Category Archives: Mortality - Page 2

Sugar and spice, and salt is not very nice Part I

“No matter how we look at it, the story is the same – there will be huge benefits in reducing sodium,” said Pam Coxson, PhD, a UCSF mathematician and the lead author on the paper who performed one of the three analyses published in Hypertension.

The quotation is an understatement–the studies claim that hundreds of thousands of lives can be saved by less salt. What are the facts?

Let’s start with the Centers for Disease Control and Prevention (CDC):

About 90% of Americans eat more sodium than is recommended for a healthy diet. Too much sodium increases a person’s risk for high blood pressure. High blood pressure often leads to heart disease and stroke. More than 800,000 people die each year from heart disease, stroke and other vascular diseases, costing the nation $273 billion health care dollars in 2010.

The key point is the relationship of sodium to hypertension and cardiovascular events:

About 45 percent of these cardiovascular deaths are attributable to high blood pressure, and numerous medical studies have already demonstrated how reducing dietary salt – the primary source of sodium – can lower blood pressure and reduce the risk of a heart attack or stroke.

The study’s three analyses came up with varying numbers of saved lives, ranging from 250,000 to 1,200,000 over the next decade by reduced sodium intake–they averaged 280,000 to 500,000. We have long known that certain populations are more salt-sensitive and should radically reduce intake. The CDC list below tells that story, but we all should reduce sodium, not merely by not picking up the salt shaker, but by eating more fresh foods and looking at the labels on the processed foods we eat. Salt-sensitive populations

We can all benefit by a reduction in sodium, long before we become part of a vulnerable population. Next time, let’s look at some strategies we can use while waiting for food companies to offer lower sodium alternatives and government action in this domain.

Helpful links for more information about dietary sodium

The Verdict on US Health: Shorter Lives, Poorer Health Part II

Last time we looked at the findings of the consensus report of the Institute of Medicine that concludes that we face shorter lives and poorer health compared to other advanced countries.

The report includes a comparison of deaths among both men and women under 50. I included the chart for men last time, but overlooked the chart for women. My bad.

US-Health-in-Intl-Perspective_women

The top three causes of mortality for men were 1. Non-intentional injuries, 2. Non-communicable diseases, excluding cardio-vascular, and 3. Intentional injuries.

The top three causes of mortality for women were 1. Non-communicable diseases, excluding cardiovascular, 2. Non-intentional injuries, and 3. Perinatal conditions.

Since there is a separate category of maternal conditions for women, the perinatal conditions, which appears for both men and women, obviously refers to risks while being born rather than giving birth.

But the report goes beyond those findings to suggest possible sources of the problem and recommendations for further study.

It is not a simple discussion but a complicated one, filled with the kind of nuance and qualification common to academic work, and conspicuously missing in public discussion.

The Table of Contents gives a taste of the complexity, which suggests that remediation will be equally complex and multi-modal–not as simple as the public and their political representatives might prefer:

4 Public Health and Medical Care Systems, 106
Defining Systems of Care, 107

  1. Question 1: Do Public Health and Medical Care Systems
    Affect Health Outcomes?, 109
  2. Question 2: Are U.S. Health Systems Worse Than
    Those in Other High-Income Countries?, 110
  3. Question 3: Do U.S. Health Systems Explain the
    U.S. Health Disadvantage?, 132
  4. What U.S. Health Systems Cannot Explain, 133
  5. Conclusions, 135

5 Individual Behaviors 138

  1. Tobacco Use, 140
  2. Diet, 144
  3. Physical Inactivity, 147
  4. Alcohol and Other Drug Use, 149
  5. Sexual Practices, 152
  6. Injurious Behaviors, 154
  7. Conclusions, 159

6 Social Factors 161

  1. Question 1: Do Social Factors Matter to Health?, 163
  2. Question 2: Are Adverse Social Factors More
    Prevalent in the United States Than in Other High-Income
    Countries?, 170
  3. Question 3: Do Differences in Social Factors Explain the
    U.S. Health Disadvantage?, 185
  4. Conclusions, 190

7 Physical and Social Environmental Factors 192

  1. Question 1: Do Environmental Factors Matter to Health?, 193
  2. Question 2: Are Environmental Factors Worse in the
    United States Than in Other High-Income Countries?, 199
  3. Question 3: Do Environmental Factors Explain the
    U.S. Health Disadvantage?, 203
  4. Conclusions, 205

