THE PRESENCE OF FECAL AND NON-FECAL TYPES OF THE COLON BACILLUS IN VARIOUS TYPES OF WATER

An investigation of the origin of members of the colon-aërogenes group. “High ratio” aërogenes come probably from grains or cereals, while “low ratio” colon betoken probable human contamination.     

URGENT NEED FOR THE STANDARDIZATION OF LABORATORY WORK

As a practical man familiar with the technique of the laboratory this author urges the need of establishing standards in laboratory practice. “This task will have to be faced in the near future,” he writes, “And I believe that the A. P. H. A. is the proper organization to assume this important duty.”     

VENEREAL DISEASE CONTROL IN THE MILITARY FORCES

Major Sawyer asks this question,—“The army is being sent home clean. Will your community make it easy or difficult for the men to remain so?” His short paper is an introduction to the longer one that follows it.     

THE PURIFICATION OF OYSTERS AS A CONSERVATION MEASURE

Give the oyster a chance to cleanse itself and typhoid will be as preventable here as with domestic water supplies. This is the motif of this paper by Dr. Wells, who is no new hand at discussing shellfish problems. “It can be considered a conservation measure,” he urges.     

THE USE OF LIFE TABLES IN PUBLIC HEALTH WORK

In this paper a man not professionally engaged in public health work but familiar with the difficulties of rendering vital statistics useful in that work and technically trained to cope with such difficulties, discusses some of the important features of “The Book-keeping of Public Health.”     

INFANT MORTALITY IN THE REGISTRATION AREA FOR BIRTHS

“A high infant mortality rate today is a greater disgrace than a high typhoid rate,” writes Dr. Davis. It reflects on clergy, physicians, nurses, school teachers and editors alike, and gives a low rating for the intelligence of the people. Breast feeding is the first line of attack. Mothers should be taught how to care for their children.     

FUTURE CO?PERATION BETWEEN THE AMERICAN RED CROSS AND PUBLIC HEALTH AGENCIES

Since the cessation of hostilities in Europe health officers have been asking “What is the Red Cross going to do in Public Health?” Dr. Farrand here assures the public health profession that the Red Cross proposes to be a coöperative agency and not unless circumstances seem to demand it, an operative one.     

THE HISTORICAL DEVELOPMENT OF PUBLIC HEALTH WORK IN ENGLAND

“There is much illness that might have been avoided if there had been an organized system of state medicine,” says Sir Arthur Newsholme, speaking of England. He would give a freer hand to the health officer who measures up to the standard. England''s chief defect lies in the existence of small and inefficient local health bodies.     

SOME RELATION BETWEEN OUR HEALTH AND OUR ENVIRONMENT: A STUDY OF THE PREVALENCE OF DISEASE IN THE CITY OF DETROIT WITH SPECIAL REFERENCE TO THE INFLUENCE OF THE TYPE AND SANITATION OF DWELLINGS UPON DISEASE

“It is not too much to say that an adequate solution of the housing question is the foundation of all social progress. Health, and housing, are indissolubly connected. If this country is to be the country which we desire, a great offensive must be taken against disease and crime, and the first point at which the attack must be delivered is the ugly, unhealthy, overcrowded house, in the mean street, which we all of us know too well.“If a healthy race is to be reared it can be reared only in healthy homes. If infant mortality is to be reduced, and tuberculosis to be stamped out, the first essential is the improvement of housing conditions; if drink and crime are to be successfully combated, sanitary houses must be provided. If `unrest'' is to be converted to contentment, the provisions of good housing may prove one of the most potent agencies in that conversion.”     

Changes in Dietary Patterns through a Nutritional Intervention with a Traditional Atlantic Diet: The Galiat Randomized Controlled Trial

