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Buchberger: Non-drug treatments for osteoporosis

Osteoporosis is a disease that is typically characterized by a notable decrease in bone mass and density. This results in bones becoming thinner, structurally weaker, and brittle. This process progressively increases your risk of fracture either spontaneously or from trivial incidents. The National Institutes of Health refers to osteoporosis as a silent disease because it rarely displays symptoms prior to onset.

Osteoporosis occurs in people over the age of 50 with increasing frequency. After age 50, about 50% of women and about 25% of men will be diagnosed with osteoporosis after suffering a fracture. While non-Hispanic Caucasian women and Asian-American women are more likely to develop osteoporosis, African-American women and Latino women are less likely to develop osteoporosis. Women are five to six times more likely to develop osteoporosis than men. Fractures related to osteoporosis increase after age 70 in both men and women.

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Smoking and alcohol intake have a direct correlation to osteoporosis. Non-smokers and people who reduce alcohol intake have a lower incidence of osteoporosis. Quitting smoking and reducing alcohol intake are habit modifications that can reduce your risk of developing osteoporosis. A low to moderate alcohol intake has been associated with reduced fracture risk. Smoking can increase the risk of fracture by up to 40%. If someone quits smoking it can take up to 10 years to negate the risk.

It is important to check with your prescribing doctor about medications you are taking, as these may contribute to development of osteoporosis. Many of these medications are commonly prescribed and may include over-the-counter items such as vitamin A or antacids.

Another risk factor is calcium and/or vitamin D deficiency. Because bone density needs to be maximized before age 35, it is important to have proper calcium and vitamin D intake during the first 35 years of life. It is also important to maintain optimal levels after age 35 to help prevent deterioration of bone density. In order to achieve a benefit of improved bone density, calcium and vitamin D must be taken together. If you are taking medications for other conditions, you should speak to your doctor before taking supplements to assess the possibility of interaction. It is now recommended that your blood levels of vitamin D approach 50 nanograms per milliliter. Make sure you ask your doctor what your actual number is.

Physical activity in the form of weight-bearing exercise (walking, hiking, running, etc.) in combination with resistance exercise (lifting weights, body weight exercises, etc.) has been shown to increase bone mineral density in the lumbar spine. It is considered helpful in the prevention and management of osteoporosis. In a recent study, the authors stated, “Based on the available information, resistance exercise, either alone or in combination with other interventions, may be the most optimal strategy to improve the muscle and bone mass in postmenopausal women, middle-aged men or even the older population.” People with osteoporosis should avoid high-impact activities that include jumping and rapid bending and/or twisting motions.

Dr. Dale Buchberger

Dr. Dale Buchberger

Protein is a dietary nutrient that is not talked about often or is overshadowed by emphasis on calcium. However, protein in the form of collagen makes up the framework for bone. Without a protein matrix to form a foundation for bone, the structure becomes brittle. Collagen provides flexibility to bone while calcium and other minerals provide stiffness. It is this combination that makes for strong bones. Dietary protein levels of 0.8 to 1.5 grams per kilogram of body weight have been associated with increased bone mass and reduced occurrence of osteoporotic fractures. Patients with diets higher in protein show increased rates of calcium absorption, while patients with dietary protein levels less than 0.8 grams per kilogram of body weight show lower calcium absorption.

Osteoporosis is no different than any other disease or illness in the sense that there is no magic, one-size-fits-all pill to cure it. As scientific publications continue to manifest, they reveal that the best management plan is one designed for the individual that deals with multiple factors. Osteoporosis is a complex disease requiring a complex solution tailored to the patient and their individual structure, function, stage of disease and metabolism. Research continues to point to combined supplementation of calcium and vitamin D along with combined weight-bearing and resistance exercise as viable and effective strategies for the prevention and management of osteoporosis. Along with smoking cessation and reduced alcohol intake, these are perhaps the most cost-effective and readily available methods to treat patients with osteoporosis. As always, before making drastic changes, you should consult with your trusted health care provider to be sure that a given strategy is safe, given your current medical history. 

There’s growing concern over a potential link between air pollution and osteoporosis.

