chronic disease

Study: Kids with chronic health problems will face greater financial burdens if forced out of CHIP

kkrisberg — Tue, 25 Apr 2017 21:04:14 +0000

Study: Kids with chronic health problems will face greater financial burdens if forced out of CHIP

More than 8 million U.S. children depend on the Children’s Health Insurance Program for access to timely medical care. The program is authorized through 2019, but its federal funding expires in September and it’s unclear what Congress will do.

That uncertainty stresses all the systems and families that depend on CHIP, but it may be especially risky for the 2 million chronically ill children who get care through the program, which was originally designed for families falling in the gap between market affordability and Medicaid eligibility. In a study published this month in Health Affairs, researchers found that low-income children with chronic conditions would face higher out-of-pocket costs if forced to move from CHIP to the individual marketplace.

With the future of CHIP funding unclear, researchers simulated two scenarios: one in which CHIP funding is extended, and another in which CHIP children are enrolled in the Affordable Care Act insurance markets. After analyzing health plan data from CHIP and the marketplace, they found that CHIP enrollees may face thousands of dollars in additional costs on the individual market, with families of children with diabetes, epilepsy or mood disorders facing the highest additional costs.

Study co-author Alon Peltz, a physician who cares for children with special health care needs, noted that about one in every four kids in CHIP has a chronic health condition.

“We’re coming up on the 20^th year of CHIP and there are concerns about how to maintain coverage for these children,” Peltz, also a postdoctoral fellow in the Robert Wood Johnson Foundation’s Clinical Scholars Program at Yale School of Medicine, told me. “We wanted to think more critically about different avenues policymakers could take as they think about the future of health insurance coverage.”

In conducting the study, which included more than 7,000 children with one or more chronic conditions, Peltz and colleagues assumed that ACA subsidies would still be available to help former CHIP families buy coverage on the marketplace. (Unfortunately, the future of those subsidies is also unclear.) They found that at every income level, children with chronic health problems would pay more for coverage in the marketplace than they would have in CHIP. For example, a family living at 100-150 percent of the federal poverty level (that’s about $30,000 for a family of three) would spend about $233 more in the marketplace annually, while a family at 251-400 percent of poverty (or between $51,000-$81,000 a year) would pay $1,078 more in the marketplace.

Researchers also found that marketplace costs were higher for all six of the chronic conditions studied: asthma, ADHD, developmental disorders, diabetes, epilepsy and mood disorders. Children with epilepsy experienced the biggest spending increase in shifting to the marketplace, with the difference ranging from about $400 to nearly $2,500 depending on household income. The study attributed a majority of the out-of-pocket differences to spending on prescription drugs and inpatient hospitalizations. For instance, among children with asthma or ADHD, higher prescription expenses accounted for much of difference in CHIP and marketplace spending. For kids with diabetes, epilepsy and mood disorders, higher spending was typically associated with hospitalization costs.

The study’s findings also assume that children shifted to the marketplace would continue to get all the services they need. However, researchers cautioned that “in reality, families could encounter networks that are inadequate to meet their children’s specialty care needs and (that could) lead to even higher out-of-pocket expenses.” In addition, about 2 million children now covered by CHIP don’t currently qualify for ACA subsidies due to a loophole known as the “family glitch,” which would certainly impact their ability to afford coverage outside of CHIP. (Right now, families can get ACA subsidies as long as they don’t have access to affordable employer-sponsored coverage. However, that affordability determination is based on coverage for the individual employee, not the employee and her or his family. Hence, the “family glitch.”)

The study offered three strategies for leveling affordability between CHIP and marketplace plans: enhancing cost-sharing reductions in the ACA marketplace; re-examining cost-sharing for the two big drivers — drugs and hospitalization — of CHIP-marketplace spending differences; and monitoring whether marketplace deductibles negatively impact a child’s ability to access timely care. (CHIP plans rarely include deductibles.) However, all those strategies are based on an assumption that the ACA isn’t repealed and any changes to the law are relatively small. With that in mind, the researchers concluded that keeping CHIP funded is the best option for kids who need reliable access to care.

“Given concerns about the viability of the marketplace, the legal battles regarding the cost-sharing reduction payments and the efforts to repeal the ACA, reauthorizing funding for CHIP is most likely the least disruptive strategy moving forward,” researchers wrote.

Peltz said that if federal CHIP funding did disappear, many states would likely continue the program in some form. But with only state funds — and no matching federal funds — CHIP families may see reductions in services or higher cost-sharing requirements. He also noted that the ACA increased federal CHIP reimbursement to states. If Congress eliminated that enhanced reimbursement that could negatively affect state CHIP plans as well.

Still, Peltz said he’s hopeful that policymakers can find a solution that ensures care for the 8 million children who depend on CHIP.

“With some uncertainty right now in the political landscape, the CHIP program seems to be the best option for making sure that children, particularly those with chronic conditions, can continue accessing affordable care,” he told me. “We have a strong history of providing services to this vulnerable group of children…and as both a researcher and clinician, I hope we’ll continue the tradition of caring for these children.”

For a copy of the CHIP study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.

kkrisberg Tue, 04/25/2017 - 17:04

Categories

Medicine

More soda tax success: Study finds Mexico’s tax reduced sugary beverage buys two years in a row

kkrisberg — Fri, 10 Mar 2017 15:25:34 +0000

More soda tax success: Study finds Mexico’s tax reduced sugary beverage buys two years in a row

Another day, another study that shows soda taxes work to reduce the consumption of beverages associated with costly chronic diseases in children and adults.

This time it’s a study on Mexico’s sugar-sweetened beverage tax, which went into effect at the start of 2014 and tacked on 1 peso per liter of sugary drink. Published this month in the journal Health Affairs, the study found that purchases of sugary drinks subject to the new tax went down more than 5 percent in 2014 and nearly 10 percent in 2015. At the same time, purchases of untaxed drinks went up by slightly more than 2 percent. The study notes that prevalence of overweight and obesity reached 70 percent among Mexico’s adults and 30 percent among the country’s children as of 2012. In addition, sugar-sweetened beverages account for 70 percent of added sugars in the typical Mexican diet, making sugary beverages a “logical target for lowering the intake of added sugars,” the study stated.

To conduct the study, researchers used data on monthly household store purchases from the Nielsen’s Mexico Consumer Panel Services between January 2012 and December 2015. They found that purchases of taxed beverages declined by an average of 5.5 percent in 2014 and 9.7 percent in 2015, resulting in an overall average decline of 7.6 percent. Purchases of taxed sugary drinks went down at all socioeconomic levels, though such reductions were largest among the lowest-income households.

Researchers noted that the larger purchasing decline in the second year after the tax was enacted “suggests that in the case of these beverages, the long-term impact of a price change may also be larger than the short-term effect.” They went on to say that such results contradict statements from the beverage industry that the effects of a soda tax tend to wane after the first year of implementation. Researchers also noted that declines in sugary beverage consumption could have positive impacts on people’s health as well as on health care expenditures in Mexico. Study authors M. Arantxa Cochero, Juan Rivera-Dommarco, Barry Popkin and Shu Wen Ng write:

Given the sustained effect of the tax on sugar-sweetened beverages over a two-year period and findings that responses to prices of cigarettes (price-elasticities) increase monotonically with prices, the impact of the tax on sugar-sweetened beverages in Mexico could be increased by raising the tax to at least 2 pesos per liter (resulting in a 20 percent increase in price). At the global level, findings on the sustained impact over two years of taxes on the beverages in Mexico may encourage other countries to use fiscal policies to reduce the consumption of unhealthy beverages along with other interventions to reduce the burden of chronic diseases.