8 Policies and Social Values 207

  1. The Role of Public- and Private-Sector Policies, 209
  2. The Role of Institutional Arrangements on
    Policies and Programs, 211
  3. Societal Values, 219
  4. Policies for Children and Families, 225
  5. Spending Priorities, 233
  6. Conclusions, 236

The report notes:
It will also be important for Americans to engage in a thoughtful discussion about what investments and compromises they are willing to make to keep pace with health advances other countries are achieving. Before this can occur, the public must first be informed about the country’s growing health disadvantage, a problem that may come as a surprise to many Americans.

The report summarizes the costs of inaction:

20130108 Costs of Inaction from IOM report

The Verdict on US Health: Shorter Lives, Poorer Health Part I

If national defense were a simple matter of military might, the United States would have no concerns. We are clearly the military power of the century–the go-to nation when military power is to be projected.

The premise of this blog is that national defense depends upon more than military power–including economic power and the health of the citizenry. If that premise is correct, we’ve got problems.

As Americans we like to think we have the best of everything including a health care delivery system. That is simply, and demonstrably, not true.

A consensus report of the Institute of Medicine concludes that we face shorter lives and poorer health compared to other advanced countries.

A chart shows part of the problem, deaths before age 50:

US Deaths Before 50 Compared to Peer Countries

The latest report has a table showing the US in 17th place in longevity at birth.

US Life Expectancy at Birth Compared to Peer Countries
We are worse than other countries in 9 areas.

1. infant mortality and low birth weight
2. injuries and homicides
3. adolescent pregnancy and sexually transmitted infections
4. HIV and AIDS
5. drug-related deaths
6. obesity and diabetes
7. heart disease
8. chronic lung disease
9. disability

Next blog will deal with some of the report’s recommendations and conclusions.

Violence Prevention and Mental Health

The White House plan to reduce gun violence has substantial mental health provisions:

Children and Young Adults

  1. Project AWARE (Advancing Wellness and Resilience in Education) directed at students in schools
    • Mental health “first aid” training for teachers
    • Referral services for students
  2. Support individuals 16 to 25 outside of and beyond school
  3. School-based violence prevention, including mental health services for trauma and anxiety
  4. Train 5,000 mental health professionals to serve in the schools
  5. Initiate a national conversation to address stigma associated with mental illness

Ensure Mental Health Coverage

  1. Issue final regulations on private health insurance coverage of mental health treatment
  2. Ensure that Medicaid programs are meeting mental health parity requirements

In addition:

  • The $150 million Comprehensive School Safety program will help finance new school resource officers (police) or mental health professionals (psychologists, social workers, counselors).
  • The hiring decisions will be with local school districts.

My Take (this is a blog, isn’t it?)

  1. The problem of obtaining adequate mental health coverage for anyone is a major challenge because:
    1. There is neither a test nor a cure for mental illness, which means that diagnosis is expensive and difficult, and management is expensive and difficult
    2. Mental illness resembles a chronic illness with transitory remission, so there is a temptation to halt treatment during remission and hoard resources to deal with crises.
    3. Nearly all families and individuals, save the super wealthy (think $1 million in annual income), have insufficient resources to address the full spectrum of mental illness symptoms, some of which require residential treatment for long period to be optimally addressed
  2. Large segments of the population continue to provide moral diagnoses rather than accepting a medical diagnosis of mental illness
    1. Depressed people are seen as lazy and unmotivated; bipolar people are seen as lacking discipline
    2. The symptoms are largely invisible and intermittent–mental illness is only partially and rarely someone walking down he street talking to imaginary people.
    3. Consequently, a large part of the public is unwilling to finance the treatment of those seen as slackers.

    Bottom line: the Administration is to be commended for first steps, but any reasonable approach will require billions not millions of dollars

Policy, Politics, and Guns. Oh my!

No solutions here. Just some clarifications of a complicated subject.

1. While we have a constitutional right to “bear arms,” there is no obligation to do so.

Some people need guns. Most of us don’t. If you are a hunter (and not a bow hunter), you need a rifle or shotgun when you are hunting, but you can lock it up soundly the rest of the time.

For most people the use of a gun for self-defense is illusory—you aren’t going to get to the gun before someone gets to you.