Dr. Dale Buchberger is a licensed chiropractor, physical therapist, certified strength and conditioning specialist and diplomate of the American Chiropractic Board of Sports Physicians with 35 years of clinical sports injury experience. He can be contacted at (315) 515-3117, activeptsolutions.com or shouldermadesimple.com.

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University of Michigan’s pharmacist-centric care model replicated by CDC to tackle hypertension

Embedding pharmacists as part of the health care team at University of Michigan primary care clinics and community retail pharmacies has proven so effective in controlling blood pressure that the Centers for Disease Control and Prevention is now replicating the model of care and expanding it to the southeastern United States.

A CDC evaluation (PDF) of U-M’s Hypertension Pharmacists’ Program found that 66% of patients who met with an HPP pharmacist had their hypertension under control within three months, compared with 42% of patients who did not meet with a pharmacist. At six months, 69% had their blood pressure under control, compared with 56% of nonparticipants.

The CDC’s Division for Heart Disease and Stroke Prevention is seeking to scale up and extend the U-M model to other regions of the country as part of its goal to close the health disparity gap by 5% among Black adults. The CDC chose the southeastern U.S. as it primarily serves African American populations at a higher risk of hypertension and uncontrolled blood pressure.

Hypertension affects nearly half of adults and 55% of African Americans—making hypertension a major contributor to heart attacks and strokes, according to the American Heart Association.

Hae Mi Choe, clinical professor at the U-M College of Pharmacy and chief population health officer for Michigan Medicine, first developed the pharmacist-centric care model in 1999. By 2009, the program had expanded to add pharmacists to clinic locations at U-M Health, and in 2017 the program moved into select Meijer store pharmacies near U-M health clinics.

The model provides patients who have hypertension, or high blood pressure, with individualized and accessible care and education provided by specially trained pharmacists in tandem with a patient’s primary care physician.

The goal is better blood pressure control with fewer primary care physician visits for hypertension issues, Choe says. While many Americans struggle to access primary health care regularly, nearly 90% of the U.S. population lives within five miles of a pharmacy, making the community pharmacist the most accessible health care provider.

Pharmacists are an essential part of the care team, and HPP has shown they can be part of the answer to improving access to care and outcomes, too.”

Hae Mi Choe, clinical professor, U-M College of Pharmacy

Having the pharmacist as part of the patient care team gives patients quicker access to a health care provider and frees up the time of physicians, she says.

“Any patient who is newly diagnosed with hypertension or uncontrolled blood pressure may be referred to the pharmacist for a consultation on how to manage their condition,” Choe said.

At patient consultations, HPP pharmacists discuss lifestyle factors such as diet, exercise, smoking and stress—all influencers on blood pressure. They also can identify allergies, review and adjust medications, instruct on at-home monitoring and assess factors that could keep the patient from taking prescribed blood pressure medications regularly, including cost.

High blood pressure can be virtually symptom-free and often goes undiagnosed. About 25% of those with the condition have it under control. Hypertension is controllable with the combination of medication and/or lifestyle changes.

In late 2023, the CDC Division for Heart Disease and Stroke Prevention invited proposals from health care systems and community pharmacy settings in the southeastern U.S. interested in implementing HPP in settings that serve African American patients. One site will be selected to implement the core components of HPP, and the CDC will evaluate outcomes.

“The program Dr. Choe and her team have built has the potential to be a game-changer in bringing pharmacists into the care team to better serve patients. We are so proud of this program and excited to further our collaboration with the CDC to help conquer hypertension throughout the country,” said Vicki Ellingrod, dean of the U-M College of Pharmacy and the John Gideon Searle Professor of Clinical and Translational Pharmacy.

There’s a racial disparity among Michigan’s organ donors. Fixing it would save lives.

Aniyah Harris, 17, of Riverview, briskly paced in her fifth-hour biology classroom at Detroit’s Renaissance High School. Then, she closed her lips around a cocktail straw, and tried to breathe through the tiny tube.

It wasn’t easy.