Of course, this study isn’t the only one to show the positive impacts of sugary beverage taxes. This study on Berkeley’s soda tax found a whopping 21 percent decrease in sugary beverage consumption. At Harvard, researchers predicted that Philadelphia’s sugary beverage tax, which went into effect this year, could prevent 36,000 cases of obesity over 10 years, prevent more than 2,000 cases of diabetes in the first year after the tax reaches its full effect, and save $200 million in health care costs over a decade. (On a side note, Pepsi recently announced it was laying off workers at its Philadelphia-area plants due to the new soda tax. However, a spokesperson for the city called the action a “new low,” citing the company’s $6 billion in profits last year. In addition, the mayor’s office recently announced that the city is on track to meet soda tax-related revenues, which are being invested in education and anti-poverty programs.)

Last year, voters approved soda taxes in Oakland, San Francisco and Albany, California, and in Boulder, Colorado. In San Francisco alone, officials predict the soda tax will generate $7.5 million in fiscal year 2017-2018 and $15 million in fiscal year 2018-2019. In Boulder, the approved ballot initiative requires the city to release an annual report showing how soda tax revenues are used — the revenues are intended to support healthier school food initiatives as well as programs aimed at preventing diabetes and other costly chronic diseases.

Research shows that sugary drink consumption is associated with a higher risk of developing type 2 diabetes. The American Diabetes Association estimates that the cost of diabetes in the U.S. went from $174 billion in 2007 to $245 billion in 2012 — that’s a 41 percent increase in just five years.

For a copy of the new study on Mexico’s soda tax, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years.

kkrisberg Fri, 03/10/2017 - 10:25

That's excellent news! In Seattle the mayor has proposed a $0.02/oz tax on sugar-sweetened bottled beverages (fizzy or flat).
There has been some concern expressed that the populations who buy more sugar-sweetened beverages, as opposed to diet beverages, are more likely to be people of color and have lower socieo-economic status, and therefore would be unfairly targeted by this tax. Personally I think diet soda should be taxed too and only unsweetened beverages excluded, but this is a simpler distinction to make.

It's great to see that these taxes are effective at reducing consumption as well as raising fund for prevention.

Parallel statistics for beer sales, por favor--

Worth reading: Ebola, artificial sweeteners, and outdated parking laws

lborkowski — Mon, 11 Aug 2014 07:00:03 +0000

Worth reading: Ebola, artificial sweeteners, and outdated parking laws

A few of the recent pieces I've liked:

Everything Tara C. Smith at Aetiology is writing about Ebola, especially her re-post of What's it like to work an Ebola outbreak?

Chris Young at the Center for Public Integrity: Critic of artificial sweeteners pilloried by industry-backed scientists

Dena E. Rifkin in Health Affairs: A Fighting Chance: How Acute Care Training Is Failing Patients With Chronic Disease

A-P Hurd at CityLab: How Outdated Parking Laws Price Families Out of the City

Charles Orenstein at ProPublica: Suspicious Prescriptions for HIV Drugs Abound in Medicare

lborkowski Mon, 08/11/2014 - 03:00

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Public Health - General

artificial sweeteners

chronic disease

ebola

A Practical Playbook to help primary care and public health team up

lborkowski — Wed, 05 Mar 2014 11:58:05 +0000

A Practical Playbook to help primary care and public health team up

Brian Castrucci, who’s worked in city and state health departments and is now Chief Program and Strategy Director at the de Beaumont Foundation, likes to ask people two questions: Do you know who your primary care provider is? And, Do you know who’s head of your local public health department? The fact that many people can answer the first question but not the second, he says, demonstrates why public health needs to partner with health care.

“US medical providers are giving people some of the best medical care in the world, but if they’re returning patients to communities and environments that are antagonistic to good health, patients will still fare poorly,” Castrucci explains. “Public health can help create environments that are supportive of the medical interventions people are getting from the healthcare system.” For instance, doctors might recommend that patients with diabetes and high blood pressure engage in regular physical activity, but it’s hard for people to follow those recommendations if they live in communities with few safe opportunities for exercise. Public health departments can play a role in identifying such communities and working to make them more supportive of healthy lifestyles.

With a new tool called the Practical Playbook, the de Beaumont Foundation, Duke Community and Family Medicine, and the Centers for Disease Control and Prevention aim to help local and state public health professionals and local, state, and regional primary-care groups collaborate with one another to improve their communities’ health and reduce healthcare costs. It offers tips and resources for partners working through each stage of the integration process: organize and prepare; plan and prioritize; implement; monitor and evaluation; and celebrate and share. The Practical Playbook site also contains a wealth of success stories, including the following:

Indiana’s Asthma Emergency Department Call Back Program conducts outreach to asthma patients seen in the emergency department of Parkview Health emergency rooms in northeast Indiana to help patients improve their asthma management. With support from the Indiana Department of Health, the not-for-profit Parkview Health system has a trained community health nurse or respiratory specialist contact patients soon after an emergency department visit for asthma to assess patients’ needs and offer assistance. Patients who cannot afford medication to control their asthma are enrolled in Parkview’s Medication Assistance Program, and those without a medical home are referred to a Parkview physician, community health center, or free clinic. The program also works with the Fort Wayne-Allen County Department of Health and local school districts to provide families with resources to help manage asthma and avoid future hospital visits. A survey of program participants found that 59% reported missing zero days of school or work since joining. Program resources available on the Practical Playbook website include contact forms that Parkview Health uses for the initial contact with asthma patients following their emergency department visit and six months after the initial contact. A program evaluation found 38 fewer asthma-related emergency room visits and nine fewer hospitalizations after the program’s first year, for an estimated savings of more than $600,000.

Massachusetts’ Mass in Motion program helps 33 communities support healthy eating and active living. In response to an alarming ride in statewide obesity rates, especially among African-Americans and Latinos, the Massachusetts Department of Health partnered with local organizations and healthcare teams (Massachusetts Department of Public Health, the Harvard Pilgrim Health Care Foundation, The Boston Foundation, Blue Cross Blue Shield, Tufts Health Plan Foundation, MetroWest Health Foundation) to provide technical assistance and support for 11 pilot sites to build capacity and establish multi-sector partnerships to increase active living and healthy eating, with an emphasis on health equity. With a federal Community Transformation Grant and funding from Partners HealthCare, the program was able to scale up. Communities are participating in Healthy Corner Store, Adopt-a-Park, Farm to School, and Safe Routes to School Programs; improving sidewalks and roads to encourage walking and biking; and launching community gardens and mobile veggie markets. In an early analysis of body mass index (BMI) levels, five Mass in Motion communities saw a 2.4% decrease in BMI levels classified as overweight or obese, while other communities experienced only a 0.4% decrease. Mass in Motion’s Practical Playbook page links to the program’s annual highlights and information on Community Transformation Grants.

Michigan’s Healthy Futures program is a partnership between Munson Medical Center and local health departments to assure pregnant women and new mothers have the healthcare and resources they need. The partners launched the program in response to findings that many women were not able to get necessary prenatal care and that families had complex health needs that could not be addressed within the scope of doctor’s visit. Now, expectant mothers participating in Healthy Futures get support from a registered nurse during pregnancy and during the first two years of their children’s lives. They also receive newsletters covering topics such as immunizations, safety, and nutrition. Research has found that among enrollees, breastfeeding rates and immunization rates for two-year-olds are higher than national, regional, and state averages. The program’s Practical Playbook page includes links to the Healthy Futures newsletters that go to women at various stages of pregnancy and to parents throughout their children’s first two years of life.

The Practical Playbook doesn’t just aim to lengthen the list of success stories, though; it’s part of a larger effort to build a system that integrates primary care and public health in order to address the chronic illnesses that account for a growing share of the US disease burden. In 2012, the Institute of Medicine released the report Primary Care and Public Health: Exploring Integration to Improve Population Health. It recommended bringing the two sectors together and identified a set of core principles for integration efforts. Dr. J. Lloyd Michener, who chairs the Department of Community and Family Medicine at Duke University Medical Center and served on the IOM committee that produced the report, recalls, “In putting the IOM report together, we noticed that there were lots of examples of successful primary care-public health integration, but people didn’t know about them.”

