Don’t you sometimes wonder why you could eat so many Krispy Kreme doughnuts, then some chocolate followed by ice cream and still feel like you could eat baklava and kunafah or even ma’soob?  Not that I actually do that, but I admit that I get the urge to do it once I start munching on some of those hearty sweets.  Who could blame us?  That stuff tastes really good!

It turns out tasty and delicious food, high in fat, could be as addictive as heroin!

You think I’m joking?  Not according to this recently published study in the Nature Neuroscience journal.  Here is what the abstract said:

“We found that development of obesity was coupled with emergence of a progressively worsening deficit in neural reward responses. Similar changes in reward homeostasis induced by cocaine or heroin are considered to be crucial in triggering the transition from casual to compulsive drug-taking. Accordingly, we detected compulsive-like feeding behavior in obese but not lean rats, measured as palatable food consumption that was resistant to disruption by an aversive conditioned stimulus. Striatal dopamine D2 receptors (D2Rs) were downregulated in obese rats, as has been reported in humans addicted to drugs. Moreover, lentivirus-mediated knockdown of striatal D2Rs rapidly accelerated the development of addiction-like reward deficits and the onset of compulsive-like food seeking in rats with extended access to palatable high-fat food. These data demonstrate that overconsumption of palatable food triggers addiction-like neuroadaptive responses in brain reward circuits and drives the development of compulsive eating. Common hedonic mechanisms may therefore underlie obesity and drug addiction.”

So in simple terms, when those rats ate high-fat foods they began suppressing or diminishing their reward pathways.  As a result, their regular amount of high-fat diet did not satisfy their hunger.  Rather, they had to eat more of the same in order to feel the pleasure of the food, similar to how people with addiction problems behave towards the addictive substances.  The study also showed that the high-fat foods caused neural changes, changes in the nervous system, in the brains of the rats similar to those changes occurring in humans with addiction problems.

There is still much to be done in order to explain these physiological reactions.  However, it is important to stress the fact that foods high in saturated fats and cholesterol are bad for our health.  We always have to impose moderation to our eating habits.  In addition, we need to keep physically active in order to burn any extra calories we consume.  So, enjoy your sweets and tasty meals, just eat reasonably and exercise plenty.

… the intended direction of the intervention.  CNN highlighted the details of this study in an editor’s choice video, and for the first time, it seems as though this may be a solution that may actually work.  33% of the kids who received the intervention engaged in sexual intercourse as opposed to 52% of the kids who received a safe sex lesson.  662 African American students in the 6th and 7th grades participated over a 24 month period.

Unlike the Just Say No to Drugs intervention, which seemed to magically increase the use of drugs amongst high school students in the United States, this abstinence (with a focus on life goals) program seems to actually work in addressing making behavioral choices that lead to more favorable consequences.

Personally, I have been in favor of a hybrid of the abstinence-only and safe sex discussions, which has been known as comprehensive sex education.  Comprehensive sex education, however, still carried this heavy safe sex message, so much that parents and faith-based groups could not see past the three-letter word in the middle.   This program, which leads with the more favorable term “abstinence” seems to do the trick while not leaving out factual information on ways to prevent sexually transmitted infections and unintended pregnancy.

The greatest disservice that we have created in this debate is the all or nothing approach – either you have sex or you don’t.  There are teenagers who are catching and spreading STIs unwittingly because they think just because they are not having vaginal intercourse they are not at risk.  A course like this allows facilitators to address abstinence, sex and everything in between.

The next step, however, is to see how this program works in other ethnic and socioeconomic  groups.  It would also be helpful to determine if there is an age, where these groups “catch up” in terms of sexual activity or if there is a cut-off age where these programs lose effectiveness.

A biopsy is the test that doctors do in order to determine if  a lump is cancerous or not.  Although, there were several presentations to illuminate the rationale for the Task Force recommendations, medical providers and outreach specialists alike decried the recommendations as irresponsible for women’s health.  In the end, Avon Foundation asserted that they will continue to follow the American Cancer Society guidelines, which have not changed with the Task Force recommendations, and provided other presentations by scientists in the field to illuminate the other side of the argument.

