As an addendum to my last post related to the health hazards of excess sitting, a study in the American Journal of Preventive Medicine added more evidence that excessive sitting is a risk factor for mortality. Using survey data from 54 countries, the researchers analyzed the association between time spent sitting more than three hours a day and mortality. They found that >60% of respondents worldwide sat for > 3 hours/day (mean = 4.7 hours/day), contributing to an extra 433,000 deaths from 2002 through 2011. Reducing that time by 50 percent would result in a 2.3 percent decline in all-cause mortality.
Alternatives to the traditional desk chair have become popular as increasing evidence shows that prolonged sitting increases heart failure risk and disability risk and shortens life expectancy. A review found that sitting time was independently associated with poor health outcomes regardless of physical activity. Alternatives to sitting have become a new industry:
The studies’ primary outcome measure was time sitting. They found, overall, that sit-stand desks, pedaling desks and treadmill desks do not decrease time sitting by much because people do not use them; thus, the desk chair alternatives were not expected to improve health status.
(This post = 2400 steps on my treadmill desk.)
Much research and media attention have focused on personalized medicine. The National Cancer Institute defines personalized medicine as “a form of medicine that uses information about a person’s genes, proteins, and environment to prevent, diagnose, and treat disease.” Although this definition includes prevention, much of the focus of personalized medicine has been on treatments, with a focus on genetics as the key determinants of a patient’s predicted response. President Obama’s Precision Medicine Initiative, for example, which this month is 12 months old, focuses on tailoring treatments to the individual, with little mention of personalizing preventive medicine modalities.
Per the CDC’s Preventive Care site, preventive care includes both health promotion and disease screening.
- Health promotion includes proper immunizations, managing one’s weight, being physically active, eating a healthy diet, not smoking, drinking moderate amounts of alcohol, wearing seat-belts/helmets, getting enough rest, surrounding oneself with family and friends, driving safely, managing stress, and, in general, living what most would agree is a healthy lifestyle. These are activities that often do not require medical personnel–they are often individually guided, or can be policy-related, such through laws requiring seatbelt use, taxing cigarettes, and restricting the availability of sugary drinks at schools.
- Disease screening includes health services like mammograms, colonoscopies, Pap tests and regular tests of blood pressure and cholesterol. These services generally involve medical personnel.
The CDC site also includes a tool you can use to identify the recommended disease screening services by age and gender, reflecting a basic level of preventive care personalization by these two factors. A Health Affairs article provides a more detailed overview of preventive health modalities and the potential cost-benefit for them.
A recent NY Times post highlights the value of personalized preventive medicine: it summarizes recent studies that show the way we absorb and metabolize various foods is highly variable and thus dietary advice is not one-size-fits-all. Some of the factors that determine an individual’s response to various foods include demographics, genetic makeup, gut bacteria, body type, medications, family history, lifestyle, and chemical exposures. A video summary of one study featured, “Personalized Nutrition by Prediction of Glycemic Responses” is available here. Although recently we have learned more about the ideal “dosing” of exercise for the population, the recommendations are not personalized.
One of the more controversial attempts at personalizing preventive care was the U.S. Preventive Services Task Force guidelines on mammography. After review of existing research, the Task Force decided against recommending mammography for some women in their 40s. The personalized preventive medicine approach also took into account family history: the Task Force recommended that women with mothers or sisters with a history of breast cancer may benefit more from screening in their 40s.
As a pediatric emergency medicine provider, many of the reasons patients show up in the Emergency Department are related to symptoms–a fever, cough, rash, ache, nausea, runny nose, diarrhea, etc. What is this causing it? What will make it go away as soon as possible?
A commentary on NPR’s Shots series notes that, often, despite our best medical evidence and diagnostic technology, “what we doctors do is more about making educated guesses”.
What causes a child’s ear infection or pneumonia? Mostly we guess at what’s causing it and treat accordingly. When I explain the uncertainty involved in various options, this is often puzzling and frustrating to patient families. They want certainty–they want their child feeling all better. Who wouldn’t?
In contrast to the uncertainty around whether to treat an ear infection with antibiotics, we have far better evidence supporting preventive health. Although I have focused a lot on preventive vaccines lately, other aspects of preventive medicine are supported by similarly large bodies of epidemiological research. Most of prevention is fairly straightforward, rather boring, and lacks the appeal of a quick fix (gluten free donuts!)
Summarizing, here is the Shots commentary’s list:
- Get enough sleep.
- Move your body throughout the day.
- Eat well — a healthy assortment of unprocessed foods. Mostly plants, and not too much. (An idea popularized by author Michael Pollan, whose movie can be seen free for the next month here).
- Interact socially. Isolation is not good for the body, soul or mind.
- Take some time to reflect on what you are grateful for.
These life habits are key–so much so that some medical schools are even teaching their students to cook so they can better support their patient’s healthy eating choices.
I append this list with the also-important (and even less sexy) screening recommendations of the US Preventive Services Task Force.
Today’s NY Times op ed from pathologist Bemmet Omalu “Don’t Let Kids Play Football”, compares the sport to public health menaces including tobacco smoke, asbestos and fetal alcohol exposure. The stance he takes is far more extreme than even the American Academy of Pediatrics’ position on tackle football among youth, which reviewed the evidence and determined that the decision is an individual one: “players must decide whether the benefits of playing outweigh the risks of possible injury”.
Dr. Omalu states in his op ed: “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage, which we know now by the name Chronic Traumatic Encephalopathy, or C.T.E., a disease that I first diagnosed in 2002.” Moving beyond anecdote to research, a recent and well-done review of the literature on CTE, concludes that “there are more questions than answers about all aspects of the CTE concept, from biomechanical substrates to molecular pathogenesis to the existence of CTE as a distinct entity.” Two other articles–here and here–by leading researchers in this area also found no association between football and CTE among retired football players. Among the researchers investigating the association between concussion and outcomes in children are my two University of Colorado School of Medicine Department of Pediatrics colleagues Michael Kirkwood and Joe Grubenhoff; check out their research here.
A third colleague–Dawn Comstock–had her head injury epidemiology work featured in a different NY Times op ed piece.
Returning to anecdote, working in an emergency department in a children’s hospital, I treat plenty of sports-related concussions; however, the morbidity I treat among sedentary and overweight children is far more common. A recent article in the New England Journal of Medicine found that, among children starting 8th grade, 20.8% were obese and an additional 17.0% were overweight. Although these children have physical exercise options other than football, for those who love most of all to play football, it is hard to know whether following the New York Time’s op ed’s admonition is a correct balance of risks and benefits.