Arranged marriages, unlikely partners. How will their offspring look?

In the new era of managed care, many religious healthcare providers are making "arranged marriages"--permanent partnerships with secular organizations. As they do so, the religious partners naturally ponder how best to ensure that their values permeate the new entity and thus prevail in later organizational "offspring." The organizations most likely to perpetuate their values are those with ethical corporate cultures and climates. These include religiously based healthcare providers, but such providers seem to lack confidence today in their ability to maintain culture and climate in newly formed partnerships. That may be fortunate because it prevents them from trying to impose their values on secular partners. Nevertheless, such values are often attractive to a prospective partner. A religious healthcare provider will need market leverage, as well as attractive values, to make a good "marriage." Even so, religious providers and secular investor-owned organizations are unlikely partners, because their motives and incentives differ radically. But religious providers can form solid relationships with secular, not-for-profit healthcare organizations if they take care to negotiate a binding commitment to maintain an ethical culture and climate. However, Catholic providers are at a disadvantage in such negotiations because Catholic religious congregations are unlikely to continue as owner-sponsors much beyond another decade. It is crucial that a stable source of influence develop to ensure a religious presence in the offspring of new partnerships.     

High hepatitis C incidence in new injecting drug users: a policy failure?

OBJECTIVE: Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney. METHODS: IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n = 215) were enrolled and followed-up at 3-6 monthly intervals. New IDUs (n = 204) were defined as aged below 30 years or injecting for < or = 6 years at baseline. RESULTS: A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR = 3.10; 95% CI 1.47-6.54), female gender (IRR = 2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR = 2.03; 95% CI 1.06-3.89) and intravenous cocaine use (IRR = 2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs. CONCLUSION: Incidence of HCV infection among new IDUs in Sydney is unacceptably high. IMPLICATIONS: Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.     

Piloting the Affordable Medicines Facility-malaria: what will success look like?

The Affordable Medicines Facility-malaria is an innovative financing mechanism, managed by the Global Fund to Fight AIDS, Tuberculosis and Malaria. This initiative aims to increase the use of artemisinin-based combination therapies for treating malaria. A pilot is underway in eight countries to determine whether the mechanism reduces the consumer price of these drugs and increases their availability in public and private outlets, their market share and their use. To evaluate the pilot, an analysis was done to estimate predetermined "benchmarks" of success at 1 and 2 years. The analysis used a mixed-methods approach, triangulating data from a literature review with information from 33 interviews with experts. A sensitivity analysis and other methods were used to verify the results. Benchmarks used to determine success include an increase in availability of artemisinin-based combination therapies of 40 percentage points from baseline, and an increase in their use of 10-15 percentage points from baseline at year 2. These benchmarks were based on evidence that national public health programmes aimed at increasing the use of a specific health commodity in developing countries have generally achieved only modest changes in use within a 2-year time frame. Evaluation should also take individual country contexts into account.     

Invited commentary: How early in life does the risk of obesity originate?

Mothers and fathers influence the risk of obesity in their children through genetic, environmental, and behavioral factors. Unique to the mother, however, is the intrauterine environment in which the fetus develops, and it is during this time in the uterus that the risk of later obesity in the child may develop. In this issue of the Journal, Fleten et al. (Am J Epidemiol. 2012;176(2):83-92) investigate whether the intrauterine environment plays a role in the development of adiposity by comparing the association between maternal prepregnancy body mass index (BMI; measured as weight in kilograms divided by height in meters squared) and offspring BMI at 3 years of age with the paternal-offspring association at the same age in the Norwegian Mother and Child Cohort Study. In that large study of stable, relatively healthy and well-educated families, significant differences in maternal-offspring and paternal-offspring BMI associations were not identified. These findings are interpreted as indicating that the influence on the child's BMI of the intrauterine environment is less important than that of genetics and shared environment. Results from that study suggest that further consideration should be given to the specificity of the fetal overnutrition hypothesis in terms of which aspects of the intrauterine environment may influence offspring adiposity and when across the life course these effects may manifest themselves.     

How will care be rationed?

No bill before Congress fully answers the explosive question of who gets how much care--and who ultimately makes the hard choices. But experts say health care rationing of some kind is inevitable. Here's how to decipher the debate, and what it means for your practice.     

