Sodium Reduction

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Colleagues:

You have probably seen coverage in the media today regarding a report by the IOM on recommended levels of sodium for consumers. The conclusion of the report was that the scientific analysis of the existing studies did not support the lowering of recommended levels beyond the current 2,300 mg.

As you know, the AHA has advocated strongly for a reduction to 1,500 mg, not only for the high risk populations identified by the CDC, but for the general population as well.

We disagree with the IOM reports conclusions, primarily for two reasons – the methodology involved in analyzing existing scientific studies, and the focus on ‘health outcomes’, NOT the impact of sodium on blood pressure….one of the major risk factors for heart disease.

In this video link, longtime AHA volunteer Elliott M. Antman, M.D., Director of the Samuel A. Levine Cardiac Unit at Brigham and Women’s Hospital in Boston explains our position. http://youtu.be/OQtoDD6DYPk. You can read more on this in our formal AHA our response to media.

The takeaway for staff – we still believe in and strongly support the science behind our 1500 recommendation. That has not and will not change. And, in addition, whether 2300 or 1500, the fact that the general public is now at an average level of 3400, it is clear that we need to do more, now, to reduce consumption.

I urge you to watch this video so that you can better informed and more able to present our position to volunteers or other interested parties. If you have any questions, please reach out to your local Communications staff who can elevate concerns through the appropriate channels at National Center.

Communication Technology Tools in Public Health

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Even before the internet, and the emergence of social media, communication tools were key elements of a public health campaign, including television and radio, printed media and materials and live or recorded multi-media presentations (Resnick & Siegel, 2013). Radio is an effective media for public health because of its potential to reach a large audience and its relatively low production cost, especially in the form of a live, talk radio program or a public service announcement (Resnick & Siegel, 2013). Print media, including magazines, newspapers and newsletters or direct mail are used in public health because of its ability to target certain groups of people (Resnick & Siegel, 2013). Finally, multi-media presentations, including live presentations or recorded video presentations can be used to target specific groups of people and can have a greater impact if the presenter is viewed as an expert and if the material is informative (Resnick & Siegel, 2013).

Communication technology and cardiac rehabilitation
For patients that choose to participate in a home-internet based cardiac rehabilitation program, the communication strategy must include not only physical activity, but education on risk factors and social support (Blanchard et al. 2010). Two communication technologies that will be used in the campaign to increase participation in cardiac rehabilitation will include printed materials provided by their healthcare provider and an interactive web site that includes social media. These two strategies will focus on two primary access points for the cardiac rehabilitation patient, the health care provider and the internet. The printed materials will be in the form of flyers, posters, and educational booklets with clear instructions and contact information that will be available in the hospital and physician’s office. These materials will be given to the patient directly by their healthcare provider. The web site will include multi-media educational materials, blogs that are written and administered by cardiac rehabilitation professionals, and discussion groups on a variety of topics. All of the educational materials will be developed with patients with low levels of health literacy in mind, but will be interactive so that patients with adequate health literacy will also benefit.

One challenge to the use of communication technology in the campaign to increase participation in cardiac rehabilitation is the low rates of health literacy in the United States (Kutner, Greenberg, Kin & Paulsen, 2006). According to Kutner et al. (2006) over 90 million Americans lack the skills necessary to interpret, process and act upon health information. Patients that do not participate in a cardiac rehabilitation program must pull information together from a variety of sources in order to implement a cardiovascular risk reduction program on their own, which is extremely challenging if they have low health literacy. According to Balady et al. (2011) patients with low levels of health literacy, poor self-management skills, and do not speak English as their primary language are less likely to be referred to a cardiac rehabilitation program by their health care provider.
Addressing the challenge
A strategy for addressing low levels of health literacy is to make the printed and web based materials an opportunity for teaching and learning, rather than simply a medium for exchanging information. The U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010) has developed an action plan for improving health literacy. Simplifying the message and building from foundational content and skills are methods of addressing low levels of health literacy that will be used in the campaign to increase participation in cardiac rehabilitation. Materials will be interactive and multi-media, so that the same material can be accessed through pencil and paper as well as smart phone applications.
References
Balady, G.J., Ades, P.A., Bittner, V.A., Franklin, B.A., Gordon, N.F., Thomas, R.J., Tomaselli, G.T., & Yancy, C.W. (2011). Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: A presidential advisory from the American Heart Association. Circulation. 124, 2951-2960.
Blanchard, C.M., Reid, R.D., Morrin, L.I., McDonnell, L., McGannon, K., Rhodes, R.E., Spence, J.C., and Edwards, N. (2010). Demographic and clinical determinants of moderate to vigorous physical activity during home-based cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation. 30,240-245.
Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483).U.S.Department of Education. Washington, DC: National Center for Education Statistics.
Resnick, E.A., & Siegel, M. (Eds.). (2013). Marketing Public Health: Strategies to promote tocial change. (3rd ed.). Burlington, MA, Jones & Bartlett.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.

