Anthony Robbins

What's the Relative Risk? A Method to Directly Estimate Risk Ratios in Cohort Studies of Common Outcomes

PURPOSE In cohort studies of common outcomes, odds ratios (ORs) may seriously overestimate the true effect of an exposure on the outcome of interest (as measured by the risk ratio [RR]). Since few study designs require ORs (most frequently, case-control studies), their popularity is due to the widespread use of logistic regression. Because ORs are used to approximate RRs so frequently, methods have been published in the general medical literature describing how to convert ORs to RRs; however, these methods may produce inaccurate confidence intervals (CIs). The authors explore the use of binomial regression as an alternative technique to directly estimate RRs and associated CIs in cohort studies of common outcomes. METHODS Using actual study data, the authors describe how to perform binomial regression using the SAS System for Windows, a statistical analysis program widely used by US health researchers. RESULTS In a sample data set, the OR for the exposure of interest overestimated the RR more than twofold. The 95% CIs for the OR and converted RR were wider than for the directly estimated RR. CONCLUSIONS The authors argue that for cohort studies, the use of logistic regression should be sharply curtailed, and that instead, binomial regression be used to directly estimate RRs and associated CIs.

Predictors of low physical fitness in a cohort of active-duty U.S. Air Force members.

BACKGROUND Each branch of the U.S. armed forces has standards for physical fitness as well as programs for ensuring compliance with these standards. In the U.S. Air Force (USAF), physical fitness is assessed using submaximal cycle ergometry to estimate maximal oxygen uptake (VO2(max)). The purpose of this study was to identify the independent effects of demographic and behavioral factors on risk of failure to meet USAF fitness standards (hereafter called low fitness). METHODS A retrospective cohort study (N=38,837) was conducted using self-reported health risk assessment data and cycle ergometry data from active-duty Air Force (ADAF) members. Poisson regression techniques were used to estimate the associations between the factors studied and low fitness. RESULTS The factors studied had different effects depending on whether members passed or failed fitness testing in the previous year. All predictors had weaker effects among those with previous failure. Among those with a previous pass, demographic groups at increased risk were toward the upper end of the ADAF age distribution, senior enlisted men, and blacks. Overweight/obesity was the behavioral factor with the largest effect among men, with aerobic exercise frequency ranked second; among women, the order of these two factors was reversed. Cigarette smoking only had an adverse effect among men. For a hypothetical ADAF man who was sedentary, obese, and smoked, the results suggested that aggressive behavioral risk factor modification would produce a 77% relative decrease in risk of low fitness. CONCLUSIONS Among ADAF members, both demographic and behavioral factors play important roles in physical fitness. Behavioral risk factors are prevalent and potentially modifiable. These data suggest that, depending on a members risk factor profile, behavioral risk factor modification may produce impressive reductions in risk of low fitness among ADAF personnel.

Unplanned Pregnancy among Active Duty Servicewomen, U.S. Air Force, 2001

Unplanned pregnancy is a major public health problem in the United States. Although the U.S. Air Force has the highest proportion of active duty women of any of the U.S. military services, there are no published data on the occurrence of unplanned pregnancy among active duty Air Force (ADAF) women. Civilian female interviewers conducted telephone interviews with a random sample of 2,348 ADAF women during early 2002, using questions that were closely based on the 1995 National Survey of Family Growth. During 2001, approximately 12% of ADAF women had one or more pregnancies. By National Survey of Family Growth criteria, approximately 54% of these pregnancies were unplanned. Thus, approximately 7% of ADAF women had one or more unplanned pregnancies during 2001. Roughly one-half of unplanned pregnancies represented contraceptive nonuse and the other half represented contraceptive failure or misuse. Unplanned pregnancy is a serious and frequently occurring problem among ADAF women, with many opportunities for prevention.

How to understand the results of the climate change summit: Conference of Parties21 (COP21) Paris 2015.

