Sickle cell disease and Nigeria

An interesting piece on life with sickle cell disease in Nigeria (here).  An all-too-realistic account of the everyday struggle of a single mother and her daughters, in a country with rudimentary health care – or none at all – for most people.  Nigeria has the largest population in Africa – approaching 200 million - and it is estimated the 150,000 babies are born each year with sickle cell.  Only 5-10% probably live into adulthood, and those are plagued with frequent pain crises, as is the girl in this story. Having been on those streets not so long ago, I know the atmosphere as the night progresses and the streets become empty.  There is a dark cloak of anger and violence that hangs over the roadway. 

Most medical schools in the US have greatly expanded their global health programs, and students find the opportunities an exciting break from endless study.  It is important to actually feel what life means in poor countries and not romanticize the experience of "global health".  For sure, travel in low income countries is an adventure, full of strange and exotic happenings. But it is equally important to realize that life in many poor countries is not strange, exotic or adventuresome of many people who live there.  It is a bitter struggle for a chance to improve your circumstances, raise your family and remain healthy.  To be a competent citizen of the world we have to know what life is like for those made miserable by the global economic system.  We are part of the unequal balance.

Please note: The "vigilantes” referred to are the citizen's patrols that are run at night in the absence of police.  If they encounter would-be thieves they have to kill them on the spot, or else the thieves will return for revenge and kill them.  911 is not functional.

We are hoping that our own small effort to improve life for sickle cell patients – a trial of low dose hydroxyurea in Ibadan, Nigeria – will someday lead to widespread use of this important drug.

Economic growth and mortality: do social protection policies matter?

Since the Depression of the 1930’s there has been an interest in the impact of economic cycles on health.  While much of the news related to the recent economic downturn has focused on the depression and related illnesses that accompany job loss, it has been shown repeatedly that the health of the population improves during economic slowdown, and worsens with period of growth.  

Together with a team from Johns Hopkins and several other institutions, investigators at Loyola were involved in an analysis of recent trends in the main industrialized countries to identify factors that might modify this cyclic pattern.   Not unexpectedly, countries that provide social support systems have a much smaller amplitude of change in death rates.  These analyses were published last week and the full paper can be found here.  

PRESS RELEASE ON PUBLICATION FROM PUBLIC HEATLH SCIENCES FACULTY

Paper will appear in Circulation, and an advance copy can be found – here.

Researchers have projected that aggressively lowering blood pressure could help prevent more than 100,000 deaths each year.

“The public health impact of adopting intensive treatment in the right patients is enormous,” said Adam Bress, University of Utah assistant professor of population health sciences.

Bress and his fellow experts from institutions across the country built upon the landmark Systolic Blood Pressure Intervention Trial, which found that decreasing blood pressure to less than 120 mmHg compared to 140 mmHg reduced heart attack, stroke and death in people that were at high risk. But -- until now -- the potential number of lives that could be saved by the 2015 SPRINT results if fully implemented was unknown.

The University of Utah-led team of researchers used data from the National Health and Nutrition Examination Survey from 1999 to 2006 conducted by the National Center for Health Statistics. Using the science of survey design, they focused on about 2,000 men and women who met the SPRINT eligibility criteria to determine the projected 107,500 lives saved each year.

The leading cause of death in the U.S. is heart disease. In past decades, doctors had typically worked to keep patients’ blood pressure less than 140 mmHg. SPRINT concluded that there could be a 27 percent reduction in mortality through the intensive blood pressure regimen.

Most Americans will experience high blood pressure at some point in their lives.

“The lifetime risk of high blood pressure in the US is about 80 percent,” said Richard Cooper, professor and chairman of Public Health Sciences at Loyola University Medical School, who collaborated with Bress. “Optimal management is one of the most significant contributions of medical care to patient survival. So we need to understand that small improvements in individual management can make a major impact on people’s health.”

To achieve blood pressure of 120 or less, it’s likely people would need to take three or four medications instead of two recommended for the higher rate, the assistant professor said. They would likely also see the doctor more frequently and need more lab tests. Though this would require some additional spending, the overall cost of high blood pressure in the U.S. is large.

“Currently about 80 million Americans have higher blood pressure: 1 out of 3,” Bress said. “And the treatment cost of hypertension is about $80 billion a year.”

