventing factors that cause disease (i.e., drinking soda). Wellness is a function of, and must be understood in the context of, justice at the interpersonal, organizational, and community (national) level. This goes beyond merely debating the equity burden of a soda tax and forces us to look at soda taxes within a larger institutional environment that determines resource distribution among members of a society. Public health professionals should concern themselves with the wellness implications of sugar taxes in terms of justice and systems that support people to have healthy lifestyles rather than penalizing them for the choices they make within the context of systems or environments that are unsupportive of healthy lifestyles.

Procedural justice is concerned with how resources are distributed to members of society. It is possible that resources can be distributed to low-income households in paternalistic ways that do not affirm dignity. Penalizing low-income individuals for their soda consumption with additional taxes may raise revenues for public institutions to provide nutrition education or fruit and vegetable subsidies to “benefit” these households. But who has the power to determine what constitutes a benefit, or which benefits are valued more highly than others? This resource allocation decision is often made by powerful individuals or institutions to serve their own agendas rather than by the individuals most affected by poor health and/or soda taxes. Therefore, imposing soda taxes to nudge low-income soda-drinkers into changing their behavior and justifying it by “giving” them nutrition programs do not cultivate wellness in the big picture. To truly promote wellness, resources should be distributed to those most in need through procedures that are just. Soda taxes do not meet this criterion.

The current discourse on soda taxes as a desirable public health strategy shifts conceptualization of health away from being a public good that is supported by an institutional environment consistent with standards of distributive and procedural justice. Viewing health as an individual responsibility divorced from one’s social environment further marginalizes disadvantaged populations and reinforces current health inequities. Public health advocates should consider the following wellness-oriented guidelines when supporting public health policies:  (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well; (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); (3) elevate the importance of social justice and consider the harmful effects to health and wellbeing of reductionist policies that penalize or demonize people for health-related lifestyle choices; and finally (4) stimulate the development of innovative policies that cultivate the environmental and institutional conditions for these desired outcomes to occur. Public health advocates need to look beyond soda taxes and use their political capital to advocate for investment in systems like universal health care, public education, and living wages if they are truly concerned about health and equity.

 

 

 

 

 

Advancing the Wellness Profession: Is it Time for Competency Standards and Professional Certification?

NWI Wellness Promotion Competency Model Graphic

The wellness profession has grown significantly over the past 50 years as more and more companies offer worksite wellness programs. Nevertheless, one of the key challenges currently faced by practitioners as how to implement best-practices and pull together the multi-disciplinary nature of these practices to form cohesive wellness programs. Although the literature on wellness strategies and methods is abundant, little is known about the professional competencies required for the practitioner to be effective at wellness promotion.

Wellness is defined as an active process through which people become aware of, and make choices toward, a more successful existence (National Wellness Institute, n.d.). It is a positive and affirming method of personal growth and becoming aware of our multi-dimensional and holistic nature. Counselors, social workers, nurses, health educators, and chiropractors, among others, are integrating wellness concepts into their practice to address the needs of their patients, clients, or employees through a whole-person approach. Despite the growing popularity of the wellness profession and wellness programs, some researchers argue that a misalignment between the philosophy and actual practice of wellness promotion continues to exist, leading to criticism of the wellness paradigm for discriminatory and unethical practices.

As an approach to improving quality of life, wellness promotion lacks a clearly defined set of competencies to guide the academic preparation and professional development of practitioners. The need for professional wellness competencies is evident from the conflation of methods to promote disease management with those that aim to promote wellness. For example, the use of conditional incentives is popular in worksite wellness programs to motivate employee health behavior change, despite being inconsistent with person-centered wellness methods and the human values of fairness and equity. Furthermore, many health behavior change strategies focus on eliciting emotions such as fear, shame, or guilt to motivate individuals to lose weight, become more active, or eat more vegetables to reduce their risk of disease.

While control-oriented methods like contingent incentives or fear-based messaging might motivate individuals to change their behavior short-term, it may have adverse consequences to their capacity to exercise practical autonomy and work toward their own vision of what makes life worth living. Wellness promotion offers an alternative paradigm to the traditional methodologies of health promotion and public health. However, to be fully realized, a standard of wellness practice that is consistent with the philosophy and theory must be adopted.

