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The new AJPM blog is a forum for professional discussion of the issues raised in the articles we publish and in selected perspective we solicit from leading authorities in prevention, public and population health.
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TF: Thanks for taking this impromptu call, but I needed to get a few things off my chest. You can imagine my schedule, what with all the dimes under the pillows and whatnot, and a lot of other responsibilities and issues that demand my attention.
AJPM: Such as?
TF: Access to oral health, disease and injury prevention, and the link between oral health and general health are my top priorities right now. It’s really keeping my policy wonks busy. And don’t get me started about oral health literacy or those fruitcakes still arguing about fluoridation. You saw what happened in Portland, Oregon in May? That’s the fourth time they’ve rejected community water fluoridation since 1956, and each time they get the science wrong. It’s making me crazy.
AJPM: Yes, Portland’s regular rejection of an evidence-based public health measure is a bit puzzling, but they are known for their eccentricities.
TF: Eccentricities, my pouch of dimes! Of the 30 largest cities in the U.S., Portland is the only one that doesn’t fluoridate its drinking water to help prevent tooth decay!
By the way, did you see the latest study on fluoridation in the Journal of Dental Research? Good stuff. Don’t forget that the CDC calls fluoridation one of the 10 great public health achievements of the 20th century, and it’s endorsed by the biggies like the AMA and the WHO. What more do those fact-free thinkers in Portland need?
And speaking of the CDC, what’s with states not developing Oral Health Plans? 18 states have no plan! This also is making me crazy. Washington, DC is among those without a plan, which doesn’t surprise me, but what’s up with the rest? Pathetic. Get with the program! The CDC can help, so there’s really no excuse. And remember, more young children suffer from tooth decay than from any other chronic condition, including asthma.
AJPM: Good point. You mentioned access to oral health. What does this mean in practical terms?
TF: It’s simple to say, harder to do; kids, teenagers, adults, and seniors can find and see a dentist when they need to, and everyone can afford it. That means enough dentists relative to the population, and a way for poor folks to pay for dental services.
Poverty is no fun, and to add to the misery financially strapped families, for a bunch of reasons, have higher rates of tooth decay. I don’t want to bore you with statistics, but close to one in four kids living in poverty have untreated decay, as do 42% adults aged 20–64, and the occurrence of untreated decay is nearly three times greater among adults aged 65 and over living in poverty. So far, too many publicly funded programs don’t cover oral health care for adults with low incomes.
It’s probably news to you that more than one-third of older adults aged 65–74 living below the federal poverty level are without teeth. Any idea what that means? Poor chewing efficiency can limit food choices and diminish the pleasures of eating. Being without teeth might also change your physical appearance and even affect speech. Folks report oral pain, food avoidance, and self-consciousness or embarrassment because of their mouth, teeth, or dentures. Social contact and intimacy can be restricted and your self-esteem can take a nosedive. In a nutshell, your quality of life suffers.
TF: That’s not all. The medical, functional, emotional, and social consequences of oral health makes it an important contributor to overall health for individuals and the population. To take just one example, tooth loss among older people has been shown to be associated with both weight loss and obesity—often as a result of avoiding some foods and eating easier-to-chew junk food. Appropriate oral treatment would not only enhance quality of life but also encourage healthier eating patterns that could result in improved long-term health.
While on my soap box, I’ll argue that oral health must be better integrated into medical care. People reporting poor health are significantly more likely to have multiple chronic conditions (including oral health problems), but because these folks are more likely to visit a physician than a dentist, it’s important that clinicians recognize common oral conditions and risk factors, and refer the patient for subsequent treatment. Oral health care must be regarded as a specialty like cardiology, neurology, or internal medicine, rather than distal to general health.
Which reminds me, when are those health literacy people going to address jargon like “dental caries” and “edentulous” when they mean tooth decay and no teeth? It’s enough to bring back my bruxism. I must remember to send a stern memo to the IOM.
AJPM: Thanks very much Tooth Fairy for sharing your thoughts, and keep up the good work.
— Michael Lytton, AJPM Blog Editor
Dye BA, Li X, Beltrán-Aguilar ED. Selected Oral Health Indicators in the United States, 2005–2008. NCHS data brief 96. 2012.
Dye BA, Li X, Thornton-Evans G. Oral Health Disparities as Determined by Selected Healthy People 2020 Oral Health Objectives for the United States, 2009–2010. NCHS data brief 104. 2012.
Lin M, Sappenfield W, Hernandez L, Clark C, Liu J, Collins J, Carle AC. Child- and State-Level Characteristics Associated with Preventive Dental Care Access Among U.S. Children 5–17 Years of Age. Matern Child Health J 2012;16 (Suppl 2):320–9.
Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. Burden of Oral Disease Among Older Adults and Implications for Public Health Priorities. Am J Public Health 2012:102(3):411–418.
Malvitz DM, Barker LK, Phipps KR. Development and Status of the National Oral Health Surveillance System. Preventing Chronic Disease 2009;6(2).
Selwitz RH, Ismail AI, Pitts NB. Dental Caries. Lancet 2007;369(9555):51–9.
Bader JD, Rozier RF, Lohr KN, Frame PS. Physicians’ Roles in Preventing Dental Caries in Preschool Children: A Summary of the Evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2004;26(4):315–25.
Truman BI, Gooch BC, Evans CA, Jr. The Guide to Community Preventive Services: Oral Health. Am J Prev Med 2002;23(1 Suppl 1):1–2.
Treadwell H, Ro M. Community-Based Oral Health Prevention: Issues and Opportunities. Am J Prev Med 2002;23(1 Suppl):8–12.
Stavisky J, Bailit H. The Robert Wood Johnson Foundation’s Response to Improving the Nation’s Oral Health. Am J Prev Med 2002;23(1 Suppl):13–15.
Recently the IOM Roundtable on Health Literacy convened a workshop titled Implications of Health Literacy for Public Health, which included a presentation on a San Francisco program in which youth speak to youth about diabetes. The Bigger Picture Campaign is an anti-diabetes multimedia project; a collaboration between the UCSF Center for Vulnerable Populations and Youth Speaks, the leading nonprofit presenter of spoken-word performance, education, and youth development programs in the country.
The campaign is designed to raise awareness about the social and environmental factors that have led to the explosive rise of type-2 diabetes in California. Its health literacy innovations include peer-to-peer communication, high-quality video public service announcements, eloquence and poetry, and frank messages about the social determinants of health. Check it out here, and if you have time to watch only one of the public service announcements, make it “Health Justice Manifesto,” a compelling wakeup call. The lack of healthy food choices and opportunities for physical activity in poor communities are key messages.
In addition to producing 11 public service announcements that are available on the Web, there have been 15 school assemblies, and the development of an educators’ toolkit, a free resource for educators and students to learn more about type 2 diabetes.
The plan is to take the program statewide in California, starting with such high priority areas (with large underserved communities) as Stockton, Richmond, and the Inland Empire, and eventually introduce it across the country. The presentations are potent, but to reach a wide audience, school administrators, nurses, wellness coordinators, and teachers must ensure that students have the opportunity to see and hear the campaign messages.
Last week the IOM conducted another workshop, this one for the Roundtable on Population Health Improvement and the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities. The daylong meeting examined the history and sociology of social change movements, with an aim to identify key elements of a theoretical and practical framework for movement building. This fundamentally political agenda is consistent with the San Francisco awareness program that also wants to change people’s thinking and priorities. And both workshops fit within the contextual bigger picture of social determinants of health.
Whether past social movements have relevant lessons to current population health crises or if information, no matter how it is packaged and delivered, is sufficient to mobilize effective action against broad social determinants of illness are issues for debate. Richard Carmona, the 17th Surgeon General of the U.S., describes the ‘trauma of politics’ in this country and issues a stern warning. “As Surgeon General I also realized that most of the disease and economic burden we incurred as a nation were preventable, but that the trauma of politics was a confounding variable that prevented us from addressing many of the issues in a timely, nonpartisan, evidence-based, scientifically driven manner.”
Can we acknowledge this part of the bigger picture, and if so do anything about it? Eventually. Maybe.
— Michael Lytton, AJPM Blog Editor
Further Reading in AJPM:
Carmona R. The Trauma of Politics: A Surgeon General’s Perspective. Am J Prev Med 2013;45(6):742–4.
Moulton AD, Albright AL, Gregg EW, Goodman RA. Law, Public Health, and the Diabetes Epidemic. Am J Prev Med 2013;45(4):486–93.
Ramirez AG, Ayala GX. Addressing Latino Childhood Obesity Through Research and Policy: Findings from the Salud America! Experience. Am J Prev Med 2013;44(3 Suppl):S173–296.
Kraak VI, Story , Wartella EA. Government and School Progress to Promote a Healthful Diet to American Children and Adolescents: A Comprehensive Review of the Available Evidence. AM J Prev Med 2012;42(3):250–262.
Kraak VI, Story M, Wartella EA, Ginter J. Industry Progress to Market a Healthful Diet to American Children and Adolescents. Am J Prev Med 2011;41(3):322–33.
A catastrophe on the scale of the Philippines typhoon focuses critical attention on the susceptibility of poor and vulnerable populations to natural disasters. Yet, it is no less important to remember that poor and vulnerable populations, particularly children, are susceptible to shocks and health risks on a regular basis wherever they live.
