Peter D. Jacobson

Bariatric Surgery and Long-term Cardiovascular Events

CONTEXT Obesity is a risk factor for cardiovascular events. Weight loss might protect against cardiovascular events, but solid evidence is lacking. OBJECTIVE To study the association between bariatric surgery, weight loss, and cardiovascular events. DESIGN, SETTING, AND PARTICIPANTS The Swedish Obese Subjects (SOS) study is an ongoing, nonrandomized, prospective, controlled study conducted at 25 public surgical departments and 480 primary health care centers in Sweden of 2010 obese participants who underwent bariatric surgery and 2037 contemporaneously matched obese controls who received usual care. Patients were recruited between September 1, 1987, and January 31, 2001. Date of analysis was December 31, 2009, with median follow-up of 14.7 years (range, 0-20 years). Inclusion criteria were age 37 to 60 years and a body mass index of at least 34 in men and at least 38 in women. Exclusion criteria were identical in surgery and control patients. Surgery patients underwent gastric bypass (13.2%), banding (18.7%), or vertical banded gastroplasty (68.1%), and controls received usual care in the Swedish primary health care system. Physical and biochemical examinations and database cross-checks were undertaken at preplanned intervals. MAIN OUTCOME MEASURES The primary end point of the SOS study (total mortality) was published in 2007. Myocardial infarction and stroke were predefined secondary end points, considered separately and combined. RESULTS Bariatric surgery was associated with a reduced number of cardiovascular deaths (28 events among 2010 patients in the surgery group vs 49 events among 2037 patients in the control group; adjusted hazard ratio [HR], 0.47; 95% CI, 0.29-0.76; P = .002). The number of total first time (fatal or nonfatal) cardiovascular events (myocardial infarction or stroke, whichever came first) was lower in the surgery group (199 events among 2010 patients) than in the control group (234 events among 2037 patients; adjusted HR, 0.67; 95% CI, 0.54-0.83; P < .001). CONCLUSION Compared with usual care, bariatric surgery was associated with reduced number of cardiovascular deaths and lower incidence of cardiovascular events in obese adults.

Investing in youth tobacco control: a review of smoking prevention and control strategies

OBJECTIVE To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy. DATA SOURCES Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates. DATA SYNTHESIS Interventions and policy approaches that have been assessed or evaluated were categorised using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories. CONCLUSIONS Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programmes, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating “youth centred” tobacco prevention and control activities.

Implementing Clinical Practice Guidelines: Social Influence Strategies and Practitioner Behavior Change

Clinical practice guidelines offer potentially valuable tools for rationalizing health care delivery and improving patient outcomes. Currently, major efforts are under way to develop, test, and refine guidelines for a wide variety of medical conditions and procedures. Although methods for producing guidelines are fairly well understood and continue to improve, experience suggests that guidelines rarely translate directly into changes in practice. For various reasons, including physician resistance or incomplete understanding of the need for guidelines, they have proven difficult to implement. This article describes a broad range of strategies for implementing clinical practice guidelines based on the social influences that affect health practitioner behavior. The article also examines issues surrounding the selection and use of individual strategies or combinations of strategies in specific efforts to improve the quality of health care.

The implementation and enforcement of tobacco control laws: policy implications for activists and the industry.

We examine the process by which antitobacco laws and ordinances were implemented and enforced in seven states and nineteen localities. Our findings indicate that state- and local-level clean indoor air laws were rarely enforced by governmental agencies. Instead, these laws were largely self-enforcing in that changed social norms regarding appropriate smoking behavior led to generally high compliance rates. In contrast, teen access laws were not self-enforcing, but were often enforced through periodic vendor compliance checks. We also found that antitobacco forces did not devote a significant amount of attention of implementation and enforcement issues. Their focus was primarily on enacting new legislation and fighting tobacco industry attempts to weaken existing laws. Our results do not augur well for public health measures that require state-level enforcement and that are opposed by powerful and politically well-connected interests. For tobacco control laws to be effective, public health advocates need to consider the locus of enforcement responsibility and the sanctions available to the enforcement agency, such as license removal by local authorities. These results suggest that failure to specify such mechanisms in the legislation will lead to delays in implementing and enforcing the laws as well as to a number of compliance problems. Antitobacco coalitions will also need to become more actively involved in the implementation and enforcement process.

