Tuesday, October 05, 2010

Is Public Health Doing Enough to Address Chronic, Non-Communicable Diseases?

September 2010 happened to be the first-ever National Childhood Obesity Awareness Month in the United States. This designation was meant to increase awareness of the issue and the bill (now a law) was introduced by my own U.S. Senator Kirsten Gilibrand (of New York) back in February, and passed (unanimously, if I'm not mistaken) on March 26, 2010. Its not surprising, then, that in September, there was a fair amount of chatter and news stories about the issue. In fact, in September, officials from the U.S. National Institutes of Health (NIH) via the National Heart, Lung, and Blood Institute (NHLBI) and the Centers for Disease Control announced new plans meant to help prevent and supposedly treat childhood obesity, although exactly how the program would treat the already diagnosed cases remains unclear. Curiously the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) chose NOT to participate in spite of having a vested interest to do so. The NIDDK has also opted NOT to participate in the Autoimmune Diseases Coordinating Committee, which is being coordinated by the National Institute of Allergy and Infectious Diseases (NIAID), even though type 1 diabetes is proven to be an autoimmune disease -- raising the question is just what the NIDDK is actually doing, but that's a separate conversation!

This idea of the childhood obesity awareness month was championed by First Lady Michelle Obama's "Let's Move" campaign. And while no one questions the necessity of these programs today, more than a few thought leaders are left wondering if the U.S. would still have such an epidemic of type 2 diabetes today had these investments actually been made 30 years ago when the problem actually began? Also, why the primary focus on kids?

The sad reality is that the type 2 diabetes "epidemic" isn't occurring in children specifically (yes, some are now getting it, but the real epidemic is among adults, not kids), and can be attributed to the demographic onslaught of the Baby Boom headed into their retirement years, when many people are more likely to develop type 2 diabetes anyway, regardless of body weight. These things tend to happen with age, its just that we are entering a "silver boom" of the elderly. But it does raise the question why public health officials have chosen to focus exclusively on children, when the bulk of the problem exists in adults? I suppose its easier to focus on kids, and the long-term payoff could be beneficial in a few decades. But what about America's short-term issues leading Tea Party activists to argue we must drastically reduce our spending on such frivolous programs? It looks like policymakers are trying to score PR points while investing almost nothing into the real issues. Unfortunately, U.S. politics is too often reactive, rather than proactive on a majority of important social issues, and public health is no exception to this rule.

When it comes to public health as a function, the ONLY proven way to control any disease has historically been to eradicate the disease, not by keeping the disease around but "under control". We did not maintain polio as a chronic disease that could be managed (with sufferers having iron lungs, the way PWD's may someday get "artificial pancreases" assuming the 2014 timeline is accurate). However, if polio was discovered today, we might have people with portable iron lungs walking around given the modus operandi of the drug/biotech companies (rather than researchers and/or universities) were doing the most of the research into the disease today, as is so often the case with new diabetes treatments.

Most commonly, disease eradication has been accomplished with efforts aimed at disease prevention (such as with population-wide vaccinations, etc.). But besides initiatives to improve sanitation, there there is really no relevant historical precedent for how to control chronic, non-communicable diseases such as asthma, hypertension, cardiovascular disease, or any type of diabetes. Consequentially, to date, public health intiatives to try and do this have produced mainly disappointing, and widely inconsistent results. The word "control" regarding diabetes also gets used a lot by public health people these days, yet the disease itself cannot be addressed with the same tools used to responded to acute, communicable ailments like influenza, tuberculosis or even STDs like gonorrhea. There's a not-so-little problem with the logic of public health and chronic disease: surveillance really doesn't work the same way with chronic diseases because the causes of these ailments is not viral in nature, but a combination environmental and miscellaneous other factors (such as lifestyle issues). Yet too often, the public health response has been one of blame-transferrence to the individuals inflicted with diabetes, rather than taking a closer look at the problems and trying to address them in a logical and creative way.