Michener, who also worked on the Practical Playbook, stresses that he and his colleagues are working to “build on local strengths and expertise.” He points out that with the Affordable Care Act starting to reward healthcare providers for prevention (with initiatives such as accountable care organizations and shared-savings models), primary-care practices have new incentives to invest in improving the health of the populations they serve. But they don’t always know that public health can be a key partner. “We’re trying to help public health departments and primary-care providers take advantage of the tools the ACA provides, as well as the knowledge and experience that clinicians and public-health practitioners can share with one another,” he says.

The jump in rates of heart disease, diabetes, and other chronic diseases has also made the integration necessary. “We’ve gone from a time when disease was primarily caused by microbes to a time when it’s originating in social and environmental conditions – but our healthcare system hasn’t necessarily made the switch,” says Castrucci. “We need to allow public health to address some of the upstream concerns – and public health has 300 year old infrastructure and experience to do it.”

lborkowski Wed, 03/05/2014 - 06:58

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New study confirms that eating healthy does indeed cost more

kkrisberg — Fri, 13 Dec 2013 13:58:24 +0000

New study confirms that eating healthy does indeed cost more

On average, eating healthy costs about $1.50 more per day than the least healthy diets, a new study finds. The extra cost seems insignificant at first — a small cup of coffee often costs more — but it all adds up to be a considerable barrier for many low-income families.

Researchers with the Harvard School of Public Health set out to find the evidence behind the conventional wisdom that healthier foods cost more, conducting the most comprehensive meta-analysis to date of price differences between healthy and unhealthy foods. In examining data from 10 high-income nations, researchers found that among food groups, meats and proteins had the largest cost difference, with healthier options costing 29 cents more per serving and 47 cents more per 200 calories than less healthy options. Overall, diets rich in healthy options — fruits, veggies, fish and nuts — cost significantly more than diets based on processed foods, meats and refined grains.

“It’s less than what we might have expected, but it’s important to think about what $1.50 means to some people,” lead study author Mayuree Rao told me. “It translates to about $550 a year for one person, so that’s a lot for many low-income families, especially when you multiply it by three or four family members.”

So, why the price gap? Rao and her colleagues said differences in manufacturing could explain some of it. For example, producing skinless chicken and leaner meats requires more work at the processing plant. They also gave a nod to arguments that years of agricultural policies and subsidies that favor the production of less healthy foods — “inexpensive, high volume” commodities like corn — have contributed to cheaper prices. Overall, they called for more research into the reasons underlying the price differences.

While the study, which was published last week in the journal BMJ, does emphasize that the collective cost of healthier eating is a real barrier for many families, Rao said it’s still a “drop in the bucket” compared to what we spend on diet-related chronic disease. For instance, obesity is estimated to have cost the country as much as $147 billion in medical costs in 2008 alone, according to the Centers for Disease Control and Prevention. And many of the same low-income populations that have difficulty affording healthier foods also suffer disproportionately from diet-related chronic disease, such as obesity and diabetes. Rao and study authors Ashkan Afshin, Gitanjali Singh and Dariush Mozaffarian wrote:

A daily price difference of $1.50 translates to $550 higher annual food costs per person. For many low-income families, this additional cost represents a genuine barrier to healthier eating. Yet, this daily price difference is trivial in comparison with the lifetime personal and societal financial burdens of diet-related chronic diseases. For example, suboptimal diet quality was recently estimated to account for 14% of all disability-adjusted life years in 2010 in the USA; if translated to a proportion of national health expenditures in 2012, this corresponds to diet-related healthcare costs of $393 billion/year or more than $1200/year for every American.

Rao, who is also a junior research fellow within Harvard’s Department of Epidemiology, hopes the study will inform policy discussions, especially at a time when issues of food security and chronic disease are making headlines. She said policies that favor healthy foods — such as taxing unhealthy choices and subsidizing healthy ones — is “one way to nudge people toward a healthier diet.” Another example is the Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, which is expected to experience a cut of $5 billion in fiscal year 2014 alone. Right now, SNAP benefits average out to about $1.40 per person per meal.

“You hear a lot about how difficult it is to eat healthy on the minimal amount of assistance provided by SNAP and these findings shed some light on exactly what that barrier might be,” Rao told me. “Thinking about how to design those programs more effectively to help people buy healthier foods will only help contribute to long-term health.”

The Harvard study made a big media splash last week and Rao told me that it’s quite gratifying to see the study resonate with so many people — “it speaks to the fact that it’s very much a part of people’s everyday lives.” But even though $1.50 may not be much to some, public health practitioners still face a challenge in changing people’s behaviors.

“It’s part of that age-old problem in public health,” Rao said. “How do we persuade people to make an immediate investment in preventing (disease) that seems so distant in the future?”

For a copy of the full study, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 12/13/2013 - 08:58

you just saved my homework assignment thank you so much

Im so tired of ignorant people claiming it DOES not cost more to eat healthy. It sure does! Think of it this way, not everyone is able to do large grocery shops. Say someone has a $20 food budget for the week. What will they buy? 5 boxes of kraft dinner, or they buy a package of chicken and some vegetables that may last two days tops?...I think the answer is obvious. Survival wins every time.

Study finds high support for public health interventions, few worries about encroaching 'nanny state'

lborkowski — Mon, 18 Mar 2013 09:55:06 +0000

Study finds high support for public health interventions, few worries about encroaching 'nanny state'

by Kim Krisberg

When it comes to public health law, it seems the least coercive path may also be the one of least resistance.

In a new study published this month in Health Affairs, researchers found that the public does, indeed, support legal interventions aimed at curbing noncommunicable diseases such as diabetes, heart disease and obesity. However, they're more likely to support interventions that create the conditions that help people make the healthy choice on their own. They're less likely to back laws and regulations perceived as infringing on individual liberties. It's a delicate balance, but encouraging news for public health workers.

"Public health should feel emboldened by this study," said co-author Michelle Mello, director of the Program in Law and Public Health at the Harvard School of Public Health. "There is public support for the enterprise they've embarked on...the question is how to do it in a way that capitalizes on (that support)."

Mello and her co-author Stephanie Morain examined public perceptions of what they called the "new frontier" in public health law — legal interventions focused on human behavior to prevent noncommunicable disease. Such "new frontier" interventions include reducing trans fat consumption, increasing cigarette taxes or implementing school-based efforts to identify overweight or obese children. The study notes that in 2000, the nation's three leading causes of death were tobacco use, poor diet and physical inactivity, and alcohol consumption. More than 75 percent of U.S. health care costs are related to preventable chronic conditions. Mello and Morain write:

The controversy calls into question the public’s willingness to view as legitimate uses of the power of the state any new-frontier interventions that attempt to use the law to prevent noncommunicable disease by influencing personal health behavior. Securing and maintaining legitimacy — that is, the public belief that officials have moral and legal authority to address the problem of noncommunicable disease and its behavioral underpinnings — is critically important because that authority affects people’s willingness to support and comply with public policies. Compliance with such interventions, in turn, is a critical determinant of the extent to which the policies will achieve their objectives.

"We were really interested in the novel efforts by public health departments to make new entrees into the chronic disease realm," Mello told me. "This isn't a totally new realm (for public health), but there is a new emphasis."

In surveying more than 1,800 U.S. adults, the two researchers found high support for government action on "new frontier" public health efforts. For example, more than 80 percent of respondents supported government action to prevent cancer, heart disease, childhood obesity and to help people control their diabetes. An even higher proportion of respondents said the government had a responsibility to address more traditional public health issues, such as providing vaccines and preventing food-borne illness. Respondents also had positive opinions of public health agencies, especially the Centers for Disease Control and Prevention and state and local health officials.

