Laura A. Schmidt

Public health: The toxic truth about sugar

Added sweeteners pose dangers to health that justify controlling them like alcohol, argue Robert H. Lustig, Laura A. Schmidt and Claire D. Brindis.

Substance abuse and the course of welfare dependency.

OBJECTIVES New provisions in welfare reform target recipients with addictions, even though there is limited research on how substance abuse affects peoples experiences on welfare. This prospective study examined substance abuse as a determinant of subsequent welfare dependency. METHODS Representative samples of clients on Aid to Families with Dependent Children (AFDC) and general assistance in a California county were interviewed while applying for services in 1989 and were reinterviewed in 1995. RESULTS Among AFDC recipients, substance abuse was not a significant determinant of long welfare stays, repeat welfare use, or the total time a person remained on welfare during the 6-year period. However, substance abuse was a strong predictor of repeat welfare use among general assistance recipients. CONCLUSIONS Alcohol and drug problems have played dramatically different roles in welfare dependency within the AFDC and general assistance populations. Under welfare reform, local general assistance programs will be the final safety net for recipients removed from federal entitlement programs. These programs will probably be confronted with clients with more complex disabilities related to addiction, as well as with greater family needs for cash assistance.

Alcohol and drug problems among diverse health and social service populations.

OBJECTIVES This study responds to clinical and research interest in identifying alcohol- and drug-related problems in health and social service agency populations. These problems are associated with a variety of illnesses and social problems, and community agencies serve important screening functions. METHODS Indicators of problematic alcohol and drug use are compared across representative samples of clients within a countys alcohol, mental health, and drug treatment systems; hospital emergency rooms; primary health clinics; criminal justice and welfare systems; and general population. RESULTS Agencies followed a consistent rank ordering in the prevalence of substance abuse indicators. Highest prevalences were found in the populations of behavioral health agencies, including alcohol, drug, and mental health treatment facilities and criminal justice, followed by welfare agencies. General medical agencies served populations with the lowest prevalence and problem severity. CONCLUSION Health and social service agencies provide significant opportunities for the screening and referral of individuals with problematic alcohol and drug use. Although behavioral agencies have higher potential for referral and intervention, general medical services may be more effective in conducting prevention and early case-finding activities.

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents

Early warning signals of the coronary heart disease (CHD) risk of sugar (sucrose) emerged in the 1950s. We examined Sugar Research Foundation (SRF) internal documents, historical reports, and statements relevant to early debates about the dietary causes of CHD and assembled findings chronologically into a narrative case study. The SRF sponsored its first CHD research project in 1965, a literature review published in the New England Journal of Medicine, which singled out fat and cholesterol as the dietary causes of CHD and downplayed evidence that sucrose consumption was also a risk factor. The SRF set the reviews objective, contributed articles for inclusion, and received drafts. The SRFs funding and role was not disclosed. Together with other recent analyses of sugar industry documents, our findings suggest the industry sponsored a research program in the 1960s and 1970s that successfully cast doubt about the hazards of sucrose while promoting fat as the dietary culprit in CHD. Policymaking committees should consider giving less weight to food industry-funded studies and include mechanistic and animal studies as well as studies appraising the effect of added sugars on multiple CHD biomarkers and disease development.

Evaluation of patient centered medical home practice transformation initiatives.

Background:The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Methods:Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. Results:A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Conclusions:Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Interpersonal Violence Among Women Seeking Welfare: Unraveling Lives

OBJECTIVES Exposure to violence is a widespread problem among women who receive welfare benefits. Research has focused on partner violence among women with children on Temporary Assistance for Needy Families (TANF), ignoring low-income women without dependent children who are eligible for General Assistance (GA). METHODS We report findings from a survey of 1235 women seeking TANF (N=1095) and GA (N=140) throughout a California county. RESULTS Estimates of recent physical, sexual, and severe violence were high in both populations. However, the highest rates occurred among women without children seeking GA, suggesting that they are at higher risk for sexual violence and more severe forms of physical violence, especially from intimate partners. This increased risk is partly accounted for by the co-occurrence of other serious health and social problems. In multivariate analyses, past-year violence was associated with substance use (adjusted odds ratio [AOR]=2.0, 95% confidence interval [CI] = 1.5, 2.9), recent homelessness (AOR = 1.9, 95% CI = 1.4, 2.6), family fragmentation including divorce or separation (AOR=3.1, 95% CI 1.8, 5.2), or foster care involvement (AOR=2.2, 95% CI=1.1, 4.5) CONCLUSIONS Welfare reform created TANF programs to address domestic violence. Women seeking GA may need similar services because of the high prevalence of violence.