Type 2 Diabetes: "A Public Health Humiliation"

This summer, an editorial in the esteemed British medical journal The Lancet referred to the the worldwide epidemic of Type 2 diabetes as a "public health humiliation," in what many regarded as a rebuke of public health's collective posture about diabetes. While much progress has been made in such public health areas as infant health (especially for low-income families), in many respects, as we've done more to help children and the elderly, so much urban health among adults has simultaneously declined rapidly from lack of access to healthy, nutritious foods, and little if any genuine public access to safe and convenient places to get exercise. Investing in children may be politically popular, but it won't solve the diabetes problem unless every child can be protected from ever getting any form of diabetes -- and since a majority of children with diabetes are diagnosed with type 1 (not type 2), that's a tall order without an approved vaccination to offer.

Meanwhile, recent worldwide trends, such as demographic aging, urbanization, and the globalization of less physically active lifestyles have all contributed to a rise in chronic noncommunicable diseases, whereas acute, communicable diseases worldwide have been dramatically reduced over the past 100 years and exist mainly in places where proper santitation does not exist. The tools in public health authorities' arsenal were built primarily to prevent acute illnesses, while non-communicable diseases have remained at the bottom as a global health priority, and their utter lack of understanding of the issues speaks volumes about why efforts to bring diabetes under control have failed. Some in public health leadership circles acknowlege the issue with chronic diseases frankly, but have yet to offer any solutions. For example, the World Health Organization under the leadership of Dr. Margaret Chan, is finally acknowledging that the worldwide paradigm has shifted away from acute, communicable diseases towards chronic ailments, and this trend is not limited to the developed world. Whether the traditional tools being used (surveillance combined with prevention) will work in this instance remains an unanswered question.

Diabetes Education Gets Lots of Talk, But Isn't Necessarily The Answer to an Epidemic

Diabetes education gets a lot of discussion from public health officials; doctors and diabetes educators love to argue that it tends to get short-changed by Medicare and private insurance companies alike (usually because their paychecks are adversely impacted) in favor of costly new drugs and medical devices. While that may be so, the medical profession turns an annoyingly blind-eye to a sad reality most don't really want to admit: education is really just another Band-Aid meant to cover-up their failure to eradicate diabetes in the first place. Diabetes Education is essentially just another form of Palliative Care (e.g. treatment aimed at relieving symptoms of the disease, rather than eradicating the disease itself), but one cannot call it a public health tool. Also, its worth reminding everyone that it's a bit too late to stop an epidemic that has been many decades in the making -- we must now reap what was sewn decades ago, and public health officials have done almost nothing on that front.

Indeed, while chronic diseases of all types (not only diabetes) are gobbling an increasing share of limited healthcare dollars, the response from public health officials is perhaps best exemplified by the Partnership to Fight Chronic Disease (PFCD), which focuses mainly on prevention, while simultaneously neglecting the challenges -- and enormous costs -- involved in actually managing a chronic disease in perpetuity. In effect, the victims of this epidemic are being blamed for the costs they are inflicting, while receiving little of the kind of help they really need to fix things: healthcare insurance (many Tea Party advocates want to dismantle the healthcare bill that was passed into law earlier this year; Colin Powell, a moderate Republican who endorsed Barack Obama in 2008, recently told "Meet the Press" that the impact of Tea Party candidates, if elected, who have been most vocal on the healthcare bill -- could very well be that Republicans will be forced to actually DO something about the issues instead of just saying "no" to everything and sitting around beating up the President ... a very interesting perspective!).

Many people lack access to healthy foods in urban (and even suburban) environements, as well safe places to exercise without additional expense, etc. Besides sexually transmitted diseases, how many any other diseases are out there where the victims are routinely blamed for getting the disease, and/or their failure to manage it? The answer is not very many. Interestingly, although we know that many cancers are actually fueled by adipose tissue and even fructose (such as high-fructose corn syrup) consumption, few cancer victims ever have to bear the blame for their conditions the way so many people with diabetes routinely are.

