An Ounce of Prevention...

A Publication of the
Program on Prevention
In Education & Practice

February 2002 - Volume 1, Number 11

AAMC Calls for a "New Partnership" between Academic Medicine and Public Health

In the wake of national events last fall, the visibility of the role of public health has greatly increased. Practicing physicians are seen more and more as a vital part of the public health system. The Association of American Medical Colleges (AAMC) is working to encourage partnership between public health and academic medicine in an attempt to insure the health of individual patients but also the health of the public.

In the January edition of the AAMC newsletter, Reporter, Eric Henley, MD, MPH from the University of Illinois College of Medicine compares the relationship between clinical medicine and public health to the relationship between the numerator and denominator of a fraction. "Physicians work with the numerator, one patient. Public health officials work with the denominator, or the population from which the person comes." The challenge then is to get doctors to think about the denominator as well as the numerator. Edwards Dismuke, MD, MSPH, former UNC faculty member and current Dean at the University of Kansas School of Medicine at Wichita, suggests "private physicians are the best surveillance system we have in this country for bioterrorism." However, if physicians are to be active in the detection of bioterrorist threats, new relationships must be developed. Not only will physicians need to understand the role of the CDC, but also their state and local health departments. They will need to join forces with local emergency planning committees, firefighters, police, the FBI and the Department of Defense. To be most effective, this will need to be a combined and coordinated effort.

AAMC developed a cooperative agreement with the CDC in 2000 to improve the collaborations between the academic medicine and public health communities. Such efforts include attempts to integrate public health teaching into medical school curricula and to create faculty development programs that foster the public health perspective in teachers who pass it on to their students. The AAMC recognizes that traditional medical school teaching will not be sufficient for doctors of the 21st century. Dr. Lichtveld, from the CDC Public Health Practice Program office, says "traditionally when medical students graduate, they are heavily focused on the curative side [of medicine]. But prevention is going to become critical, and more students will accordingly need more than a superficial knowledge of our nation's public health system."

The American Medical Association (AMA) is also interested in strengthening ties with public health. The organization has partnered with the US Department of Health and Human Services to develop Roadmaps for Clinical Practice. The Roadmaps series is intended to assist physicians and other health professionals to integrate disease prevention and health promotion into routine medical care. The Roadmap's Primer on Population-Based Medicine is the introductory volume and it contains information on a population health perspective and a population-based medicine approach to clinical care. The primer introduces these concepts and discusses how this perspective and approach provide a context and strategy for disease prevention and health promotion.

We in the Program on Prevention continue to work on ways to integrate these and other related topics into the medical student curriculum. You can find more information on the Roadmaps series at the AMA website.

The Surgeon General's Call To Action to Prevent and Decrease Overweight and Obesity

As a culmination to his longtime commitment to decreasing the epidemic of overweight individuals in the United States, Dr. David Satcher recently issued a report on obesity and overweight. The report comes at the end of Dr. Satcher's role as Surgeon General which he relinquished on February 13. He is now Director of Morehouse University School of Medicine's new National Center for Primary Care.

The report has a detailed explanation of the obesity problem, including epidemiology, risk factors and disparities in prevalence. The bulk of the report, however, focuses on developing strategies to curb the overweight problem among specific target audiences- families and communities, schools, health care settings, media and communications outlets and worksites. The remainder of the report addresses strategies to create and sustain national action and visions for the future. Dr. Satcher also identifies research areas and funding possibilities and states that "obviously, individual behavioral change lies at the core of all strategies... Successful efforts, however, must focus not only on individual behavioral change, but also on group influences, institutional and community influences, and public policy." The report can be found at http://www.surgeongeneral.gov/topics/obesity/calltoaction/toc.htm.

North Carolina Prevention Partners-
Report on the Health of NC Childcare Centers

Closer to home, NC Prevention Partners takes on the issue of overweight and obesity in NC. They recently released a report summarizing formative research looking at nutrition and physical activity in NC child-care centers. The report was part of the NC Initiative for Healthy Weight in Children and Youth which was developed to address the growing prevalence of obesity among NC youth. The initiative recognizes that early intervention is critical to promote healthful environment and behaviors to prevent overweight. One main element of the initiative is to develop policy and environmental supports for healthy nutrition and physical activity in regulated child-care centers. The Initiative also includes an all-star statewide task force and committees working on primary prevention, secondary prevention (screening, treatment, and reimbursement) and public awareness.

