Prevention and Control Strategies for Non-Communicable Disease: Goldberger, Pellagra and Rose Revisited.

This paper argues that the public health conceptual framework of epidemiologist Geoffrey Rose, first published as "Sick Individuals and Sick Populations" in 1985, provides a useful way to critically analyze prevention and control options for modern non-communicable diseases (NCD) and their forerunner, obesity, a pandemic now engulfing Lower-and-Middle-Income-Countries. That framework is based on the notions of primordial, primary, secondary and tertiary prevention-the full spectrum of "more upstream and more downstream" approaches, each with its pros and cons. These are illustrated using the pellagra epidemic in the southeastern USA from 1900 to the 1940s, which still has much to teach us about these same basic policy options for controlling the modern NCD pandemic. In particular, Rose's dictum, "Seek the causes of (population) incidence, not of (individual) cases", points up the compelling advantages of upstream prevention for controlling both epidemics.

Controlling the obesity pandemic: Geoffrey Rose revisited.

The ongoing obesity pandemic threatens the health of hundreds of millions globally. However, to date, no country has had much success in limiting its growth, let alone reversing it. This commentary demonstrates the relevance to the obesity pandemic of the public health conceptual framework of epidemiologist Geoffrey Rose, first published as "Sick Individuals and Sick Populations" in 1985. That framework provides a useful way to analyze the pandemic's prevention and control options, based on the notions of primordial, primary, secondary and tertiary prevention-the full spectrum of "more upstream and more downstream" approaches, each with its pros and cons. Based on an analysis of key studies to date, this commentary argues strongly that only the primordial prevention approach is likely to be successful against the obesity pandemic-but its onerous requirements for society-wide behavioural and cultural change may make that public health struggle a long one.

RéSUMé: La pandémie d'obésité en cours menace la santé de centaines de millions de personnes dans le monde. Jusqu'à maintenant toutefois, aucun pays n'a eu beaucoup de succès à en limiter la croissance, et à plus forte raison à l'inverser. Notre commentaire démontre la pertinence, pour la pandémie d'obésité, du cadre conceptuel de santé publique de l'épidémiologiste Geoffrey Rose publié pour la première fois sous le titre de « Sick individuals and sick populations ¼ en 1985. Ce cadre offre un moyen utile d'analyser les options de prévention et de contrôle des pandémies en partant des notions de la prévention primordiale, primaire, secondaire et tertiaire ­ tout le spectre des approches « d'amont et d'aval ¼, chacune ayant ses avantages et ses inconvénients. Fondé sur une analyse des principales études menées jusqu'à maintenant, notre commentaire soutient fermement que seule l'approche de prévention primordiale est susceptible de fonctionner contre la pandémie d'obésité, mais que les lourds changements comportementaux et culturels que cela nécessiterait à l'échelle de la société risquent de rendre la lutte de la santé publique très longue.

Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II. DESIGN: Pragmatic randomised clinical trial with blinded outcome assessment. SETTING: Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada. PARTICIPANTS: 340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury. INTERVENTIONS: Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury. RESULTS: The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (Χ2=3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported. CONCLUSIONS: Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life. TRIAL REGISTRATION NUMBER: NCT00546806.

Failures in reproductive health policy: overcoming the consequences and causes of inaction.

It is assumed that long-established research findings and internationally accepted evidence should, and will, be translated into policy and practice. Knowledge about what prevents harm and promotes health has, in fact, guided and resulted in numerous beneficial public health actions. However, such is not always the case. The authors examine three notable, and unwelcome, exceptions in the UK-all in the field of reproductive health and all focused on the period prior to pregnancy. The three examples of counterproductive inaction discussed are: fortifying flour with Vitamin B9 (folic acid); preventing foetal alcohol spectrum disorders; and reducing risks and better regulating a highly teratogenic medication (valproate). The adverse consequences, as well as the causes, of inaction are analysed for each example. Reasons for optimism, and recommendations for overcoming inaction, are also offered, in particular, greater priority should be accorded to preconception health, education and care.