A particularly interesting, but probably not surprising, finding was dramatically lower levels of support for measures believed to be individually coercive. For example, policies to make fresh fruits and vegetables more affordable or to post calorie counts received supports of 83.6 percent and 80.8 percent, respectively. But support for an insurance premium surcharge for obese individuals only received the support of 37.6 percent of respondents. Similarly, more than 72 percent of respondents supported providing people with free nicotine patches; only 20 percent supported allowing employers to test and fire employees for tobacco use.

"These findings suggest that continuing the current focus on using law to shape health environments, instead of exerting more direct pressure on individual behavior, is a sound strategy for maximizing the legitimacy of policies," the study authors wrote.

Engaging the public in public health

Mello told me she was surprised at the high levels of support almost all the interventions received, noting the constant warnings of encroaching nanny states and over-reaching government that tend to dominate the media. In contrast, "our study revealed a quiet majority that supports the aims of these types of interventions...actually they want the government to do more," she said. She said she also thought that those people targeted by the interventions would be less likely to support them. But, with the exception of smokers, that wasn't the case. People who were overweight or living with diabetes tended to welcome public health interventions.

"In terms of political feasibility...we saw a gradient in public support that matched the gradient in coercion," said Mello, who is also a professor of law and public health in Harvard's Department of Health Policy and Management. "As a political matter, the smoothest path is to pick interventions that aren't choice restricting, that don't infringe on personal liberties. The dilemma, however, is that those (interventions) might not be the most effective."

Both Mello and Morain said engaging the public in the policymaking process could be key to public buy-in and compliance. Their study noted that the "strongest predictor among the belief measures we tested was the perception that 'people like me' can influence government priorities in public health." Morain, a doctoral candidate in the ethics tracks of the Interfaculty Initiative in Health Policy at Harvard, told me that support levels ticked up when people believed the government understood their values.

"It's really important to involve the public in priority-setting activities, to understand the values held by different populations and to be able to communicate how their values are being reflected in the policymaking process," Morain said.

Scott Burris, director of the Public Health Law Research Program at Temple University, said the Health Affairs study is among those "exploding the myth that people don't like public health interventions." Referencing his own body of work, Burris said that in the last 50 years, there's been few public health developments more important, more effective or more popular than the use of law to intervene on behaviors and environments to make people safer. For instance, he cited laws restricting tobacco use and making motor vehicles safer — "today, nobody would say we shouldn't have laws against drunk driving or promoting seat belts," he said.

"What's happening now is we're moving toward deeper causes ... how health is built into our society," Burris told me. "We're not talking about someone crashing into a wall and being saved by an airbag — there's that strong link between intervention and harm. ...We don't have the epidemiology yet that has convinced people that buying a Big Gulp soda is the same as smoking a cigarette."

The food and beverage industries are formidable — as was witnessed this week when a judge struck down New York City's law restricting certain establishments from selling sugary drinks larger than 16 ounces (the ruling will go to appeal this summer) — but they're not unbeatable, Burris noted.

"If you take the long view and look at our public health successes and how they've bubbled up from all over the place...you see that we continue to have a pretty good record of beating the big money," he said.

Luckily, people are beginning to realize that serious problems such as obesity and diabetes aren't simply related to a person's individual choice. It's also the physical, organizational and social environments that shape our behaviors — "now, people are saying, 'hold on, this isn't just natural, it's a logical consequence of the way we organize our communities and our society,'" said Alex Wagenaar, associate director of the Public Health Law Research Program and a professor of health outcomes and policy at the University of Florida. Wagenaar said it's entirely conceivable that in a couple of decades, laws targeting obesity and diabetes will be as commonplace and accepted as the public health laws and regulations we take for granted today. (For example, he noted that it was a big fight to get car manufacturers to install seat belts and yet today buckling up is the norm.)

"It's hard at the start, but it seems like we have no other choice," Wagenaar told me. "We have to take on these issues...and use policies to shape the environment in a more healthy way."

Mello noted that an interesting solution is to use "nudge interventions" in which choices aren't restricted, but the choice environment is altered. For example, in a cafeteria, make the healthy food choices the first choices people see. In other words, use what we know about human decision-making tendencies to the advantage of better health, she said.

"I think we'll see gradual changes over time," Mello said "This all very new and it may take a generation for people to appreciate the magnitude of these health threats and to really accept concrete interventions."

To read more about the Health Affairs study, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

lborkowski Mon, 03/18/2013 - 05:55

Categories

Social Sciences

Nobody wants big brother telling us we can't drink a big gulp, even though you can go buy 3/ 20 oz. colas. The reason is pretty simple. What will they try to control next and the reasoning is very legitimate. As far as giving away free patches, the tobacco companies should be 100% responsible for that. But I think their way of thinking is we need to save big bucks so we can spend 50 to 100 million on each case defending ourselves against smokers who are dying or died of lung cancer when they know and have know for decade that smoking causes cancer. The same is with alcohol. The alcohol industries should be paying billions on treating chronic alcoholism. The problem is that both industries would rather spend a billion to save a million from any lawsuit that come up against them. If it weren't for their lobbyist with unlimited amount of dollars tucked away in the deepest pockets in America supplied by tobacco and alcohol industries, both

Kim,
I am a graduate student at the University of Texas McCombs School of Business. We are studying the efforts of the Texas legislature to ban smoking in public spaces. If possible, we would like to interview you for our project. Can you please contact me to meet to discuss this issue?
Thank you,
Julian

Treatment of Chronic Otitis Media: Guidelines versus Practice

tsmith — Mon, 25 Feb 2013 21:14:57 +0000

Treatment of Chronic Otitis Media: Guidelines versus Practice

First of five student guest posts by Kristen Coleman

Every morning as I prepare for class, I go through the same internal dialogue, “to wear or not to wear my hearing aide.” I am forced to do this because when I was a child I, like most American children (about 80% by age 3 as estimated by the American Academy of Family Practitioners, AAFP), suffered from otitis media and my treatment resulted in hearing loss. The treatment I underwent was called tympanostomy with ventilation tube insertion, which has rapidly become the most common reason for general anesthesia in children in the United States. However, the AAFP reports that meta-analysis of studies exploring the effectiveness of this procedure indicate that benefit is only marginal at best. So why is it that our children are being exposed to this potentially quality of life altering procedure, if there is little benefit? In order to explore the reasons, we must delve further into the disease in question.

Previously, it had been commonly thought that chronic otitis media was characterized by a virus-laden sterile effusion behind the ear drum; meaning that bacteria were not thought to be present and thus, antibiotic therapy was not indicated. Now we know that chronic otitis media is most commonly due to infection of the middle ear by Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, (all of which are bacteria) or respiratory viruses. The organisms contribute to the buildup of fluid and pus behind the ear drum that is characteristic of this disease. Dr. Kim Stol and collaborators have reported findings that demonstrate that immune inflammatory response, measured through the presence of immune mediators called cytokines, may play a role in the damage to the ear during bacterial infection that commonly results in hearing loss or diminishment. As demonstrated by the research of Dr. Lusk of the University of Iowa, this immune-mediated damage can persist even after surgical intervention if bacteria persist in the middle ear, making medical management of the bacteria through antibiotic therapy even more essential.