Competency standards are recognized world-wide as a tool to ensure professionals can competently perform skills and behaviors required to be successful in their role. As an approach to improving quality of life, wellness promotion has lacked a clearly defined set of competencies to guide the academic preparation and professional development of practitioners. Recently, however, the National Wellness Institute published a set of wellness competencies for entry-level wellness professionals. This preliminary iteration is an attempt to bring wellness professionals together in establishing a foundation and vision for the education and professional development of practitioners. Bridging the gap between philosophy, theory and practice by identifying the core competencies of wellness promotion is an essential step in training practitioners to successfully promote ethical and effective wellness strategies.

Are our Wellness Associations Well? 3 Questions to Ask When Joining a Wellness Professional Association

Wellness Caesar Augustus Capri Italy

As a wellness professional, you may choose to join a professional association for many reasons. It may be because you want to stay up to date on current information, stay engaged in the profession, and perhaps earn some continuing education credit. As the wellness profession matures, it is important that our professional associations also mature as they continue advancing their mission to educate, mentor, and elevate the field. After working for a professional association with a long history of promoting wellness worldwide, there are a few questions I suggest wellness professionals consider asking when deciding which association will deliver the professional development experience they need and maintain the credibility of the wellness industry as a whole:

  1. How does your association set quality standards for their education, certification, and content marketing programs? Or, what best-practices does your association follow in these areas?
  2. How does your association demonstrate accountability to stakeholders?
  3. How does your association’s organizational and leadership practices foster a culture of wellness?

Professional associations serve as thought leaders in the profession and are often key stakeholders in developing industry-wide standards that guide higher education, certification and continuing education programs. When joining a wellness association, it is important that its leaders are either involved with setting standards or following established national standards and best-practices. For instance, if your association offers certification programs, you may want to ask if they are accredited by the National Commission for Certifying Agencies (NCCA) to ensure the program meets the highest standards in the certification industry. Or, if you plan to attend their conferences or training programs, you may want to ask if they use a peer-review process for training content, blind reviews for conference session selection, and have visible conflict of interest disclosures for presenters. Finally, does your wellness association have quality standards for the information they post on social media? The internet is full of spurious claims and dubious research, which is why many of us turn to our professional association to help us sort out the “click bait” and find credible resources. Therefore, it is important that wellness associations have quality standards and avoid sharing questionable media stories or research articles as part of their content marketing strategy under the guise of providing you up to date and credible information.

We may assume that if our wellness association is teaching us about worksite wellness, that they are probably the epitome of a well organization. But what if that is not the case and your wellness association is organizationally unwell? Since many wellness associations are in the business of educating professionals about standards, practices and ethics in worksite wellness, the wellness association has an obligation to act as a role model in this area. Does the Executive Director consume fast food for lunch everyday, ignoring personal, community, and environmental health? Do board members routinely serve their entire term or resign early because of internal incivility? Do staff feel their work is meaningful and valued by the organization or do they just show up for the paycheck? You may not be able to find answers to questions like these, but inquiring more about the organization’s leadership practices and wellness programming, or gauging their response to a suggestion that they include employee wellness metrics in their annual report might provide some insight on the extent to which they “walk the walk.” The culture of an organization has ripple effects on the quality of products, services, and support it is ultimately able to provide for its members or customers.

As professionals, we need to ensure that our professionals associations are transparent and accountable to stakeholders. Many wellness associations are not-for-profit entities and enjoy a public appearance of honesty and integrity. However, without access to their annual reports and outcome evaluations, how can we know for certain that they are being fiscally responsible and actually meeting their stated mission and objectives? Professional associations, especially those with non-profit status, should have items such as their bylaws, board minutes, and annual reports that include financials publicly available on their website. If you cannot find these items on their website, your wellness association may not be able to demonstrate that it is serving your needs or making a meaningful impact on your career development. Asking questions about your wellness organization’s evaluation processes and transparency protocols ensure that you can be confident your organization is providing value and achieving its goals with donor and tax-exempt monies rather than spending thousands dollars on golf outings and family trips for the Executive Director.