In the late 1990s, Vincent Felitti and Robert Anda conducted a landmark study that examined the effects of adverse childhood experiences (ACEs)—including abuse, neglect, domestic violence, and family dysfunction—and found a persuasive connection between the level of adversity faced and the incidence of many health and social problems. The first article from the Adverse Childhood Experiences (ACE) Study was published in AJPM in 1998. It struck a deep chord and has been one of the most cited papers and requested full-text articles from the Journal in the past 15 years.
More recent articles by the authors include: Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences (2010), and Adverse Childhood Experiences and the Risk of Premature Mortality (2009).
There is now a collective body of evidence suggesting that childhood traumatic stressors (“toxic stress” is the term used at the Center on the Developing Child at Harvard University) represent a common pathway to a variety of long-term behavioral, health, and social problems. There is growing acceptance that childhood abuse and other adverse childhood experiences are overlapping risk factors for long-term adult health problems and that the accumulation of these adverse experiences increases the risk of poor adult health.
Social determinants such as neighborhood economic distress and disadvantage, housing inadequacy, low social capital, poverty, low parental education, and lack of social support are all associated with child maltreatment. Community adversity alone exerts a persistent influence through a sequence of adverse social, behavioral, and psychological experiences (a chain of insults) that in turn contribute to adverse health outcomes.
Extensive biological and developmental research also shows that significant neglect—the ongoing disruption or significant absence of caregiver responsiveness—can cause more harm to a young child’s development than overt physical abuse. The consequences include subsequent cognitive delays, impairments in executive functioning, and disruptions of the body’s stress response.
And traumatic experiences in early life can not only leave emotional scars and developmental impairment, they appear to leave a genetic mark as well. Children who are physically abused and bullied tend to have shorter telomeres—structures at the tips of chromosomes whose shrinkage has been linked to aging and disease. Researchers have found associations between stress and accelerated telomere loss, and shortened telomeres correlate with several health problems, including diabetes, dementia, and fatigue. The findings are suggestive, but much more work needs to be done.
That children need to be protected is unarguable, but how to do so is open to debate. Britain and the United States are taking very different paths, a topic that I will explore in the next blog.
— Michael Lytton, AJPM Blog Editor
The CDC, WHO, and the UN Road Safety Collaboration encourage governments and nongovernmental organizations worldwide to commemorate November 17, 2013, as the World Day of Remembrance of Road Traffic Victims. The aim is to draw the public’s attention to motor vehicle crashes, their consequences and costs, and prevention measures. Automobiles, in their capacity to kill and injure, their resource depletion and emissions, their dominion over our landscapes, and their exclusion of healthier forms of transportation are surely among the most dangerous things ever produced by the human imagination.
Road crashes kill nearly 3,500 people each day and injure or disable 50 million each year around the world. Road traffic crashes are the leading cause of death among people aged 10–24 years worldwide and the leading cause of death among those in the first three decades of life in the U.S.
On November 14, just in time for the Day of Remembrance of Road Traffic Victims, the National Highway Traffic Safety Administration (NHTSA) released its Fatality Analysis Reporting System data. In 2012, 33,561 people died in motor vehicle crashes in the U.S., and another 2.36 million (estimated) were injured. These figures represent 3.3% more deaths than in 2011—the first increase in fatalities since 2005—and 6.5% more injuries, the first statistically significant increase since 1995.
For decades males have consistently comprised about 70% of motor vehicle fatalities. And in 2012 there were 10 times (1,858 versus 178) as many unhelmeted motorcyclist fatalities in states without universal helmet laws. No surprises in either case.
Of victims not in motor vehicles, fatalities among pedestrians increased for the third consecutive year, up 6.4% over 2011, while pedal cyclist fatalities increased by 6.5%. Between 2003 and 2012, the proportion of non-occupant fatalities has grown from 13% to 17%, with data showing that the large majority of pedestrian deaths occur in urban areas, at non-intersections, at night, and many involve alcohol.
Coincidentally, the NHTSA just released a report, 2012 National Survey of Bicyclist and Pedestrian Attitudes and Behavior. The survey is a status report on attitudes, knowledge, and behavior related to outdoor walking and bicycling. It updates national telephone survey data collected by NHTSA in 2002, and addressed safety and mobility issues, obtained trip information, and explored perceptions and use of public facilities such as sidewalks, bicycle lanes, and bicycle paths. It was administered to a probability-based sample of randomly selected people 16 and older.
When asked whether they felt threatened for their personal safety while riding a bicycle on their most recent travel day, 12% of respondents said that they felt threatened at some point on their ride. In terms of how their community was designed for bike riding safety, 27% of cyclists reported they were dissatisfied.