Due to this evidence, the AAFP and other leading organizations that publish guidelines for treatment recommend antibiotic therapy as the gold standard of care for children suffering from chronic otitis media. These guidelines indicate rigorous treatment with high doses of antibiotics such as amoxicillin/clavulanate, cephalosporins and macrolides. If these antibiotics do not offer relief, clindamycin and tympanocentesis (removal of fluid from behind the ear drum with a needle) are then warranted. It is only when all of these medical treatments fail that tympanostomy tubes may be an appropriate option. However, it has been reported by researchers at Mount Sinai School of Medicine in New York City that of the 682 children who received tympanostomy tubes as treatment for chronic otitis media in their study in 2002, only 7.5% did so in accordance to the guidelines set forth by these organizations, and that most of these operations occurred before adequate attempts at antibiotic management of the disease could be utilized. In the study performed by Dr. Stol, it was reported that of the 116 participants in the study who were suffering from chronic otitis media, only 6.9% had received a recent antibiotic prescription, despite the fact that 53% of these patients were suffering from a bacterial form of the disease that may have responded favorably to antibiotic therapy.

As for me and my story, I had an initial round of ventilation tubes places in my ear drums when I was 6 years old, along with an adenoidectomy which was thought to help diminish my ear infections. My family was told that my disease was due to a virus and I was not prescribed any antibiotics prior to my surgical procedure. These tubes fell out the next year, and my chronic otitis media still had not resolved. More permanent tubes were placed in my ears at age 8 and these became lodged in my ear drums until college, all the while I suffered from chronic fluid and pain in my ears. When I had the tubes removed at age 19, my ear drums were permanently scarred and I had to undergo a bilateral tympanoplasty in which a surgeon tried to patch the holes in my ear drums, to no avail. All of this resulted in me having to wear a hearing aide in order to hear adequately at the age of 28.

As the report from Mount Sinai Medical School indicates, the discrepancy between practice and guidelines, as well as the overuse of surgical management in lieu of less-invasive medical management cannot be in the best interest of the children suffering from this disease, and steps need to be taken in order to educate physicians and families alike as to the most appropriate steps for treatment of this chronic disease in order to save our children from having stories like mine.

References:

1.Stol, Kim et al. Inflammation in the Middle Ear of Children with Recurrent or Chronic Otitis Media is Associated with Bacterial Load. The Pediatric Infectious Disease Journal. Volume 31, Number 11, pages 1128-1134. November 2012.

2.Lusk, Rodney P. et al. Medical Management of Chronic Suppurative Otitis Media Without Cholesteatoma in Children. Layngoscope: February 1986.

3.Keyhani, et al. Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort. Mount Sinai Medical School. BMJ: 2008.

4.American Association of Family Practitioners. www.aafp.org/afp/2007/1201/p1650.html

tsmith Mon, 02/25/2013 - 16:14

Tags

Infectious causes of chronic disease

Excellent!

Great post! Have you heard about the new guidelines on treating ear infections? http://www.npr.org/blogs/health/2013/02/25/172588359/pediatricians-urge…

The new practice guidelines wisely discourage needless use of antibiotics, but for children with frequent repeat infections, they recommend going right to shoving tubes into the kids rather than using antibiotics. As this guest column so eloquently notes, that can have permanent repercussions. Before our current state of permanent war began, I remember hearing that the military had rejected some potential recruits for having tubes in their ears. I don't know if they still do that or not, but it certainly seems to me that parents shouldn't be needlessly rushed into making decisions, for a child too young to grant consent, that could permanently limit his or her future options in life.

It seems to me that tympanostomy is more popular in the US than in Europe. I must admit that this article is the first time I've even heard the term tympanostomy. Over here antibiotics seem to be "the weapon of first choice" and tympanostomy is treated as the last resort.

Recent research has associated chronic ear infection with biofilm formation. The biofilm protects bacteria from the antibiotic. They do no damage while in the biofilm, but they eventually come out of the biofilm, become planktonic and created infection - again!
The key is finding a way to disrupt or destroy the biofilm while killing the bacteria with the antibiotics. There are a number of potential therapies being studied in the US, but in Europe they are beginning to employ. Take a look at the research. Very hopeful.

Hemolytic uremic syndrome (HUS): history and implications

tsmith — Fri, 24 Jun 2011 20:20:50 +0000

Hemolytic uremic syndrome (HUS): history and implications

Part One

It appears that the E. coli O104 sproutbreak is starting to wind down, with more than 3,500 cases diagnosed to date and 39 deaths. Though sprouts remain the key source of the bacterium, a recent report also documents that human carriers helped to spread the organism (via H5N1 blog). In this case, it was a food service employee working at a catering company, who spread infection to at least 20 people before she even realized she was infected.

As with many infectious diseases, there are potential lingering sequelae of infection, which can occur weeks to years after the acute infection has cleared up. Like almost 800 others involved in this outbreak, the woman who unwittingly infected others via food developed hemolytic uremic syndrome, or HUS. We now know that the most common cause of HUS are bacteria such as STEC ("shiga toxin-producing E. coli"); the "shiga toxin" that they produce inhibits protein synthesis in the host and cause cell death. This can have systemic effects, and leads to clotting in affected organs--most commonly the kidneys, but other organs can also be affected. Dialysis may be necessary, and the infection can lead to kidney failure and the need for organ transplantation. There is already concern that, because of the huge numbers of HUS cases, many patients will have long-term kidney damage, including the potential need for additional organs (and possibly, re-vamping the way donations are made as well):

In previous E. coli outbreaks, up to half of patients who developed the kidney complication were still suffering from long-term side effects 10 to 20 years after first falling sick, including high blood pressure caused by dialysis.

In addition to possible kidney problems, people who have survived serious E. coli infections may also suffer from neurological damage, as the bacteria may have eaten away at blood vessels in the brain. That could mean suffering from seizures or epilepsy years after patients recover from their initial illness.

While it's common knowledge in the medical community now that STEC can lead to HUS, which can lead to chronic kidney issues, for many years, the link between E. coli and HUS was obscured. HUS first appears in the literature in 1955, but the link to STEC wasn't confirmed until the early 1980's. In the interim, myriad viruses and bacteria were examined, as well as genetic causes. (There are cases of HUS caused by host mutations and other etiologies, but they are much less common than HUS caused by STEC and related organisms). I'll delve into the history of HUS and look at a few studies which examined alternative hypotheses of causation, until finally STEC was confirmed as the causative agent. I'll also discuss what this means as far as discovering infectious causes of other "complex" and somewhat mysterious diseases whose causes are unknown, as HUS was a mere 30 years ago.

Part Two

The epidemiology of hemolytic uremic syndrome (HUS) was murky for several decades after it was first defined in the literature in 1955. In the ensuing decades, HUS was associated with a number of infectious agents, leading to the general belief that it was a "multifactorial disease"--one that had components of genetics and environment, much like we think of multiple sclerosis today, for example.

Several HUS outbreaks made people think twice about that assumption, and look deeper into a potential infectious cause. A 1966 paper documented the first identified outbreak of HUS, which occurred in Wales. The researchers examined a number of possible environmental factors the patients may have had in common--including food, water, and various toxins--but came up empty. They sum up:

Since it is almost invariably preceded by a gastrointestinal or respiratory illness, it seems probable that it represents a response to an infection. Although Gianantonio et al. (1964) have identified one possible causative virus, it may be that various infective agents can initiate the syndrome.

This idea held throughout the next 20-odd years, as numerous studies looked at both environmental and genetic effects that may be leading to HUS. A 1975 paper examined HUS in families, suggesting that there may be two types of HUS (which we now know to be true--the genetic form is less often associated with diarrhea, and tends to have a worse prognosis as I mentioned yesterday). But still, no definitive cause for either.

There were also a number of studies testing individuals for many different types of pathogens. A 1974 paper enrolled patients in the Netherlands between 1965 and 1970, but one of the inclusion criteria was a "history of a prodromal illness in which gastrointestinal or respiratory tract symptoms were present." The respiratory tract symptoms are mentioned in a number of papers, and were probably a red herring that sent people in search of the wrong pathogens for awhile. In this particular paper, they examined children for infection with a number of viral and bacterial pathogens, using either culture or serological methods (looking for antibodies which may suggest a recent infection). In that portion of the paper, they note a possible association with adenoviruses, but state that the data don't support a bacterial infection--a viral etiology was deemed more likely. Regarding basic epidemiology, they did note a few small clusters of cases in families or villages, as well as a peak in cases in spring/summer--as well as an increasing number of cases from the first year of their study to the last. The epidemiology of HUS was starting to become clearer, and the syndrome appeared to be on the rise.