Narrowing mortality gap between men and women over two decades: a registry-based study in Ontario, Canada.

BACKGROUND: Historically, women have lower all-cause mortality than men. It is less understood that sex differences have been converging, particularly among certain subgroups and causes. This has implications for public health and health system planning. Our objective was to analyse contemporary sex differences over a 20-year period. METHODS: We analysed data from a population-based death registry, the Ontario Registrar's General Death file, which includes all deaths recorded in Canada's most populous province, from 1992 to 2012 (N=1 710 080 deaths). We calculated absolute and relative mortality sex differences for all-cause and cause-specific mortality, age-adjusted and age-specific, including the following causes: circulatory, cancers, respiratory and injuries. We used negative-binomial regression of mortality on socioeconomic status with direct age adjustment for the overall population. RESULTS: In the 20-year period, age-adjusted mortality dropped 39.2% and 29.8%, respectively, among men and women. The age-adjusted male-to-female mortality ratio dropped 41.4%, falling from 1.47 to 1.28. From 2000 onwards, all-cause mortality rates of high-income men were lower than those seen among low-income women. Relative mortality declines were greater among men than women for cancer, respiratory and injury-related deaths. The absolute decline in circulatory deaths was greater among men, although relative deciles were similar to women. The largest absolute mortality gains were seen among men over the age of 85 years. CONCLUSIONS: The large decline in mortality sex ratios in a Canadian province with universal healthcare over two decades signals an important population shift. These narrowing trends varied according to cause of death and age. In addition, persistent social inequalities in mortality exist and differentially affect men and women. The observed change in sex ratios has implications for healthcare and social systems.

An overview of prevention of multiple risk behaviour in adolescence and young adulthood.

The observed clustering, and shared underlying determinants, of risk behaviours in young people has led to the proposition that interventions should take a broader approach to risk behaviour prevention. In this review we synthesized the evidence on 'what works' to prevent multiple risk behaviour (focusing on tobacco, alcohol and illicit drug use and sexual risk behaviour) for policy-makers, practitioners and academics. We aimed to identify promising intervention programmes and to give a narrative overview of the wider influences on risk behaviour, in order to help inform future intervention strategies and policies. The most promising programme approaches for reducing multiple risk behaviour simultaneously address multiple domains of risk and protective factors predictive of risk behaviour. These programmes seek to increase resilience and promote positive parental/family influences and/or healthy school environments supportive of positive social and emotional development. However, wider influences on risk behaviour, such as culture, media and social climate also need to be addressed through broader social policy change. Furthermore, the importance of positive experiences during transition periods of the child-youth-adult phase of the life course should be appropriately addressed within intervention programmes and broader policy change, to reduce marginalization, social exclusion and the vulnerability of young people during transition periods.

A mixture model to correct misclassification of gestational age.

PURPOSE: Misclassification of gestational age based on the last menstrual period (LMP) in routinely collected data creates bias in newborn birthweight and gestational age-related indicators. Common correction methods have not been evaluated. We developed a normal mixture model for use with SAS software to correct misclassification of gestational age and compare its performance with other available correction methods and estimates of gestational age. METHODS: Using the 2007 United States natality file from the National Center for Health Statistics, we compared LMP preterm and postterm birth rates and gestational age-specific birthweight percentiles against a reference subset of births, where the likelihood of misclassification in gestational age was minimized, before and after correction by a normal mixture model, two truncation methods, and the clinical/obstetric estimate of gestational age. RESULTS: The mixture model corrected preterm and postterm birth rates by 90% and 41% respectively, but previous methods performed poorly. The mixture model was also superior in correcting birthweight percentiles 50 and 90 with error reductions in the range of 68% to 85% between 28 and 36 weeks of gestation, where most misclassification occurred. CONCLUSIONS: The mixture model behaved consistently better than truncation methods, particularly between weeks 28 and 36 of gestation.

From places to flows. International secondary migration and birth outcomes.