Increasing the use of Cardiac Rehabilitation

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Cardiac Rehabilitation is a program of exercise training and lifestyle modification for individuals that have had a myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, and stable angina (Wenger, 2008). According to Roger, et al. (2012) an estimated 82.6 million Americans, one in three, have cardiovascular disease, including 8 million heart attack survivors, 10 million suffering from stable angina pectoris, 6.5 million suffering from heart failure and 8 million with peripheral artery disease (Roger, et al. 2012). While all of these patients meet the indication for cardiac rehabilitation, only 22.1% of male and 14.3% of female myocardial infarction survivors are referred to a traditional cardiac rehabilitation program (Suaya, Shephard, Normand, Ades, Prottas and Stason, 2007).
Is the low referral rate because cardiac rehabilitation is not effective? In an observational study, a dose response between exercise training and death was found (Hammill, Curtis, Schulman and Whellan, 2010). Patients that participated in all 36 exercise sessions had a 47% lower risk of death and a 31% lower risk of myocardial infarction compared to these that only attended 1 session (Hammill, Curtis, Schulman and Whellan, 2010). In a randomized trial, exercise training following compared favorably to angioplasty in patients with stable coronary artery disease (Hambrecht, et al. 2004). Finally, Chow, et al (2010) and Witt et al. (2004) found cardiac rehabilitation and lifestyle modification to reduce the risk of death and recurrent myocardial infarction.

If cardiac rehabilitation is a medical service provided by hospitals, why should there be a public health campaign to increase participation? Despite evidence that cardiac rehabilitation is both safe and effective, there are significant barriers including reimbursement, lack of access to a facility, and poor motivation on the part of the patient (Wenger, 2008). Since healthcare providers are unable or unwilling to provide and refer to programs, public health may be the only way to make cardiac rehabilitation a viable entity.
One potential challenge of developing the campaign
If all patients that had a myocardial infarction, coronary artery bypass surgery, and percutaneous intervention were referred to cardiac rehabilitation, the capacity of traditional cardiac rehabilitation programs would need to increase approximately 2.5 million patients per year (Roger, et al., 2012). This would require adding facilities, equipment and staff, creating additional financial stress to the system. Since reimbursement for cardiac rehabilitation is already inadequate, it is unlikely that hospitals would be willing to make such a capital investment.

A way to address the financial pressure of adding patients into a system that has been unable to solve this problem is to promote the use and development of home and web based cardiac rehabilitation. Balady, et al. (2011) has proposed the development of alternative forms of cardiac rehabilitation including Home based and web based programs, which have been shown to be both safe and effective. A home-web based cardiac rehabilitation program would be much more cost effective to develop and would not have the capacity constraints of a traditional, hospital based cardiac rehabilitation program. The focus of the public health campaign to promote the use of cardiac rehabilitation will be on educating patients and healthcare providers about the benefits of cardiac rehabilitation, motivating and engaging patients to participate, and providing content, tools and parameters for participation.

References
Balady, G.J., Ades, P.A., Bittner, V.A., Franklin, B.A., Gordon, N.F., Thomas, R.J., Tomaselli, G.F., and Yancy, C,W. (2011). Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: A presidential advisory from the American Heart Association. Circulation. 124, 2951-2960.
Chow, C.K., Jolly, S., Rao-Melancini, P., Fox, K.A.A., Anand, S.S., and Yusuf, S. (2010). Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndrome. Circulation. 121,750-758.
Hambrecht, R., Walther, C., Mobius-Winkler, S., Gielen, S., Linke, A., Conradi, K., Erbs, S., Kluge, R., Kendziorra, K., Sabri, O, Sick, P and Schuler, G. (2004). Percutaneous coronary angioplasty with exercise training in patients with stable coronary artery disease: A randomized trial. Circulation. 109, 1371-1378.
Hammill, B.G., Curtis, L.H., Schulman, K.A., and Whellan, D.J. (2010). Relationship between cardiac rehabilitation and long term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation. 121, 63-70.
Roger, VL., Go, A.S., Lloyd-Jones, D.M., Benjamin, E.J., Berry, J.D., Borden, W.B., Bravata, D.M., Dai, S., Ford, E.S., Fox, C.S., Fullerton, H.J., Gillespie, C., Hailpern, S.M., Heit, J.A., Howard, V.J., Kissela, B.M., Kittner, S.J., Lackland, D.T., Lichtman, J.H., Lisabeth, L.D., Makuc, D.M., Marcus, G.M., Marelli, A., Matchar, D.B., Moy, C.S., Mozaffarian, D., Mussolino, M.E., Nichol, G., Paynter, N.P., Soliman, E.Z., Sorlie, P.D., Sotoodehnia, N., Turan, T.N., Viriani, S.S., Wong, N.D., Woo, D., Turner, M.B., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee (2012. Heart disease and stroke statistics – 2012 update: A report from the American Heart Association. Circulation, 125, e2-e220.
Suaya, J.A., Shepard, D.S., Normand, S.T., Ades, P.A., Prottas, J., and Stason, W.B. (2007). Use of cardiac rehabilitation by medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 116,
Wenger, N.K. (2008). Current status of cardiac rehabilitation. Journal of the American College of Cardiology. 51, 1619-1631.
Witt, B.J., Jacobsen, S.J., Weston, S.A., Killian, J.M., Meverden, R.A., Allison, T.G., Reeder, G.S., and Roger, V.L. (2004). Cardiac rehabilitation after myocardial infarction in the community. Journal of the American College of Cardiology. 44, 988-996.

