All posts on November, 2015

Affordable Care Actcervical cancerHealthwomen's health

ACA coverage expansion has led to earlier detection of cervical cancer, study suggests

Here’s something we can be grateful for this Thanksgiving weekend: A new study reports that increasing numbers of young women with cervical cancer are having the disease diagnosed earlier than in the past — at a stage when the cancer is highly treatable.

And it appears we may have the Affordable Care Act to thank for this life-saving trend.

Cervical cancer screening is one of the great successes of modern medicine. Before the Papanicolaou (Pap) screening test was developed in the 1940s, cervical cancer was a leading cause of death among women of childbearing age in the United States. That death rate has since fallen by more than 60 percent.

Yet cervical cancer still poses a deadly threat to women, particularly when it’s not caught in its earliest stages. Each year, about 12,000 women are diagnosed with cervical cancer in the U.S., and about 4,000 die of the disease, according to the Centers for Disease Control and Prevention.

Before and after ACA

For this new study, which was published Tuesday as a research letter in the Journal of the American Medical Association (JAMA), researchers from the American Cancer Society (ACS) used data from the large National Cancer Data Base to compare the rates of cervical cancer diagnoses in American women aged 21 to 25 before and after September 2010. That is the date when the Affordable Care Act’s Dependent Coverage Expansion (ACA-DCE) program began allowing young adults to be on their parents’ health insurance plans until the age of 26.

Cervical cancer screening is a routine part of the annual medical checkup for women, and is covered by insurance providers. Current guidelines recommend that women start getting regular Pap tests at age 21.

After examining the data, the researchers found that in the two years (2007-2009) prior to the ACA’s 2010 insurance expansion, 71 percent of cervical cancers in women aged 21 to 25 were diagnosed early (at stage 1 or 2). In the two years after the expansion (2011-2012), that percentage jumped to 79 percent.

But among women aged 26 to 34 — a group not covered under the ACA-DCE program — the rate of early diagnosis remained essentially flat during those years, rising from 71 percent to 73 percent.

Interestingly, the biggest increase in early diagnoses among the 21- to 25-year-olds occurred in 2011, the first year after implementation of the ACA-DCE program. About 84 percent of women aged 21 to 25 had early-stage diagnoses in 2011, compared with 68 percent in 2009. In 2012, the proportion of early-stage diagnoses among this group dropped to 72 percent.

As one of the study’s authors told the New York Times, the 2012 percentage drop would be expected, given that many of the early-stage cancers would have been detected in this age group during the first year of the women’s insurance eligibility.

The data also revealed that after 2010, women in the 21 to 25 age group were significantly more likely to be eligible for less aggressive treatments, which usually allow them to avoid a hysterectomy and, thus, have children in the future. In 2011-2012, 39 percent of cervical cancer patients in this age group underwent fertility-sparing treatment, compared to just 26 percent in 2007-2009.

‘Preliminary but promising’

This study cannot prove that the Affordable Care Act directly led to more young women having their cervical cancer diagnosed at an earlier, more treatable stage. For, as Dr. Margaret Madeleine, a cancer epidemiologist with the Fred Hutchinson Cancer Research Center who was not involved in the study, told a reporter for her organization’s news service, these findings are only “preliminary.”

But they are also promising, she added. “What they saw right away in 2011 was this bump in diagnoses in early invasive cervical cancer — and that’s exactly when you want to catch it with screening,” she said. “This observation supports the idea that women who might not have been picked up with a cancer until they were older might be getting picked up earlier. That’s fabulous because earlier cancers require less extensive treatment.”

You’ll find an abstract for the study on the JAMA website, but the full study is behind a paywall.

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conflicts of interestfoodHealthnutritionscientific research

Credibility of nutrition research threatened by studies’ ties to food industry, NYU professor says

In a commentary published online Monday in JAMA Internal Medicine, Marion Nestle, professor of nutrition, food studies and public health at New York University and the author of “Soda Politics,” argues that the food industry’s longstanding influence on nutrition research threatens the credibility of the entire field.

“It’s time,” she says, “that food and nutrition researchers and societies recognize the influence of food-industry sponsorship, take steps to control its effects, and ensure that sponsored studies promote public health, not the marketing of food products.”

To back up her arguments, she points to two recent investigative articles in the New York Times. One documented how Coca-Cola has been funding academic researchers through a nonprofit “front” organization called the Global Energy Balance Network, which promotes the message that physical exercise is more effective at keeping weight down than limiting calories (such as those in sugar-sweetened sodas).

The second article describes how companies like Monsanto, the world’s largest seed company, and the organic foods industry have both used academics to push their agendas in Congress.

Predictable results

Industry-funded studies almost always end up with results that favor the sponsor’s interest, Nestle points out. Earlier this year, she began collecting a sampling of food-and-beverage-industry sponsored studies as they appeared in journals she was reading. Between March and October, she identified 76 such studies.

“Of these, 70 reported results favorable to the sponsor’s interest,” Nestle reports.