Child obesity: what can be done and who will do it?

Among the measures recommended by the WHO to reduce the risk of obesity and non-communicable disease, the consumption of a diet rich in micronutrients but with a relatively-low energy density features prominently. However, only a small percentage of the UK population (<1) appears to be consuming the recommended diet. Dietary behaviour is strongly influenced by the dietary environment, shaped by food supplies, investment policies and advertising, to create an obesogenic food market. Substantial resources have been invested in food production of a sort that does not promote better health; agriculture and food supply sectors have benefited from decades of public-sector support, but this practice has encouraged the production of meat, dairy, oils and sugar and the withdrawal from sale of fruit, vegetables and fish. The result is an 'obesogenic economy', i.e. a market economy that encourages weight gain, in which children are a prime target. Interventions in the obesogenic market need to be considered and several opportunities are described in the present paper. Recent moves to strengthen national and international food policies aimed to promote healthier behaviour have been undertaken, but they will need political support if they are to be fully implemented. Alliances of public health interests can help to create that political support and promote health-enhancing environments.     

Breastfeeding in Africa: will positive trends be challenged by the AIDS epidemic?

In Africa, more than 95% of infants are currently breastfed, but feeding practices are often inadequate: feeding water, and other liquids, to breastfed infants is a widespread practice. Consequently, the rate of exclusive breast-feeding is low, particularly in West Africa. The rate of bottle-feeding is high in some countries (exceeding 30% in Tunisia, Nigeria, Namibia and Sudan). Nevertheless prolonged breastfeeding is common, and the median duration of breastfeeding ranges between 16 and 28 months. Urbanization and mothers' education are the major factors that tend to shorten breastfeeding. Nevertheless recent trends show an increase in early initiation and in duration of breastfeeding as a result of promotion efforts deployed by WHO and Unicef, local governments, and non-governmental organizations. The importance of breastmilk as a food resource of African countries is generally not recognized. In 31 countries where data on prevalence of breastfeeding are available, consumption of breastmilk by children under three years is estimated at 3.5 million tons per year. The AIDS epidemic could threaten breastfeeding because the virus can be transmitted through breastmilk, as demonstrated by numerous studies. A study suggests that feeding breastmilk and other liquids to infants could be the feeding mode associated with the highest rate of transmission. To prevent mother-to-child transmission of HIV, WHO recommends replacement feeding if it is feasible and safe. Otherwise, mothers are encouraged to practice exclusive breastfeeding for the first months of life followed by early and rapid weaning. The feasibility of replacement feeding with breastmilk substitutes, however, is very uncertain. In a study where free substitutes were given to HIV-positive mothers, the mortality of the formula-fed infants was the same as that of the breastfed infants. HIV-positive mothers may find it difficult to cope with the constraints of replacement feeding, in terms of cost, workload and time, and with the additional health care needs of non-breastfed infants. Exclusive breastfeeding for a few months could carry a lower risk of death than replacement feeding. But success in promoting exclusive breastfeeding has been limited in Africa, and new promotion methods are needed. Infants of all mothers, whether HIV-positive or not, will benefit from improving the rate of exclusive breastfeeding. The major problem is to ensure that early and rapid weaning, between 4 and 6 months, does not have a negative impact on the child's health. Early weaning is known to increase susceptibility to infections and can cause malnutrition. The feasibility and safety of this recommendation will have to be monitored carefully. A strong determination of African governments to promote exclusive breastfeeding among all mothers and to protect prolonged breastfeeding among non-infected mothers will limit the mother-to-child transmission of HIV while preserving the benefits of breastfeeding.     

Increase of regional total cancer incidence in north Sweden due to the Chernobyl accident?

