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Chronic disease prevention: public health potential and research needs.

This paper, arising out of an event to honour the statistical and scientific contributions of Professor Peter Armitage, is concerned with research strategies and needs for chronic disease prevention. A few highlights from recent intervention trials for the prevention of cancer, cardiovascular disease, fractures and diabetes is provided, along with a discussion of some settings where intervention trial results seem discrepant with a body of preceding observational data. This background is used to identify research strategies and infrastructure needs for moving this vitally important research area forward, for both chemoprevention and lifestyle modification interventions.

Cardiovascular Diseases↗

Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases.

OBJECTIVES: This study examined the relationships between wealth and income and selected racial and ethnic differences in health. METHODS: Cross-sectional data on a national sample of 9744 men and women aged 51 through 61 from the 1992 Health and Retirement Survey were analyzed to examine the association between socioeconomic status and racial and ethnic differences in functional status among those with hypertension, diabetes, a heart condition, and arthritis. RESULTS: Compared with Whites, African Americans report higher rates of hypertension, diabetes, and arthritis, while Hispanics report higher rates of hypertension and diabetes and a lower rate of heart conditions. Accounting for differences in education, income, and wealth had little effect on these prevalence differences. In general, among those with chronic diseases, African Americans and Hispanics reported worse function than Whites. This disadvantage was eliminated in every case by controlling for socioeconomic status. CONCLUSIONS: While socioeconomic status, including wealth, accounts for much of the difference in functional status associated with these chronic diseases. It plays a relatively small role in explaining differences in the prevalence of chronic disease, possibly reflecting different causal pathways.

Black or African American↗

Using an Internet comanagement module to improve the quality of chronic disease care.

BACKGROUND: Web-based applications have the potential to support the ongoing care needs of patients with chronic disease. At the University of Washington, a diabetes care module was developed, and the feasibility of allowing patients with type 2 diabetes to comanage their disease from home was pilot tested. METHODS: The disease management module consisted of five Web sites that enabled patients to access their electronic medical records; upload blood glucose readings; enter medication, nutrition, and exercise data into an online diary; communicate with providers by using clinical e-mail; and browse an education site with endorsed content. All data could be viewed by patients and providers in online trended displays that a nurse practitioner case manager used to review cases weekly. RESULTS: "Proof-of-concept" was demonstrated by the three pilot participants who were the module's most active users. For example, one newly diagnosed patient was started on an oral hypoglycemic, underwent two upward dose adjustments, and achieved control (glycohemoglobin [HbA1c] from 8.0% to 6.1%). His treatment was conducted by exchanging 14 e-mails based on the 231 glucose-meter readings sent from home without requiring in-person follow-up visits. CONCLUSIONS: The Internet offers the opportunity to involve patients and providers in collaborative management of chronic diseases between office visits.

Adult↗

Survival of neural precursor cells in growth factor-poor environment: implications for transplantation in chronic disease.

A key issue for therapeutic neural stem cell transplantation in chronic diseases is the long-term survival of transplanted cells in the brain. The normal adult central nervous system does not support the survival of transplanted cells. Presumably, the limited availability of trophic factors maintains the survival of resident cells but is insufficient for supporting the survival of transplanted cells. Specifically, in multiple sclerosis, a chronic relapsing disease, it would be necessary to maintain long-term survival of transplanted cells through phases of relapses and remissions. It may be beneficial to transplant cells as early as possible, in a form that will keep their survival independent of tissue support and ready for immediate mobilization upon tissue demand during disease relapse. In the present study, we examined whether, in the form of neurospheres, multipotential neural precursor cells (NPCs) survive in a growth factor-poor environment while maintaining their potential to respond to environmental cues. We found that after removal of growth factors from the culture medium of neurospheres in vitro, NPC proliferation decreased significantly, but most cells survived for a prolonged time and maintained their stem cell characteristics. After re-exposure to growth factors, neurosphere cells resumed proliferation and could differentiate along neural lineages. Furthermore, neurospheres, but not single NPCs, that were transplanted into the brain ventricles of intact animals survived within the ventricles for at least a month and responded to induction of experimental autoimmune encephalomyelitis and brain inflammation by extensive migration into the brain white matter and differentiated into glial lineage cells.

Animals↗

Total body protein in chronic diseases and in aging.