Can Biology + Behavior Be Defused?

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African Americans with Hypertension

The link between the biological mechanisms affecting blood pressure and the behaviors related to high blood pressure is stress (Miller, Chen, & Cole, 2009). Upstream from the stress response are social factors related to elevated blood pressure, such as education and income disparities, while downstream from this is the risk of hypertension, heart disease, stroke and end-stage renal disease (Gereab, 2012). While these factors are present in all humans, and are a necessary component of the sympathetic system’s response to acute and chronic stress, they are especially true in the African American population. The prevalence of hypertension is 43% in African American males compared to 33.9% among white males and 45.7% among African American females compared to white females and according to Roger et al. (2012) the gap is getting wider and rate of hypertension among African Americans is among the highest in the world (Roger, 2012).
Health inequities and Hypertension in African Americans
While much attention focuses on adult behavior and genetic factors, there is a growing understanding that many diseases, including heart disease, hypertension and stroke are determined by socioeconomic conditions, intra-uterine development and early life experiences (Shonkoff, Boyce & McEwen (2009). The rate of high blood pressure in children and adolescents has been increasing since 1988 and African American and Hispanic children have a much higher prevalence than while children (Roger et al. 2012). African American children are also less active than while children (Roger et al. 2012).

According to Gravlee, Dressler, and Bernard (2005) social classification, rather than genetic factors, skin color, dietary habits, and body mass index is the main determinant of both systolic and diastolic blood pressure. Years of education and household income had the strongest relationships with blood pressure. According to Wilkinson and Pickett (2009) the effects of chronic stress is high blood pressure. Of course, there are different types of stress; some stressors impact the wealthy, while others impact the poor. The stress of violence and survival that is confronted by people of low socioeconomic status appears to have a greater impact on health (Wilkinson & Pickett, 2009). In the Jackson Heart Study, stress at least partially explained the relationship between hypertension and socioeconomic status in African Americans (Gereab, 2012). One component of stress, present in many African Americans is discrimination, and was found to be associated with hypertension in African Americans (Sims et al., 2012). Lifetime discrimination burden and discrimination burden were found to be related to hypertension, while to relationship was found with everyday discrimination (Sims et al. 2012).

Health inequities and Life Expectancy in African Americans

There are 76 million Americans living with hypertension, or high blood pressure (Roger et al. 2012). The death rate from hypertension is increasing but disproportionately impacts the African American population (Roger et al. 2012). The death rate for white males is 16.5 and 50.3 for African American males; the death rate for while females is 14.5 and 38.6 for African American females. African Americans develop hypertension earlier in life and compared to whites have a 1.8 times risk of stroke, 1.5 times risk of heart disease and 4.2 times risk of end stage renal disease (Roger et al. 2012).