Even as additional case reports occasionally targeted foods as a precursor to HUS outbreaks, it wasn't until the late 1970s and early 1980s that HUS really started to come into focus. In 1977, a paper was published identifying the "Vero toxin"--a product of E. coli that caused cytotoxicity in Vero cells (a line of African green monkey kidney cells, commonly used in research). Researchers were closing in.

Part Three

I left off yesterday with the initial discovery of "Vero toxin," a toxin produced by E. coli (also called "Shiga toxin" or "Shiga-like toxin"). Though this may initially seem unconnected to hemolytic uremic syndrome (HUS), the discovery of this cytotoxin paved the way for a clearer understanding of the etiology of this syndrome, as well as the mechanisms by which disease progressed. By the early 1980s, several lines of research pointed toward E. coli, and particularly O157:H7, as the main cause of HUS.

A 1982 Centers for Disease Control and Prevention MMWR report found a rare E. coli serotype, O157:H7, associated with hemorrhagic colitis following consumption of hamburgers. Similar results were reported in a 1983 Lancet paper, which found serotype O157 among their collection of verotoxin-producing strains. Another paper that same year from a Canadian group showed that O157:H7 was the second most common cytotoxic strain in their collection of over 2,000 E. coli isolates. The most common was serotype O26--more on that below. This paper also discussed an outbreak of hemorrhagic colitis that had occurred at a nursing home, with O157 identified as the cause. The evidence was mounting, but these were small studies and not always associated with HUS. Still, these papers collectively were suggestive of a connection between E. coli infection (especially with strains that produced the shiga/vero toxin), hemorrhagic colitis, and HUS.

In 1985, a new study came out which really helped to seal the deal. Rather than look only at cases in isolation, the authors designed a case-control study looking at patients with "idiopathic HUS" (in other words, HUS of unknown origin which started with diarrhea, rather than the other variant lacking this symptom). They ended up with 40 patients who qualified. They then picked a single control for each patient, matching them on age, sex, and season of the year. The controls were children either diagnosed with Campylobacter enterocolitis (and therefore, enterocolitis of a known cause) or were healthy children either from a local daycare center, or kids coming in for elective surgeries. Stools were collected from each group and tested for a variety of organisms, including vero toxin-producing E. coli (VTEC, also known as STEC for the shiga-like toxin nomenclature). They also tested for activity of the toxin itself in fecal samples. Finally, in the case patients, attempts were made to collect what are called "acute" and "convalescent" blood samples. These are samples taken when the patient is actually sick ("acute"), and then ones taken a few weeks later ("convalescent), to look at the presence of antibodies in the blood. If it was an infection by the suspected organism (in this case, STEC/VTEC), you should see a rise in antibodies the host produces that target the organism--for these kids, they were looking for antibodies to the shiga/vero toxin.

They found either vero toxin or VTEC in 60% of the case patients, but in none of the controls. Of the VTEC isolated, serotypes included O26, O111, O113, O121, and O157. For the latter, it was the most common type isolated (25% of the VTEC found). Of the patients who were negative for both VTEC and vero toxin, from those who had paired blood samples (12/16 of the remaining cases), 6 did show a rise in antibody titer against the vero toxin--suggesting they had been exposed and were producing antibodies to neutralize the toxin. So, for those keeping score, 75% of the cases had evidence of VTEC infection either by culture or serological techniques. It may not have been the nail in the coffin and there are certainly some flaws (the diversity of controls and lack of analysis of blood titers for the controls being two that pop out at me), but this paper went a long way toward establishing VTEC/STEC as the cause of HUS, which has been subsequently confirmed by many, many studies worldwide.

The most common vehicles of transmission of these organisms have also come into clearer focus since the 1950s, with almost all HUS/STEC outbreaks associated with food products; most common is still the O157:H7 serotype. O157 is a bit unique, in that this strain typically doesn't ferment sorbitol--as such, this is often used as a diagnostic feature that sets it apart from "normal" E. coli. However, as I mentioned above (and as the current outbreak has shown), a number of other serotypes besides O157:H7 can also cause HUS. Most of these don't appear to be as commonly associated with outbreaks--rather, they may more commonly cause sporadic disease where fewer people may become sick. Because these don't have the unique sorbitol-non-fermenting feature, these may be overlooked at a diagnostic lab. There are assays that can detect the Shiga-like toxin directly (actually, we now know there are multiple families of related toxins), but not all labs use these routinely, so it's likely that the incidence of infection due to non-O157 STEC is higher than we currently know.

HUS was once a mysterious, "complex" disease whose perceived etiology shifted almost overnight, as scientific advances go. What implications does this have for other diseases whose etiology is similarly described as HUS was 50 years ago? More on that tomorrow.

Part Four

As I've laid out in parts 1-3, the realization that a fairly simple, toxin-carrying bacterium could cause a "complex" and mysterious disease like hemolytic uremic syndrome came only with 30 years' of scientific investigation and many false starts and misleading results. Like many of these investigations, the true cause was found due to a combination of hard work, novel ways of thinking, and simple serendipity--being able to connect the dots in a framework where the dots didn't necessarily line up as expected, and removing extraneous dots as necessary. It's not an easy task, particularly when we've had mostly culture-based methods to rely on since the dawn of microbiology.

If you read start digging around in the evolutionary medicine literature, you'll see that one oft-repeated tenet is that many more "chronic" and "lifestyle" diseases are actually caused by microbes than we currently realize. (I'll note that there is active disagreement here in the field--one reason noted is that many of these diseases would decrease one's fitness and thus they are unlikely to be genetic, but many of them also have onset later in life than the prime reproductive years, so--still controversial). But whether you agree on the evolutionary reasoning or not, I think it's safe to say that those who make this claim (like the Neese & Williams book I linked) are probably right on the overall assertion that more and more of these "lifestyle/genetics" diseases are going to be actually microbial in cause than we currently realize.

Why do I agree with this claim? History is a great indicator. Many infectious diseases were thought to be due to complex interactions of genetics (or "breeding," "lineage," etc.) with "lifestyle." Think of syphilis and tuberculosis in the Victorian era. Syphilis (and many other diseases which we know now to be sexually-transmitted infections) was considered a disease which affected mainly the lower social classes ("bad breeding"), and was thought to be rooted in both family history as well as an over-indulgence in sex or masturbation. Tuberculosis, because it affected those throughout the income spectrum, was still blamed on "poor constitution" in the lower classes, but was a disease of the "sensitive" and "artistic" in the upper classes. It was also thought to be due to influences of climate in combination with genetics. Or, look to more recent examples of Helicobacter pylori and gastric ulcers, which were also ascribed to dietary habits and stress for a good 30 years before their infectious nature was eventually proven. And from that same era, HIV/AIDS--which even today, some are still all too ready to write off as merely a behavioral disease, rather than an infectious one.

So, we still view many of these diseases of unknown etiology as multi-factorial, "complex" diseases. And undoubtedly, genetic predisposition does play a role in almost every infectious disease, so I'm not writing off any kind of host/pathogen interplay in the development of some of these more rare sequelae, such as HUS as a consequence of a STEC infection. But looking back over history, it's amazing how many diseases which we view now as having a documented infectious cause were studied for years by researchers thinking that the disease was the result of exposure to a toxin, or diet, or behavior, or a combination of all three.

