Tuesday, May 9, 2017

Stark Inequality: Study Finds 20-Year Difference in Life Expectancy Between Counties in United States

By Hank Dart

Differences in life expectancy in the United States can vary greatly depending on the county in which you live.  That's the finding of a new analysis out of the University of Washington and published in the journal JAMA Internal Medicine.

Using data from the Human Mortality Database, National Center for Health Statistics, and U.S. Census Bureau, researches calculated the average life expectancies of counties between the years 1980 and 2014.  They also assessed factors in the counties that could impact health - and therefore life expectancy - such as health behaviors, socioeconomic status (SES), and access to health care.

The analysis revealed a very large 20-year difference in life expectancy between the counties with the longest life expectancy and those with the shortest.  While average life-expectancy for women and men combined was 79 years in 2014, counties with the highest life-expectancy averaged 87 years.  Those with the lowest averaged just 66 years. Comparing the top 1 percent of counties with the lowest 1 percent, the life-expectancy gap was 11 years. Comparing the top 10 percent of counties with the lowest 10 percent, the gap was 6 years.

Counties on the lower half of the Mississippi River and those on some Native American reservations in South and North Dakota had some of the lowest life expectancy in the nation, while those in central Colorado Counties had some of the highest.  A related online dynamic tool allows users to explore life expectancy and mortality rates for counties across the nation.

Looking at trends since 1980, the researchers conclude that inequality in life expectancy in United States is "large and increasing."  Though such inequality has dropped in younger groups, it remains stark in older groups and populations as a whole.

In trying to tease out the causes of these disparities, the researchers found that certain health and behavioral factors had the biggest influence.  Obesity, lack of physical inactivity, smoking, high blood pressure, and diabetes were found to account for 74 percent of the life expectancy differences between counties.

This new analysis further confirms the importance of addressing growing inequality in the United States. Populations with lower incomes, less education, and more discrimination are more likely to suffer from lifestyles and diseases that result in premature mortality.  Programs and policies need to be put in place to narrow these gaps and address these issues.

How long you live and how healthy you are should not depend on where you live.  Right now, it can.  And we need to change that.

Wednesday, May 3, 2017

Study Looks at Economic Cost of Physical Inactivity. Hint: It's Big.

A new analysis published last week in the British Journal of Sports Medicine found that physical inactivity results in a significant economic burden the world over. Though the authors found that studies looking at the economic impact of inactivity lacked consistent methodology - which, therefore, limited specific conclusions - sedentary lifestyles were found to account for large percentages of direct health care expenditures in a number of countries. In the United States, 2.4 - 11.1 percent of direct health care expenditures on things like doctors visits and hospital stays were linked to inactivity.  In New Zealand, it was 4.5 percent.  In China, it was 2.4 percent. And in the United Kingdom, it was 0.3 - 1.5 percent.  Globally, the "pandemic" of physical inactivity - as the authors describe it - was estimated in one study to be 0.64 percent.

Ding D, et al. Br. J Sports Med. 2017
And these are just direct health costs from diseases and conditions caused by physical inactivity.  Indirect costs, which take into account other economic burdens of  physical inactivity, such as lost work productivity and wages, are also substantial.

As the authors conclude:
Based on the findings from the studies reviewed, it is evident that physical inactivity is a costly pandemic that is associated with a substantial disease burden in almost every country where estimates exist.  

Related Cancer News in Context posts on physical activity.

Friday, April 21, 2017

Reaching the Goal of 80% Colon Cancer Screening by 2018: Practical Lessons from Community Clinics

A great interview this week with Belma Andrić, MD, MPH on the 80% by 2018 blog highlights successful approaches that can boost colon cancer screening rates at community clinics with underserved populations.

During her tenure as Medical Director with C. L. Brumback Primary Care Clinics in Florida, colon screening rates increased from 21 percent in 2013 to 82 percent in 2016 - meeting and surpassing the National Colorectal Cancer Roundtable's goal of an 80 percent screening rate by 2018.

How did they do this?  By tackling the issue at multiple levels and developing creative ways to work around barriers.  Some lessons from their experience include:

Collaborate.  Groups within the clinic not only worked together to improve screening rates but the clinics also worked with the Florida state primary care health systems manager and an American Cancer Society local liaison.

Staff a patient navigator.   "This proved to be one of the best decisions we made," Andrić says. The navigator was key to addressing the needs and concerns of the patients while also making sure screening efforts synched within the clinic system.  One key aspect of the navigators' work was to walk patients through the steps of colonoscopy bowel prep and to check in with them during the process.