Unhealthy dietary patterns (DPs) can lead to cardiovascular and other chronic diseases. We assessed the effects of a community-focused intervention with a traditional Atlantic diet on changes in DPs in families and the associations of these changes with weight loss. The Galiat study is a randomized, controlled trial conducted in 250 families (720 adults and children) and performed at a primary care setting with the cooperation of multiple society sectors. Over 6 months, families randomized to the intervention group received educational sessions, cooking classes, written supporting material, and foods that form part of the Atlantic diet, whereas those randomized to the control group followed their habitual lifestyle. At baseline, five DPs that explained 30.1% of variance were identified: “Caloric”, “Frieds”, “Fruits, vegetables, and dairy products”, “Alcohol”, and “Fish and boiled meals.” Compared to the controls, the intervention group showed significant improvements in “Fruits, vegetables, and dairy products” and “Fish and boiled meals” and reductions in the “Caloric” and “Frieds”. Changes in bodyweight per unit increment of “Frieds” and “Fruits, vegetables, and dairy products” scores were 0.240 kg (95% CI, 0.050–0.429) and −0.184 kg (95% CI, −0.379–0.012), respectively. We found that a culturally appropriate diet improved DPs associated with weight loss.     

Relative Importance of Determinants of Changes in Eating Behavior during the Transition to Parenthood: Priorities for Future Research and Interventions

Background: Healthy eating behavior throughout pregnancy and postpartum is important. This study aimed to investigate the perceived sex-specific importance of determinants of changes in eating behavior during pregnancy and postpartum. Methods: Fifty-four determinants were rated by first-time parents (n = 179) on their impact. Experts (n = 31) rated the determinants in terms of their modifiability, relationship strength, and population-level effect from which a “priority for research”-score was calculated. Results: During pregnancy, the three highest rated determinants by women were “health concerns”, “physiological changes”, and “fatigue”. Men perceived “health concerns”, “health consciousness”, and “influence of the pregnant partner” as important. Postpartum, the three highest rated determinants by women were “adaptation to rhythm of baby”, “baby becomes priority”, and “practical constraints because of the baby”. Men perceived “adaptation to rhythm of baby”, “fatigue”. and “(lack of) anticipation” as important. According to the experts, “professional influence”, “food knowledge”, and “home food availability” received high priority scores for both sexes and during both periods. Conclusions: Priority for research and interventions should go towards tailored family-based approaches focusing on food education in a broad sense taking into account aspects such as health consciousness, self-efficacy skills, and the social and home food environment while being supported by healthcare professionals.     

Curcumin-Rich Curry Consumption and Neurocognitive Function from 4.5-Year Follow-Up of Community-Dwelling Older Adults (Singapore Longitudinal Ageing Study)

The potential neurocognition protective effects of dietary curcumin in curry consumed with food was investigated in this study of 2734 community-dwelling adults (aged ≥ 55, mean ± SD: 65.9 ± 7.4). We analyzed longitudinal data of baseline curry consumption (“never or rarely”, “occasionally”: <once a month, “often”: >once a month and <once a week, “very often”: >once a week or daily) and baseline and 4.5-year follow-up cognitive function in mixed model analyses controlling for confounding risk factors. Significant between-exposure differences were found for Digit Span-Backward (DS-B), Verbal Fluency-Animals (VF-A) and Block Design (BD). Compared to “never or rarely” consumption, “very often” and “often” consumptions were associated with higher DS-B performance; “very often”—with higher VF-A, and “occasional”, “often” and “very often” consumptions—with higher BD: Cohen’s d: from 0.130 to 0.186. Among participants with cardiometabolic and cardiac diseases (CMVD), curry consumption was associated with significantly higher DS-B and VF-A. Among CMVD-free participants, curry consumption was associated with significantly higher DS-B, VF-A and BD: Cohen’s d: from 0.098 to 0.305. The consumption of dietary curcumin was associated with the maintenance over time of higher functioning on attention, short-term working memory, visual spatial constructional ability, language and executive function among community-dwelling older Asian adults.     

WHAT THE CAMPAIGN AGAINST VENEREAL DISEASE DEMANDS OF HOSPITALS AND DISPENSARIES

Doctor Davis presents here the relation between the dispensary clinic and hospital to our so-called medical-social problems. He does away with the conception that these clinics are “charities” and describes the work as a necessary public health service.     