Sugar Industry Influence on the Scientific Agenda of the National Institute of Dental Research’s 1971 National Caries Program: A Historical Analysis of Internal Documents

Background In 1966, the National Institute of Dental Research (NIDR) began planning a targeted research program to identify interventions for widespread application to eradicate dental caries (tooth decay) within a decade. In 1971, the NIDR launched the National Caries Program (NCP). The objective of this paper is to explore the sugar industry’s interaction with the NIDR to alter the research priorities of the NIDR NCP. Methods and Findings We used internal cane and beet sugar industry documents from 1959 to 1971 to analyze industry actions related to setting research priorities for the NCP. The sugar industry could not deny the role of sucrose in dental caries given the scientific evidence. They therefore adopted a strategy to deflect attention to public health interventions that would reduce the harms of sugar consumption rather than restricting intake. Industry tactics included the following: funding research in collaboration with allied food industries on enzymes to break up dental plaque and a vaccine against tooth decay with questionable potential for widespread application, cultivation of relationships with the NIDR leadership, consulting of members on an NIDR expert panel, and submission of a report to the NIDR that became the foundation of the first request for proposals issued for the NCP. Seventy-eight percent of the sugar industry submission was incorporated into the NIDR’s call for research applications. Research that could have been harmful to sugar industry interests was omitted from priorities identified at the launch of the NCP. Limitations are that this analysis relies on one source of sugar industry documents and that we could not interview key actors. Conclusions The NCP was a missed opportunity to develop a scientific understanding of how to restrict sugar consumption to prevent tooth decay. A key factor was the alignment of research agendas between the NIDR and the sugar industry. This historical example illustrates how industry protects itself from potentially damaging research, which can inform policy makers today. Industry opposition to current policy proposals—including a World Health Organization guideline on sugars proposed in 2014 and changes to the nutrition facts panel on packaged food in the US proposed in 2014 by the US Food and Drug Administration—should be carefully scrutinized to ensure that industry interests do not supersede public health goals.

How Do Integrated Health Care Systems Address Racial and Ethnic Disparities in Colon Cancer

PURPOSE Colorectal cancer (CRC) disparities have persisted over the last two decades. CRC is a complex disease requiring multidisciplinary care from specialists who may be geographically separated. Few studies have assessed the association between integrated health care system (IHS) CRC care quality, survival, and disparities. The purpose of this study was to determine if exposure to an IHS positively affects quality of care, risk of mortality, and disparities. PATIENTS AND METHODS This retrospective secondary-data analysis study, using the California Cancer Registry linked to state discharge abstracts of patients treated for colon cancer (2001 to 2006), compared the rates of National Comprehensive Cancer Network (NCCN) guideline-based care, the hazard of mortality, and racial/ethnic disparities in an IHS versus other settings. RESULTS More than 30,000 patient records were evaluated. The IHS had overall higher rates of adherence to NCCN guidelines. Propensity score-matched Cox models showed an independent and protective association between care in the IHS and survival (hazard ratio [HR], 0.87; 95% CI, 0.85 to 0.90). This advantage persisted across stage groups. Black race was associated with increased hazard of mortality in all other settings (HR, 1.15; 95% CI, 1.04 to 1.27); however, there was no disparity within the IHS for any minority group (P > .11 for all groups) when compared with white race. CONCLUSION The IHS delivered higher rates of evidence-based care and was associated with lower 5-year mortality. Racial/ethnic disparities in survival were absent in the IHS. Integrated systems may serve as the cornerstone for developing accountable care organizations poised to improve cancer outcomes and eliminate disparities under health care reform.

Behavioral health problems as barriers to work: results from a 6-year panel study of welfare recipients.

Over the course of welfare reform, behavioral health problems have emerged as significant issues. Welfare time limits have added urgency to recipients’ efforts to obtain economic self-sufficiency and have raised new concerns about mental health and substance abuse problems as barriers to work. However, there is limited research on how behavioral health problems operate to impede the employability of welfare recipients. This analysis draws on data from a 6-year panel study of welfare recipients (n = 341) to examine how a broad spectrum of mental health and substance abuse problems impact efforts to obtain work while on aid and subsequent transitions from welfare to work. Recipients who reported symptoms of depression at baseline were less likely to actively search for work while on aid compared to others. However, they were no less likely to leave welfare for work within a 2-year time frame. In contrast, other problems – including hostility, interpersonal sensitivity, psychoticism, and heavy drug use – had significant effects on work exits from welfare but little association with job search activities. Overall, these results suggest that behavioral health problems do not operate in the same manner to inhibit transitions from welfare to work. Welfare-to-work programs should direct interventions towards the unique constellations of problems that recipients face.