Criminals often get guns by stealing them from licensed owners—so your gun is making lots of people unsafe.

Your gun is much more likely to be used for a suicide or discharged accidentally than for self-protection.

2. The constitutional right is not unlimited. The First Amendment is not unlimited: child pornography is not protected speech. The Second Amendment is not unlimited.

    a. There are prohibitions on owning automatic weapons and sawed-off shotguns.

    b. There is no protection for magazines with 30 rounds.

    c. The recent Heller case establishing a personal right was a 5-4 decision. Such decisions are often reversed when there is an absence of a national consensus.

3. There is no historical evidence that personally-owned guns have maintained freedom. There is clear evidence that they are the source of death from homicides, suicides, and accidents.

If we take a fantasy trip to an authoritarian United States of the future—several lifetimes from now, we will find that the U.S. military outguns any opposition, so in that fantasy world, only defections with weapons would have any impact on regime change.

In the present, civilian weapons are used to kill other civilians.

4. Personal automobiles are no more likely to be taken away than firearms, yet vehicles are registered, require proof of proficiency to operate, and require liability insurance.

The idea that anyone is taking away the firearms of the US civilian population is an excellent marketing ploy that has been successfully implemented several times in the past half century: someone suggests that there will be gun control as a first step to confiscation, and gun owners rush to the store to get more.

I do not claim to have answers to the problem of more than 30 thousand deaths from firearms annually.

However, I assert that in a democratic society we have the means to address the problem—and the obligation. We can do so with minimal inconvenience to anyone who wishes to legally own a firearm for hunting, target-shooting, or self-defense, while making it prohibitively inconvenient for individuals who wish to shoot school children.

Firearm Trends Leave Me Clueless

One of the more interesting aspects of firearm mortality is the trend over the past 15-20 years. Beginning in 1994 the rate of mortality began to drop. That was the year that the assault weapon ban passed. Note that the rate of firearm deaths was close to the rate for deaths in motor vehicle accidents.

Injury Deaths 1979_2007

The rate of firearm deaths dropped from 1993 to 1999 and has remained level since then. The rate of death from motor vehicle accidents has dropped, but not as steeply.

The rate of death from poisonings has nearly tripled. What is that all about?

It might be thought that the assault weapons ban brought down the death rate, but that is not likely. The chart below compares 1993 to 2004, showing that the rate for suicide with firearms dropped about the same as the rate for homicides. I may be mistaken, but assault weapons are not the weapon of choice for suicide. Something else must have been happening in those ten years, or until 1999, at least. I don’t know what it was, but it would be nice to replicate it.

Firearms 1993_2004

When events like the Newtown massacre dominate the airwaves, we would like to act to prevent the next one. I think we should act to prevent the next one. However, the data demonstrate how difficult it is to decide what will work. An effective policy does not have to solve the problem by ending all future incidents: it just has to demonstrate a substantial change in a positive direction. That will be challenge enough.

I really don’t want to write about guns . . .

Everyone has opinions on the subject, and few are indifferent.

The opinions are strongly held, not preferences. And everyone has recited the top 5 arguments for or against societal action, according to one’s opinion.

But how can anyone seriously write about health care in the United States without considering the impact of firearms?

I know that I am not interested in becoming one more activist in the debate—there are plenty of those on both sides. I also know that no opinion on any subject is without dissenters, including whether the sun will rise tomorrow morning.

Knowing that, I plan to point out some facts that might be generally agreed upon, no matter where one’s opinions lie.

First, firearm deaths are a public health concern. In 2010 there were 2,468,435 deaths in the United States from all causes, of which 31,328 were related to firearms. Deaths from firearms were 1.27 percent of all deaths, or one of every 78.8 deaths.

For purposes of comparison, there were 35,332 deaths from motor vehicle accidents that year, or 1.43 percent of all deaths, and one out of every 69.9 deaths. Source: National Vital Statistics Report, October 12, 2012, Centers for Disease Control and Prevention

Second, while the rate of death from firearms has been steady for the past ten or more years at about 10.2 per 100,000 of population, it is not equally distributed among age groups.

The risk of homicide by firearm is greatest between ages 18 and 44, while the risk of suicide rises with age through life.

Firearm Deaths by age and intent, 2001-2009

More to follow, reluctantly.