The food companies then use those results to promote their products. Nestle offers this example:

Mars Inc, … the maker of chocolate candies such as M&Ms, funds studies on the effects of cocoa flavanols on arterial function and blood pressure. One such study, published in September 2015, concluded that these compounds “improved accredited cardiovascular surrogates of cardiovascular risk, demonstrating that dietary flavanols have the potential to maintain cardiovascular health even in low-risk subjects.” The study investigators, one of whom is employed by Mars, followed well-established scientific protocols in conducting the research. Science is not the issue here. Marketing is the issue. The question is why Mars would fund a study like this and assign one of its employees to help design and write it.

In this instance, the answer is obvious. Mars issued a press release “Cocoa flavanols lower blood pressure and increase blood vessel function in healthy people,” and noted these results in a full-page advertisement in the New York Times on September 27, 2015, Neither the press release nor advertisement explained that cocoa flavanols are largely destroyed during all but the most careful processing of chocolate, nor did they mention chocolate at all. They didn’t have to. Uncritical readers are likely to interpret the statements as evidence that chocolate is good for them and that its sugar and calories can be ignored. 

Influencing policymakers

As for Monsanto and the organic food industry, both “recruit scientists to speak on their behalf, [but] Monsanto has far greater resources,” says Nestle.

“In 1994, I was a member of the Food Advisory Committee to the US Food and Drug Administration (FDA) when that agency approved genetically modified (GM) foods,” she writes. “I observed how Monsanto-funded scientists convinced the FDA that labeling GM foods would be misleading.”

And that lobbying is even more aggressive today, as Nestle explains:

Confronted with increasing public support for labeling foods that are produced with GM ingredients, the biotechnology industry supported — and the House of Representatives passed — H.R. 1599 in July 2015. This bill, expected to be considered by the Senate before the end of 2015, has the Orwellian title, “The Safe and Accurate Food Labeling Act,” but some critics call it the “Denying Americans the Right to Know (DARK) Act.” Proposed by Representative Mike Pompeo (Kansas) on the basis that GM foods are safe and, therefore, acceptable, the act would block states from enacting labeling laws (as Vermont has already done) and permit GM foods to be labeled as “natural.”

Opponents question the safety of GM foods. But they also raise additional reasons for full transparency in labeling — patents, control of seed stocks, the widespread application of chemical herbicides to GM crops, and the increasingly widespread resistance of weeds to those herbicides. When evaluating conflicting scientific and policy arguments about GM foods, it is useful to know who funds the researchers and their studies.

Disclosure not enough

Simply requiring researchers to disclose who’s paying for their studies isn’t enough, says Nestle. 

Professor Marion Nestle

Professor Marion Nestle

“From my observations,” she writes, “nutrition researchers, journals, and professional societies, like medical researchers, often fail to realize that food-industry funding may affect their work and its credibility.”

“If food companies and trade associations want to fund research,” she stresses, “they should consider pooling resources and setting up an independent foundation to administer the grants. Everyone involved in this system should be doing everything possible to advocate for more research funds from federal granting agencies. Nothing less than the credibility of nutrition research and advice is at stake.”

Unfortunately, JAMA Internal Medicine has placed the commentary behind a paywall, but you can follow Nestle’s writings on this issue at her “Food Politics” blog.

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circadian rhythmsDiabetesHealthheart diseasesleep

People with ‘social jetlag’ may have higher risk of chronic illness, study suggests

Did you have a long sleep-in last weekend?

If you did, you may be among the estimated two-thirds of Americans who regularly experience “social jetlag” — a shift in their weekend sleep schedule to one that is more aligned with their body’s natural, circadian rhythms.

For most Americans, that shift means waking up later than they do on weekdays.

Social jetlag is difficult to avoid in today’s 9 to 5 (or 8 to 6?) working world. But, unfortunately, there is mounting evidence that it is bad for our health.

The latest piece of evidence comes from a study published last week in the Journal of Clinical Endocrinology & Metabolism. In that study, researchers from the University of Pittsburgh found a strong association between social jetlag and an increased risk of metabolic changes in the body that can contribute to obesity, type 2 diabetes and heart disease.

Scientists have long known that shift workers are at greater risk than normal daytime workers of developing chronic diseases such as diabetes and heart disease. This new study is the first one, say its authors, to show quantitatively that social jetlag — which essentially involves traveling back and forth each week between two time zones — can also lead to unhealthy metabolic changes linked to those diseases.

Study details

For the study, the researchers studied data collected from 445 healthy men and women aged 50 to 54. Each worked for at least 25 hours a week outside the home, but not as a shift worker.

The participants wore devices on their wrists that tracked their movement and sleep for 24 hours a day for a week. They also filled out questionnaires about their diet and health habits. Blood samples were collected to measure various health-related biomarkers, such as cholesterol and blood glucose levels.

The data revealed that about 85 percent of the participants went to sleep later and woke up later on their “free” days than on their workdays. The other 15 percent did the opposite: They got up earlier on their non-working days.

A further crunching of the data revealed that the participants with the greatest differences between their working- and non-working-day sleep schedules tended to have poorer cholesterol profiles, higher fasting insulin levels, and more resistance to insulin than the participants with less social jetlag. They also had larger waist circumferences and higher body mass indexes.