Substantial losses of total body protein (TBP) can occur in chronic diseases and in aging. Such losses impact negatively on immunity and quality of life, and on growth rates in children. Direct measurements of total body nitrogen (TBN) monitor the integrated changes in TBP over time and allow comparison with normal subjects. TBN assessment via neutron capture analysis is therefore the gold-standard method of TBP estimation, so that risk factors for protein deficit can be identified and patient management optimized. The nitrogen index (NI) can be used to predict prognostic outcome: an NI < 0.9 is associated with substantial wasting in HIV disease, an NI < 0.8 predicts significant pathophysiology in chronic renal failure, and a low NI is predictive of neutropenia in breast-cancer patients. These findings emphasize the central importance of adequate protein stores in recovery from disease or in maintaining quality of life. Aging appears to involve a gradual loss of TBP throughout adulthood. Cross-sectional data suggest that TBP declines curvilinearly with age, such that there is an accelerated decline after 65 years of age. However, longitudinal data are scarce, and little is known about the relative loss of visceral protein, as opposed to skeletal muscle protein. More clearly-defined data are essential if the effects of aging per se are to be separated from the effects of chronic disease. A further complication is the knowledge that physical activity also declines with age. Thus sarcopenia, the loss of skeletal muscle mass, could primarily result from disuse rather than aging. The economic impact of unsuccessful aging places a pressing need for multicompartment data in longitudinal study designs.

Adult↗

Uneven dietary development: linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases.

In a "nutrition transition", the consumption of foods high in fats and sweeteners is increasing throughout the developing world. The transition, implicated in the rapid rise of obesity and diet-related chronic diseases worldwide, is rooted in the processes of globalization. Globalization affects the nature of agri-food systems, thereby altering the quantity, type, cost and desirability of foods available for consumption. Understanding the links between globalization and the nutrition transition is therefore necessary to help policy makers develop policies, including food policies, for addressing the global burden of chronic disease. While the subject has been much discussed, tracing the specific pathways between globalization and dietary change remains a challenge. To help address this challenge, this paper explores how one of the central mechanisms of globalization, the integration of the global marketplace, is affecting the specific diet patterns. Focusing on middle-income countries, it highlights the importance of three major processes of market integration: (I) production and trade of agricultural goods; (II) foreign direct investment in food processing and retailing; and (III) global food advertising and promotion. The paper reveals how specific policies implemented to advance the globalization agenda account in part for some recent trends in the global diet. Agricultural production and trade policies have enabled more vegetable oil consumption; policies on foreign direct investment have facilitated higher consumption of highly-processed foods, as has global food marketing. These dietary outcomes also reflect the socioeconomic and cultural context in which these policies are operating. An important finding is that the dynamic, competitive forces unleashed as a result of global market integration facilitates not only convergence in consumption habits (as is commonly assumed in the "Coca-Colonization" hypothesis), but adaptation to products targeted at different niche markets. This convergence-divergence duality raises the policy concern that globalization will exacerbate uneven dietary development between rich and poor. As high-income groups in developing countries accrue the benefits of a more dynamic marketplace, lower-income groups may well experience convergence towards poor quality obseogenic diets, as observed in western countries. Global economic policies concerning agriculture, trade, investment and marketing affect what the world eats. They are therefore also global food and health policies. Health policy makers should pay greater attention to these policies in order to address some of the structural causes of obesity and diet-related chronic diseases worldwide, especially among the groups of low socioeconomic status.

Journal Article↗

Serum levels of erythropoietin and selected other cytokines in patients with anemia of chronic disease.

Serum levels of erythropoietin and five other cytokines potentially operational in erythropoiesis were determined in patients with anemia of chronic disease. No correlation between erythropoietin levels and severity of anemia was found. A spectrum of abnormality was encountered among patients in whom there was less than expected erythropoietin response to increased levels of erythropoietin and among others in whom the erythropoietin levels were subnormal for their degree of anemia. Increased serum levels of interleukin-3, granulocyte colony-stimulating factor, and granulocyte-macrophage colony-stimulating factor were encountered in limited numbers of patients, especially those with increased erythropoietin levels. Deficient erythropoietin production is concluded to be the major cause of anemia of chronic disease.

Aged↗

Sex differences in the risk of frailty for mortality independent of disability and chronic diseases.