In a segment by Katie Couric, she highlights the various sides of the breast cancer screening guidelines argument.  See the video link from the Washington Post here.  She covers both the human component and the scientific basis for the guidelines.  She does a brief expose on a woman who receives a cancer diagnosis in her early 40s, almost 10 years younger than the guidelines deem is worthwhile for mammography screening.  The woman highlighted is a mother of two children, and her doctor credits her full recovery to the fact that she caught her breast cancer early in a routine mammography screening.

Couric briefly highlights what the Task Force says would only be a modest gain in lives saved if women continue to screen as they have for the last 20 years.  Her segment provides illustrations on what the Task Force is trying to demonstrate is excess – procedures that do not drastically improve the quality of public health.

In all, I found the segment making modest attempts to remain balanced, but it definitely provided the audience with the fuel to continue to feel justified in their outrage with the suggestions made by the Task Force, a team of medical doctors, insurance policy  analysts and medical administrators.

As a public health professional working directly with the community, it is exceptionally difficult to have a discussion concerning women’s health with just the numbers.  Every woman’s life counts.

Over the course of Avon’s national forum, the recurring and prevailing sentiment was that a biopsy could never be deemed “unnecessary” until it was determined that there was no breast cancer.  For the women who had found their breast cancers through screening mammography or breast self-exams and later biopsy, these tests were very necessary to save their lives.  Not one of them would call themselves statistically insignificant – all carry the worth of  human life, and all believe in their absolute right to obtain the necessary screening and procedures to preserve it.

SEP has been implemented in this country for more than twenty years and has helped in reducing the transmission of HIV and Hepatitis C. The way it works is very simple: Those who share needles, either to inject drugs or hormones can exchange their used needles for sterile ones.  This prevents users from sharing contaminated needles with one another thereby preventing the spread of HIV, Hepatitis C and other blood borne diseases . SEP is administered throughout the country including D.C. by hundreds of not-for-profit and community- based organizations. SEP has been proven to  cost-effective, effective in reducing transmission and overall rates of HIV and Hepatitis C and do not promote substance use/abuse. SEP also reduce the sharing of needles among users and encourage users to use sterile needles until they are ready to quit using.

more after the jump…

According to October 2007, AIDS Action policy Brief, syringe sharing was reduced by two thirds in Washington D.C in a study conducted among 2000 users in 1992. Additionally, according to a study conducted in 2005 by American Foundation for AIDS Research, the rate of new AIDS cases by Intravenous Drug Use dropped by 73% when compared to 52% drop in overall AIDS cases in D.C. Furthermore, CDC calculated that each syringe costs only $0.97 and successful implementation of SEP to prevent HIV infection in a person/family costs $4,000 – 12, 000. But lifetime medical costs of someone who is HIV positive is $619,000. According to Dec 2005 CDC fact sheet, many research studies and positive results led the National Institutes of Health Consensus Panel on HIV Prevention, to conclude that:

“An impressive body of evidence suggests powerful effects from needle exchange programs….Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs.”

Syringe Exchange Programs not only include exchanging needles, but most organizations provide a comprehensive harm reduction program that includes syringe exchange, counseling, HIV/STD testing, and information about sexual health and risky sexual behavior. While many organizations have one-for-one policy, where users can exchange only one sterile needle for one used needle, few other organizations do not have such a restriction thereby allowing users to take as many needles as they need in exchange for used needles.

In spite of overwhelming evidence in favor of SEP, and the support of such programs from government agencies such as  CDC, NIH etc…, many community-based organizations face problems locally from residents that have moral objections or restrictive policies put in place by governments.  In D.C. currently there are at least four organizations, which administer SEP: Prevention Works, Bread for the City, Family Medical Counseling Services and HIPS. Until recently these organizations were struggling to render their services which were restricted by 1000 feet ban. This ban which was in place for over 2 years prevented the SEPs from being implemented within a 1000 feet of any place where children gathered in the district. But the ban was lifted through the FY 2010 appropriations bill in Congress. Additionally President Obama also lifted a ban of federal dollars from being used for SEP. While these policies are a step in the right direction to address the HIV/AIDS epidemic in the district, President Obama’s recent announcement of spending freeze for three years on non-defense discretionary spending might jeopardize community-based organizations that receive any federal funding for SEP. Thus it is not only important to have good science and evidence for successful implementation of a harm-reduction program, but it is also essential that such evidence is supported with smart policies in local, state and federal level.