Those factors are all associated with an increased risk of type 2 diabetes and heart disease. 

The findings held even after the researchers adjusted for health behaviors, such as physical activity, calorie intake and alcohol consumption, and for how long people slept.

Limitations and implications

This study does not prove that having mismatched sleep schedules on working and non-working days contributes to diabetes or heart disease. It just found an association between social jetlag and markers for those illnesses. Other factors — ones not identified in this study and having nothing to do with social jetlag — may also explain the results.

Furthermore, the study’s findings do not mean that sleeping in on the weekends is bad for you.

What it does suggest, however, is that societal imposed work schedules that are not in sync with our natural, circadian rhythms may be harmful to our health.

“If future studies replicate what we found here, then we may need to consider as a society how modern work and social obligations are affecting our sleep and health,” said Patricia Wong, a graduate student at the University of Pittsburgh and the study’s lead author, in a released statement. “There could be benefits to clinical interventions focused on circadian disturbances, workplace education to help employees and their families make informed decisions about structuring their schedules, and policies to encourage employers to consider these issues.”

You’ll can read the study in full at the Journal of Clinical Endocrinology & Metabolism website.

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Americans with Disabilities Actautomobile safetydisabilitiesHealth

Pedestrian wheelchair users are at increased risk of dying in road collisions, study finds

Pedestrians who use wheelchairs are a third more likely to be struck and killed by a car or other motor vehicle than other pedestrians, according to a study published Thursday in the journal BMJ Open.

The findings demonstrate yet another reason why we need to improve our pedestrian infrastructure so that our streets are safer for everyone, including people using motorized or standard wheelchairs.

“When there is poor pedestrian infrastructure or it’s poorly adapted to people with mobility impairments, people who use wheelchairs often are forced to use the streets, or are otherwise exposed to greater risk,” said John Kraemer, the study’s lead author and a public health epidemiologist at Georgetown University, in a released statement.

Each year in the U.S., about 5,000 pedestrians — in and out of wheelchairs — are killed and another 76,000 are injured in crashes on public roads, according to government statistics.

Men at greatest risk

For the study, Kraemer and his co-author, Dr. Connor Benton, a resident at MedStar Georgetown University Hospital, used data from two sources: the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System (FARS) and news stories about fatal car crashes published on the LexisNexis U.S. newspaper database.

From this data, they estimated that 528 pedestrians using wheelchairs were killed in traffic collisions between 2006 and 2012 — a rate that was 36 percent higher than that for other pedestrians.

The risk was especially high for men who use wheelchairs, especially those between the ages of 50 and 64. They were 75 percent more likely to be killed in a pedestrian-car accident their other men their age.

A failure to yield

Digging deeper into the data, Kraemer and Benton found that more than half of the fatal pedestrian accidents involving people using wheelchairs occurred on arterial roadways — busy streets that serve as “collector roads” to freeways. They also found that about half of the accidents were at intersections.

Of those intersection accidents, almost 40 percent occurred where there were no crosswalks, pedestrian signals or other infrastructure to help people on foot — or in wheelchairs — cross the road.

Most of the accidents — 90 percent — took place during fair weather, and almost half took place during daylight. According to the police reports, 11 of the pedestrians and 9 percent of the drivers had been using alcohol or drugs.

In three-quarters of the accidents, men were behind the wheel of the car or other motor vehicle. The most common reason for the accident (cited by the police in 36 percent of the cases) was failure of the vehicle driver to yield the right of way. In about 15 percent of the accidents, the police said the leading contributing factor was the wheelchair not being visible to the driver.

In 76 percent of the accidents, the driver had taken no braking, steering or other manuevers to avoid hitting the pedestrian.

Making pedestrian safety a priority

“That crashes frequently were attributed by police to a driver’s failure to yield right-of-way underscores the challenges faced by pedestrians who use wheelchairs as they seek to safely [use] existing pedestrian infrastructure,” write Kraemer and Benton.

“Improving pedestrian safety for people using wheelchairs should be a policy priority,” they add. “Some improvements are general to road safety: reducing distracted driving and pedestrian activity, improving safe crossing behaviour, reducing incapacitated driving, and improving pedestrian infrastructure — all of which appear to have played a role in a significant number of fatal crashes identified in this study. Others are specific to pedestrian risks faced by wheelchair users: low conspicuity of the wheelchair and pedestrian infrastructure that is particularly ill-suited to pedestrians who use wheelchairs.”

Under the Americans with Disability Act, roads are required to be wheelchair accessible by having curb cuts and ramps. But, as Kraemer told The Atlantic CityLab reporter Linda Poon, traffic engineers and other urban planners don’t focus enough on people with disabilities.

“If you really want to have zero pedestrian death we have to not only think about pedestrians as whatever our archetype is,” he said, “but also people who use wheelchairs, who are blind or deaf, who otherwise might be at greater risk because of the environment.”

You can read Kraemer’s study in full on the BMJ Open website.

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