Wellness associations offer many valuable resources and programs to support professionals in making a difference each day. However, if our wellness associations are not being held accountable, how can we ensure the wellness profession and industry as a whole are operating at the highest standard? This begins by ensuring that our wellness associations truly walk the walk of wellness by following best-practices in educational programming, being transparent and accountable to members and consumers, and creating thriving organizational cultures within their own organization. We can nudge our profession in this direction by asking these type of questions before joining a wellness organization or attending their educational programs.

What Health Professionals Need to Know about Sugar Taxes

light-painting-2148675_1920

Calls for taxes on sugar-sweetened beverages (SSB) by health professionals and advocates continue to occupy news headlines. Many of these commentaries rely extensively on emotional justifications for implementing these taxes as a public health measure to prevent weight gain, diabetes and cavities.

Taxes on sugar sweetened beverages are not new and have been implemented in many areas in many different ways. In theory, this sounds like a great idea, but what is the actual evidence that they meaningfully impact public health?

Theoretically, given a large enough excise tax on SSB, consumption levels decrease, leading to significant improvements in weight and obesity rates. In Mexico for example, one analysis estimates that a SSB excise tax may have resulted in a 7.5% average reduction in SSB consumption, with the greatest decrease among households at the lowest socio-economic level, while an analysis of 15 cities in the United States that have implemented an excise tax on SSB estimates that the incidence of diabetes could potentially decrease by 6% within a year of the tax reaching its full effect. However, the estimates from these economic models only predict a decrease of less than one pound of body weight, with no real improvement in health. Furthermore, empirical evidence of self-reported soda consumption did not significantly change after Berkeley, CA, implemented its tax on SSB as people shifted their purchases to neighboring counties or online vendors. This may be because demand for sugar-sweetened beverages tends to be slightly inelastic among the general population when prices increase, meaning that price does not significantly influence a consumers decision to purchase them.

But at what cost? Are the actual changes in consumption or health outcomes substantial enough to be considered worthwhile? How sustainable or long-lasting are these improvements? And are there other programs or policies that would lead to more significant health outcomes and have a societal or individual cost that is equivalent to or lower than a sugar tax?

It is important to remember that while sugar taxes may be associated with improved weight status at the population level, there is no evidence that they cause improvements in actual health status. One reason may be because lifestyle choices contribute to less than a quarter of one’s of current health status and sugar-sweetened beverage consumption is just one of many lifestyle variables. A greater proportion of an individual’s health risk is due to social determinants of health such as one’s social environment, physical environment/total ecology, and health services/medical care.

Focusing the health conversation on taxing sugar-sweetened beverages may actually be distracting efforts to take action in addressing more substantial causes of poor health like low wages, poor housing conditions, access to affordable healthy food, violence and trauma, systemic oppression, and quality healthcare. Increasing the price of SSB may deter consumption of these products, but it does nothing to increase access to affordable healthy food or healthcare services in the communities that are affected most by food insecurity and diet-related health issues. Policy alternatives, like subsidizing the cost of fruits and vegetables, and investing in community-based food systems would do more to improve access to healthy choices–without the need to penalize people for taking pleasure in a sugary beverage now and then.

While the case of Mexico shows that a SSB tax may reduce consumption of the taxed beverages, they also estimated a 2.1% increase in purchases of un-taxed beverages due to the substitution of SSB with other products like juice, milk, diet soda, and even alcohol. While certain substitutions may be beneficial, a focus on decreased consumption of SSB and changes in BMI are too narrow to be meaningful. Without empirical evaluations of the SSB tax impacts on actual health outcomes, it is difficult to determine if the tax is actually worthwhile in achieving anything more than imposing administrative costs on society and placing an unnecessary burden on the individual autonomy of both healthy and unhealthy individuals.

Unfortunately, few studies have empirically evaluated the effects of taxes on sugar-sweetened beverages and the evidence that they improve public health measures is limited. Many studies in this area rely on econometric modeling rather than measuring peoples’ actual behavioral response to the tax. Before getting on the SSB tax band-wagon, health professionals should advocate for more extensive empirical research in this area as a way to promote evidence-based policy decisions in public health.