The Obama Administration is proposing to spend $286 million in 2011 on comparative effectiveness research (CER) according to Carey and Appleby of the Kaiser Family Foundation. The topic of comparative effectiveness has been often picked up by the media in light of healthcare reform, since it has been identified as one tool to reduce healthcare spending. The Department of Health and Human Services (HHS) has defined comparative effectiveness as:

The conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.

Much has been written in the last decade on comparative effectiveness, but policy and government have not made a concerted effort to fund it or put it to use. That isn’t to say there haven’t been attempts going back all the way to the 1970’s, with the Congressional Office of Technology Assessment. The last big push was the Agency Health Care Policy & Research (AHCPR) Clinical Guidelines effort.   This agency is now known as the Agency for Healthcare Research and Quality (AHRQ) and has been identified as the institution that would administer the funds.

We need to be concerned with this as healthcare spending has an increasingly large share of our Gross Domestic Product (GDP). For example, in 2007, healthcare spending commanded about 17% of the GDP according to the Congressional Budget Office. It is predicted to rise to 25% in 2025 if no changes are made to our healthcare system. Comparative effectiveness research has been repeatedly suggested as one way of controlling healthcare costs. Often, this phenomenon of reducing healthcare costs in comparison to our productivity has been termed “bending the curve”.

According to the New York Times’ Barry Meier, critics of funding comparative effectiveness say , that it will lead to rationing healthcare. One group critical of the effort is Partnership to Improve Patient Care as it feels that the use of CER will lead to a “one-size-fits-all” approach to healthcare. For that reason, proponents of CER have refashioned the terminology for the practice as “patient-centered health research” in an attempt to shift the semantics of the topic.

Within a year’s time, it will be interesting to see where the U.S. is with comparative effectiveness research. Surely, there will be more data on its applicability to controlling healthcare costs.

You probably recall several recent recalls of beef, implemented by the USDA’s Food Safety and Inspection Service (FSIS). In fact, the FSIS indicates there have already been 2 this year totaling over 865,000 pounds of recalled meat due to E. coli O157:H7 contamination, and we’re not even through the 7th week of 2010 yet! This is hardly a new problem.  In 2008 in one recall alone, 143 million pounds of beef was recalled according to a CNN article. In recent years, you might remember other recalls for a variety of food, including green onions, hot peppers and peanut butter due to a variety of contaminants, such as E.coli, Listeria and Salmonella. Of course, this was after they made people severely ill. CDC reports that each year about 5,000 Americans die from foodborne illness.

Don’t you think the death of 5,000 people per year on account of contaminated food  is excessive? Some would cite our federal regulatory agencies as having something to do with the problem.

The USDA is responsible for the consumer safety of meat, poultry and related products.  The Food and Drug Administration (FDA) regulates fruits and vegetables, as well as food packaging, labeling, and medicine and food supplements for humans as well as veterinary medicine for treating livestock. Industry is closely invested in regulation efforts by USDA. Did you know that the beef industry, via the National Cattlemen’s Beef Association (NCBA) has close ties to it? For example, a former USDA director was a large-scale pig farmer according to Food Politics by Marion Nestle. Another top USDA official,  Ann Veneman, was a former NCBA lobbyist according to the Leiter Reports blog, which further posits that there was inside influence to more loosely regulate food industry.

Finances also play a major role in the regulation of our food:  Agriculture IS big business. The Center for Responsive Politics reported that in 2008, the agricultural industry donated over $143,000,000 to federal political campaigns, with the majority of that funding going to the Republican party. Over $2,000,000 of that came from the livestock industry, the largest portion coming from the National Cattlemen’s Association.

In light of all of the food-borne illness stories making it to the papers in recent years, citizens have organized to ensure that the food industry is more responsible in ensuring that food is more safe for consumption. The Food Safety Modernization Act of 2009 resulted largely from that effort. This act attempts to improve the ability to expect that our food supplies will be safe for ingestion by emphasizing prevention and shifting some of the responsibilities to agribusiness.  Though the bill is still in legislation, it has been roundly espoused from within and without the food industry. Consumer groups such as Consumers Union and the Center for Science in the Public Interest have been especially vocal about improving food safety.  In light of all of the illness and lost productivity brought by contaminated food, it’s hopeful that this bill becomes law.