References
Gereab, S.Y., Diez-Roux, A.V., Hickson, D.A., Boykin, S., Sima, M., Sarpong, D.F., Taylor, H.A., and Wyatt, S.B. (2012). The contribution of stress to the social patterning of clinical and subclinical CVD risk factors in African Americans: The Jackson Heart Study. Social Science & Medicine. 75, 1697-1707
Gravlee, C.C., Dressler, W.W., & Bernard, H.R. (2005). Skin color, social classification, and blood pressure in southeastern Puerto Rico. American Journal of Public Health. 95, 2191-2197.
Miller, G., Chen, E., & Cole, S. (2009). Health psychology: Developing biologically plausible models linking the social world and physical health. Annual Review of Psychology, 60, 501–524.
Roger, VL., Go, A.S., Lloyd-Jones, D.M., Benjamin, E.J., Berry, J.D., Borden, W.B., Bravata, D.M., Dai, S., Ford, E.S., Fox, C.S., Fullerton, H.J., Gillespie, C., Hailpern, S.M., Heit, J.A., Howard, V.J., Kissela, B.M., Kittner, S.J., Lackland, D.T., Lichtman, J.H., Lisabeth, L.D., Makuc, D.M., Marcus, G.M., Marelli, A., Matchar, D.B., Moy, C.S., Mozaffarian, D., Mussolino, M.E., Nichol, G., Paynter, N.P., Soliman, E.Z., Sorlie, P.D., Sotoodehnia, N., Turan, T.N., Viriani, S.S., Wong, N.D., Woo, D., Turner, M.B., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee (2012. Heart disease and stroke statistics – 2012 update: A report from the American Heart Association. Circulation, 125, e2-e220.
Shonkoff, J., Boyce, W., & McEwen, B. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. JAMA: Journal of the American Medical Association, 301(21), 2252–2259.
Sims, M., Diez-Roux, A.V., Dudley, A., Gereab, S.Y., Wyatt, S.B., Bruce, M.A., James, S.A., Robinson, J.C., Williams, D.R., & Taylor, H.A. (2012). Perceived discrimination and hypertension among African Americans in the Jackson Heart Study. American Journal of Public Health. 102, 5258-5265.
Wilkinson, R., & Pickett, K. E. (2009). The spirit level: Why greater equality makes societies stronger. New York, NY: Bloomsbury Press.

Moving Upstream to Improve Population Health Down the Road

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We are all born equal

Although we live in a culture that believes that we are all born equal, the facts simply do not bear this out. While the infant mortality rate for white women is the United States is 3.7 per 1000 births, it is 10.2 per 1000 births for African American women and this is true even educated and professional women (Strain, MacLowry, & Stange), Ignoring these facts creates a political climate that resists and rejects measures designed to level the playing field (Bezrushka, 2005). Among the 24 wealthiest nations in the world, the United States ranks near the bottom in measures of childhood inequality, including material, education and health well-being (Adamson & UNICEF, 2010). If wealth, or the lack of it was solely based on merit, or achievement, there would be less concern, but both extremes, the rich are the poor, are largely determined by the circumstances of their birth, that of their parents, especially their mother, and even the maternal grandmother.

Origins of Life and Adult Mortality

According to Bezrushka (2005) life begins in the womb of the maternal grandmother, and much of health is determined in the first 5 years of life. Heart disease is the leading cause of death in the United States, placing enormous emotional and economic burden, and its origins can be traced back to the origins of life (Cota & Allen, 2010). Maternal nutrition affects the development of the placenta and weight of the infant at births, which are predictors of heart disease, hypertension, diabetes and osteoporosis later in life (Cota & Allen, 2010). After birth, the nutrition of the infant and child also impact health of the individual well into the next generation (Gluckman, 2010). Stress on the fetus and the development of the placenta impact the development of the immune system, other metabolic pathways and even the phenotypic expression of genes (Cota & Allen, 2010).

Challenges

A challenge facing our ability to address the upstream health related issues is the quality and priorities of our current educational system (Wilkinson & Pickett, 2009). Mirroring the relationship between income inequality and health, income inequality also impacts educational performance and these inequalities, such as low health literacy create health disparities (Wilkinson & Pickett, 2009). For example, my children are not required to take health or physical education in school, further reinforcing a sedentary lifestyle and low levels of health literacy. According to Bezrushka (2005), another challenge is our tax policy, which is an advantage to the rich and to corporations, but is not good for the health of the Nation. Sweden, for example, has high tax rates and requires one full year of maternity leave, has a much lower income gap and better health outcomes, and this is a benefit to all, including the rich (Bezrushka, 2005).

Improving child health.

One solution to improving child health is to place more emphasis on better nutrition, not only for the children, but also for the mother. Better nutrition for the mother will improve fetal development, resulting in a higher birth weight and a healthier child. Also, the nutritional habits of the mother will be passed on to her children, creating a genetic a behavioral legacy for generations to come.
Another strategy is to create a more egalitarian society, as described by Bezrushka (2005) that emphasizes caring and sharing. Greed is bad for health, and if we could convince the rich and powerful that they would be happier and healthier if they shared some of that wealth, we would be all better off (Bezrushka, 2005). Wealth can be redistributed, not by creating a welfare state, but by creating a level playing field, especially as it relates to education and healthcare. Creating a culture of education, where it was socially acceptable, even desired to seek higher education would benefit all, including the rich.