Related: Junk-food Taxes: Do They Work?

What to do When you Hate Beets?

Fresh Beets
I don’t like beets.  When we hear this from children, we encourage them to try again, hoping they might like them once they get older.  Curiously though, once we become adults, encouragement to try disliked foods ceases and we develop the belief that our food preferences are fixed.  We might even justify this belief by claiming a genetic predisposition to dislike certain flavors or foods.  I don’t like beets, and at this point, I never will.  However, even a genetic predisposition to a certain trait does not necessarily equate to predetermination of behavior.  Our mental beliefs play a substantial role in our preferences for food.  And the good news is, our mental beliefs change.
As living beings, we are constantly changing.  At the conscious level, new experiences shape our ideas.  And at the unconscious level, all of our cells are reproducing and dying, our atomic energy arises, then passes away instantaneously.   We are literally changing both at an emotional level and physical level in every moment.  Consequently, we are not the same person we were yesterday, or last year, so how can we expect that our food preferences also do not change?
I certainly did not grow up eating fruits and vegetables.  Nor did I have parents who ate them. Typical childhood meals consisted of frozen pizza, Ramen noodles, and macaroni & cheese until I was 24 years old.  I doubt I even heard the word nutrition until my early 20’s, although I had certainly heard the word “diet” and been on several of them by that time.  All of that changed when I moved to Burma.  I was astonished by what real, fresh food looked like on the table in front of me when sharing meals with Burmese friends.  Needless to say, the dearth of fast food restaurants and Western packaged food meant that I had to learn how to eat vegetables.  Funny thing is, I now wonder why nobody ever told me how delicious they are!
It is well documented that it can take children 15-20 exposures to develop a taste for a new food. Trust, independence-seeking behaviors, and taste bud development all play a role.  However, more fundamentally, at each exposure we are an entirely new person, and this doesn’t stop when one reaches adulthood.  Therefore, even as adults, we can learn to like previously disliked foods if we keep these two facts in mind.  We can choose just one or two vegetables for our “let me learn to like this” bucket list, and make a strong determination to try them in various forms over the next few months or even years.
Practicing mindful eating can help enhance our expectation of liking a food (2). Prepare smaller quantities and taste the food slowly.  Notice the flavor and texture without labeling it as good or bad.  Be aware of how you feel about the flavor or texture, without judging the feeling.  Just notice.  If you still don’t like the food, accept the reality of that moment with kindness, and be determined to try again another day-knowing the person who tries this food again in the future will be new and different.
I now like beets.  It happened recently with a roasted beet and brie salad, and then again with a beet and coconut curry over rice.  With a strong determination to taste them, without consideration of past preferences, after 2 years of trying, at the age of 32, I finally like beets.
1. Ellyn Satter’s Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook, Kelcy Press, 2008.
2. Hong, P. Y., Lishner, D. A., Han, K. H., & Huss, E. A. (2011). The positive impact of mindful eating on expectations of food liking. Mindfulness, 2(2), 103-113.

The Multiple Dimensions of Food

I recently had the opportunity to attend the National Wellness Conference 40th Anniversary Legacy & Vision Dinner, during which several pioneers of the Wellness movement discussed their involvement in shaping the dialogue and structures inherited by younger generations.  One particularly grounding message for me was a reminder by John Travis, MD, MPH, that above all, the currency of wellness is connection.  We understand that what we eat is important for maintaining our physical wellness, and foodies have long advocated that being connected to our food helps us make healthy food choices.  However, as many of us intuitively know, food is about more than just healthy or unhealthy choices.  Food is a medium through which we connect to multiple dimensions of wellness.
Social connection is crucial to our well-being.  Quality social connections can reduce mortality by 50% (1) and observations from Blue Zones indicate that social connection contributes to the long, healthy lives enjoyed by the centenarians living in these communities (2).  However, many Americans have developed the habit of eating alone- at our workstations, in restaurants, and in our cars.  Food is a natural facilitator of social bonding.  Everyone eats, and everyone can talk about food.  While food is not the only way to facilitate social bonds, sharing cake at a friend’s wedding, enjoying a tomato salad with colleagues, or tasting mango-chicken curry on a family night out builds shared experiences and enhances opportunity for meaningful social connection.