Make the offer of screening "second nature."  One initial top barrier to screening was the fact that many patients were simply not being offered screening at their clinic visits.  They addressed this problem through a combination of provider/team education, weekly check-ins, and some friendly competition between care teams - "doctors are very competitive." 

Make it easy and immediate.  Clinics implemented a "Poop on Demand" program that asked patients if they wanted to provide a stool sample for testing while they were at the clinic.  This boosted rates of FIT testing by 30 - 40 percent.

"Don't get discouraged."  Barriers of all kinds pop up with any program.  Expect that they will come up, even if the specific barriers are unexpected.  Most can be overcome.

Seek extra funding.  The clinics applied for - and received - an American Cancer Society Community Health Advocates implementing Nationwide Grants for Empowerment and Equity (CHANGE) grant, which helped them explore and implement strategies for improving screening rates.

Tuesday, April 18, 2017

Looking for a Good Return on Investment? Fund Public Health Programs

In a recent New England Journal of Medicine Sounding Board article, Karen Emmons and Cancer News in Context's Graham Colditz detailed the well-established health and economic benefits of disease prevention programs.   One example they highlighted was the more than double return on investment (ROI) of dollars put towards a tobacco cessation program in Massachusetts.

Now, a new systematic review by Rebecca Masters and fellow researchers in the United Kingdom shows that that very good doubling of ROI may actually be on the low end of returns when it comes to the positive economic benefits of many public health interventions.  Looking at published studies on interventions as varied as speed limits, needle exchange, soda taxes, vaccination, medication adherence, and tobacco cessation, the researchers found that the average ROI across all such interventions was 14.  This means that for every dollar invested in the reviewed public health programs, 14 dollars (plus the initial dollar invested) was saved.  

While a small number of individual studies in the review showed a negative ROI, the vast majority found positive results, with some very large, such as the ROI for sugary soda tax legislation.  The table below highlights some of the individual studies used to calculate the overall ROI for the public health interventions.

Selected interventions (single study results) ROI
Sugar-sweetened beverage tax $55.00
Tobacco cessation (pregnant women) $6.72 - 17.18
Workplace health management $4.51
Cycling & walking trails $2.94
Universal Hepatitis B vaccination $2.98
Tobacco cessation (general) $2 - 2.25

With such large and consistent findings of economic benefit, it is hard to understand why such health programs need to fight so hard for adequate funding.  As the authors write, "even with the most rudimentary economic evaluations, it was clear that most public health intervention are substantially cost saving."

Unfortunately, success in public health can take time and it can feel muted next to flashier news items - both of which can hamper funding efforts.  To capitalize on these numbers - to realize the potential of their great return on investment - we need to find a way to effectively tell our stories, to build public interest, and to garner the political will to fund public health appropriately.  The economic and health benefits could be enormous.  We should not leave them on the table.

The Coeur d'Alene Tribe Promotes Physical Activity Through a Program of Traditional Dance

National Public Radio aired a really nice piece yesterday about a fitness program developed by the Coeur d'Alene Tribe of northern Idaho that focusses on traditional American Indian dance.  With funding from the Centers for Disease Control and Prevention, the program uses exercise classes and a series of fitness videos based on powwow dances to get tribal members moving.

Featuring both men's and women's dances, the "Powwow Sweat" videos have engaging whimsical touches and interlace dancers in standard workout clothes and those in traditional dress. Similar exercise classes are also offered at the Tribe's wellness center.

As reported in the piece, the traditional, cultural approaches of the program may help it reach and engage people to a greater degree than one solely based on physical activity alone.
"It's this combination of tradition and exercise that keeps tribal member Ryan Ortivez and his neighbors coming to class each week, to watch the videos and dance alongside each other. 
'It's a lot more attractive than doing jogging or the bicycle for me, because it also relates to my culture,' says Ortivez."

This kind of tailored approach and support is key to improving health behaviors in all populations.  We respond to messages that resonate with us, and that are supported within our broader communities.    "Powwow Sweat" is a great example of a program working to do just that.

It is also of particular interest to us as we've had the opportunity to partner with the Buder Center for American Indian Studies at Washington University on health outreach.  And we've recently tailor two of our 8 Ways to Prevent Cancer series titles to American Indian and Alaska Native populations (Breast Cancer & Colon Cancer), each of which was distributed at the Center's 27th Annual Powwow this past March.