Key informant interviews were held with key staff from child-care centers around the state including two Partnership for Children/Smart Start Offices. Parent focus groups were also held. The report findings are mixed. The good news is that very young children are largely active at child-care settings and childcare providers and parents are both interested and aware of physical activity needs. Also, both parents and providers have an interest in good nutrition. Less favorable findings are that while centers follow the NC Child and Adult Care Food Program Guidelines, these guidelines are not adequate to assure that centers serve healthy food for young children. Parents shared that their children don't get as much physical activity at home, that television was a primary activity at home. Current child care guidelines require that centers offer gross motor and fine motor skills, but were not developed to promote active sustained play. In terms of nutrition, staff may be uncertain about what healthy/balanced meals are and both staff and parents are often not good role models regarding food consumption and activity. There is also concern about how child care providers and parents create meal and snack settings and behavioral guidance to young children regarding hunger and satiation cues.

Recommendations, based on these findings, include:

Work to enhance the rating scales (both regulatory and voluntary) since they seem to be effective incentives. Enhancing requirements and training elements for child care centers to promote fine motor, gross motor and sustained active play opportunities for children would also encourage staff to promote active play in more creative ways.

Extensive staff development in nutrition and physical activity so that all staff can play a role in promoting healthy positive behaviors. Also include this information in teacher training programs.

Parents should be made aware of what to look for in childcare centers. A guide or checklist and companion materials about nutrition and physical activity may be helpful. This may encourage parents to choose centers with positive environments and may support support positive healthy behavior in the home.

Public awareness campaign should be developed to include a set of messages that address and reinforce the ideas of hunger, satiation and how to stop eating when full. Messages should be developed at different levels for both children and parents.

Complimentary materials should be developed and continued in K-12 grades to encourage a positive environment for nutrition and physical activity.

Findings will be used to enhance the current NC Child Care 5 Star Rating Scale or to create a new environmental rating scale for nutrition and physical activity. They will also provide data for future efforts of the NC Initiative for Healthy Weight in Children. The executive summary and full report are available at: http://www.ncpreventionpartners.org/events.

Newsworthy Notes

Prevention News Around The Program...

Student Does CDC Elective Investigating Anthrax

This year, for the first time, fourth-year UNC medical students are able to sign up for a 6-8 week elective at the CDC in the Epidemiology Program Office. The purpose of the elective is to provide an introduction to preventive medicine, public health, and the principles of applied epidemiology. Students are offered the opportunity to actively assist in epidemiologic investigations of infectious diseases or in areas such as cancer, congenital malformations, environmental and occupational diseases, injuries (intentional and unintentional), chronic diseases, and reproductive health and population dynamics. Students are also exposed to the day-to-day operation of the CDC's nationwide surveillance system. For more information about this elective go to http://www.cdc.gov/epo/dapht/eis/elective.htm.

Here is a report from fourth-year student Menoj Menon, who did this elective in October-November, 2001. Little did he know, when he signed up last spring, that he'd be involved in such a high profile investigation.

Widened Mediastatinum in Florida
by Menoj Menon (M4)

As a fourth year medical student, I was fortunate to have participated in an elective rotation in applied epidemiology, offered by the Centers for Disease Control and Prevention. Prior to arriving in Atlanta, I was familiar with the objective of this rotation. Specifically, the CDC hopes to provide students with experience in applied epidemiology in a hands-on fashion, preferably with a component of field based epidemiology, such as participation in an investigation of an urgent, acute public health problem. Typically, these investigations consist of food-borne or respiratory outbreaks. The timing of my arrival, however, ensured that I would have a unique educational experience.

"Widened mediastinum in Florida". While I initially did not realize the impact of these four words, the consequence of such a finding would severely threaten the infrastructure of the U.S. public health system. This characteristic radiographic finding, typical of inhalation anthrax, raised a host of concerns regarding the method of contamination. Even prior to the events of September 11, 2001, the CDC had considered the possibility of an intentional release of a biological weapon. However, the x-ray findings, confirmed via blood culture, obviously hastened the response of our public health system.

Soon after the index case in Florida, additional cases of anthrax, both the cutaneous and inhalation forms, were identified. Epidemiological surveillance activities, in conjunction with law enforcement agencies, assessed that the mode of transmission was via the U.S. mail. However, an additional case of inhalation anthrax was identified in New York. This patient had no known connection to other infected patients, and unlike the other cases, she neither had contact with a media outlet nor handled mail as part of her job responsibilities.