“Would you want to breathe like that 24 hours a day, seven days a week?” asked Taneisha Carswell, community relations coordinator for Gift of Life Michigan’s Minority Organ Tissue Transplant Education Program.

Harris and the two other students with straws in their mouths shook their heads, no.

“A person waiting for a lifesaving lung transplant breathes like that 24 hours a day, seven days a week,” Carswell said during an interactive presentation about the need for organ and tissue donors, especially in diverse communities, on a snowy late January day.

By going from classroom to classroom, talking to students across the region, Carswell is hopeful she’ll chip away at some of the racial disparities and myths about organ and tissue donation.

Racial disparities high in organ donation

The need in the Black community is especially high.

Black Michiganders accounted for 30.2% of residents on the state’s waiting list for an organ transplant as of Feb. 7, even though they make up just 14.1% of the Michigan population, according to the the Organ Procurement Transplant Network. Of the 2,587 people in need of a lifesaving organ in Michigan, 781 are Black.

“African Americans … have increased risk for heart disease, high blood pressure and diabetes,” Carswell told about a dozen students in Emily Phillips’ international baccalaureate biology class. “I guarantee you everybody here knows somebody who either has high blood pressure or diabetes. Those are the two leading causes of kidney failure.

“African Americans are the top ethnicity/race that are waiting for kidney transplant, making up 60% of those waiting for lifesaving kidney transplant. And African Americans are more likely to find a genetically compatible match within their own race or ethnic group.”

Jelisa Bargainer, 17, of Detroit, looks through the Gift of Life brochure about organ donation as the organization's community relations coordinator Taneisha Carswell, 41, of Macomb, speaks to seniors in a biology class at Renaissance High School in Detroit on Tuesday, Jan. 30, 2024.

The reasons are complex, and swirled in with such social determinants of health as poverty, access to health care, transportation, housing and nutritious food along with a historic lack of trust in the health care system, said Remonia Chapman, who oversees the multicultural organ and tissue transplant program at Gift of Life Michigan, the state’s organ procurement organization.

“There are environmental factors that are impacting people’s health because of where they live, and many times people aren’t able to do something about that,” Chapman said. “I think there’s a combination of the social determinants of health, of environment, of access, of having food deserts, you name it.”

Carswell looked across the classroom and said her job is to open students’ minds, but not pressure them to become donors.

“One thing I do not do is ask them if they plan on joining the Michigan Organ Donor Registry,” Carswell said. “My main focus is to just allow them to be informed so when they are asked, they understand what they’re being asked to do.”

Recruiting new donors, one person at a time

The efforts are paying off, said Chapman said.

For years, Chapman has made it her mission to reduce the racial and ethnic inequities among donors and recipients. She oversees the work of Carswell and other regional education coordinators, who bring the message to classrooms and churches, barbershops and town halls — wherever people gather.

“They are ambassadors and advocates in their communities because they see these people every day,” Chapman said. “They’re not trying to reach the community, they live in the community. They’re part of the community. They’re able to pull organizations together that the community already trusts and marry our message with their message of health and wellness. It’s been tremendous work expanding our department and our footprint.”

Since 2016, the percentage of people from diverse backgrounds on the Michigan Organ Donor Registry rose from 23.9% to 49.5% by the end of 2023, according to Gift of Life Michigan.

And a record 578 people became organ donors last year, giving 1,372 lifesaving organs to people on the waiting list for a transplant. In addition, 1,858 Michiganders donated tissue.

The numbers have improved steadily each year since Dorrie Dils was named CEO of Gift of Life Michigan in 2016.

“It’s not something that gets turned around overnight,” she said. “And it’s very, very grassroots. There is no ad campaign that’s going to convince people. It’s talking to people like Remonia or Taneisha and getting their questions answered, hearing their stories. That happens one person at a time — in church basements, schools, at community events. Anywhere we can go where we can talk to people about organ and tissue donation, we attempt to be there.”

Gift of Life Michigan seeks an education mandate

Gift of Life Michigan’s leaders also are lobbying for legislation that would mandate all ninth graders enrolled in Michigan public schools get one hour of instruction about organ, eye, and tissue donation and the donor registry.