Thursday, April 13, 2017

Large Study Further Confirms Overweight & Obesity Increase Risk of Premature Death

 A "normal" weight - with BMI between 22.5 and 24.9 - was linked to lowest risk

by Hank Dart

It turns out that a healthy weight is a healthy weight. That's the essential conclusion of a large and well-designed new study looking at long term weight and its relation to premature death.

What makes this seemingly common sense finding especially newsworthy is that it runs counter to some recent high-profile studies that have concluded that being overweight or slightly obese may actually provide the best protection against premature mortality, even more so than being at what is classified as a "normal" or "healthy" weight.

Not surprisingly, these past "obesity paradox" studies made a splash in both the media and scientific circles, grabbing headlines the world over.

Yet, many researchers had concerns about the design of these studies, and therefore the

trustworthiness of their findings. The main issue was that the studies did not seem to adequately take into account smoking status and pre-clinical disease, which can have an important impact on both weight and the risk of death. Pre-clinical disease is an illness that has not yet been diagnosed but that can lead to weight loss and increased risk of dying. And weight loss from such illness can happen many years before it is diagnosed. Likewise, smokers also tend to weigh less and have a higher risk of dying. Unless a study is designed correctly, each of these factors can incorrectly sway results to show that being a normal weight increases the risk of death, and being overweight lowers risk.

This new study, performed by researchers at the Harvard School of Public Health and Harvard Medical School, was design to address such issues by using participants' maximum weight over a 16-year period. This way, the impact of weight loss due to pre-clinical disease could be limited. A participant with a maximum weight in the "normal" category, for example, would not have gotten there by losing weight -- such as due to an unknown illness.


Following 225,000 middle-aged men and women for another 8 - 20 years, the researchers found a steady increase in risk of premature death with overweight and obesity, compared to normal weight (see figure). Underweight also increased risk in women. The lowest risk of premature death was with a body mass index (BMI) between 22.5 - 24.9, which is a weight of 148 - 164 pounds for someone 5 feet, 8 inches tall.

While these findings are not necessarily surprising - since they fall in line with the guidelines for healthy weight and unhealthy weight - they are quite an important counter to the widespread "obesity paradox" coverage. Next to smoking, weight is the most important health issue in the nation - and increasingly the globe. In addition to lowering quality of life, overweight and obesity increase the risk of heart disease, diabetes, stroke, osteoarthritis, liver disease, and thirteen different cancers. 

Working to maintain a healthy weight remains one of the best things people can do for their health and well-being.  While it's not easy, it's certainly worth it. 

See our recent post for simple tips to help keep weight in check.



Photo: Mini-me-7 by Marcel Oostervijk (CC License, CC BY-SA 2.0) (Edited: Cropped)

Thursday, March 23, 2017

Another Look at Luck and Cancer: Risk Accumulation & Prevention

by Graham Colditz

The debate regarding luck, prevention, and cancer risk is in the media again today (see Science, NPR, Forbes, and many others).

The authors of this new paper -- a follow-up of their original published two years ago and which caused such stir -- make a clear effort too classify cancer risk as due to H - hereditary (our parents - who we cannot change), E - environmental exposures (modifiable risk factors, such as cigarette smoking, weight gain in adult years, and lack of physical activity) and R - rate of DNA damage accumulated as cells divide.  By taking this approach, however, we continue to focus on the underlying rate of division and DNA damage, not the factors that modify this rate and certainly are known to modify cancer risk.

Doll and Armitage showed in 1954 that 5 to 6 mutations were needed to generate cancer in lung, colon, and numerous other organ sites. Yes, the multistage model proposed in 1954 was largely correct based only on assessment of age and cancer mortality in the UK. Of course, back then, treatment did not change outcomes to any great extent.

Today, we have more evidence that the rate of DNA damage varies by age.  For example, breast cancer shows this clearly in animal models and through incidence in women. The stages of a woman's life are associated with different rates of cell division - faster from the time a woman has her first menstrual period to the time she has her first baby, then more slowly after each baby, to even slower after menopause (unless a women uses hormone therapy that consists of estrogen-plus-progestins).

We wrote on this some time ago, (see below) as have many others.

While risk accumulates through cell divisions, we know that avoiding smoking and other major risk factors dramatically reduces the risk of specific cancers.

As the cancer burden continues to increase globally, using what we know from decades of cancer research lets us as a society reap benefits now.  Our return on investment on what we already know is waiting to be collected.  We just need the foresight and political will to do it.