Non-Surveillance: New York City's HbA1c Registry Excludes Populations Most At Risk

Public health authorities have had real trouble "thinking outside the box" when it comes to chronic, non-communicable diseases like diabetes. In 2006, New York City's Department of Health and Mental Hygiene implemented a non-disclosed, involuntary HbA1c "registry" that patients have no means of opting out of (individuals CAN opt out of receiving communications from the NYC Health Department, but there is no "opt out" provision for having their medical information excluded from the registry itself, which would be called the "nanny state" in the UK, except unlike in the UK, New Yorkers do not have access to a state-funded healthcare insurance to pay for their costly healthcare).

Indeed, I have written and spoken about the assault on my personal medical records and even appeared on Canadian television (see that interview HERE). I also established a website called "StopNYCA1CTracking.org" (which I am presently making some modifications to) to provide interested parties with more balanced information about this registry than what has come from public health officials, which has been mostly self-congratulations, in spite of the fact that the program has yet to prove it was worth the invasion of medical record privacy.

In 2005, Dr. Diana K. Berger, the medical director of the city's so-called diabetes prevention and control program, boldly claimed "that Surveillance and intervention are essential if we are going to deal with this epidemic."

The idea for this registry was the brainchild of the Director (at the time) Dr. Thomas R. Frieden, who today is President Obama's Director for the U.S. Centers for Disease Control and Prevention ["CDC"] in Atlanta, but was formerly the Director of the New York City Department of Health and Mental Hygiene. Dr. Frieden was something of a dictator; quite unlike one of his predecessors, Dr. Margaret Hamburg, who was tasked by President Obama to run (and clean up) the Food and Drug Administration.

The NYC Health Department boldly promised that the registry would help to reduce the risk of blindness, kidney failure, leg amputations and early death among people with diabetes, but the department has yet to provide a shred of solid evidence to validate those bold assertions. In reality, the program has done little to prevent diabetes since being implemented several years ago; the rate of diabetes diganoses has grown since that time, as has the rate of childhood obesity in the city's public schools. Meanwhile, according to a May 21, 2010 PowerPoint presentation prepared by the NYC Department of Health and Mental Hygiene (see HERE), the city is planning to release some data in 2011; 5 years after being implemented.

At the time the registry was implemented, the City claimed that the first area they hope to target was the South Bronx, a neighborhood known for being among the poorest in the City with high unemployment and an equally high crime rate. But what good is surveillance data that excludes people who AREN'T receiving hemoglobin A1c tests done? After all -- those groups would seem to be most at risk, and we aren't even capturing data about their glycemic control (or lack thereof)! As of December 31, 2009, the program was reportedly only reaching 16% of New York City residents with diabetes. The New York City Department of Health and Mental Hygiene has provided little if any solid evidence to validate its assertions about improved patient outcomes, although it claims "outcome evaluation [is] currently being designed" and completion is anticipated by 2011". Many suspect the department will be busy massaging the numbers to focus on areas that actually did show improvement in glycemic control, but really, does this take 5 years to accomplish? All of this, while simultaneously violating patient and doctor privacy is hardly a terrific accomplishment in my humble opinion!

People with diabetes are ideally supposed to have a glycosated hemoglobin (HbA1c) test 4 times per year to help track their glycemic management, but in general, those who are actually getting these lab tests regularly represent a segment of the population with diabetes who are already receiving medical attention. Their numbers may not be within the narrow recommended goals of the American Diabetes Association, but the fact that they are even having the test done suggests that they doing something right, and health department intervention is unlikely to change that, but could piss a lot of patients (and caregivers) off. Sending them a postcard telling them they're too fat and need to walk more and eat better is unlikely to produce dramatic improvements in patient outcomes. So many doctors have already told the health department they don't want any intervention that the program had to add opt-out procedures for doctors that were never part of the initial plan. Nothing has been done for angry patients who don't want their data included in the surveillance plan.