In Paris on 13 December 2015, the Parties (state signatories) to the United Nations Framework Convention on Climate Change (UNFCCC) reached an agreement to guide future global climate change policy and actions. No country dissented – a tribute to the advocates, scientists, and investors who made up most of the 40 000 attendees at COP21. Reaching a global agreement, even a weak one, drew them together. They can now move forward assured that the world sees climate change as everyone’s problem and a global priority. How each party acts in the future will be ‘nationally determined’, a requirement that makes it hard to imagine that the global agreement will have revolutionary consequences. I attended COP21 at Le Bourget, the old airport north of Paris, the landing site in 1927 for Charles Lindbergh’s historic solo transatlantic flight. (The Secretariat of the UNFCCC kindly accredited me as a media representative for the Journal of Public Health Policy even though the Secretariat’s staff was at first stymied by my application. Ours was the first scholarly/academic journal to be so accredited.) The science and practice of public health are well-suited to understanding global warming and its effects. Yet the causes of global warming remain unusual forms of environmental pollution. Over the last three centuries, since the industrial revolution, human economic activity has discharged a group of chemicals called ‘greenhouse gases’ into the environment. Human activities, anywhere on earth, release these pollutants into the atmosphere. The gases, principally carbon dioxide, mix in the atmosphere, capturing heat and raising temperatures on the earth’s surface. Where they were released plays no role in how they cause the earth to warm, producing dangerous changes in climate. The effects

Weight gain as a barrier to smoking cessation among military personnel.

Purpose. To assess the relationships between active-duty military status, military weight standards, concern about weight gain, and anticipated relapse after smoking cessation. Design. Cross-sectional study. Setting. Hospital-based tobacco cessation program. Subjects. Two hundred fifty-two enrollees, of 253 eligible, to a tobacco cessation program in 1999 (135 men, 117 women; 43% on active duty in the military). Measures. Independent variables included gender, body mass index (weight/height2), and military status. Dependent variables included concern about weight gain with smoking cessation and anticipated relapse. Results. In multivariate regression analyses that controlled for gender and body mass index, active-duty military status was associated with an elevated level of concern about weight gain (1.9-point increase on a 10-point scale; 95% confidence interval [CI], 1.0- to 2.8-point increase), as well as higher anticipated relapse (odds ratio [OR] = 3.6; 95% CI, 1.3 to 9.8). Among subjects who were close to or over the U.S. Air Force maximum allowable weight for height, the analogous OR for active-duty military status was 6.9 (p = .02). Conclusions. Occupational weight standards or expectations may pose additional barriers for individuals contemplating or attempting smoking cessation, as they do among active-duty military personnel. These barriers are likely to hinder efforts to decrease smoking prevalence in certain groups.

Obesity as collateral damage: A call for papers on the Obesity Epidemic

In this call for papers, we encourage authors to submit articles considering how to change the behavior of the food industry. Here’s why. Since we published the Special Section on Legal Approaches to the Obesity Epidemic from the Public Health Advocacy Institute in 2004, the Journal has fully engaged in debates over obesity – its causes and how to prevent it. (The JPHP website displays a collection of articles on nutrition and obesity at http://www.palgrave-journals.com/jphp/ collections/food_and_obesity_collection.html.) Obesity surely constitutes an epidemic – a global phenomenon, seen in low income, as well as affluent countries. It often coexists with hunger and malnutrition. What are the underlying, root causes of obesity and its public health consequences? We know that almost every country has created policies to prepare for and to avoid famine and food shortages that might damage their people, and disrupt their economies and social fabric. In 2010, Russia blocked wheat exports when bad weather destroyed its crops. The United States government, since early in the last century, has supported food production through subsidies and other policies, resulting in large surpluses of food commodities, meat, and calories. These policies maintain the price of food at artificially low levels and have reduced the percentage of personal income spent on food to the lowest in the world. In this artificial market, large food producers and corporations – Big Agriculture and Big Food – became very profitable. The first set of countries to experience economic concentration, starting before the Great Depression – the United States, Japan, and countries in Europe – found that just a few corporations came to dominate each segment of the food industry. These firms integrated vertically to the point where they now own, and increase their profitability from, every step in the chain of production from farms to wholesale distribution of processed foods. In the past 30 years in the United States, for example, consolidation by corporations means that the number of separately owned hog farms decreased by nearly 90 per cent, and only four per cent of the millions of hogs raised by US

International childhood vaccine initiative.