“Ohio, Indiana, Illinois and many other states require that,” said Patrick Wells-O’Brien, vice president of communications for Gift of Life Michigan. “Michigan does not. As a result, only 21% of new drivers register as organ donors. That abysmally low rate is not because Michigan teenagers are less generous. It is because of a lack of education.”

Students taking driver’s education classes in Michigan spend only about 10 minutes learning about organ and tissue donation. Worse, a procedural change with the Michigan Secretary of State means teens are asked whether they’d like to join the donor registry before they get any education about organ donation at all, Wells-O’Brian said.

Gift of Life Community Relations Coordinator Taneisha Carswell, 41, of Macomb, left, looks on as Jelisa Barginere, 17, a senior at Renaissance High School in Detroit, takes a look at a preserved set of lungs and heart on Tuesday, Jan. 30, 2024 during her biology class. The class was being taught the importance and impact of organ donations.

“Additional legislation is required to correct that,” he said. “Michigan is at a policy disadvantage.”

State Rep. Felicia Brabec, D-Pittsfield Township, introduced House Bill 5174 in October to require an hourlong in-school instruction for high school freshmen statewide. The legislation was referred to the House Committee on Education, where it remains.

Without a mandate, Gift of Life Michigan has been limited in how effectively it can reach students, Wells-O’Brien said.

“Out of 1,800 high schools in our state, we got into 362,” Wells-O’Brien said. “We need legislation to get an education program like ours into all high schools.”

The lack of an education requirement is especially inequitable in the city of Detroit, Wells-O’Brien said, where the population is majority Black and the cost of auto insurance is so high that many teenagers don’t take driver’s ed classes because they can’t afford insurance. That means Detroit teens are more likely to miss out on the 10 minutes of instruction other Michigan teens get through driver’s ed classes.

Dils said requiring education could make all the difference.

“We think we can get to the point where no one has to die waiting for a lifesaving organ,” she said. “But it means more people saying yes, putting the heart on their driver’s license. It means us educating more young people before they get asked that question to keep those numbers growing.”

‘Helping others is my passion’

At Renaissance, Carswell put images on a big screen at the front of the room — a heart, then kidneys. Next came lungs and a liver, followed by a pancreas.

She explained that donor organs are placed by the United Network for Organ Sharing, also known as UNOS, which gives priority to people who have the most severe disease, dividing them up by blood type, antigens, geography and wait time to make the best match.

Body size matters, too.

“Can Shaquille O’Neal donate to Kevin Hart? No, he can’t, and that’s because of the size difference,” Carswell said.

Then she showed the faces of kids whose lives were saved by donors.

There was a boy named Mohamed, who got a heart transplant at 16.

There’s the face of a girl named Dayja, who got a kidney transplant at age 16.

Students saw a girl named Kyle, whose first heart transplant at age 2 gave her 17 more years of life. She died at 19 while waiting for a second heart transplant.

“With pediatric patients, when they get a transplant at a young age we sometimes see that by the time they become middle-aged, they need a second heart transplant,” Carswell said. “But what we also know is that the additional time that a person gets with their family is priceless, because without this transplant, they wouldn’t have had that additional time at all.”

And then there’s a photo of a young woman named Taneisha.

“Who’s that?” she asked the class. “That’s right. It’s me.”

Gift of Life Community Relations Coordinator Taneisha Carswell, 41, of Macomb, right, has a group of seniors in a biology class at Renaissance High School in Detroit try on glasses to replicate what a person who need a cornea transplant might see on Tuesday, Jan. 30, 2024.

Carswell got a lifesaving kidney 16 years ago. She talked about the “sweet 16” celebration she and her donor have planned for later this week.

“What could be sweeter than a cake-decorating party for your sweet 16?” she asked.

Harris was moved to join the registry the first time she heard Carswell speak at Renaissance a year ago.

“It was a big part of the decision, learning about it,” said Harris, who works as a certified nursing assistant and hopes to one day become a surgeon. “Helping others is my passion, so why not?”

Contact Kristen Shamus: kshamus@freepress.com. Subscribe to the Free Press.