I've mentioned the example of multiple sclerosis in previous posts. Multiple sclerosis is an autoimmune disease; the body produces antibodies that attack and eventually destroy parts of the myelin sheath covering our nerves. The cause of MS, like HUS 40 years ago, is unknown, though it's thought to be a combination of genetics and environmental influences. Going through the literature, it seems like almost everything has been implicated as playing a causal role at one point or another: pesticides, environmental mercury, hormones, various other "toxins," and a whole host of microbes, including Chlamydia pneumoniae, measles, mumps, Epstein-Barr virus, varicella zoster (chickenpox), herpes simplex viruses, other herpes families viruses (HHV-6 and HHV-8), even canine distemper virus. They've done this looking at both microbe culture (from blood, brain tissue, CNS, etc.) as well as using serology and DNA/RNA amplification in various body sites. None have shown any strong, repeatable links to the development of MS--much like the spurious associations that were seen with adenovirus and HUS.

Although no microbial agent has been convincingly implicated to date, there are tantalizing hints that MS is caused by an infectious agent. There have been "outbreaks" of MS; the most famous occurred in the Faroe Islands in the 1940s. Studies of migrants show that the risks of developing MS seem to be tied to exposures in childhood, suggesting a possible exposure to an infectious agent as a kid. And one of the most common mouse models used to study MS has the disease induced by infection with a virus called Theiler's murine encephalitis virus (TMEV). If it can happen in mice, why not humans?

It might seem implausible that infection with some microbe could lead to the eventual neurological outcomes of MS, but again, examples abound of weird connections between microbes and health outcomes. For STEC, it might not be intuitively obvious at first glance how a fecal organism could be a cause of kidney failure. The respiratory bacterium Streptococcus pyogenes usually causes throat infections ("strep throat"), but if left untreated, it can also cause kidney damage (glomerulonephritis) or even heart failure due to rheumatic heart disease. A microbial cause of MS could lie in a virus, bacterium, parasite, or fungus--maybe one that we haven't even discovered yet, but that perhaps will pop up as we learn more and more about our metagenome. Perhaps 30 years down the road, the way we view many of these "complex" diseases will look as short-sighted as it does looking back at old HUS papers from today's vantage point.

tsmith Fri, 06/24/2011 - 16:20

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General Epidemiology

Historical studies of disease

Infectious causes of chronic disease

hemolytic uremic syndrome

HUS

post-infectious sequelae

infectious disease

public health

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Brain and Behavior

The Global "Slow-motion Catastrophe" of Chronic Disease

lborkowski — Mon, 02 May 2011 15:43:46 +0000

The Global "Slow-motion Catastrophe" of Chronic Disease

Last week in Moscow, the World Health Organization and Russian Federation held the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, which addressed the "slow-motion catastrophe" of rising rates of non-communicable illnesses like heart disease and diabetes. WHO Director-General Margaret Chan warned that diabetes rates have skyrocketed in both rich and poor countries, but in poor countries "health services are almost totally unprepared to cope with the onslaught of chronic demands that come with the rise of non-communicable diseases."

As the WHO points out in a discussion presentation (PDF), just four NCDs are responsible for more than 60% of deaths worldwide: cancers, cardiovascular diseases, diabetes, and chronic pulmonary diseases. Tobacco use, harmful use of alcohol, physical inactivity, and poor diet are major risk factors for these conditions. And while developed countries are worried about chronic diseases' contributions to soaring healthcare expenditures, the effects on developing nations are even more severe. The presentation explains:

However it is in developing countries, particularly on the African continent, where the expanding NCD epidemic is fanning poverty, stifl ing economic growth and hindering development. In many households, the bulk of a family's income will go to caring for a loved one ailing from a NCD. Such "catastrophic expenditures" are preventing millions of people of advancing their lives and providing for their children's futures.

The Moscow Declaration that came out of the meeting emphasizes that "prevention and control of NCDs requirs leadership at all levels, and a wide range of multi-level, multi-sectoral measures aimed at the full spectrum of NCD determinants (from individual-level to structural) to create the necessary conditions for leading healthy lives." It includes a commitment to action on a total of 23 steps -- 11 of which are for national governments, six for ministries of health, and six for the international level. The steps include:

At the national level:

Implementing cost-effective policies, such as fiscal policies, regulations and other
measures to reduce common risk factors such as tobacco use, unhealthy diet, physical
inactivity and the harmful use of alcohol;

At the ministry of health level:

According to country-led prioritization, ensuring the scaling-up of effective, evidence-based and cost-effective interventions that demonstrate the potential to treat
individuals with NCDs, protect those at high risk of developing them and reduce risk
across populations.

At the international level:

Examining possible means to continue facilitating the access of low- and middle
income countries to affordable, safe, effective and high quality medicines in this area
consistent with the WHO Model Lists of Essential Medicines, based on needs and
resource assessments, including by implementing the WHO Global Strategy and Plan
of Action on Public Health, Innovation and Intellectual Property.

Although the WHO stresses that low-cost solutions to the NCD epidemic exist, it's hard not feel daunted by the scale of the challenge. Jake Marcus of the Institute for Health Metrics and Evaluation has a great piece in The New Republic considering why there's no global movement to combat NCDs, and he compares the fight against chronic illnesses to the global campaign against HIV/AIDS. NCDs, he point out, will be harder to organize around than AIDS because they build up over many years and have far more than one pathway for transmission; tend to take their most visible toll on older people, who are less likely to spark emotional responses from potential donors; and don't create the fear that a higher rate of infection increases everyone's chance of contracting the disease.

I'll add another challenge to his list: HIV doesn't have a manufacturer that benefits when people engage in risky behaviors, but their are plenty of companies that benefit from the unhealthy lifestyles that increase the risk of NCDs. Tobacco companies will collapse if everyone stops smoking. Alcohol companies will see their profits drop if excessive drinking stops. The manufacturers of high-calorie/low-nutrient food stand to lose millions if people adopt healthier eating habits. Carmakers could see their markets shrink as local governments make it easier for people to get around by walking, biking, and riding public transportation.

One of the national-level steps in the Moscow declaration is "Engaging the private sector in order to strengthen its contribution to NCD prevention and control according to international and national NCD priorities." The Washington Post's Will Englund reported from Moscow that "Unhealthy food, and what to do about it, was the most sensitive topic at the gathering." He notes that 10 big producers have formed "an alliance that says it is committed to reducing salt, sugar and fat in processed food and restricting advertising aimed at children. And he provides a couple of examples from countries that have addressed the issue of salt:

Finland tried to reduce the amount of salt in food by seeking voluntary commitments from manufacturers, with mild success, said Sirpa Sarlio-Lahteenkorva, an official in the Finnish Health Ministry. But when the government required salt labeling, consumption dropped sharply, she said. The same happened when the government increased taxes on alcohol. (Finland is the world leader in reducing deaths from non-communicable disease.)

The government of Argentina leaned on the country's bakeries and, without resorting to formal measures, got them to reduce by nearly one-third the amount of salt in bread over a few months, said C. James Hospedales, coordinator for chronic disease at the Pan American Health Organization.

I hope the Moscow meeting generates some additional funding and high-level attention to the problem of non-communicable diseases, because it's going to take a lot of work to reduce the global risk.

lborkowski Mon, 05/02/2011 - 11:43

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physical activity

Public Health - General

chronic disease

non-communicable diseases

World Health Organization

physical activity

Getting the whole story- attempting to make sense of disease through evolutionary medicine

tsmith — Wed, 24 Feb 2010 13:00:00 +0000

Getting the whole story- attempting to make sense of disease through evolutionary medicine

Student guest post by Anne Dressler

The idea of evolutionary medicine is new to me and my understanding is quite shallow but it has piqued my interest. Currently, the book "Why We Get Sick" by Randolph M. Nesse and George C. Williams has been satisfying my curiosity during the 15 minutes of intellectual thought I have left at the end of the day while reading before bed. From what I've read, I'm finding how useful it can be to consider disease in light of evolution and I'm left wondering how I haven't heard of it before. I'm guessing I'm not the only one interested, so let's talk evolutionary medicine, starting with some of the basics and finishing with why I find this particularly interesting for the nexus between infectious and chronic disease.