The Politics of Antismoking Legislation

To understand why some states have enacted relatively stringent laws to control smoking in public places while others have not, we examined the political evolution of tobacco control initiatives in six states: New York, Minnesota, Florida, Illinois, Texas, and Arizona. Taken together, the case studies demonstrate the difficulties inherent in enacting strong statewide tobacco control legislation. More important, several unmistakable themes emerge from these case studies, shedding light on the barriers to greater legislative success. These themes include the manner in which the legislative debate is framed by antismoking advocates and the tobacco industry, the relative dearth of leadership provided by medical and health organizations, the role of public opinion, and the complex interaction that exists between statewide antismoking legislation and local antismoking ordinances. Understanding how these issues affect legislative outcomes may help antismoking advocates enact future statewide tobacco control initiatives. It may also present lessons applicable to future battles over other public health legislation.

Litigation and Public Health Policy Making: The Case of Tobacco Control

Many tobacco control advocates, believing that legislators and regulators have failed to enact and implement sufficiently stringent tobacco control laws, have supported litigation as a means of achieving public health policy goals. In this article, we exa mine the relationship between litigation and public health policy formulation in the context of the debate over tobacco control policy. The fundamental questions are how social policy should be made regarding the use of tobacco products, and which institu tions should be responsible for controlling tobacco use: the market, the political system (i.e., the legislative and regulatory branches of government), or the courts. On balance we conclude that litigation is a second-best solution. We see a distinct rol e for litigation as a complement to a broader, comprehensive approach to tobacco control policy making, rather than as an alternative to the traditional political apparatus of formulating and implementing public health policy. Our analysis suggests that, in general, public health goals are more directly achievable through the political process than through litigation, though situations such as those concerning tobacco control blur the bounds between litigation and the politics of public health. Litigation has stimulated a national debate over the role of smoking in society and may well move the policy agenda. But we conclude that a sustained legislative and regulatory presence ought to be the foundation of meaningful policy changes.

ALK7 expression is specific for adipose tissue, reduced in obesity and correlates to factors implicated in metabolic disease

Human adipose tissue is a major site of expression of inhibin beta B (INHBB) which homodimerizes to form the novel adipokine activin B. Our aim was to determine if molecules needed for a local action of activin B are expressed in adipose tissue. Microarray analysis showed that adipose tissue expressed activin type I and II receptors and that the expression of activin receptor-like kinase 7 (ALK7) was adipose tissue specific. In obesity discordant siblings from the SOS Sib Pair study, adipose tissue ALK7 expression was higher in lean (n = 90) compared to obese (n = 90) subjects (p = 4 × 10−31). Adipose tissue ALK7 expression correlated with several measures of body fat, carbohydrate metabolism and lipids. In addition, ALK7 and INHBB expression correlated but only in lean subjects and in subjects with normal glucose tolerance. We conclude that activin B may have local effects in adipose tissue and thereby influence obesity and its comorbidities.

“Listen to the People”: Public Deliberation About Social Distancing Measures in a Pandemic

Public engagement in ethically laden pandemic planning decisions may be important for transparency, creating public trust, improving compliance with public health orders, and ultimately, contributing to just outcomes. We conducted focus groups with members of the public to characterize public perceptions about social distancing measures likely to be implemented during a pandemic. Participants expressed concerns about job security and economic strain on families if businesses or school closures are prolonged. They shared opposition to closure of religious organizations, citing the need for shared support and worship during times of crises. Group discussions elicited evidence of community-mindedness (e.g., recognition of an extant duty not to infect others), while some also acknowledged strong self-interest. Participants conveyed desire for opportunities for public input and education, and articulated distrust of government. Social distancing measures may be challenging to implement and sustain due to strains on family resources and lack of trust in government.

Alcohol consumption and alcohol problems after bariatric surgery in the swedish obese subjects study

Increased sensitivity to alcohol after gastric bypass has been described. The aim of this study was to investigate whether bariatric surgery is associated with alcohol problems.

Reducing Distracted Driving: Regulation and Education to Avert Traffic Injuries and Fatalities

In this article, we consider the legal and policy implications of distracted driving (the tendency of people to use electronic devices while operating a motor vehicle). After reviewing the empirical evidence showing that distracted driving has serious adverse consequences, we discuss the legal basis for governmental interventions to reduce distracted driving. These interventions include laws restricting the use of electronic devices while driving, especially sending text messages. Since drivers have at best a reduced expectation of privacy, these restrictions should easily survive legal challenges. At the same time, it is important to consider the responsibility of automobile manufacturers to improve safety though design changes. We also advocate health education to change social norms to reduce distracted driving.