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The Awfulness of Elite Hypocrisy on Marriage

“Is it morally wrong to have a baby outside of marriage?”

“No” is the answer I received from about two-thirds of my sociology-of-family class at the University of Virginia last spring, when I put that question to them in an anonymous online poll. The class of approximately 200 students was diverse geographically, racially, and ethnically. But on questions like this one—asking whether society should promote or value one type of family structure over another—the students I teach at UVA generally say it shouldn’t.

Yet when I asked these same students—who are almost all unmarried—“Do you personally plan to finish your education, work full-time, marry, and then have children?,” 97 percent said yes.

And when I asked, “If you came home at Thanksgiving and told your parents you (or your girlfriend) were having a baby, would your parents freak out?,” 99 percent said yes.

In one sense, these answers are unsurprising. The great majority of my students, about 80 percent, report hailing from an intact family with married parents. (My class at UVA is not exceptional in this regard: 73 percent of students at elite colleges and universities nationally were born to married parents who have since stayed married, versus 51 percent of high-school seniors across the country.) At the same time, a majority of my students are liberal or progressive on many social issues—they are, at a minimum, nonjudgmental about lifestyles unlike their own.

But there’s a problem with this disjunction between my students’ public family ethic and their own private family orientation, a disjunction I see regularly in elite circles. Voluminous research shows that being born into a married, stable household confers enormous benefits on children, whether the parents are rich or poor. The question I put to my students about their life plans involves a variant of what social scientists call the “success sequence.” Research clearly shows that taking three steps—(1) getting at least a high-school degree, (2) working full-time in your 20s, and (3) marrying before you have children—dramatically increases your odds of reaching the middle class or higher and minimizes the chances of your children growing up in poverty.

Yet many elites today—professors, journalists, educators, and other culture shapers—publicly discount or deny the importance of marriage, the two-parent family, and the value of doing all that you can to “stay together for the sake of the children,” even as they privately value every one of these things. On family matters, they “talk left” but “walk right”—an unusual form of hypocrisy that, however well intended, contributes to American inequality, increases misery, and borders on the immoral.

Rob Henderson witnessed this strange dynamic as an undergraduate at Yale in 2016. Henderson, who recently completed a doctorate in psychology from Cambridge University and whom I came to know through correspondence on Twitter, told me recently that during his second year at Yale, a psychology professor asked the students in his class how many of them had been raised by both of their birth parents. Henderson had grown up in a working-class area characterized by lots of family instability, and his childhood had been particularly unstable: He had cycled through 10 different foster families. He knew his own family background was rare at Yale. Nonetheless it “was a shock,” he told me, when 18 out of 20 students in the class raised their hand.

This got Henderson thinking. “Why is it that these people are studying at this great university,” while many of his friends back home were in jail or working at a batting cage or strung out on drugs?

He came to believe that family structure was a big part of why some young adults had a shot at success and others did not. But he discovered that talking about this possibility at Yale was not easy. “I remember discussing my life in this class and there being this weird silence,” Henderson said, partly “because a lot of these students had never met anybody like me.”

Whenever the idea that family structure could affect life prospects came up in any way, “there was always an effort to bring it back to poverty,” he said. Most of his fellow students “retreated into ideas like ‘We just need to give people more money’ or ‘economic opportunities.’” These responses, Henderson believes, were driven partly by the notion that family diversity—the idea that all family forms are equally valid and valuable for kids—is a mark of moral progress in society.

The phenomenon of people in society’s upper strata talking left but walking right is especially easy to spot at elite universities, but it extends well beyond university culture. A survey I helped lead of California adults in 2019 for the Institute for Family Studies, a think tank that seeks to strengthen marriage and family life, manifested a similar sociological pattern. Eighty-five percent of Californians with a college or graduate degree, ages 18 to 50, agreed that family diversity, “where kids grow up in different kinds of families today,” should be publicly celebrated (compared with 69 percent of Californians without a college education). But a clear majority of college-educated Californians, 68 percent, reported that it was personally important to them to have their own kids in marriage. Among those who were already parents, 80 percent were in intact marriages, compared with just 61 percent of their peers in the state who did not have a college degree.