STUDY OBJECTIVE: Is there any epidemiologically visible influence on the cancer incidence after the Chernobyl fallout in Sweden? DESIGN: A cohort study was focused on the fallout of caesium-137 in relation to cancer incidence 1988-1996. SETTING: In northern Sweden, affected by the Chernobyl accident in 1986, 450 parishes were categorised by caesium-137 deposition: < 3 (reference), 3-29, 30-39, 40-59, 60-79, and 80-120 kiloBecquerel/m(2). PARTICIPANTS: All people 0-60 years living in these parishes in 1986 to 1987 were identified and enrolled in a cohort of 1 143 182 persons. In the follow up 22 409 incident cancer cases were retrieved in 1988-1996. A further analysis focused on the secular trend. MAIN RESULTS: Taking age and population density as confounding factors, and lung cancer incidence in 1988-1996 and total cancer incidence in 1986-1987 by municipality as proxy confounders for smoking and time trends, respectively, the adjusted relative risks for the deposition categories were 1.00 (reference < 3 kiloBecquerel/m(2)), 1.05, 1.03, 1.08, 1.10, and 1.21. The excess relative risk was 0.11 per 100 kiloBecquerel/m(2) (95% CI 0.03 to 0.20). Considering the secular trend, directly age standardised cancer incidence rate differences per 100 000 person years between 1988 to 1996 and the reference period 1986-1987, were 30.3 (indicating a time trend in the reference category), 36.8, 42.0, 45.8, 50.1, and 56.4. No clear excess occurred for leukaemia or thyroid cancer. CONCLUSIONS: Unless attributable to chance or remaining uncontrolled confounding, a slight exposure related increase in total cancer incidence has occurred in northern Sweden after the Chernobyl accident.     

Ciliary neurotrophic factor: a role in obesity?

Ciliary neurotrophic factor (CNTF) is a neurocytokine expressed by glial cells in peripheral nerves and the central nervous system. CNTF is generally recognized for its function in support and survival of non-neuronal and neuronal cell types. Following a serendipitous finding, CNTF was recently acknowledged for its potential role in the control of obesity.     

New NHLBI clinical guidelines for obesity and overweight: will they promote health?

OBJECTIVES: The purpose of this study was to assess the justification, on the basis of mortality, of the new National Heart, Lung, and Blood Institute (NHLBI) guidelines on obesity and overweight and to discuss the health implications of declaring all adults with a body mass index of 25 through 29 "overweight." METHODS: The relationships between NHLBI body mass index categories and mortality for individuals older than 31 years were analyzed for 6253 Alameda County Study respondents aged 21 through 75 years. Time-dependent proportional hazards models were used to adjust for changes in risk factors and weight during follow-up. RESULTS: Adjusted relative risks of mortality for 4 NHLBI categories compared with the category "normal" indicated that only being underweight or moderately/extremely obese were associated with higher mortality. Specific risk varied significantly by sex. CONCLUSIONS: Our results are consistent with other studies and fail to justify lowering the overweight threshold on the basis of mortality. Current interpretations of the revised guidelines stigmatize too many people as overweight; fail to account for sex, race/ethnicity, age, and other differences; and ignore the serious health risks associated with low weight and efforts to maintain an unrealistically lean body mass.     

The aging population in Sweden: can declining incidence rates in MI, stroke and cancer counterbalance the future demographic challenges?

It is often taken for granted that an ageing population will lead to an increased burden for the health care sector. However, for several diseases of big public health impact the rates have actually come down for a substantial period of time. In this study we investigate how much the incidence rates for myocardial infarction (MI), stroke, and cancer will have to decline in order to counterbalance future demographic changes (changes in population size and age structure) and compare these figures with observed historical trends. Information on incidence rates were obtained from the National Board of Health and Welfare and referred to the total Swedish population. Population projections were obtained from Statistics Sweden. We projected the number of MI events to increase 50–60% between 2010 and 2050. The decline in incidence rates that is required to keep the number of events constant over time is, on average, 1.2%/year for men and 0.9%/year for women, somewhat higher than the trend for the past 10 years. For stroke the corresponding figures were 1.3% (men) and 1% (women), well in line with historical trends. For cancer the results indicate an increasing number of events in the future. Population ageing is more important than population growth when projecting future number of MI, stroke and cancer events. The required changes in incidence rates in order to counterbalance the demographic changes are well in line with historical figures for stroke, almost in line regarding MI, but not in line regarding cancer. For diseases with age dependence similar to these diseases, a reduction of incidence rates in the order of 1–2% is sufficient to offset the challenges of the ageing population. These are changes that have been observed for several diseases indicating that the challenges posed by the ageing population may not be as severe as they may seem when considering the demographic component alone.