Dietary Patterns and Birth Weight—a Review

Being born with low birth weight (LBW) is recognized as a disadvantage due to risk of early growth retardation, fast catch up growth, infectious disease, developmental delay, and death during infancy and childhood, as well as development of obesity and non-communicable diseases (NCDs) later in life. LBW is an indicator of fetal response to a limiting intrauterine environment, which may imply developmental changes in organs and tissue. Numerous studies have explored the effect of maternal intake of various nutrients and specific food items on birth weight (BW). Taking into account that people have diets consisting of many different food items, extraction of dietary patterns has emerged as a common way to describe diets and explore the effects on health outcomes. The present article aims to review studies investigating the associations between dietary patterns derived from a posteriori analysis and BW, or being small for gestational age (SGA). A PubMed search was conducted with the Mesh terms “pregnancy” OR “fetal growth retardation” OR “fetal development” OR “infant, small for gestational age” OR “birth weight” OR “infant, birth weight, low” AND “diet” OR “food habits”. Final number of articles included was seven, all which assessed diet by use of food frequency questionnaire (FFQ). Five studies explored dietary patterns using principal component analyses (PCA), while one study used cluster analyses and one study logistic regression. The studies reported between one and seven dietary patterns. Those patterns positively associated with BW were labeled “nutrient dense”, “protein rich”, “health conscious”, and “Mediterranean”. Those negatively associated with BW were labeled “Western”, “processed”, “vegetarian”, “transitional”, and “wheat products”. The dietary patterns “Western” and “wheat products” were also associated with higher risk of SGA babies, whereas a “traditional” pattern in New Zealand was inversely associated with having a SGA baby. The dietary patterns associated with higher BW or lower risk of having babies born SGA were named differently, but had similar characteristics across studies, most importantly high intakes of fruits, vegetables and dairy foods. Dietary patterns associated with lower BW or higher risk for giving birth to a SGA baby were characterized by high intakes of processed and high fat meat products, sugar, confectionaries, sweets, soft drinks, and unspecified or refined grains. All studies in this review were performed in high-income countries. More research is warranted to explore such associations in low and middle income countries, where underweight babies are a major health challenge many places. Furthermore, results from studies on associations between diet and BW need to be translated into practical advice for pregnant women, especially women at high risk of giving birth to babies with LBW.     

THE NEED OF BETTER CONTROL OF SOME NEGLECTED CONTAGIOUS DISEASES

Under the title here given, Doctor Lane discusses ringworm and favus of the scalp as communicable diseases. Reference is also made to infections following vaccination and finally Doctor Lane speaks of the problem of syphilis, of which he says, “We realize its importance but in most places we do nothing about it.”     

Section of Epidemiology and State Medicine and Section for the Study of Disease in Children: DISCUSSION ON INFECTION IN THE DORMITORY: Joint Discussion No. 7

(1) An attempt is made to show that infection in the dormitory is of paramount importance in most of the epidemics which occur in boarding schools and residential institutions. (2) The conditions in dormitories which favour a rapid and easy transmission of infection are: proximity of beds, deficient and not “cross” ventilation, insufficient floor space, “dead” space in ceiling, and “dead” corners. More than two rows of beds are to be deprecated. (3) The occurrence of epidemic tonsillitis or of serious complications of measles and influenza, and, bacteriologically, the presence of high carrier rates of hæmolytic streptococci, may indicate the presence of such conditions in dormitories. (4) The minima suggested by the Board of Education (a) for dormitories and (b) for sanatorium wards or sick rooms are important for the prevention of the spread of infection.     

Secondhand Tobacco Smoke Exposure in Open and Semi-Open Settings: A Systematic Review

Background: Some countries have recently extended smoke-free policies to particular outdoor settings; however, there is controversy regarding whether this is scientifically and ethically justifiable.Objectives: The objective of the present study was to review research on secondhand smoke (SHS) exposure in outdoor settings.Data sources: We conducted different searches in PubMed for the period prior to September 2012. We checked the references of the identified papers, and conducted a similar search in Google Scholar.Study selection: Our search terms included combinations of “secondhand smoke,” “environmental tobacco smoke,” “passive smoking” OR “tobacco smoke pollution” AND “outdoors” AND “PM” (particulate matter), “PM_2.5” (PM with diameter ≤ 2.5 µm), “respirable suspended particles,” “particulate matter,” “nicotine,” “CO” (carbon monoxide), “cotinine,” “marker,” “biomarker” OR “airborne marker.” In total, 18 articles and reports met the inclusion criteria.Results: Almost all studies used PM_2.5 concentration as an SHS marker. Mean PM_2.5 concentrations reported for outdoor smoking areas when smokers were present ranged from 8.32 to 124 µg/m³ at hospitality venues, and 4.60 to 17.80 µg/m³ at other locations. Mean PM_2.5 concentrations in smoke-free indoor settings near outdoor smoking areas ranged from 4 to 120.51 µg/m³. SHS levels increased when smokers were present, and outdoor and indoor SHS levels were related. Most studies reported a positive association between SHS measures and smoker density, enclosure of outdoor locations, wind conditions, and proximity to smokers.Conclusions: The available evidence indicates high SHS levels at some outdoor smoking areas and at adjacent smoke-free indoor areas. Further research and standardization of methodology is needed to determine whether smoke-free legislation should be extended to outdoor settings.     