Likewise, the 2022 American Family Survey, a national survey, found that among college-educated liberals, ages 18 to 55, only 30 percent agreed that “children are better off if they have married parents.” Yet 69 percent of the parents within this same group were themselves stably married.

Graph showing which Californians are the most likely to endorse family diversity
Graph showing that educated Californians are the most likely to be married

College-educated elites have outsize power over American culture and politics, and on matters of family, they are abdicating it. They typically don’t preach what they practice, despite the megaphones they hold in traditional and social media, and elsewhere. Sometimes they preach the opposite, celebrating practices they privately shun. More often, they are simply silent and do very little politically or culturally to strengthen the foundations of marriage for Americans outside of their own privileged circles.

As a nation, we have not been shy, historically, about advocating for certain behaviors that typically lead to better lives for individuals and fewer problems for society. Targeted educational campaigns—in schools and the culture—have brought down the rates of teen pregnancy and cigarette smoking, for instance. But when it comes to marriage before children, or the success sequence more broadly, nothing comparable has been done at a national scale.

Social media, meanwhile, tends to send bad signals to kids and young adults. The dopamine-driven ethos that infuses much of TikTok and Instagram enriches the executives at Sequoia Capital and Meta but provides little support for anything but living for the moment, and undercuts the values and behaviors needed to sustain long-term love, not to mention marriage.

Traditional media oscillate between occasionally acknowledging the benefits of marriage and frequently praising the alternatives to it. As David Leonhardt, a columnist at The New York Times, observed, “I think that my half of the political spectrum—the left half—too often dismisses the importance of family structure.”

People with powerful voices aren’t entirely idle when it comes to marriage promotion. Over the years, they have fought, successfully, for the end of “marriage penalties” within the tax code that had made marriage more expensive than single living or cohabiting. The 1986 and 2001 tax bills, for instance, addressed many such penalties. But these laws, quite notably, were aimed at the pocketbooks of the rich and middle classes, who pay the lion’s share of federal income taxes. For poor and working-class Americans, substantial disincentives to marriage remain coded into many federal and state tax-and-benefit laws, and there seems to be little pressure to change that.

These actions and omissions are not small failures. The latest social science tells us, for instance, that children raised in single-mother homes are about five times more likely to be poor than kids raised in stably married homes. That young men raised apart from a stably married home are, according to my recent research, more likely to land in jail or prison than to graduate from college. That the biggest driver of recent declines in happiness is the nation’s retreat from marriage. And that, at the community level, the strongest predictor of economic mobility for poor children is family structure: Poor kids hailing from communities with more two-parent families have a markedly better shot at moving up into the middle class than poor kids from neighborhoods dominated by single parents.

Much of this research is well summarized in the Brookings Institution economist Melissa Kearney’s new book, The Two-Parent Privilege: How Americans Stopped Getting Married and Started Falling Behind. And though some people argue that the active element behind many of these findings is a stable relationship, rather than marriage per se, the social science is equally clear that American couples with kids who do not put a ring on each other’s finger are at least twice as likely to call it quits as those who do.

Some experts acknowledge the evidence indicating that marriage is good for children, adults, and communities but say nothing much can be done to revive falling marriage rates. “The genie is out of the bottle,” Isabel Sawhill, another Brookings economist, wrote in a 2014 essay titled “Beyond Marriage,” in which she noted that “college-educated young adults are still marrying before having children” but the “rest of America, about two-thirds of the population, is not.” The latter group was hit especially hard by the wave of divorces and single-parent households that began in the 1970s; since then, she wrote, the kind of family-go-round characterized by high levels of instability for couples and kids has become more of a norm.

Sawhill laments that “even some of our biggest social programs, like food stamps, do not reduce child poverty as much as unmarried parenthood has increased it.” But from her vantage point, the cultural, economic, and political forces that have been eroding our most important social institution—outside the well-guarded lives of the American elite—are too powerful to resist.