OBJECTIVES: To determine the effect of static and dynamic frailty on mortality in older men and women. DESIGN: A prospective cohort study with three 3-year measurement cycles. SETTING: Population based. PARTICIPANTS: The sample was derived from the Longitudinal Aging Study Amsterdam and consisted of respondents who participated in two cycles (T1: 1992/1993 and T2: 1995/1996) and for whom there was complete data on disability and chronic diseases (N=2,257). MEASUREMENTS: Nine frailty markers were assessed at T1 and T2. The frailty markers were defined in two ways: low functioning at T2 (static frailty) and change in functioning between T1 and T2 (dynamic frailty). Survival time, calculated in days from T2 to January 1, 2000, was used as the outcome variable. Predictive ability was examined using Cox proportional hazards analyses separately for men and women. RESULTS: Women were frailer than men. Static frailty was significantly associated with mortality in men (relative risk (RR)=2.4) and in women (RR=2.6). Dynamic frailty was also associated with mortality in women (RR=2.6), but it was not significantly associated with mortality in men (RR=1.3). When disability and chronic diseases were included in the model as possible mediators, these RRs dropped to 1.6, 2.0, 2.1, and 1.2, respectively, of which the first three were still significant. CONCLUSION: Frailty was associated with mortality to a greater extent in women than in men, and this effect was independent of disability and chronic disease. In men, the static definition of frailty was more predictive of mortality than the dynamic definition.

Aged↗

Measuring the health burden of chronic disease and injury using health adjusted life expectancy and the Health Utilities Index.

OBJECTIVES: To estimate the burden of illness from chronic disease and injury using a population based health survey, which contains both measures of chronic disease and a utility based health related quality of life (HRQOL) measure. DESIGN: An adapted Sullivan method was used to calculate cause deleted health adjusted life expectancies for chronic conditions. SETTING: Ontario, Canada, 1996/97. SUBJECTS: The 1996/97 Ontario Health Survey (n=35 527) was used to estimate the prevalence of chronic conditions. A cause deleted approach was used to estimate the impact of these conditions on the Health Utilities Index (HUI). Cause deleted probabilities of dying were derived with the cause eliminated life table technique and death data from vital statistics for Ontario 1996/97 (n=156 610). RESULTS: Eliminating cardiovascular disease and cancer will cause an "expansion of morbidity", while eliminating mental conditions and musculosketal disorders will result in a "contraction of morbidity". The HUI score varies depending on chronic condition, age, and sex-most of which were assumed not to vary in previous summary measures of population health. CONCLUSIONS: Health adjusted life expectancy estimated for chronic conditions using a utility based measure of health related quality of life from population health surveys addresses several limitations of previous studies that estimate the burden of disease using either a categorical measure of disability or expert opinion and related epidemiological evidence.

Adolescent↗

Social network, social support, and loneliness in older persons with different chronic diseases.

OBJECTIVES: This study examines whether patterns of social network size, functional social support, and loneliness are different for older persons with different types of chronic diseases. METHODS: In a community-based sample of 2,788 men and women age 55 to 85 years participating in the Longitudinal Aging Study Amsterdam, chronic diseases status, social network size, support exchanges, and loneliness were assessed. RESULTS: Social network size and emotional support exchanges were not associated with disease status. The only differences between healthy and chronically ill people were found for receipt of instrumental support and loneliness. Disease characteristics played a differential role: greater feelings of loneliness were mainly found for persons with lung disease or arthritis, and receiving more instrumental support was mainly found for persons with arthritis or stroke. DISCUSSION: The specifics of a disease appear to play a (small) role in the receipt of instrumental support and feelings of loneliness of chronically ill older persons.

Aged↗

Contributions of Ernst L. Wynder to chronic disease control worldwide and to preventive medicine.

Ernst L. Wynder is internationally known for his important discoveries in the field of human chronic disease causation, that is the underlying mechanisms, studied in various animal models, as a foundation for recommendations on the prevention of these diseases. These include coronary heart disease, and the main human cancers including cancer of the lung, caused by traditional smoking habits, and the nutritionally linked cancers, namely cancer of the breast, prostate, colon, pancreas, and urinary bladder. Much of this research was performed in a chronic disease prevention institution--created by Dr. Wynder--the American Health Foundation. There were outreach programs to educate people about proper lifestyles to secure disease prevention, including beginning health education in children.

Chronic Disease↗

A new MF59-adjuvanted influenza vaccine enhances the immune response in the elderly with chronic diseases: results from an immunogenicity meta-analysis.