References
Adamson, P., & UNICEF. (2010). The children left behind—A league table of inequality in child well-being in the world’s most rich countries. Innocenti Report Card 9. Florence, Italy: UNICEF Innocenti Research Centre.
UNICEF (2010), ‘ The Children Left Behind: A league table of inequality in child well-being in the world’s rich countries’, Innocenti Report Card 9, UNICEF Innocenti Research Centre, Florence.
The Barker Foundation. (n.d.) The Barker Theory. Retrieved from http://www.thebarkertheory.org/

Bezruchka, S. (Producer). (2005, April 15). From womb to tomb: The influence of early childhood on adult health [Audio podcast]. Retrieved from http://www.alternativeradio.org/products/bezs002
Bezruchka, S. (2005, April 15). From the Womb to the Tomb [Podcast identification number: BEZS002aM]. Alternative Radio. Podcast retrieved from: http://www.alternativeradio.org/programs/BEZS002.shtml
Cota, B., & Allen, P. (2010). The developmental origins of health and disease hypothesis. Pediatric Nursing, 36(3), 157–167.
Haflon, N. (2009, February). Life course health development: A new approach for addressing upstream determinants of health and spending. Expert Voices. Retrieved fromhttp://www.nihcm.org/pdf/ExpertVoices_Halfon_FINAL.pdf
Life Course Health Development: A New Approach for Addressing Upstream Determinants of Health and Spending by Halfon, N., in Expert Voices.
Strain, T. H., MacLowry, R., & Stange, E. (Producers), & Strain, T. H. (Director). (2008). How racism impacts pregnancy outcomes [Video excerpt]. In L. Adelman (Executive producer), Unnatural Causes: Episode 2—When the Bough Breaks. United States: Public Broadcasting Service. Retrieved fromhttp://www.unnaturalcauses.org/video_clips_detail.php?res_id=70
(c) California Newsreel, 2008. www.unnaturalcauses.org
Wilkinson, R., & Pickett, K. E. (2009). The spirit level: Why greater equality makes societies stronger. New York, NY: Bloomsbury Press.
World Health Organization. (Producer). (2010, August 13). Good health in youth sets the stage for well-being in later life [Audio podcast, Episode 102]. Retrieved fromhttp://terrance.who.int/mediacentre/podcasts/WHO_podcast_102.mp3
World Health Organization. (2010 August 13th). Good Health in Youth Sets the Stage for Well-Being in Later Life [Episode 102]. WHO Podcast. Podcast retrieved from http://terrance.who.int/mediacentre/podcasts/WHO_podcast_102.mp3

Health Literacy Instruction in Adults with Hypertension

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Health Literacy
The purpose of this review is to summarize the relevant literature related to health literacy instruction and to identify existing gaps in the literature. According to Ratzan and Parker (2012), health related decisions and healthcare related outcomes are significantly influenced by an individual’s ability to understand, process and take action on health information. In 2004, the Institute of Medicine made health literacy a national priority because of the very large number of Americans with low health literacy, and because of its impact on the healthcare system, especially those with health disparities (Neilsen-Bohlman, Panzer and Kindig, 2004).
A National action plan to improve health literacy, designed to restructure the ways that health information is disseminated, has set the vision and goals for the future (U.S. Department of Health and Human Services (DHHS), 2010). These goals include the development and dissemination of clear and accurate information, use of evidence based and developmentally appropriate information and encourage new and innovative approaches (DHHS, 2010).

Health Literacy Assessment
The National Assessment of Adult Literacy (NAAL) used health related tasks that measured prose, document and quantitative literacy in clinical, prevention and navigation of the healthcare system domains (Kutner, Greenbery, Jin and Paulsen, 2006). Quantitative literacy scores are lower than prose and document literacy, with 61% of respondents below basic and only 2% proficient (Kutner et al. 2006). While age greater than 65, those that live in poverty, and those of whom English is not their native language had lower scores, a large number of younger, well educated, English speaking individuals have below basic health literacy scores (Kutner, 2006).
Since the NAAL is impractical as a screening tool, and since there is no other goal standard measurement of health literacy, several assessments of print, number and oral health literacy are used in studies involving health literacy, making comparisons among these studies difficult. According to Berkman et. al. (2011) the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy in Adults (TOFHLA) are the most commonly used validated assessments of health literacy. The REALM is a test of word recognition, while the TOFHLA measures reading and numeracy, which is the ability to understand and manipulate numbers (Berkman, et al. 2011).

Health Literacy and Health Related Outcomes
Cross sectional studies, prospective observational studies and randomized, controlled trials have been conducted on patients with diabetes and hypertension, heart failure and obesity. The outcomes have included knowledge, self-management skills, an improvement in numbers, hospitalizations and mortality. Numeracy is a key aspect of health literacy as it relates to the understanding of numbers, which are important for the management of weight, blood pressure, and glucose.