Sawhill is right that the problem is difficult. But this kind of view is nonetheless too fatalistic. If we cared to bridge our nation’s marriage divide, the more privileged among us could do more in government, business, education, media, and civil society to reinforce marriage. We could do this in at least three ways.

First, people who teach classes or write articles and books could tell the truth about marriage and family to their students and audiences. Yes, marriage is hard. Yes, some families are dysfunctional. Yes, there are poisonous partners out there. And, yes, it is of course possible to build a good life without marrying. But also … today most marriages are happy, the odds of getting divorced are now well below 50 percent, and married parents (ages 18 to 55) are happier than any comparable group. The public, especially our children and young adults, need to hear this more clearly and more often. The goal would not be to hector young people but rather to underline the ways that marriage and family life foster meaning, direction, and happiness. We can still be tolerant of individual circumstances without losing sight of the fact that not all pathways are equally likely to end at their desired outcome.

Second, to help more young Americans build healthy, stable family lives, we could push our schools to teach them the success sequence as a pathway through education, work, marriage, and child-rearing that is powerfully linked to positive economic outcomes. A 2021 survey by the American Enterprise Institute indicates that teaching it in public schools would be popular with the public across both class and racial lines—for instance, more than 68 percent of Black, Hispanic, and low-income Americans express support for teaching the sequence in public schools.

The success sequence offers an accessible framework, a compelling narrative, and a launching pad for teachers and mentors to help young adults approach family formation with greater clarity and purpose. And it is already being taught in pilot programs and local experiments—in charter schools in the South Bronx, urban public schools in Kentucky, rural schools in downstate Illinois, and more. The full results of these projects likely will be seen only over many years, but so far they have been promising. They should inspire a range of public and private campaigns. Private campaigns, led by churches and nonprofits, may prefer to use moral or religious language. Public campaigns will undoubtedly use a more descriptive model. A successful initiative to promote the sequence, modeled on earlier successful campaigns that focused more narrowly on reducing teen pregnancy, will leave room for a wide range of approaches.

Third, our leaders must tackle the economic obstacles to marriage facing too many couples. Many of our public policies—including food stamps and Medicaid—penalize marriage for a significant number of low-income families. The impact is seldom entirely straightforward—from program to program, it may depend on how poor the family is, or where they live, or how many kids they have. But these penalties tend to hit working-class families with children especially hard—some couples face penalties as high as almost one-third of their total household income.

Policy makers in Congress could tackle penalties in means-tested programs such as Medicaid and public housing by doubling the income thresholds for these programs for married parents with young children. That would be expensive. But having eliminated many of the marriage penalties facing middle- and upper-income families in the tax code, ignoring the financial penalties that many lower-income families still face is inexcusable. Uncle Sam should not be in the business of discouraging working-class Americans from getting married.

More still could be done—and arguably should be done—to encourage marriage financially. The Department of Defense, for instance, provides particularly generous benefits for married service members. Marriage in the military is a pathway to a bigger housing allowance, better health care for your partner and any children you have, and other benefits. The military does not provide these benefits to cohabiting couples, which sets it apart from the more laissez-faire approach practiced by many other federal agencies serving families. But the same incentive could be provided simply by giving bigger benefits, of various sorts, including a more generous child tax credit, to people who marry, without reducing benefits to those who don’t.

We should not underestimate the power of incentives like these. Certainly, they have helped foster a more marriage-friendly culture in the military. Almost 20 years ago, the sociologist Jennifer Lundquist found that working-class and African American members of the military married at much higher rates than their peers in the civilian world, in part because of these benefits. My own, updated analysis of the General Social Survey (GSS) indicates that this pattern continues today. To be sure, some of this is selection: The kinds of Americans who enlist in the military tend to be more marriage-minded. Nonetheless, after controlling for factors such as race, ethnicity, age, and education, the GSS data indicate that a military background among men strongly predicts being married today.

At a minimum, the military’s approach to marriage tells us that we could take stronger measures if we were interested in bridging the marriage divide that has emerged in America over the past half century. Growing up in a married home should not be a privilege reserved for the children of educated and affluent Americans.


This article is adapted from Brad Wilcox’s new book, Get Married.


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