Similarly, when pedestrians were asked whether they felt threatened for their personal safety during the most recent day they had walked outside, 8% reported that they had. And 18% of respondents were somewhat or very dissatisfied with the design of their community for walking purposes.
In the face of such carnage and anxiety, information is made available. The NHTSA offers the 388-page report, Countermeasures That Work: A Highway Safety Countermeasures Guide for State Highway Safety Offices, 7th edition. The CDC has its Guide to Community Preventive Services, a free website resource to help you choose programs and policies to improve health and prevent disease in your community. Motor vehicle injury prevention is one of the 22 health topics on the site.
There is also the Day of Remembrance. It serves an important purpose because:
- it draws attention to the devastation caused and calls for government action
- it creates a link between road victims throughout the world
- lack of information about this catastrophe provokes social indifference
- the number of people killed and injured on the road represents the largest human-made disaster
- modern societies tolerate enormous numbers of victims of wholly preventable technical risks, and
- we remember lost lives and evoke the names of real people, who deserved to be alive today, to have fulfilled their dreams.
British poet Heathcote Williams gets the final word.
Seventeen million dead,
More than twice the number in the death-camps,
Eighteen times the count in Korea.
A hundred and thirty times the kill at Hiroshima,
Eight thousand five hundred Ulsters…
The Hundred Years war in a week.
The crusades in under thirty seconds.
A humdrum holocaust…the third world war nobody bothered to declare.
— Michael Lytton, AJPM Blog Editor
Further Reading in AJPM:
Vladutiu CJ, Marshall SW, Poole C, Casteel C, Menard MK, Weiss HB. Adverse Pregnancy Outcomes Following Motor Vehicle Crashes Am J Prev Med 2013;45(5):629–36.
Schlotthauer AE, Guse CE, Brixey S, Corden TE, Hargarten SW, Layde PM. Motor Vehicle Crashes Associated with Alcohol: Child Passenger Injury and Restraint Use, Am J Prev Med 2011;40(3):320–3.
Elder RW, Voas R, Beirness D, et al. Effectiveness of Ignition Interlocks for Preventing Alcohol-Impaired Driving and Alcohol-Related Crashes: A Community Guide Systematic Review, Am J Prev Med 2011;40(3):362–76.
Task Force on Community Preventive Services. Recommendations on the Effectiveness of Ignition Interlocks for Preventing Alcohol-Impaired Driving and Alcohol-Related Crashes, Am J Prev Med 2011;40(3): 377.
Krahl PL, Jankosky CL, Thomas RJ, Hooper TI, Systematic Review of Military Motor Vehicle Crash–Related Injuries, Am J Prev Med 2010;38(1 Suppl):S189-96.
Hall AJ, Bixler D, Helmkamp JC, Kraner JC, Kaplan JA. Fatal All-Terrain Vehicle Crashes: Injury Types and Alcohol Use, Am J Prev Med 2009;36(4):311–6.
Richter ED, Friedman LS, Berman T, Rivkind A. Death and Injury from Motor Vehicle Crashes: A Tale of Two Countries. Am J Prev Med 2005;29(5):440–9.
Elder RW, Shults RA, Sleet DA, et al. Effectiveness of Mass Media Campaigns for Reducing Drinking and Driving and Alcohol-Involved Crashes: A Systematic Review, Am J Prev Med 2004;27(1):57–65.
Rivara FP, MacKenzie EJ. Systematic Reviews of Strategies to Prevent Motor Vehicle Injuries. Am J Prev Med 1999;16(1 Suppl):S1–89.
Williams AF, Ctalano RF, Mayhew DR, Millstein SG, Shultz RA, Williams AF (editors). Teen Driving and Adolescent Health: New Strategies for Prevention. Am J Prev Med 2008;35(3 Suppl):S253–346.
Zaza S, Thompson RS (editors). Reducing Injuries to Motor Vehicle Occupants: Systematic Reviews of Evidence, Recommendations from the Task Force on Community Preventive Services, and Expert Commentary. Am J Prev Med 2001;21(4 Suppl):1–90.
In addition to a variety of other diabetes awareness efforts, the CDC Division of Diabetes Translation recognizes November 14 as World Diabetes Day.
Diabetes is the seventh leading cause of death in the U.S., and there are 371 million people living with diabetes worldwide. Another 280 million are at high risk of developing the disease. By 2030, half a billion people are expected to be living with diabetes.
The good news is that type 2 diabetes can be prevented or delayed. A number of studies have shown that people at increased risk of developing type 2 diabetes can significantly reduce their risk of developing the disease by making modest lifestyle changes including:
- Losing 5–7 percent of your body weight.
- Getting 150 minutes of physical activity per week.
- Eating a balanced diet, including fruits and vegetables.
— Michael Lytton, AJPM Blog Editor