 In April 2006, the Washington Post published an article titled “Prophylactic Measures” that highlighted the inaccessibility of condoms in CVS stores” within these neighborhoods in DC. “At the end of 2007, DC Department of Health (see page 18) released a report that there were a total of 15,120 people living with HIV/AIDS in the District, accounting for about 3% of all District residents.”In that same report, it was noted that the leading modes of transmission of HIV/AIDS in DC are through men who have sex with men and heterosexual contact, 37% and 28% respectively.

Man Overboard

While there are many dimensions to decreasing the burden of HIV/AIDS in DC, one component to prevention is eliminating barriers. In this scenario, eliminating barriers involves making sure condoms are both available and accessible.

• Availability refers to condoms being in stock or in inventory.
• Accessibility refers to the ease by which condoms are easily obtained. For instance, some condoms are in locked cases that require the use of a store clerk to unlock. In this example, limited accessibility increases the probability that customers may feel embarrassed to purchase condoms if they are “locked.”

Where are the life guards?

So, who are the key players in making sure condoms are available and accessible?  While we all are accountable for the public health of our communities, it is CVS’s national headquarters that can play a vital role in exercising good public policy while being a good corporate citizen. Consequently, last year CVS wrote a letter to the DC City Council stating they would no longer make condoms inaccessible. On behalf of the Council, graduate students at George Washington University are evaluating the compliance of CVS policies. Stay tuned for the results of this evaluation…

• Infants who are exposed to secondhand smoke are more likely to die of SIDS (Sudden Infant Death Syndrome) compared with infants who are not exposed.
•  Children who are exposed to secondhand smoke are at increased risk for bronchitis, pneumonia, ear infections, severe asthma, respiratory symptoms, and slowed lung growth.

In my experience, as a research assistant in a randomized-controlled study in a inner city obstetrics clinic in Washington, DC, I learned that while many pregnant women may not know all the risks of second-hand exposure they do know smoking in general is unhealthy. Preliminary results show that of the women given an education intervention, many women considered second-hand smoke exposure during pregnancy of high importance. However, the women’s ability to be confident in avoiding second-hand smoke exposure was more varied.  Some of this variance can be attributed to an expectant mother living’s arrangements and the habits of the people who she keeps company with. Helping mothers to understand the risks and take a stand against secondhand tobacco exposure can be challenging especially if they live with someone who smokes be it a boyfriend, husband, or even grandparent. Being able to negotiate with family members is critical to the health of a newborn or infant. The mother must think of her child first and weigh the costs even if it means alternative living arrangements.

In my opinion, there needs to be a paradigm shift about smoking in front of pregnant women and children. Mothers should be informed and be able to explain the risk to family members. Mothers should ask family members, especially the ones they live with, to smoke outside of the house because smoking inside tends to remain inside materials like fibers of a sofa. This is an example of indirect tobacco exposure over an extended time. Additionally, mothers must advocate for loved ones to wash their hands before any interaction with the baby because of the risk of second-hand exposure is present. Mothers should encourage and support loved ones who they know are trying to quit smoking.

Last but not least, the burden of responsibility should not be all on mothers but also on the public health community to do a better job at social marketing by developing a campaign for this specific population of pregnant women and their children. Public health educators can also support tobacco free homes and legislation that would prevent individuals from smoking in public places. Additionally, doctors can provide counseling and/ or referrals for fathers or family members who would like to stop smoking. However, it is important to keep in mind nicotine is very addictive and so patience is needed to be able to wean smokers off of tobacco. With these positive changes, I believe the days of miscarriages and low birth weight and premature infants as a result of tobacco exposure will be numbered.

The influence commercial food ads have on children was discussed in Oslo, Norway in 2006 by experts from the WHO, agreeing that,

WHO should support national actions to substantially reduce the volume and impact of commercial promotion of energy-dense,micronutrient-poor food and beverages to children; and consider the development of an international code on the marketing of food and beverages to children to address issues such as cross-border television advertising and global promotional activities, and to protect children in countries where national action has not been fully implemented.