Critics of this registry, including a fair number of doctors, have noted the surveillance data that comes from a registry of this sort is actually far too biased and could be misleading because it only includes the data of people who are now receiving medical care and having these tests done, while completely missing those who never have hemoglobin A1c tests done -- the very population that is MOST at risk for complications from poorly-managed diabetes.

Dr. Diana K. Berger, the medical director of the city's diabetes prevention and control program admitted this to The New York Times when she told the newspaper that people with diabetes should get HbA1c tests two to four times a year, but she acknowledged that "many people do not". Her former boss, Dr. Frieden himself also acknowledged this, although brushed the criticism aside. In an October 22, 2006 interview with Bloomberg News, he stated "I can't tell you what portion of how many people are in poor control. Ninety percent don't know themselves." What's more, the registry also conveniently excludes, according to NYC Health Department Statistics, "almost a third who don't even know they have diabetes." Hello .... the reason these populations don't know is because they aren't even having the HbA1c tests done!!

... And the Intervention Is?!

It's one thing to use surveillance, one of the primary tools used by public health officials, to indicate that the incidence of diabetes is growing in prevalence, but it's not possible (at least presently) to vaccinate populations for diseases that medicine doesn't really have a well-defined etiological agents for.

Today, medicine cannot even predict with certainty exactly who will develop diabetes (although there are some good clues about who might be at risk for type 2 diabetes, type 1 diabetes is an entirely different matter, and that is much more costly and complex to predict, although great strides have been made), nor can they defininitely prove what causes either these diseases (which have different etiologies).

The City's intervention was mainly aimed at doctors providing them with a stratified listing of their patients by HbA1c range. Some vocal supporters said this would be very helpful, but critics claimed it would not be a meaningful intervention or initiative (for the record, doctors can now be excluded if they don't want to receive this information from the city, unlike patients who have no way of actually being excluded from the registry). Most doctors, even general practitioners, will look at patient lab results prior to an appointment. But it is typical for low-income patients who do not have healthcare insurance to avoid going to the doctor unless they are actually ill, so while the program can alert doctors to patients that are not within recommended HbA1c ranges, it is unclear what they can actually do about it -- does the Health Department think that doctors are going call patients on the list in their spare time to prompt people whose glycemic control is deemed "poor" (meaning an HbA1c of >9) to come in for a visit? A reminder postcard isn't going to prompt someone who can't afford to see a doctor to do so, either. Patients who lack healthcare insurance aren't going to come in until they are sick, and by then, too often, it's too late.

The same patients also receive letters from the Health Department telling patients their HbA1c is too high, complete with a chart that might be the kind aimed towards individuals with a pre-school education or less. (see HERE for a sample of the letters being sent to patients). Between September 2008 and December 2009, the NYC Department of Health and Mental Hygiene reports that "over 16,750 of the high A1C letters were mailed to approximately 14,000 people". (see HERE for details), and letters to those who are overdue for an HbA1c test supposedly began in Spring 2010. To date, the city has been mum about just how effective these campaigns have been, but has stated that "outcome evaluation currently being designed" (why this wasn't done 5 years ago when the program was implemented is anyone's guess) and that the completion is anticipated by 2011.

The sad fact is that the traditional tools used by public health officials don't have a very great track record of success with chronic diseases. Vaccinations work for infectious diseases, but what would public health authorities try to vaccinate people from in order to respond to the so-called "diabetes epidemic" ... food?

A high-profile ad campaign (see The New York Times story HERE and the press release on the expensive media campaign HERE) that cost roughly $286,000 and graphically depicts globs of human fat gushing from a soft-drink bottle in a TV ad has garnered a lot of media fascination.

The print campaign also features the soda bottles and fat, but also includes an equivalent number of teaspoons/packets of sugar (26 to be exact) in each regular soft-drink bottle (The New York Times coverage can be viewed HERE) to drive the point home. These efforts get a lot of press coverage, but quantifying their impact is almost impossible.

Junk Food Is A Target, But Is It The Right Target?

