Tag Archives: public health

ED Patients Blind to Risks of Being Overweight

American tongues start wagging whenever the latest starlet puts on a few pounds, but we appear loathe to discuss our own ever-increasing waistline.

A study of 453 adults presenting to a Florida ED found that 58.5% of overweight/obese African American and Caucasian men and women feel their weight is not a health issue AND have never discussed their weight with their healthcare provider.

The average BMI in the study was 29.5 kg/m2, mean weight 184 pounds, 61% were female and the average waist circumference an undignified 39.5 inches.

Given those stats, you’d think these patients had gotten an earful from their provider, but not so.

Overall, 38% of all patients reported their weight to be unhealthy, but only 28% recalled being told so by their provider, University of Florida emergency physician Dr. Matthew Ryan reported at the recent meeting of the Society for Academic Emergency Medicine in Chicago.

It’s possible that some physicians may be afraid to bring up weight for fear their patients will scurry off to a “kinder, gentler” provider. Others may simply be short on time. Yet even when docs did start the conversation, some patients just couldn’t make the connection between obesity and health risks.

Among patients told by their provider they were overweight, 77% believe their present weight is damaging to their health, yet 23% still believe their weight is not unhealthy.

Dr. Ryan points out there’s an obvious disconnect between patients’ perceptions of their weight and their actual weight and current health, and suggests that “the first line of action toward confronting the mounting obesity epidemic in the U.S. is clear patient-provider education.”

The chaotic environment of the ED may seem like an unlikely place to help increase patient awareness about weight-related medical issues or to provide weight-loss counseling, but there may just be something to the “Willie Sutton rule” that teaches, not just bankrobbers, but medical students to focus on the obvious.

As part of the study, the investigators also measured the prevalence of obese patients presenting to their ED in order to compare it to state and national prevalence rates. It reached a whopping 38%, towering over the already hefty 26.6% obesity rate reported for the general population in Florida in 2010 by the CDC.

To their knowledge, the authors say no studies have directly measured the obesity prevalence in the ED. Thus, the ED population may be poorly represented in existing national healthcare studies, which are largely community-based. Moreover, the obesity prevalence may be higher than indicated by studies like the CDC’s that rely on self-reported height and weight.

Given the author’s findings in the ED, that’s a very real and chilling possibility.

The research was supported by a University of Florida Clinical and Translational Science Institute grant.  Dr. Ryan reported having no conflicts of interest.

– Patrice Wendling



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A Government Official’s View on Pandemic Flu

How well do you think the federal government performed in handling the 2009-2010 pandemic H1N1 influenza outbreak? Here’s the view of the physician who oversaw the effort at the U.S. Department of Health and Human Services (HHS), Dr. Nicole Lurie: “Looking back, I just feel very proud of what we accomplished as a nation.”

HHS Photo of Nicole Lurie, MD by Chris Smith

Dr. Lurie spoke last week at a meeting sponsored by the Infectious Diseases Society of America, in which participants reviewed the response to the pandemic flu in terms of what worked and what didn’t, and brainstormed to devise a list of priorities for future approaches to both pandemic and seasonal influenza.

The IDSA will incorporate those discussions into a revision of its January 2007 document, “Pandemic and Seasonal Influenza Principles for U.S. Action.” Back then, public health officials were concerned about the H5N1 “bird flu” virus as a possible pandemic strain.

“We were planning for a ‘different’ pandemic. But planning let us ‘pivot.’ Prior investments paid off in terms of vaccine manufacturing capacity and a strengthened public health system,” noted Dr. Lurie, who became the HHS Assistant Secretary for Preparedness and Response in June 2009, 2 months after the first case of pandemic H1N1 influenza was detected. Prior to that, she directed public health and preparedness work at the RAND Corporation.

Among the government’s major accomplishments, she noted, were the initial identification and sequencing of the virus, provision of test kits for states and for other countries, and delivery of the vaccine “in record time” to more than 70,000 sites, over 116,000 providers, and 10,000 retail pharmacy stores. As a result of the combined efforts of several different agencies within HHS, more than 80 million people were vaccinated.

“All-hazards public health preparedness paid off . … Unprecedented, cross-government, whole of community response is indeed possible,” Dr. Lurie said.

But, of course, there were gaps and opportunities for improvement. Response time needs to be faster for making vaccine and implementing other medical countermeasures, and for obtaining funding. Indeed, there was a time lag of about 6 months for Congressional budget appropriations to reach the federal, then state and local levels to the actual shot in a person’s arm. “We have to be more nimble about moving money.”

Photo by G C Lee via Flickr Creative Commons

Communication with the public could also be improved. “Addressing public concerns is key. The health care system handled this one well, but would be challenged in a more severe pandemic. You can never communicate enough,” she noted.

HHS is addressing these and other concerns, including building stronger day-to-day systems within those already in place, incorporating surveillance and scientific endeavors along with clinical care. The ultimate goal, as informed by the 2009 H1N1 influenza pandemic: “Ensure that we are prepared for something we have never seen.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Allergy and Immunology, Emergency Medicine, Family Medicine, Geriatric Medicine, Health Policy, Infectious Diseases, Internal Medicine, Pediatrics, Primary care, Pulmonary Diseases and Sleep Medicine

H1N1 Pandemic Slip Sliding Away?

U.S. public health officials haven’t given up on the influenza H1N1 pandemic, but it seems like the American public has. 