Nutrient Profiles of Dishes Consumed by the Adequate and High-Salt Groups in the 2014–2018 National Health and Nutrition Survey,Japan

Dish-based nutrient profile analyses are essential for setting goals to achieve a balanced diet. In 2014, the Japanese government proposed the “Healthy Meal” criteria, which requires a salt content of 3 g/650 kcal per meal. To examine the current intake status of a nationally representative sample, we conducted a series of secondary analyses of the 2014–2018 National Health and Nutrition Survey data. Participants (aged 18–74 years) were grouped as “high-salt” consumers if their salt intake was 3 g/650 kcal or higher and “adequate” consumers if they consumed less than 3 g/650 kcal. A total of 13,615 participants were identified as “adequate” consumers and 22,300 as “high-salt” consumers. The median salt intake in the “high-salt” group was 11.3 g/day, while that in the “adequate” group was 7.5 g/day. Almost all dishes consumed by the “adequate” group had significantly high energy and fat content but low salt content, compared with those consumed by the “high-salt” group. For example, the median energy, fat, and salt contents in the main dishes consumed by the “adequate” group were 173 kcal, 10.4 g, and 0.9 g/dish, respectively, while those in the main dishes consumed by the “high-salt” group were 159 kcal, 8.9 g, and 1.1 g/dish, respectively. Examples of balanced dishes that are low in both salt and fat content can be proposed to help improve the Japanese consumers’ dietary behavior.     