If basic biology and traditional medicine make up the plot of our disease "stories", evolutionary medicine would be somewhat like the moral. My roommate is a medical student and when asked, she can tell you how just about anything in the human body works and what is happening when things go wrong. When asked why things go wrong, her answer will refer to a proximate cause, such as certain foods leading to plaque build up which can lead to heart disease. If the question of why is rephrased, as in why does the disease even exist at all, then she's stumped. This is the question considered by evolutionary medicine. Why aren't our bodies able to repair clogged arteries? Why are we prone to infections? Why are our bodies so good at some things but so inept at others? At first I found theses questions strange- after studying epidemiology's risk factors for the past year, I had started viewing them as the sole reason for the existence of disease. And that kind of makes sense...if you completely ignore evolution. Enter famous and ubiquitous Dobzhansky quote:

"Nothing in biology makes sense except in the light of evolution."
-Theodosius Dobzhansky

It is through the perspective of evolution that one can consider why a disease exists beyond the obvious.

In their book, Nesse and Williams propose six categories for evolutionary explanations of disease: infection, novel environments, genes, design compromises, evolutionary legacies, and defenses. The basis for all these explanations is evolution through natural selection thus I think it is wise to keep in mind some key points. First, natural selection occurs when survival and reproduction are affected by genetic variation among individuals. Genes are only passed on by the organisms that survive to reproduce. Note, surviving to reproduce doesn't necessarily have anything to do with health or survival later in life nor does it necessarily mean good health before reproduction either.

"If tendencies to anxiety, heart failure, nearsightedness, gout, and cancer are somehow associated with increased reproductive success, they will be selected for and we will suffer even as we 'succeed,' in the purely evolutionary sense."
-Randolph M. Nesse and George C. Williams, Why We Get Sick

Also, think Richard Dawkins and "selfish genes"- selection doesn't consider populations, but rather benefits genes. With this in mind, let's go over one of the proposed categories for explaining disease- infection (even if it is just skimming the surface).

Infectious agents have long been a cause of human disease. As we have evolved means to avoid infection, pathogens have evolved means to counter us leaving us prone to infection. Due to their relatively rapid reproduction, pathogens can evolve much more quickly than we can. One way we attempt to make up for this deficiency is by using antibiotics. Interestingly, by using antibiotics we are essentially taking advantage of the evolutionary advantages of another organisms. Toxins produced by fungi and bacteria are a result of millions of years of selection to combat pathogens and competitors. Dangerously, many believed that with antibiotics we would finally be in control of infections. Unfortunately, that was an underestimation of evolutionary forces and while almost all staphylococcal strains were susceptible to penicillin in 1941, today nearly all are resistant. This pattern is standard for most newly introduced antibiotics

The concept seems simple enough, but it's not the only thing we've misunderstood about the evolution of pathogens. A common misperception is that a pathogen will evolve from being virulent to being more and more benign in order for the host to live long enough for the pathogen to pass on offspring to new hosts. This makes sense, yet doesn't fully take into account the need to pass on offspring. Being able to disperse offspring to new hosts may mean it is most beneficial to the pathogen for the host to be sneezing, coughing, or laying prostrate. Another force behind pathogens evolving increased virulence is within-host selection. Simply, if there is more than one strain of a pathogen within a host, the one that uses the host's resources most effectively will be the one to disperse the most offspring.

So if infections are one evolutionary explanation for disease, what's an example? I recently came across an interesting article about infection and it's relation to premenstrual syndrome. In the article Premenstrual Syndrome: an evolutionary perspective on its causes and treatment, Doyle et al. propose premenstrual syndrome is due to an exacerbation of a set of infectious diseases during cyclic changes of immunosuppression by estrogen and progesterone. While genetics and non-infectious environmental influences have been examined and found largely unable to explain PMS, infectious causes have been overlooked. However, it is know how immune function varies throughout the menstrual cycle in such a way that there could be less effective control of fungi, viruses, and intracellular bacteria, so making the leap to a persistent infection contributing to PMS doesn't seem too difficult. Supporting this hypothesis is a long list of chronic diseases with suspected infectious causes that are exacerbated premenstrually including Crohn's disease with Mycobacterium avium and juvenile onset OCD with Streptococcus pyogenes.

I think the most important point to take from this article is that there may be many other chronic diseases we don't yet fully understand that are caused by infectious agents.

Yet even while the who, what, when, and where of some diseases may already be understood, the why of a disease is usually ignored. With an evolutionary perspective, we can try to answer the question of why diseases arise and persist under the forces of selection. These insights could help answer some old questions, such as those regarding unknown causes of chronic diseases, and ask some new ones, such as how could PMS be treated if it's cause really is infectious. Finally, while guiding health care practices to improve health is the ultimate goal, at the very least evolutionary medicine reminds us to keep thinking about things in new ways.

Sources:

Doyle, C., H. A. Ewald, and P. W. Ewald. "Premenstrual Syndrome: An Evolutionary Perspective on its Causes and Treatment." Perspectives in biology and medicine 50.2 (2007): 181-202.

Gammelgaard, A. "Evolutionary Biology and the Concept of Disease." Medicine, health care, and philosophy 3.2 (2000): 109-16.

Nesse, Randolph M., and George C. Williams. Why we Get Sick. New York: Vintage Books, 1994.

Nesse, R. M. "How is Darwinian Medicine Useful?" The Western journal of medicine 174.5 (2001): 358-60.

Stearns, S. C., and D. Ebert. "Evolution in Health and Disease: Work in Progress." The Quarterly review of biology 76.4 (2001): 417-32.

Williams, G. C., and R. M. Nesse. "The Dawn of Darwinian Medicine." The Quarterly review of biology 66.1 (1991): 1-22.

tsmith Wed, 02/24/2010 - 08:00

Tags

General biology

General Epidemiology

Infectious causes of chronic disease

evolutionary medicine

Yes, but if a pathogen is too virulent, then it severely incapacitates or kills its host before it gets to vector to a new host and both die. This is why virulence is expected to decrease with time, the really nasty strains will more frequently die with their host. And it's why really virulent plagues are a function of dense populations (in humans an urban phenomenon). Small isolated groups just die out taking the pathogen with them. Those pathogen strains that are less virulent stand a better chance of getting passed along to new hosts. Lesson: don't be the first to catch a disease.

I think you address a lot of very key points while also bringing light against one of the most popular fallacies about evolution; the belief that evolution will progressively make us better. Even if we have a great immune system why does it tend to progressively weaken with age? Have you considered a negative fitness values? Instances where dying at a middle age would then allow for a greater distribution of resources to the children which are in their own reproductive prime.

This leads to perhaps my main criticism and as much as I am a fan of evolution and actually wish that more of it was discussed in medical school. Oftentimes evolutionary medicine runs too close to evolutionary psychology, a disciple with post-hoc justifications and a gaping deficiency of experimental evidence. How would you recommend that we incorporate a better scientific model into evolutionary medicine? What would be your methods to test the points made in this post and support or disprove your hypothesis?

I agree with your comment DrA. A pathogen that is much too virulent may be unable to cause infection in subsequent hosts and that strain may need to evolve to a reduced virulence in able to be a successful pathogen. What I was trying to say is that continual evolution toward reduced virulence is not the rule. Since it all depends on the dispersal of offspring to new hosts, whatever degree of virulence that facilitates this dispersal best will probably stick around. Depending on the mode of transmission, some degree of virulence might be required- such as a rhinovirus that causes a runny nose and sneezing. If rhinovirus were to evolve to an even lower level of virulence it probably wouldn't have much luck reaching new hosts.