In a large, multi-site, prospective study of enrollees in a Medicare managed care plan, conducted from 1997 through 2003, Baker, Wolf, Feinglass, Thompson, Gazmaranian and Huang (2007) found mortality rates to be significantly higher in participants with inadequate health literacy than participants with adequate health literacy. Reading fluency was a more powerful predictor of all-cause mortality and cardiovascular death than years of education (Baker, et al. 2007). In a randomized, controlled trial, Dewalt, Malone, Bryant, Kosnar, Corr, et al. (2006) found that education on self-management skills such as daily weight monitoring, medication management and symptom recognition reduced the risk of hospitalization and death in heart failure patients with low levels of literacy. Huizinga, Beech, Cavanaugh, Elasy and Rothman (2008) found a significant, negative correlation between numeracy and body mass index.

In a randomized trial Jay, Adams, Herring, Gillespie, Ark, et al. (2009) found that brief multimedia interventions, including a video and food label pocket cards could improve food label comprehension, but actual dietary changes or health related outcomes were not assessed. In a cross-sectional study of primary care patients, Rothman, Housam, Weiss, Davis, Gregory, et al. (2006) found that poor food label understanding was correlated with low literacy and numeracy skills, but even patients with high literacy skills had trouble interpreting labels.
In a prospective, observational trial of patients with diabetes, (Kim,Love, Quistberg and Shea, 2004) found that diabetes education was effective in improving self- management skills, knowledge of their diabetes and control of their blood glucose. Patients with low literacy reported better adherence to diet, self-glucose management and foot care (Kim, et al. 2004).
Hypertension

In 2012 an estimated 76.4 million Americans have hypertension and only 64% of those that are being treated are achieving their blood pressure goal (Roger, et al, 2012). Hypertension is associated with an increased risk of heart disease, stroke, heart failure and kidney failure resulting in a cost of $50.6 billion (Roger, et al. 2012). According to Appel, et al. (2006) there is a substantial body of knowledge demonstrating the effects of self-management skills, including dietary and physical activity interventions, on hypertension. Maintaining or achieving a desirable body weight by balancing physical activity and caloric intake, reducing sodium intake, consuming more fruits and vegetables, reducing saturated fat and cholesterol, increasing potassium intake, and consuming alcohol only in moderation are effective strategies for achieving blood pressure control (Appel, et al. 2006).

In a cross sectional study of patients with hypertension and diabetes, Williams, Baker, Parker and Nurss, (1998) found that patients with lower health literacy scores were significantly less likely to identify a normal blood pressure or blood glucose reading than patients with high health literacy scores, which poses a significant barrier to teaching self-management skills.
A key aspect of health literacy is being able to navigate the healthcare system. In a cross-sectional study of 1224 hypertensive patients, Powers, Olden, Oddone, Thorpe and Bosworth (2008) found that the challenges of navigating the healthcare system is an interactive effect in the relationship between health literacy and systolic blood pressure, but not diastolic blood pressure. Pandit, Tang, Bailey, Davis, and Bocchini, et al. (2009) found that low education and limited literacy were significant predictors of blood pressure control and that literacy was a mediator in the relationship between education and knowledge. Persell, Bailey, Tang, Davis and Wolf (2010) found that medications discrepancies and incorrect medication reconciliation are very common in hypertensive patients, further complicating this key step in the treatment of these patients. In a randomized trial of hypertensive patients, Bosworth, Olsen, Grubber, Neary, and Orr, et al.(2009) found that blood pressure monitoring and tailored telephone intervention resulted in significantly better blood pressure control compared to a usual care group.

Health Literacy Instruction
A gap in the literature is whether the interventions used in health literacy studies actually result in an increase in health literacy. Interventions that simplify the message by using plain language may improve outcomes by modifying behavior without increasing knowledge or literacy. In an American Heart Association Scientific Statement, Artinian, et al. (2011) reviewed behavioral interventions designed to improve cardiovascular outcomes and determined that the most effective strategies include goal setting, self-monitoring, frequent and prolonged contact, feedback and reinforcement, incentives, modeling, problem solving, relapse prevention and motivational interviewing.
Paasche-Orlow, and Wolf (2007) developed a causal model, linking health literacy to health outcomes. Three interrelated components of this model are access and utilization of healthcare, which have patients and system factors; provider-patients interaction including knowledge and communication; and self-care factors, including motivation, self-efficacy, knowledge and extrinsic factors, such as education and the media (Paasche-Orlow and Wolf, 2007). To test this model, Osborne, Paasche-Orlow, Bailey and Wolf (2011) investigated the mechanisms linking health literacy to behavior and health status in a cross sectional study of hypertensive patients, and determined that health education interventions should be literacy sensitive and focus on knowledge and efficacy. Health literacy was directly related to knowledge, self-efficacy was related to self-management interventions, such as physical activity, and these behaviors were related to health status (Osborne , 2011).