Research on the health status of international migrants to industrialised countries in general, and on perinatal outcomes in particular, has assumed an interpretative model based on primary migration, characterised by one permanent cross-border movement from the migrant's country of birth. However, many migrants experience more complex migration patterns that may also be associated with human health. Secondary migration, defined as a migration from a country of residence other than the country where the immigrant was born, has been growing during the last two decades, favoured by globalisation. The purpose of this study was to examine the association between secondary migration and preterm birth (PTB) and infant birthweight at term (BW) using a Canadian official immigration database to build a cohort of immigrants to Ontario, Canada, who obtained their permanent residence in the years 1985-2000. The study population comprised 320,398 singleton live infants born to immigrant women during 1988-2007. Primary and secondary migrants were categorised according to whether they were born in an industrialised country or not. Secondary migrants were further subdivided according to whether the country from which they migrated to Canada was industrialised or not. We found that compared to primary migrants, secondary migrants to Canada born in non-industrialised countries had lower odds of PTB and higher mean BW at term. However, such a protective effect was not observed among secondary migrants born in industrialised countries. In a cross-classified multilevel model restricted to secondary migrants, 5.2% of the variation in birthweight was explained by migrants' countries of birth and 0.8% by migrants' countries of last permanent residence. These findings are consistent with the so-called healthy migrant effect, implying that selective migration from non-industrialised countries is associated with protective individual characteristics.

Neighborhood context and infant birthweight among recent immigrant mothers: a multilevel analysis.

OBJECTIVES: We compared the influence of the residential environment and maternal country of origin on birthweight and low birthweight of infants born to recent immigrants to urban Ontario. METHODS: We linked delivery records (1993-2000) to an immigration database (1993-1995) and small-area census data (1996). The data were analyzed with cross-classified random-effects models and standard multilevel methods. Higher-level predictors included 4 independent measures of neighborhood context constructed by factor analysis and maternal world regions of origin. RESULTS: Births (N = 22 189) were distributed across 1396 census tracts and 155 countries of origin. The associations between neighborhood indices and birthweight disappeared after we controlled for the maternal country of origin in a cross-classified multilevel model. Significant associations between world regions and birthweight and low birthweight persisted after we controlled for neighborhood context and individual characteristics. CONCLUSIONS: The residential environment has little, if any, influence on birthweight among recent immigrants to Ontario. Country of origin appears to be a much more important factor in low birthweight among children of recent immigrants than current neighborhood. Findings of neighborhood influences among recent immigrants should be interpreted with caution.

Protocol of a randomized controlled trial of the effectiveness of physician education and activation versus two rehabilitation programs for the treatment of Whiplash-associated Disorders: The University Health Network Whiplash Intervention Trial.

BACKGROUND: Whiplash injuries are an important public health problem that is associated with significant disability and high health care utilization. Recent cohort studies suggest that physician care may be the most effective treatment for patients with whiplash-associated disorders. However, these findings have not been tested in a randomized controlled trial. The purpose of this study is to determine which of physician care or two rehabilitation programs of care is most effective in improving recovery of patients with recent whiplash associated disorders. METHODS AND DESIGN: We designed a pragmatic randomized clinical trial. A total of 444 participants (148 in each of three arms) who reside in Southern Ontario, Canada will be recruited from a large insurer. We will include individuals who are 18 years of age or older and who are diagnosed with Grade I or II Whiplash-associated Disorders. Participants will be randomized to physician-based education and activation or one of two rehabilitation programs of care currently in use in Ontario. Our primary outcome, self-rated global recovery and all secondary outcomes (neck pain intensity, whiplash disability, health-related quality of life, depressive symptomatology and satisfaction with care) will be measured at baseline by a trial coordinator and at 6 weeks, 3, 6, 9 and 12 months follow-up by an interviewer who is blind to the participants' baseline characteristics and treatment allocation. We will also collect information on general health status, other injuries, comorbidities, expectation of recovery, work status, pain coping, legal representation, and co-interventions. The primary intention-to-treat analysis will compare time to recovery between the three interventions. This trial will have 90% power at an alpha of 0.05 to detect a 20% difference in the rate of perceived recovery at one year. Secondary analyses will compare the health outcomes, rate of recurrence and the rate of adverse events between intervention groups. CONCLUSION: The results of this study will provide the public, clinicians and policy makers much needed evidence on the effectiveness of common approaches used to manage whiplash-associated disorders. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00546806.