Annals Journal Club: One Cold Autumn Day

Behavioral change is at the heart of effective primary care, but when patients don’t change, how do we account for our days? In this personal essay, I relate an encounter with a patient who wants to quit smoking, lose weight, and control her diabetes. I am discouraged when she deflects my recommendations, but a colleague’s comment encourages a deeper inquiry. Knowing the patient’s story and deepening the conversation, however, do not guarantee change. The experience reminds me why patience, humility, and faith are core values of the primary care physician.Sometimes I feel angry with the patient. She’s a 44-year old, morbidly obese, diabetic who flies in from the Alaskan bush to be seen for “medication renewal” and “wound care” at the tribal urgent care. After a brief review, I level with her: “You know if you lost weight, you could probably get off all 10 of these medicines.” I don’t say it meanly, though, because frustration is not all I feel. I care. But sometimes, when my embers have grown dim, the caring looks a bit more like cold, biomedical efficiency.“What kinds of foods do you eat?” I ask.“Just regular food,” she replies.“Uh huh. Like what?”The more I learn about her body and behaviors, the more “to the point” I become. It’s not only impatience that drives me. It’s fear. Images of cracking, yellow plaque, a fatty hardening of the arteries, sharpen my pursuit.“Do you drink?”“No.”“You smoke, though.”“Yeah.”“Have you tried to quit?”“Yeah. I’ve tried everything.”“What have you tried?”“The patches, the gum…”“Have you tried pills, like Wellbutrin or Zyban?”“I tried that. They made me really on edge.”“How about Chantix?”“I tried that twice, but they told me I couldn’t get any more.”“Yeah, they won’t give you that for more than 3 or 4 months,” I explain. “It’s really expensive.”I have the feeling it won’t matter, though, if the pharmacy cuts her a break.“Do you want to quit?”“Yeah.”“It’s just hard,” I say. My weak attempt at empathy doesn’t pass through her skin.She says she wants to change everything—the diet, the smoking, and the sugar control. If I’m a machine, she’s a baseball mitt straight from the factory. Until you oil the palm and play a season of catch, the leather is thick and unyielding. If only she’d check her blood glucoses and cut out the soda pop…“I’ve tried that,” she says. No doubt she has.I stand and take a step toward the door. “You take aspirin?” I say.“Yeah.”Maybe if I were a better doctor, or no, a better human, I’d have more luck. For now, perhaps the little white aspirin is her best hope.It was the love of patient stories that tipped my scales toward family medicine. Right now, however, I don’t see a person with a name and personality. I see a ticking time bomb, an embolic stroke or myocardial infarction waiting to happen.Brushing my badge against the scanner, I listen for the beep and enter the hidden quarters of the clinic. In my first job in northern Maine, I had an office to myself. In that quiet space, I dictated, meditated, and contemplated. Here in Alaska, we have what might be called an “open office.” Head-high dividers cordon the several dozen employees into teams. There are doctors, medical assistants, nurses, nurse practitioners, physician assistants, clerks, case managers, care coordinators, and behavioral health clinicians. There’s a trade-off: proximity facilitates collaboration; solitude favors contemplation.After notifying the wound care nurse about my patient, I approach the physician’s assistant, Stephanie, who, at the moment, seems to be everything my patient is not. A tall, confident woman with a bright smile, she has just returned from the summit of Kilimanjaro.“Ugh,” I say, as she swivels in her chair. “Everything I suggest to this patient ‘doesn’t work.’ It’s so frustrating. She’s huge and she smokes and she’s on like 10 medications.”Fifteen years my younger, Stephanie is neither jaded nor ignorant.I continue to vent: “She could get off all of them—her anti-hypertensives, her diabetes medicines, her cholesterol medicine—if she would just lose weight.”It’s not that I’m culturally ignorant. I know the traumatic history of this land: the microbial plagues, the famine, the cultural genocide. I’ve spent many weeks in the villages, and convened community meetings to dialog about cancer, substance abuse, diet, and suicide. Today, however, this knowledge is lost to me, buried beneath a thick crust of frustration.“Some people…” I say, “everything you propose, they have an answer.”Stephanie doesn’t judge me. “Those patients,” she says, “are depressed.”“Yeah,” I say. Whether or not the patient is clinically depressed is not really the question, but sometimes a friend’s advice works, not because of diagnostic accuracy, but because it slips the heart into a more productive channel of thought.After the wound care nurse leaves the room, I start back in with my patient. “Some patients who have a hard time quitting smoking have trauma in their past,” I say. “Do you have any unresolved trauma—physical or sexual?”My inquiry is too abrupt, and probably too presumptuous, but my patient levels with me, anyway. “When I was 14 years old, I was raped by someone in the village.”Statistically speaking, one-half of my female and one-quarter of my male patients have experienced sexual trauma. “Did you get care?” I say.“My Mom took me to get seen and we put the man behind bars.”The sexual trauma is not surprising. The imprisonment is. Few sexual trauma survivors or their families want to disturb the social fabric of the village. The perpetrator may be an important provider or leader, and the survivor may even fear that she’ll be the cause of his or her suicide.“Did you ever get counseling?”“I went a couple times.”“Hmm.”“I started drinking after that. They sent me to rehab in Arizona.”“Uh-huh.”“How was it?”“It was okay.”“Did it work?”“Not really. I drank for the next decade.”“Do you think the trauma is still affecting you?” I say.Though I learn a bit more about her life—that she smokes against the stress of living with her new boyfriend, occasionally has panic attacks, and frequently can’t sleep—I leave unsatisfied. And I think she does too. She doesn’t commit to quitting tobacco, dismisses the idea of a dietician with, “I’ve seen them before,” and refuses counseling, even if the counselor is waiting in the wings.Sometimes I leave a room with words of encouragement, something like, “You can do it, I know you can,” or, simply, “Take care.” It can be a bit paternalistic, I know, and today, in particular, such words would seem false. “My nurse will come in to take you to the lab,” I say. We don’t leave as friends, but we are polite.At the end of the day, a surgeon knows she’s changed the world. She commands the surgical field. “Scalpel,” she says. She cauterizes bleeders, hands off the appendix, and closes the case. What do I command beyond a steady income?Sometimes at dusk when I travel by foot down the dirt road overlooking the great flat valley where most of my patients live, I feel regret. I think that I should have spent my life creating something concrete, like bridges or movies. Maybe even now I should rekindle my dream of becoming a bigwig at the World Health Organization. As I descend from the crest line toward a grove of birch trees, I pull out my smart phone and take a sip of social media. “Chena!” I call, when a car rumbles up the slope. My golden retriever comes bounding up the road to sit by my feet until the danger is passed. I snap her picture and post it on the web.On these days, when I’m retracing my steps back up the hill between the birch, the dog again sniffing around in the alder, my phone now zipped away in my cargo pocket, I recognize my failures. I should have explored my patient’s successes, not only her deficits. I should have communed more and checked off boxes less. Cultural insight gleaned from past experience doesn’t substitute for a quiet mind, a refreshed body, and a curious heart. “Tell me about how you were able to quit alcohol,” I should have said. “Tell me about your hopes and dreams.” Maybe that simple reaching would have opened us into each other.But I also remind myself of the good I’ve done. I remember the elderly gold miner with the history of stroke who got his diabetes under control and the woman I diagnosed with primary biliary cirrhosis. I doubt any of the babies I’ve delivered would have died without my care. Even the new mother whose eyes dimmed with hemorrhage would likely have survived without me in specific. Someone else—any family doctor, midwife, or obstetrician—would have dug the clots out of her womb and cried, “Hemabate!” Maybe I’ve even made mistakes, both big and small, which have endangered human life. I know I have. But I hope that, for the most part, I have confirmed in my patients a sense of their own strength and value as human beings.And the other thing I say to myself now as I write within a hilltop of fallen leaves is this: I am that someone else. We’re all that someone else, aren’t we, whether we ascend to lofty positions or dig quietly in the valley? In primary care, most of our interventions are not determinate. We can only hope to shift the odds in the patient’s favor. Someday my little piece will make a difference, we say. We walk by faith, even while grounded in the scientific evidence. Maybe my moon-faced patient will knit socks for an uncle dying of lung cancer. He’ll pat her hand, and on her walk home, the heavens will conspire. Blue-green ribbons, the northern lights, will snake across the sky and, stopping by the river, she’ll look up. Something will shift, won’t it?She’ll fly into town and check in at the front desk. Probably I won’t be working the urgent care that day. She wouldn’t remember me, anyway. But perhaps a moment the two of us shared will join hands with other moments life brings, and those other moments will give meaning to ours. My faith is not blind: I’ve seen people heal. Some other doctor will enter the room, set her laptop down on the counter, and continue the journey.Some days we don’t feel it, do we—that lively pulse that called us to medicine? We don’t sense that fleshy compassion that inspired us. For whatever reason, we go home without a “story” to tell. But maybe it’s true that we together, imperfect doctor and impassive patient, laid down one plank on the bridge of trust. Can I be that someone else, that faceless doctor that asked the questions and listened, if not with welling heart, at least with the integrity of honest intent? Can I be that nameless man that played his part one cold autumn day? I pray that I am.     