After the WHO proposed that countries limit “junk food” ads aimed at children (one solution), the Bush administration claimed that there was insufficient proof that advertising causes obesity and did not take any action.  While not a priority of the Bush Administration, the issue of childhood obesity was likely to resurface under a future administration that would likely deal with expected higher rates of childhood overweight and obesity. 

Fast-food Ad Exposure Among U.S. Children

Children in the United States watch 3 hours of television on average daily, which is greater than the recommended time advised by the American Academy of Pediatrics of 1 to 2 hours.   American kids will see an average of nine minutes and 14 seconds of commercial advertisements per hour while watching Nickelodeon and the Cartoon Network between 8 a.m. and 1 p.m. on a Saturday morning.  The length of commercial time during children’s programming was limited to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays by the Children’s Television Act of 1990, currently still in effect. The number of television advertisements viewed by children, on average, has risen from 20,000 to 40,000 per year between the late 1970s to late 1990s, which means that children in the U.S. watch more ads than children in several industrialized countries. The above study data do not specify childrens’ ages, therefore it is assumed children of all ages are excessively exposed to television ads.

Why WHO Guidelines Aren’t Being Followed in the U.S.

An argument raised often by the fast-food industry in defense of fast-food ads is their right to commercial speech, protected in the U.S. by the First Amendment.  As part of a four-step analysis, the U.S. Supreme Court must determine if the “asserted governmental interest is substantial” before deciding to restrict product advertising.  Implementation of the WHO guidelines is not possible until a successful argument can be made that it is in the government’s best interest to limit fast-food ads.  This perhaps requires even stronger, clearer scientific evidence that fast-food ads cause obesity or that regulation of fast-food television ads is associated with lower childhood obesity rates.  Additionally, there is less likelihood of Supreme Court challenges to marketing regulation since 24 states have passed liability-clearing laws, which prevent individuals from suing fast-food companies claiming damages based on consumption of products.  Legal feasibility was a major barrier to implementation during the Bush Administration, which argued the evidence was unconvincing that fast-food ads cause obesity, and therefore asserted limited governmental interest.  Under the current or a future administration, however, this may change.

The Federal Trade Commission originally had the authority to regulate fast-food ads on television but over the years this has changed.  In 1978, the U.S. Federal Trade Commission (FTC) proposed a ban on television ads to children under 8 and ads of sugary foods to children 8-11 years old. The FTC argued that such ads were “unfair” since they targeted children who could not fully comprehend their persuasive intent, and used their authority under the FTC Act to prohibit them. Congress, under extreme lobbying pressure from the food industry, decided to remove the FTC’s authority to judge if such ads were “unfair.”   However, the FTC retained the authority to determine if ad practices are “deceptive.” The Federal Communications Commission (FCC) also shares the role of regulating food ads with the FTC.   Meanwhile, the more dominant authority on commercial food ad regulation is the Children’s Advertising Review Unit (CARU), made up in part by food industry leaders. This is a self-regulating group, in which the industry pledges to be responsible for regulation of their own ads.  The lack of a strong, unified and bias-free governing authority on regulation will make it difficult to implement WHO recommendations on “junk food” marketing practices. 

Other Solutions

Alternative and/or complimentary solutions besides adopting the WHO guidelines in the U.S. are 1) getting the current government involved in food marketing reduction to children in order to reestablish centralized authority to the FTC in decision-making on the issue, or 2) involving the First Lady in a campaign to reduce junk food ads on television, as well as reduce the number of hours children spend watching television.  The latter is somewhat feasible since Michelle Obama has already spearheaded a campaign tackling childhood obesity in America.  It seems possible that in the next several years, especially if Obama is reelected, that the First Lady can lead a successful effort to reduce the volume of junk food ads on television. 

Instead of watching ten ads for McDonald’s or Burger King on television each day, hopefully within the near future, kids will be watching more ads for nutrition, fitness, and overall wellness.  Such a small change could lead to their choosing different diets as adults and reduce the rates of childhood and adult obesity in America.