In 1974 as the global smallpox eradication program neared successful completion, the Expanded Program on Immunization (EPI) was launched. The goal of the EPI was global, universal immunization of children against tuberculosis, diphtheria, pertussis, tetanus, polio and measles. By 1990 EPI efforts in surveillance, organization, supply and education resulted in over 500 million contacts per year between EPI workers and children. Because of these efforts 80% of children born in the world today receive the six vaccines mentioned above. The efforts of the EPI are carried out in developing countries with funds contributed by industrialized nations to international agencies like the United Nations and the World Health Organization, as well as monies from local governments. Although the United States is a major supporter of the EPI, there seems to be a lack of awareness of these activities among pediatric health care providers. The purpose of this report is to raise awareness of and gain support for vaccine initiatives worldwide.

A Rightful Place for Public Health in American Law

Public health is a discipline that employs the science of epidemiology to study and explain phenomena in and affecting populations; it relies upon its own values, methodologies, and perspectives to analyze the world. The authors argue that public health perspectives and the public health implications of legal doctrines should be a component of core law school courses.

Public Health Literacy for Lawyers

ublic health professionals recognize the critical role the law plays in determining the success of public P health measures.’ Even before September 11, 2001, public health experience with tobacco use, HIV, industrial pollution and other potent threats to the health of the public demonstrated that laws can assist or thwart public health efforts. The new focus on infectious threats and biotemrism, starting with the anthrax attacks through the mail and continuing with SARS, has highlighted the important role of law. For lawyers to serve as effective partners in public health, they should have a basic familiarity with public health: how public health professionals see the world and the key issues they tackle. A practical grasp of public health can be acquired, and often is acquired, “on the job.” But perhaps that is not enough. I f lawyers are to be competent members of the public health team and understand the public health implications of the laws, iules, and regulations they draft, enforce, litigate, and adjudicate, they should be more firnlly grounded in the theory, practice, and problems of public health. That suggests that law schools should provide their students with ample exposure to public health. The idea that professional education programs should, but often fail, to incorporate elements considered to be beyond the profession’s normal domain is not new. Medicine has done poorly at teaching public health.2 An analogous deficiency has existed in schools of engineering, where few students are taught the basics of worker protection and pollution control, despite the fact that engineers design the plants and equipment that injure and pollute.’ The National Institute for Occupational Safety and Health has funded and worked with engineering schools to incorporate worker safety in the curri~ula.~

The U.S. health data privacy debate. Will there be comprehension before closure

After 25 years of debate about privacy of automated personal health data, the U.S. Congress has set a deadline of August 1999 for enacting health information privacy legislation. The urgency to establish national policy in the United States re-emerges with implementation of a 1996 law mandating a unique identifier for each participant in the U.S. medical care system and the use of a uniform electronic data set for all health information transmitted in financial and administrative transactions. The impact of electronic data storage and transmittal on privacy, health outcomes, and medical care is unclear. A three-step analytic scheme can clarify the issues in the policy debate and for future assessment. The first step is intended to elicit, for the first time, a precise, accurate, and reproducible description of personal health data transactions and chains of transactions, independent of the policy preferences of any interested party. The second step allows the reader to analyze these transactions according to who benefits first and foremost from each. This scrutiny clarifies the reasons why parties to the debate tend to disagree. The third step characterizes how Congress is likely to perceive the policy process and consider its options before enacting any particular set of compromises. Understanding the policy deliberations and potential effects of evolving information technologies and new national privacy rules should aid assessment of results.