Patterns of sick-leave and health outcomes in injured workers with back pain.

Little is known about the sick-leave experiences of workers who make a workers' compensation claim for back pain. Our objective is to describe the 1-year patterns of sick-leave and the health outcomes of a cohort of workers who make a workers' compensation claim for back pain. We studied a cohort of 1,831 workers from five large US firms who made incident workers' compensation claims for back pain between January 1, 1999 and June 30, 2002. Injured workers were interviewed 1 month (n = 1,321), 6 months (n = 810) and 1 year (n = 462) following the onset of their pain. We described the course of back pain using four patterns of sick-leave: (1) no sick-leave, (2) returned to worked and stayed, (3) multiple episodes of sick-leave and (4) not yet returned to work. We described the health outcomes as back and/or leg pain intensity, functional limitations and health-related quality of life. We analyzed data from participants who completed all follow-up interviews (n = 457) to compute the probabilities of transition between patterns of sick-leave. A significant proportion of workers experienced multiple episodes of sick-leave (30.2%; 95% CI 25.0-35.1) during the 1-year follow-up. The proportion of workers who did not report sick-leave declined from 42.4% (95% CI 39.0-46.1) at 1 month to 33.6% (28.0-38.7) at 1 year. One year after the injury, 2.9% (1.6-4.9) of workers had not yet returned to work. Workers who did not report sick-leave and those who returned and stayed at work reported better health outcomes than workers who experienced multiple episodes of sick-leave or workers who had not returned to work. Almost a third of workers with an incident episode of back pain experience recurrent spells of work absenteeism during the following year. Our data suggest that stable patterns of sick-leave are associated with better health.

Birth outcomes by neighbourhood income and recent immigration in Toronto.

OBJECTIVES: This article examines differences in birth outcomes by neighbourhood income and recent immigration for singleton live births in Toronto, Ontario. DATA SOURCES: The birth data were extracted from hospital discharge abstracts compiled by the Canadian Institute for Health Information. ANALYTICAL TECHNIQUES: A population-based cross-sectional study of 143,030 singleton live births to mothers residing in Toronto, Ontario from 1 April 1996 through 31 March 2001 was conducted. Neighbourhood income quintiles of births were constructed after ranking census tracts according to the proportion of their population below Statistics Canada's low-income cutoffs. Logistic regression was used to estimate odds ratios for the effects of neighbourhood income quintile and recent immigration on preterm birth, low birthweight and full-term low birthweight, adjusted for infant sex and maternal age. MAIN RESULTS: Low neighbourhood income was associated with a moderately higher risk of preterm birth, low birthweight, and full-term low birthweight. The neighbourhood income gradient was less pronounced among recent immigrants compared with longer-term residents. Recent immigration was associated with a lower risk of preterm birth, but a higher risk of low birthweight and full-term low birthweight.

Early aggressive care and delayed recovery from whiplash: isolated finding or reproducible result?