To date, the public health intervention target has (rightly or wrongly) been so-called junk-food such as the NYC "pouring fat" soda campaign, but if one looks closer at some large urban populations, it becomes painfully evident that many neighborhoods don't even have supermarkets with fresh produce at affordable prices, so just where do health officials think residents of those areas are going to stock their pantries?

A different New York Times article quoted Kai Siedenburg, of the Community Food Security Coalition, a group based in Portland, Oregon, that promotes access to healthy food, who said "If you are educating people to make good choices, but those choices aren't available nearby and they don’t have a car to drive out to the suburbs to the supermarket, or an hour to ride two buses to get there, then it's really hard for them to make good choices." Very wise observation!

Solid evidence backs this up. Indeed, in 2008, The American Journal of Epidemiology reported that people with no supermarkets near their homes were up to 46% less likely to have a healthy diet than those with more shopping options. It's not rocket science, it's common sense, yet it has taken public health officials soooo long to figure this out, and one has to wonder why.

Healthy Bodegas: The First Bright Idea to come from Public Health in a Very Long Time

This is one reason why I believe one of the most important initiatives undertaken by the NYC Department of Health and Mental Hygiene actually began in 2005, which it calls the "Healthy Bodegas" initiative. (see HERE), which aims to increase access to and promote healthy foods, such as fresh fruits and vegetables, whole grain bread, low-fat milk and dairy products, and low-salt and no-sugar-added canned goods. The effort, which comparatively speaking, is vastly under-funded, doesn't get nearly the same kind of press coverage as the city's higher-profile media campaign. The New York City Healthy Bodegas initiative only addressed three of the city's poorest neighborhoods: Harlem in Manhattan, the South Bronx and North and Central Brooklyn (home to the Bedford-Stuyvesant, which is acknowledged as one of the city's toughest neighborhoods with a homocide rate to prove it), which is relatively small in a city consisting of 5 counties (Boroughs), 8.4 million residents, and covering some 305 square miles over a peninsula and 4 major islands. But at least it's a starting point. However, the Healthy Bodegas program has reached out to over 1,000 stores in a variety of ways, including helping owners secure zoning permits to allow fruit and vegetable displays on the sidewalk, as navigating the city's bureauocracy and red-tape could dissuade even the most willing retailer otherwise.

Last October, The New York Times ran an interesting story about a similar program in Newark, New Jersey that went even further to assist neighborhood bodegas and convenience stores address the problem in a different manner: instead of blaming the victims, public health authorities were trying to address issues in the environment that helped cause the problem in the first place. How? The City of Newark, the State of New Jersey and the National Institutes of Health acknowledge that it's tough to tell people to eat healthy when there are few retailers selling the wholesome ingredients health officials are telling people to eat.

For the most part, local residents applaud these initiatives.

"We need more fresh produce in this area," Yvonne Melendez, a mother of three who lives near Tremont Avenue in the Bronx told The New York Times. "It's very difficult to eat healthily in the Bronx."

Similar programs have emerged in places like Philadelphia, Baltimore, Cleveland, Hartford, CT, Oakland, CA, and Louisville, KY. Each has had to adjust their strategies to work in their locations. For example, the Cleveland Corner Store project encourages small groceries to sell fruit near the check-out counter — prime locations where candy and chips are usually found — and promotes participating stores with sidewalk signs and posters and at neighborhood health events.

Jerry Jones, executive director of Hartford Food System, a 31-year-old nonprofit group in Connecticut actually quantifies the "return" on it's investment. The program encourages store owners to replace 5% of their junk food and soft drinks each year with regular groceries, including low-salt selections and produce. In return, it provides the stores with market research on what neighborhood shoppers are looking for and negotiates low prices from a big produce wholesaler.

Forty small groceries have signed up and are entitled to display a sticker that says "Healthy Food Retailer," Mr. Jones said. In 2008, after the program had been under way for about year, the Hartford Food System took measurements and reported an overall 8% switch of food inventories from junk food to regular groceries.