Has the specter of H1N1 faded like last October's goblins?/image courtesy of Flickr user chrisstreeter

The irony is that just as the H1N1 vaccine became widely available in December, rates of pandemic flu infection dropped to vanishingly low levels and concurrently concern about H1N1 largely dropped off the national radar.

The recent downturn in H1N1 infections helped further blunt any fear. Slow-to-build vaccine supplies undercut the vaccination push. The bottleneck made widespread vaccination impossible during the hyped-up early days of the pandemic’s current wave. The result: the momentum to get much of the American public vaccinated fizzled out. The only thing that could reinvigorate the vaccination campaign now would be a third wave of infection later this winter or in the spring — certainly a possibility, but hardly a given. 

The U.S. H1N1 vaccine supply stream remained at a disappointingly moderate level in December.  During the 5 weeks from late November through the last day of 2009, an additional 48 million doses shipped, bringing the total since the vaccine began appearing in early October to a hair under 100 million doses through the end of last year, half the total ordered and paid for by the Department of Health and Human Services. 

 What this meant was that until mid-December, access to the vaccine was officially limited to high risk groups. According to a report last Friday in the New York Times by Douglas G. McNeil Jr., 60 million Americans had received the H1N1 vaccine through the end of 2009. Just when vaccine availability began to open up, the pandemic wave ebbed away. During the week ending Dec 26, the Centers for Disease Control and Prevention reported that its surveillance labs identified 83 isolates as H1N1 (with another 76 isolates influenza type A, with subtyping not done). That compared with more than 9,500 H1N1 isolates identified (with another 2,100 type A isolates not subtyped) during the current wave’s peak, the week of Oct. 18-24. Four states were reporting widespread flu at the end of December, down from a peak of about 40 states in late October. 

Here’s a personal story that typifies the missed opportunities and misinformation that have hampered the H1N1 public health campaign. I’m not a member of a high-risk group, and so waited till mid-December to call my physician’s office about getting the vaccine, only to hear that they would not carry the vaccine at all, not now or at any time in the future. I was amazed, as this practice routinely administers flu vaccine each fall. I asked why, and the practice’s nurse told me: Their patients are almost entirely middle-aged or elderly, and hence faced little or no risk from H1N1. That was their conclusion, despite the fact that so far this flu season essentially the only virus in U.S. circulation has been H1N1, and despite the fact that infection by H1N1 is still a nasty experience even for older adults. During the current U.S. flu season starting last September, U.S. surveillance labs identified about 60,000 H1N1 isolates compared with fewer than 300 isolates of other flu A types or B type.

Unless the H1N1 pandemic resurges, the U.S. legacy will be a vaccine that wasn’t available for most people until the infection threat died down, and  a triaging of initially-limited vaccine supplies to high-risk groups that got mistaken by even well-informed people to mean that high-risk people were the only ones at risk. 

–Mitchel Zoler (on Twitter @mitchelzoler) 

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Filed under Family Medicine, Health Policy, IMNG, Infectious Diseases, Internal Medicine, Practice Trends, Primary care

Surgeon General Nominee Informed by Storms

I met President Obama’s surgeon general nominee Regina M. Benjamin in 2005 in Washington at an AMA  conference for science reporters.

Dr. Regina Benjamin


I recall other speakers, but I vividly remember Dr. Benjamin’s words, which I summarized in a page 1 story for the Dec. 15, 2005, issue of Family Practice News. Her story provides the strongest endorsement I can imagine for the use of electronic medical records.

The AMA conference took place just after Hurricane Katrina. Dr. Benjamin recounted the pain of her patients, many of whom were poor, who had lost even more in the storm. She stopped billing them because, “There’s no point when they don’t have an address.”

As the founder of Bayou La Batre (Ala.) Rural Health Clinic, Dr. Benjamin was used to treating patients too poor to afford medical care but who earned too much to qualify for Medicaid. When she wrote replacement prescriptions for patients who had lost them in the water, “I simply asked for the pharmacist to bill me. I had no idea how I was ever going to pay for this, but … you just do what you need to do.”

In fact, Katrina was not Dr. Benjamin’s first major storm. In 1998, her clinic was destroyed by Hurricane Georges. She had been renting space in a low-lying area when Georges hit and she lost everything. After that, she rebuilt her clinic on higher ground—and on 4-foot stilts. That worked well until Katrina’s 25-foot surge. From her previous experience with Georges, she knew that she needed to empty the office in 48 hours to prevent serious mold. She and her staff removed it everything, leaving nothing but the wooden beams, roof, and ceiling. Paper records were put outside to dry in the sun.

That’s when she knew that electronic medical records were not a luxury but a necessity. “After Hurricane Georges, I knew I wanted to get an electronic health record, but I couldn’t afford it. This time, I can’t afford not to. Even if we have to go into debt, we have to get one because it’s essential for our patients’ quality of care,” she said in 2005.

In Obama’s introduction of Dr. Benjamin as his surgeon general nominee today, he recited her impressive achievements: the first black woman to be named to the AMA’s board of trustees, president of Alabama’s State Medical Association, and a recipient of the MacArthur Genius Award. But, he added, “Of all these achievements and experience, none has been more pertinent to today’s challenges or closer to Regina’s heart than the rural health clinic that she has built and rebuilt in Bayou La Batre.” Indeed.

—Miriam E. Tucker (on Twitter: @MiriamETucker)
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