Female Endurance Runners Have a Healthier Diet than Males—Results from the NURMI Study (Step 2)

Sex has been recognized to be an important indicator of physiological, psychological, and nutritional characteristics among endurance athletes. However, there are limited data addressing sex-based differences in dietary behaviors of distance runners. The aim of the present study is to explore the sex-specific differences in dietary intake of female and male distance runners competing at >10-km distances. From the initial number of 317 participants, 211 endurance runners (121 females and 90 males) were selected as the final sample after a multi-level data clearance. Participants were classified to race distance (10-km, half-marathon, marathon/ultra-marathon) and type of diet (omnivorous, vegetarian, vegan) subgroups. An online survey was conducted to collect data on sociodemographic information and dietary intake (using a comprehensive food frequency questionnaire with 53 food groups categorized in 14 basic and three umbrella food clusters). Compared to male runners, female runners had a significantly greater intake in four food clusters, including “beans and seeds”, “fruit and vegetables”, “dairy alternatives”, and “water”. Males reported higher intakes of seven food clusters, including “meat”, “fish”, “eggs”, “oils”, “grains”, “alcohol”, and “processed foods”. Generally, it can be suggested that female runners have a tendency to consume healthier foods than males. The predominance of females with healthy dietary behavior can be potentially linked to the well-known differences between females and males in health attitudes and lifestyle patterns.