Our intellectual well-being, the degree of engagement in creative and stimulating activities to expand ones knowledge and share this knowledge with others, is an essential element in our lifelong journey toward wellness (3).  Intellectual wellness can positively impact resiliency in the face of mental health difficulties and the ability to cope with stressful situations (4).  The connection with food, by gardening, photography, cooking, and even genetic engineering, is a way through which to exercise our intellectual and creative nature.

Food and eating behaviors also serve as symbols through which individuals connect with their faith and spirituality.  Special foods are prepared to celebrate important religious events and donated as a way to show respect and selflessness.  Avoidance of certain foods and fasting are a means of obtaining spiritual purification and heightened awareness.  Even though more people are transitioning away from organized religion, food is often still a symbol of values and morality in their lives.  Avoiding harm to animals through a vegan diet or eating organic vegetables may enhance spiritual connections and a sense of oneness with the world.

Emotional wellness can be promoted through a balanced and positive approach to food.  Emotions and food influence each other bi-directionally in ways that can both support or diminish our emotional wellbeing.  Stress may cause us to reach for comfort foods, while the over consumption of unhealthy foods may be a risk factor for depression and low energy (6). Excessive worry about health is associated with a decline in quality of life as inner guilt and self-hate are not the seeds of self-care and wellness as (5).  A connection with food, absent of guilt and worry, can improve our emotional well-being.  We feel rewarded when we cook a delicious meal, or believe we improved our community by purchasing local foods.

More than 15 million people depend on food production, manufacturing or service in the United States (7).  Chefs, nutritionists, plant breeders, farmers and truck drivers connect with food through the pursuit of a meaningful livelihood.  However, many of the employment opportunities available in the food and agricultural industry still place workers in unhealthy and stressful situations that are not conducive to occupational or overall wellness. Unmanageable work-family interfaces increase the likelihood of choosing unwanted foods and eating behaviors as a coping mechanism (8). The rise in worksite wellness programs can help more individuals positively manage the work-family interface, enabling food choices they find acceptable, increasing job satisfaction and occupational wellness.

Given that food influences so many aspects of our well-being, let’s ensure, as wellness champions, that our advice and wellness programming consider the full spectrum of the human experience with food. Our promotion of healthy diets need not detract from overall wellness, but rather it should enhance balance and connection with food in all of its dimensions of wellness to support people in realizing their full potential for health and happiness.

References:

1. Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316.
2. Buettner, D. (2012).The Blue Zones: 9 Lessons for Living Longer from the People Who’ve Lived the Longest. National Geographic Books.
3. Roscoe, L. J. (2009). Wellness: A review of theory and measurement for counselors.Journal of Counseling & Development, 87(2), 216-226. http://www.stuaff.niu.edu/stuaff/grad_resources/pdfs/Wellness%20Article_Counseling.pdf
4. Hammond*, C. (2004). Impacts of lifelong learning upon emotional resilience, psychological and mental health: fieldwork evidence. Oxford Review of Education, 30(4), 551-568.
5. Sanhueza, C., Ryan, L., & Foxcroft, D. R. (2013). Diet and the risk of unipolar depression in adults: systematic review of cohort studies. Journal of Human Nutrition and Dietetics, 26(1), 56-70.
6. Rief, W., Glaesmer, H., Baehr, V., Broadbent, E., Brähler, E., & Petrie, K. J. (2012). The relationship of modern health worries to depression, symptom reporting and quality of life in a general population survey. Journal of psychosomatic research, 72(4), 318-320.
7. http://ers.usda.gov/data-products/ag-and-food-statistics-charting-the-essentials/ag-and-food-sectors-and-the-economy.aspx
8. Allen, T. D., & Armstrong, J. (2006). Further examination of the link between work-family conflict and physical health the role of health-related behaviors.American Behavioral Scientist,49(9), 1204-1221.