OBJECTIVE: To test the reproducibility of the finding that early intensive care for whiplash injuries is associated with delayed recovery. METHODS: We analyzed data from a cohort study of 1,693 Saskatchewan adults who sustained whiplash injuries between July 1, 1994 and December 31, 1994. We investigated 8 initial patterns of care that integrated type of provider (general practitioners, chiropractors, and specialists) and number of visits (low versus high utilization). Cox models were used to estimate the association between patterns of care and time to recovery while controlling for injury severity and other confounders. RESULTS: Patients in the low-utilization general practitioner group and those in the general medical group had the fastest recovery even after controlling for important prognostic factors. Compared with the low-utilization general practitioner group, the 1-year rate of recovery in the high-utilization chiropractic group was 25% slower (adjusted hazard rate ratio [HRR] 0.75, 95% confidence interval [95% CI] 0.54-1.04), in the low-utilization general practitioner plus chiropractic group the rate was 26% slower (HRR 0.74, 95% CI 0.60-0.93), and in the high-utilization general practitioner plus chiropractic combined group the rate was 36% slower (HRR 0.64, 95% CI 0.50-0.83). CONCLUSION: The observation that intensive health care utilization early after a whiplash injury is associated with slower recovery was reproduced in an independent cohort of patients. The results add to the body of evidence suggesting that early aggressive treatment of whiplash injuries does not promote faster recovery. In particular, the combination of chiropractic and general practitioner care significantly reduces the rate of recovery.

Key factors in back disability prevention: what influences the choice of priorities?

STUDY DESIGN: Survey, subgroup analysis, Q-analysis, and analysis of e-mail exchanges. OBJECTIVE: To assess what influences the choice of priorities for interventions to prevent back-related disability. SUMMARY OF BACKGROUND DATA: Back-related disability results from interaction of physical, psychological, occupational, and social factors. However, opinions differ on which factors should be targeted by interventions aimed at preventing disability. METHODS: A Delphi panel (14 researchers and 19 occupational health stakeholders) attempted to reach consensus about the relative impact and modifiability of 32 factors involved in back-related disability. Data gathered during the panel were analyzed using 4 methods: (1) a survey asking panel members what influenced their rankings, (2) subgroup analysis to compare differences in rankings according to members' backgrounds and affiliations, (3) Q-analysis to identify views shared by members, and (4) qualitative analysis of e-mail exchanges during the panel process. RESULTS: Besides research evidence about a factor, we found that the greatest influence was the personal experience of panel members, which included diverse views about the nature of back disability, expectations about how interventions would be implemented, the typical workers or patients seen by them, and their values and principles. The member's educational background and current affiliation played a lesser role in their choice of priorities. The choice of priorities was also influenced by difficulties in separating the impact of a factor from its modifiability, whether the panel member considered occupational or nonoccupational disability, and the intricate linkages between the factors. CONCLUSIONS: This study suggests the choice of priorities is primarily influenced by different views about disability and other components of personal experience. Secondary influences included process difficulties in making a choice. The person's background and affiliation had a weak association with the views and choice of priorities.

Key factors in back disability prevention: a consensus panel on their impact and modifiability.

STUDY DESIGN: Modified Delphi panel using Q-methodology. OBJECTIVE: To reach consensus on the relative impact and modifiability of factors that might prevent participation restrictions in people with back pain as defined by the WHO International Classification of Functioning, Disability and Health. SUMMARY OF BACKGROUND DATA: Back disability prevention should focus on factors with large impact that are relatively easy to change and supported by most stakeholders. An evidence-based consensus panel can provide interim direction until definitive evidence is available. METHODS: Evidence summaries for 32 factors were used by 33 researchers and stakeholders in a 3-round Delphi process to rank the factors' relative impact and modifiability. Consensus was judged as strong (>85% of panel members), moderate (50%-84%), or low (33%-49%). RESULTS: Most available research focused on return to work and often left unexplored other participation domains and environmental factors at home. The panel had substantial disagreements, particularly on the impact of changes to physical functioning and activities required at work. After 3 rounds, there was strong consensus that care provider reassurance had a high impact. There was moderate consensus that expectation of recovery and decreased fears had a high impact. Back supports, care provider reassurance, and patient knowledge were deemed most modifiable. CONCLUSIONS: Until definitive evidence is available, back disability prevention interventions will likely need to address multiple factors simultaneously and emphasize efforts to improve care provider reassurance. Consensus findings may vary depending on the panel. Research on nonoccupational participation, environmental factors at home, and reasons for discordant interpretation of evidence is needed.