BACKGROUND: The elderly are at a higher risk of morbidity and mortality associated with influenza infection than younger adults, but get less protection from conventional vaccination. OBJECTIVE: We conducted a meta-analysis of all available data from clinical trials in the elderly on a recently introduced MF59-adjuvanted influenza vaccine to determine its immunogenicity and safety in subjects with underlying chronic disease who are at highest risk of influenza infection. METHODS: Data on immunogenicity and safety from 3600 subjects immunized with either the MF59-adjuvanted or conventional comparator influenza vaccine in 13 clinical trials were analyzed by disease history. Geometric mean haemagglutination inhibition titres (GMTs) and differences between the vaccine groups were compared using two-way analysis of variance. Differences between vaccine groups in the percentages with post-immunization reactions were assessed using chi-squared test and Fischer's exact test. RESULTS: At 28 days the adjuvanted:comparator GMT ratio for the A/H3N2 antigen was 1.18 in healthy elderly subjects and 1.43 in elderly subjects with chronic disease (p = 0.004). The respective GMT ratios were 1.17 versus 1.37 for the B antigen (p = 0.065) and 1.10 versus 1.17 for the A/H1N1 antigen (p = 0.41). Although post-immunization reactions were more common in the group receiving the adjuvanted vaccine, these were predominantly mild and transient, and none were serious. CONCLUSIONS: The MF59-adjuvanted influenza vaccine is more immunogenic in elderly subjects than conventional non-adjuvanted influenza vaccines and especially so in those with chronic disease. Therefore, since its safety profile is clinically acceptable, this adjuvanted vaccine represents an excellent option for influenza immunization of elderly subjects at highest risk of complications.

Adjuvants, Immunologic↗

Health behaviors, chronic disease prevalence and self-rated health of older Asian Indian immigrants in the U.S.

The purpose of this study was to examine the correlates of healthy behaviors and self-rated health in middle-aged and older Asian Indian immigrants in the U.S. Asian Indian men (n=162) and women (n=64), 50 years of age or older completed a telephone survey which collected information regarding demographics, behavioral risk factors, acculturation, perceived control, quality of social support, depression, body mass index, chronic disease prevalence, and self-rated health. Participants' average length of residence in the U.S. was 25 years, 52% were normal weight, 41% were vegetarians, 55% incorporated aerobic activity into daily lifestyle, and only 5% smoked. Hypertension and diabetes were most common chronic diseases (31 and 18%, respectively). Younger age, longer length of residence and a bicultural or more American ethnic identity were associated with greater participation in physical activity. Likewise, higher income, a bicultural or more American ethnic identity and depression were associated with higher fat intake. Poor self-rated health was associated with older age, female gender, BMI>25, satisfaction with social support, and greater number of chronic disease conditions. A multitude of factors influence the practice of healthy behaviors and the perceived health of Asian Indian immigrants, which should be addressed when developing culturally appropriate health promotion interventions.

Acculturation↗

[Medical care for chronic disease: reflexions on methodologic procedures of a qualitative study].

Chronic diseases have been the focus of qualitative researchers. However, few studies have explained in depth the methodological options choOsed in the studies and their reasons. This paper presents some reflections on the methodological strategies and procedures used in a multisite, qualitative study whose focus are the individual's perspectives on chronic conditions and medical care. Such reflections are on the study's orientation, the selection of the area, the focus groups and the social relations among participants. We conclude stating that the methodological options and the strategies used, rather than being solely a technical issue, are deeply linked to the study's object, the social relations among participants and the context of research.

Chronic Disease↗

[Age factors and flight duration in chronic diseases].

Health disqualification is the main reason for stopping flying activity. The age limitations of flying activity have been not established. Nevertheless, the development of diseases and motivated continuation of flying activity are severely age-dependent. The cases of chronic diseases have been reported throughout the all flying careers of 1,433 pilots and navigators and disqualifying for flying activity for the health condition upon routine medical screening. The flying activity duration after a disease occurrence was found to be of bimodal distribution. The first peak coincides with the moment of an initially diagnosed illness, the second-delayed peak in elder individuals approximates the first one. Thus, in the persons in whom a chronic disease was initially diagnosed when they were twenty years old, this diagnosis was confirmed in 18-20 years and in 2-4 years in the persons in whom a disease was diagnos ++ when they were 35 years old. Thus, there are two factors greatly affecting the disqualification--a disease and age. Both these factors are closely interrelated.

Adolescent↗

Intensive rehabilitation. Recent experience in a chronic disease hospital.

An intensive rehabilitation program for persons with severe physical disabilities was carried on over a two-year period in a 35-bed unit at Rancho Los Amigos Hospital, a chronic disease hospital.Eighty-five patients were released (69 adults, 16 children) from the program after an average stay of six and a half months. Seventy-one per cent of these were discharged to their homes and the remainder were transferred to convalescent wards so much improved that they required less care, even worked on the grounds. Over half of the adult patients discharged to their homes became employed, not counting the women who resumed housework.The average hospitalization for patients in the same hospital without this program is three and a half years. Thus, despite a much higher cost per day for the patients in the intensive rehabilitation program, the total cost is about $7,640 less per patient discharged from the hospital.In addition the shorter period in hospital helps meet the ever-increasing demand for chronic disease beds.

Adult↗