According to Lesgold and Welch-Ross (2012) there is a surprising lack of rigorous research on effective approaches to adult literacy instruction and the majority of this research is based on the K-12 population and there has been virtually no research on health literacy for adults of whom English is their second language (Lesgold and Welch-Ross, 2012). In fact, the majority of research in the area of adult learning is with college students and professional development, not patient education (Lesgold and Welch-Ross, 2012). According to Grossman, Powers and McGinnis (2011) the growing digital infrastructure provides opportunities for communication and learning that have not been available previously. These opportunities can engage and empower patients, but must also be available and usable to individuals with low levels of health literacy (Grossman, 2011). The Agency for Healthcare Research and Quality has developed a toolkit for improving healthcare communications, including spoken word, written communications, self-management and empowerment and supportive systems (Dewalt, Callahan, Hawk, Broucksou, and Hink, 2010). While this toolkit provides resources for providing simplified, accurate information for patients using plain and direct language, it does not provide tools or teaching and learning strategies for increasing health literacy.

In an annual review of public health, Koo and Miner (2010) proposed the use of a multi-tiered model for developing knowledge and skills in the public health workforce. This strategy could be applied to health literacy instruction of patients and the community. Another example of adult education is medical professionals. Beckman and Lee (2009) propose applying Bloom’s taxonomy, which is a classic educational model, for the teaching medical students. The Bloom model includes knowledge, comprehension, application, analysis, synthesis and evaluation (Beckman, 2009). While Koo and Miner (2010) and Beckman and Lee (2009) are using an educational for public health and medical professionals, this strategy could be used to increase the level of health literacy in the United States.

Summary of the Gaps in the literature
It is unclear from the research whether health literacy can be improved or that an improvement in health literacy will result in improved outcomes. Also, the majority of research on literacy instruction is on subjects kindergarten through grade 12, not on adults. Finally, while simplification of the message may be an effective strategy for basic self-management skills, such as daily weight monitoring or taking medications, but there it is unclear how effective this strategy is for more complicated activities, such as making dietary changes. It is also unclear whether individuals with adequate or above average literacy. Focusing on simplifying the message that they already understand is unlikely to be a benefit.