The drugs doctors would need are already available, safe, effective, and inexpensive, he added.

Bress is the lead author of “Potential Deaths Averted from SPRINT Implementation,” which was published in the most recent issue of “Circulation.”

He acknowledges some concerns remain about dropping blood pressure so dramatically. One unknown is the impact on cognitive function. Further research related to SPRINT is underway to answer that question now. Additional blood pressure medications could cause potassium and sodium levels to fluctuate. And blood pressure that is too low could cause an individual to faint.

 “The point we’re trying to make when it comes to choices around intensive treatment is:  would you be willing to reduce your risk of stroke or early death while incurring a small increase in the risk of a fall?” said Bress.

Cooper believes the treatment goal for systolic blood pressure should be reset to at least 130. Practical trials should be created to help monitor blood pressure at home and find systems -- such as electronic recording -- that make it easier for doctors to meet that target, he said.

Additional research is underway to decipher who may best benefit from SPRINT protocol -- whether that is someone who is of a certain age group, does not have diabetes or other conditions.

Bress and the researchers crunched their data on individuals who met SPRINT eligibility: 50 or older, at high risk of cardiovascular disease and without a history of diabetes or stroke.

How to implement the reduced blood pressure protocol and how to study its result also remains a question mark, Bress said. But he doesn’t think there should be a delay.

“If it takes 10 years to implement, we could have prevented a lot more deaths,” he said.

##

Nutrition Science

Nutrition science lives under a curse.  A never-ending parade of quacks and hucksters appear on the scene with miracle diets and theories that reveal the secret truths that mainstream nutrition has been trying to hide.  One of the more prominent hucksters is Gary Taubes, a free-lance journalist who has built a career by challenging the established recommendations on first salt, then fat, and now sugar.  Taubes' is actually a very successful huckster and has been able to garner space in important journals - including Science - and newspaper - like the New York Times.  His first campaign - revealing the hidden truth that excess salt consumption is unrelated to hypertension - seems have been put aside while he concentrates on the role of fat and sugar in obesity.   He essence of his argument is that calorie-for-calorie sugar consumption, through its effect on insulin, results in a larger contribution to body fat that fat or protein.  He summarized his basic argument in this article in the NY Times last week -
https://www.nytimes.com/2017/01/13/opinion/sunday/big-sugars-secret-ally-nutritionists.html?_r=0

Motivated by a recent editorial in Nature, arguing that scientists must try to speak out in the public discourse, I wrote a "Letter to the Editor" which, alas, the NY Times chose not to publish.   But on our blog we can even publish some news that the TImes feels is not fit to print - here

I might add, at the moment in the insulin-sugar hypothesis has been disproven through feeding experiments (3).

Gary Taubes has made a journalistic career by taking contrarian stands against the “received wisdom” of nutrition science.   He has successively argued that the field has it all wrong on dietary saturated fat, salt and – most recently - sugar (NYT, Sunday, January 15).   I appreciate that, in order to be heard, journalists must stake out a position that will pique the public’s interest.  However, his voice has added nothing but noise and confusion to the public discourse on nutrition and health.  Both his key points in the recent opinion piece are wrong.  While our understanding of the role of nutrition in heart disease has advanced in the last several decades, the diet-heart theory is alive and well.  One set of key facts should make any reader skeptical of Taubes’ claims to the contrary.  Since the peak of the heart disease epidemic in the 1960’s mortality rates have dropped 80%, intake of saturated fat (mainly dairy) has fallen in parallel, and serum cholesterols have dropped about 10% (1); of course less smoking, better control of blood pressure and other medical therapies have contributed (1).  Meanwhile intake of sugar has increased 30% (2).  Control of heart disease has arguably been the most important achievement in public health in the US in the last 50 years and nutrition science played a key role.  Likewise, Taubes’ reiterates the canard that sugar somehow does not abide by the rule that “a calorie is a calorie”.  Since Taubes freely admits there is no evidence to support his claim, and definitive evidence to the contrary, one wonders why we should be interested in his opinion.