My supervisors at the CDC wanted me to play an active role in this epidemiological investigation. As such, I was sent to New York as part of the field team investigating the newly discovered case. While I was able to participate in a host of activities, perhaps the most worthwhile was in disseminating health education to U.S. postal workers. Here we answered questions regarding the signs, symptoms, mode of transmission and methods of prevention of anthrax. Anger, stemming from perceived treatment disparities based on race and social class, was both prevalent and understandable.

However, although the CDC recommendations differed among the different sites, this inconsistency was neither intentional nor malicious. Rather, the changing responses were based on the evolving investigations. Lessons learned from one case were implemented in future cases.

The events of September 11, 2001 and the subsequent bioterrorisitic events have clearly caused chaos in many sectors of everyday life and the CDC was not immune to this effect. However, it was comforting to see the public health infrastructure mobilize in a time of crisis. Equally important, the public has become more aware of the needs for and the needs of the public health system. As such, needed funds will be provided to strengthen this much necessary line of protection.

Prevention in the Curriculum

Case-Based Learning- Integrating the Basic and Clinical Sciences
First-year medical students were recently involved in a two-day session designed to bring together basic science and clinical practice to solve a case of a woman with breast cancer. This case-based problem solving session utilized some components of problem based learning in which students decide on learning issues and do individual research to answer their questions.

Feedback from the session was quite positive and students in general are in favor of adding more learning opportunities similar to this. In analyzing the student evaluations, 41% said this session was "mostly" helpful and 25% said it was "completely" helpful in synthesizing and applying basic science knowledge [in a clinical context]. One students said "I like the way it brought together the information we've studied and allowed us to enter the world of clinical medicine." Another stated "I really enjoyed the chance to think critically about medicine." And another said "When we become doctors, we won't have a test with a list of questions to answer for each patient. This approach helped us think like doctors."

Hidden Topics Days
During January and February, first-year students have been introduced to some topics that are critically important to physicians, but are sometimes neglected in the curriculum and in medical practice- "hidden topics". The Program on Prevention is involved in these days providing a thread of prevention that will run through all four days providing a specific prevention focus for each topic. The topics covered this year include substance abuse, domestic violence, sexual health and aging.

Around Campus...

Aspirin Chemoprevention

The use of Aspirin in prevention of cardiovascular events has been widely publicized and several members of the UNC community recently published an article in the Annals of Internal Medicine summarizing the most recent findings as recommended by the U.S. Preventive Services Task Force. Michael Pignone, MD, MPH from the Department of Medicine, Michael Hayden, MD, MPH and Christopher Phillips, MD, MPH, both of whom received their MPH in the Health Care and Prevention Program at UNC, have concluded that the net benefit of aspirin increases with increasing cardiovascular (CVD) risk. Their systematic review show that "for patients without known cardiovascular disease... aspirin chemoprevention reduces myocardial infarction but has no effect on ischemic stroke or all-cause mortality. Aspirin therapy also increases the risk for gastrointestinal bleeding and hemorrhagic stroke." The authors suggest that aspirin chemoprevention is likely beneficial for those who haven't had a diagnosis of CVD but are at high risk in the next five years. However, patients at low risk for CVD likely do not benefit and may actually be harmed. This evidence suggests that determining a patient's risk of CVD and his/her willingness to look past the potential harms are crucial factors that must involve shared decision making with patients and physicians.

Hayden M, Pignone, M, Phillips C, Mulrow C. Aspirin for the primary prevention of cardiovascular events: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2002;136:161-172.

Around the World Wide Web...

People have more access to health care information than ever before. Not only do they hear about health news in the media but more and more individuals are looking to the WWW for information. Directing your patients to credible and reliable information is key. The Web can be a valuable resource for educational material for patients and providers alike if it is used wisely.

The North Carolina Prevention Partners webpage is fabulous. It is rich with information about projects currently underway with the organization, NC statistics and data, and resources to help you in your prevention efforts. This page is a must see for anyone interested in the health of NC. http://www.ncpreventionpartners.org/

Another great website is the Women's Heart Health Education Initiative. This site is part of the National Heart, Lung, and Blood Institute, a branch of the National Institute of Health. The site has a nice patient education section in both English and Spanish. http://hin.nhlbi.nih.gov/womencvd/

Look for our next edition of "An Ounce of Prevention" in May, 2002.
If you have comments or questions about this newsletter or its contents, please e-mail alward@med.unc.edu.

Program Co-Directors: Russ Harris, MD, MPH and Linda Kinsinger, MD, MPH
Education Coordinator & Editor: Amy L. Ward

Go to the Program on Prevention Homepage