"There are all these neat programs popping up," said James Johnson-Piett, a consultant to Newark's program who previously worked with the Food Trust, a nonprofit group that developed some groundbreaking initiatives in Philadelphia.

Of course, coaxing supermarkets, which are increasingly turning to the big-box store designs with expansive parking areas, has had mixed results, partially because retailers are moving to a large superstore model that doesn't work everywhere. As a result, it's not just so-called urban "food deserts" that need this kind of help. Increasingly, many rural areas have lost local supermarkets to more distant big-box retailers in the exurbs and are increasingly looking at these types of programs as models to try and encourage their local convenience stores to offer healthier choices.

There are also some possible alternatives (or additions) on the horizon, although how much involvement local Health Departments are having with these is unclear. For example, Stop & Shop (part of the Royal Ahold, a major supermarket chain in the Northeast that according to Supermarket News, ranked Ahold's U.S. division No. 7 in the 2007 "Top 75 North American Food Retailers" based on 2006 fiscal year with estimated sales of $24.0 billion), operates a free delivery service in areas of it's retail markets where it has stores called Peapod which could help fill the void by enabling consumers to have fresh ingredients delivered to their doorsteps. A rival, NYC-based company called Fresh Direct has made a name for itself with it's tagline "Our food is fresh, our customers are spoiled" also operates in the space, but with more focus on more higher-end consumers. Access to these types of services requires access to a personal computer (or smartphone) and the internet, which is out-of-reach and frequently beyond the skillsets of many individuals. The elderly, for example, may need training, and may also require assistance to help navigate websites (or mobile phones) that are designed for younger eyes with perfect vision.

What if local health officials helped build an infrastructure to enable stores and delivery services to receive orders by text messages? Increasingly, mobile technology may help to bridge the gap for many customers in need, but public health can play a role in making these services more widely known.

Healthy Bodegas: Check. Access to Places to Exercise: Still Needs Work

Of course, on the fitness front, access to safe places for exercise is one front public health officials have done far too little to address, but really need to looking into. For example, ongoing healthclub memberships in NYC cost more than downpayments on homes in many parts of the U.S., and typically cater to an affluent clientele. Where does the rest of the city's residents, in Michelle Obama's words, "Let's Move"?

Public parks work fine when the weather is good, but what about mid-winter when temperatures are so cold that only the bravest souls step outside, or when it's pouring rain outside? Even the recently remodeled locations of the city's indoor public park facilities operate on very restrictive hours, and do not accommodate varied work schedules. If we want to address the diabetes "epidemic" this needs to change, although the parks department is facing budget issues, too. Can't make it to the public pool or gym by 8:00 PM? You're shit out of luck, as my paternal grandmother used to say after she'd had a few too many cocktails. Perhaps the Health Department should help fund keeping these facilities open, even if it's just a trial to see if doing so might help.

If Public Health Officials are serious about the obesity and type 2 diabetes epidemic, they need to start thinking outside of the box. For too long, they have responded using public health tools developed in the 1920's for infectious diseases, but those just don't work the same way with chronic diseases. But Health Departments can indeed play a role. In much the same way as they're helping convenience stores and bodegas navigate the city's red tape to get sidewalk produce permits, they could step in and help the parks department do an analysis of traffic patterns at their facilities. They might learn, for example, that there are many times of the day that employees are paid to work and there's nary a visitor to be found at those facilities. It might make sense to close the pool or gym during those hours, and instead stay open until 11:00 PM so clients can use the facilities when they need to. The obesity and type 2 diabertes epidemic did not happen overnight, nor will it be solved overnight. And with budgets tight everywhere, it may be harder to get the parks department to help on these issues. But we know that relying on stale old tools that work to keep infectious diseases under control simply won't work for chronic, far more complex diseases like diabetes. It will take some creativity to approach the problem in a more comprehensive manner, but the net result could prove beneficial for everyone -- not just people with diabetes!

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