Fluorodeoxyglucose positron emission tomography detects the inflammatory phase of sclerosing peritonitis.

OBJECTIVE: We studied the effectiveness of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting inflammation in known or suspected cases of sclerosing peritonitis in patients on peritoneal dialysis (PD). DESIGN: We undertook FDG-PET scanning in PD patients presenting with symptoms or signs suggestive of sclerosing peritonitis (SP), and in patients on long-term PD with no symptoms of SP. SETTING: The study was performed in a PD unit in a tertiary-care hospital. PATIENTS AND METHODS: Three patients with known or strongly suspected SP underwent FDG-PET scans, 1 within 3 months of presentation with symptoms and 2 who were scanned more than 9 months after presentation. One patient was scanned at an early and a late time point. Five patients who had been on PD for more than 5 years and who were asymptomatic also underwent FDG-PET scanning. Scans were interpreted by a specialist in nuclear medicine. RESULTS: The scan performed in the early stages of SP showed increased peritoneal uptake. However, three scans taken more than 9 months after presentation with suspected SP showed mild peritoneal abnormalities only. One of 5 asymptomatic long-term PD patients showed increased peritoneal uptake associated with loss of ultrafiltration and high transporter status. CONCLUSIONS: FDG-PET scanning may be a useful adjunct in the diagnosis of the acute phase of SP. More study is needed to define its role in the diagnosis of SP in asymptomatic PD patients.

Initial patterns of clinical care and recovery from whiplash injuries: a population-based cohort study.

BACKGROUND: Little is known about the most effective pattern of clinical care for acute whiplash. We designed a cohort study to determine whether patterns of early clinical care (involving visits to general practitioners, chiropractors, or specialists) were associated with different rates of recovery. METHODS: We studied 2486 Saskatchewan adults with whiplash injuries. We defined 8 initial patterns of care that integrated type of provider and number of visits. We used multivariable Cox models to estimate the association between patterns of care and time to recovery while controlling for injury severity and other confounders. RESULTS: There was an independent association between the type and intensity of initial clinical care and time to recovery. We found that patients in the low-utilization general practitioner group had the fastest recovery, even after controlling for injury severity and other confounders. Compared with this group, the high-utilization general practitioner group experienced a 1-year rate of recovery that was 27% slower (adjusted hazard rate ratio [HRR], 0.73; 95% confidence interval [CI], 0.61-0.87); for the high-utilization chiropractic group it was 39% slower (HRR, 0.61; 95% CI, 0.46-0.81); for the high-utilization general practitioner plus chiropractic combined group it was 28% slower (HRR, 0.72; 95% CI, 0.57-0.91); and for those who consulted general practitioners and specialists, it was 31% slower (HRR, 0.69; 95% CI, 0.55-0.87). CONCLUSIONS: The type and intensity of clinical care initiated within the first month after the injury is associated with the rate of recovery from whiplash injuries. Our study does not support the hypothesis that early aggressive care promotes faster recovery.

Risks and benefits of population-based genetic testing for Mendelian subsets of common diseases were examined using the example of colorectal cancer risk.

OBJECTIVE: Genetic testing for adult-onset, common diseases is becoming more commonplace in clinical medicine. We modeled the proportions of hypothetic populations that would potentially benefit or suffer harm from widespread predisposition testing. METHODS: Using the traditional two-by-two table from the discipline of epidemiology, we modeled three hypothetic populations using the example of genetic testing for hereditary colorectal cancer in three groups: the general population, a genetically increased-risk population, and a population at increased risk due to nongenetic factors. RESULTS: We demonstrate that the potential benefits are increased and risks are reduced when testing is limited to those at increased genetic risk when compared with testing in the general population. Where disease incidence is increased due to nongenetic factors, genetic testing has the potential to detract from the detection and reduction of other potentially important risk factors. CONCLUSION: While targeted testing can benefit those truly at increased risk, broadly applied genetic testing can do more harm than good.