1. Ford et al. Explaining the decrease in coronary heart disease, 1980 – 2000.  New Engl J Med June 7, 2007.
2. http://www.obesity.org/news/press-releases/us-adult
3.    Hall KC. A review of the carbohydrate–insulin model of obesity
European Journal of Clinical Nutrition advance online publication 11 January 2017; doi: 10.1038/ejcn.2016.260

Swing voting and midlife mortality

    In this section of the blog I will present thoughts on recent events, or otherwise interesting data, publications and such. I will attempt at least to do so every week . . .

First, it should be recognized that opinions expressed here are my own, and do not necessarily reflect a majority view in the Department or the school. 

Second, I am likely to use a fair amount of jargon or technical language  - apologies in advance.  When possible I will suggest other sources where the topic under discussion can be explored in further depth.

Third, I would like to have any feed-back that any reader has to offer.  Well, perhaps that is a bit too expansive . . . we will suppress the scandalous and scatological.  Comments should be . . .

            For many of us – certainly in medicine and public health – the recent presidential election ended in disaster.  Obviously it is to soon to judge the impact of the Trump presidency, but the vibes are note good.   Much has been written about the potential motivation and background of the 60 million Americans who cast their vote for the “outsider”, with explanations ranging from racism to nativism to disgust with “politics as usual”.  Perhaps most relevant to us in Public Health, it has been widely noted the economic hard times experienced by many middle-aged Americans, particularly those in the mid-west where good paying industrial jobs have disappeared, have been accompanied by a sharp deterioration in health.  Lumped together as “diseases of despair”, the most important causes of death that have turned upward include suicide, drug overdose (often opiates) motor vehicle accidents (often associated with heavy drinking). 

            Together with colleagues at Johns Hopkins I explored how close the severe worsening of health indicators and the rejection of the Democratic candidate were linked.  We obtained data for all the counties in the US, together with voting patterns in the last 3 presidential elections, and – sure enough – in those crucial regions of the country where swing voters determined the outcome of the election mortality in the middle-age population rose sharply.

Our manuscript describing these results is currently under review at a journal so the full text is subject to a press “embargo”, however the abstract and the main graph are presented below.  

ABSTRACT

Background: Understanding the effects of widespread disruption of the social fabric on public health outcomes can provide insight into the forces that drive major political realignment. Our objective was to estimate the association between increases in mortality in middle-aged non-Hispanic white adults from 1999-2005 to 2008-2014 and the surge in support for the Republican Party in pivotal US counties.

Methods: We conducted a longitudinal ecological study in 3321 US counties from 1999 to 2016. Increases in mortality were measured using age-specific (45-54 years of age) all-cause mortality from 1999-2005 to 2008-2014 at the county level. Support for the Republican Party was measured as the party’s vote share in the presidential election in 2016 adjusted for results in 2008 and 2012.

Results: We found a significant up-turn (p<0.001) in mortality from 1999- 2005 to 2008-2014 in counties where the Democratic Party won twice (2008 and 2012) but where the Republican Party won in 2016 (+11.5/100,000), as compared to those in which the Democratic Party won in 2016 (-10.6/100,000). An increase in mortality of 14.6/100,000 was associated with a significant (p<0.001) 1% vote swing from the 2008-2012 average to 2016.

Yes, the graph is a little hard to read at first, but what it shows is that counties with a rise in mortality – falling on the right side of the zero marker on the bottom – also switched into the category of increased Republican support.  These counties were all almost exclusively in the South and the Mid-west (blue and green dots . . . yes, I know the label at the bottom is hard to read, but the pattern of blue and green is readily apparent.)

            What does this mean?  Well certainly those regions feeling the most pain from de-industrialization were desperate for a change  . . . perhaps this is the archetypal drowning man reaching for straws.  The point we explore further in the paper is that public surveillance – ie, detection of this epidemic in hard-hit regions earlier – could help us formulate interventions to help people in these counties meet the overwhelming challenges they face.  This is not a new idea. In  the 19th century, Rudolf Virchow, one of the early public health scientists in Europe,  argued that “health is but politics on a social scale” and described epidemics as “great warning signs which

the statesman is able to read.”  Certainly the Democratic party missed that message altogether, by proclaiming that unemployment was down, more people had health insurance, and that the country was, on the whole, doing well.  Well, lots of folks were not doing so well . . . And we will all pay for turning a blind eye to those who have been less fortunate.