References
Appel, L.J., Brands, M.W., Daniels, S.R., Karanja,N., Elmer, P.J., and Sacks, F.M. (2006). Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Hypertension, 47, 296-308.
Artinian, N.T., Fletcher, G.F., Mozaffarian, D., Kris-etherton, P., Van Horn, L., Lichtenstein, A.H., Kumanyika, S., Kraus, W.E., Fleg, J.L., Redecker, N.S., Meinenger, J.C., Banks, J.A., Stuart-Shor, E.M., Fletcher, B.J., Miller, T.D., Hughes, S., Braun, L.T., Kopin, L.A., Berra, K., Hayman, L.L., Ewing, L.J., Ades, P.A., Durstine, J.L., Houston-Miller, N., Burke, L.E., on behalf of the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Circulation, 122,406-441.
Beckman, T.J., and Lee, M.C. (2009). Proposal for a collaborative approach to clinical teaching. Mayo Clinic Proceedings, 84, 339-344.
Dewalt, D.A., Malone, R.M., Bryant, M.E., Kosnar, M.C., Corr, K.E., Rothman, R.L., Sueta, C.A., and Pignone, M.P. (2006). A heart failure self-management program for patients of all literacy levels: A randomized, controlled trial. BMC Health Services Research, 6,30. doi:10.1186/1472-6963-6-30.
Dewalt, D.A., Callahan, L.F., Hawk, V. V.H., Broucksou, K.A., and Hink, A. (2010). Health literacy universal precautions toolkit. Rockville, MA., Agency for Healthcare Research and Quality, Retrieved from: http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf.
Baker, D.W., Wolf, M.S., Feinglass, J., Thompson, J.A., Gazmarian, J.A., and Huang, J. (2007). Health literacy and mortality among elderly persons. Archives of Internal Medicine. 167, 1503-1509.
Baker, D.W. (2006). The meaning and measure of health literacy. Journal General Internal Medicine. 21(8). 878-883.
Berkman, N.D., Sheridan, S.L., Donohue, K.E., Halpern, D.J., Viera, A., Crotty, K., Holland, A., Brausure, M., Lohr., K.N., Harden, E., Tant, E., Wallace, I., and Viswanathan, M. (2011). Health literacy interventions and outcomes: An updated systematic review. Rockville, MD. Agency for Healthcare Research and Quality.
Bosworth, H.B., Olsen, M.K., Grubber, J.M., Neary, A.M., Orr, M.M., Powers, B.J., Adams, M.B., Svetkey, L.P., Reed, S.D., Li, Y., Dolor, R.J., and Oddone, E.Z. (2009) Two self-management interventions to improve hypertension control: A randomized trial. Annals of Internal Medicine, 151, 687-695.
Grossman, C., Powers, B., and McGinnis, J.M. (eds) (2011). Digital infrastructure for the learning health system: The foundation for continuous improvement in health and health care. Washington, D.C. National Academies Press.
Huizinga, M.M., Beech, B.M., Cavanaugh, K.L., Elasy, T.A., and Rothman, R.L. (2008). Low numeracy skills are associated with higher BMI. Obesity. 16, 1966-1968.
Jay, M., Adams, J., Herring, S.J., Gillespie, C., Ark, T., Feldman, H., Jones,V., Zabar, S., Stevens, D., and Kalet, A. (2009). A randomized trial of brief multimedia intervention to improve comprehension of food labels. Preventive Medicine, 48, 25-31.
Kim, S., Love, F.L., Quistberg, D.A., and Shea, J.A. (2004). Association of health literacy with self-management behavior in patients with diabetes. Diabetes Care. 27, 2980-2982.
Koo, D. and Miner K. (2010). Outcome-based workforce development and education in public health. Annual review of public health. 31, 253-269.
Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483).U.S.Department of Education. Washington, DC: National Center for Education Statistics.
Lesgold, A.M., and Welch-Ross, M. (2012). Improving adult literacy instruction: Options for practice and research. National Academies Press, Washington, D.C.
National Research Council (2012). Improving Adult Literacy Instruction: Options for Practice and Research. Washington, D.C. National Academy of Sciences. Retrieved from: http://www.nap.edu/catalog.php?record_id=13242
Nielsen-Bohlman, L. Panzer, A.M., and Kindig, D.A. Editors, Committee on Health Literacy Institute of Medicine. (2004). Health Literacy: A prescription to end confusion. Washington, D.C. National Academies Press. Retrieved from: http://www.nap.edu/catalog/10883.html.
Osborne, C.Y., Paasche, M.K., Bailey, S.C., and Wolf, M.S. (2011). The mechanisms linking health literacy to behavior and health status. American Journal of Health Behavior, 35, 118-128.
Paasche-Orlow, M.K., and Wolf, M.S. The causal pathways linking health literacy to health outcomes. American Journal of Health Behavior, 31, S19-s26.
Pandit, A.U., Tang, J.W., Bailey, S.C., Davis, T.C., Bocchini, M.V., Persell, S.D., Federman, A.D., and Wolf. M.S. (2009). Education, literacy and health: Mediating effects on hypertension knowledge and control. Patient Education and Counseling, 75, 381-385.
Persell, S.D., Bailey, S.C., Tang, J., Davis, T.C., and Wolf, M.S. (2010). Medication reconciliation and hypertension control. American Journal of Medicine, 182, e9-e15.
Ratzan, R. and Parker, S. (2012). Health literacy: A second decade of distinction for Americans. Journal of Health Communication: International Perspectives. 15. 20-33.
Roger, VL., Go, A.S., Lloyd-Jones, D.M., Benjamin, E.J., Berry, J.D., Borden, W.B., Bravata, D.M., Dai, S., Ford, E.S., Fox, C.S., Fullerton, H.J., Gillespie, C., Hailpern, S.M., Heit, J.A., Howard, V.J., Kissela, B.M., Kittner, S.J., Lackland, D.T., Lichtman, J.H., Lisabeth, L.D., Makuc, D.M., Marcus, G.M., Marelli, A., Matchar, D.B., Moy, C.S., Mozaffarian, D., Mussolino, M.E., Nichol, G., Paynter, N.P., Soliman, E.Z., Sorlie, P.D., Sotoodehnia, N., Turan, T.N., Viriani, S.S., Wong, N.D., Woo, D., Turner, M.B., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee (2012. Heart disease and stroke statistics – 2012 update: A report from the American Heart Association. Circulation, 125, e2-e220.
Rothman, R.L., Housam, R., Weiss, H., Davis, D., Gregory, R., Gebretsadik, T., Shintaini, A., and Elasy, T.A. (2006). Patient understanding of food labels: The role of literacy and numeracy. American Journal of Preventive Medicine, 31, 391-398.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.
Williams, M.V., Baker,, D.W., Parker, R.M., and Nurss, J.R. (1998). Relationship of functional health literacy to patient’s knowledge of their chronic disease. Archives of Internal Medicine. 158, 166-172.

Malaria and DDT

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Impact of malaria in terms of health, mortality and economics
Malaria is an infection from a parasite, Plasmodium falciparum that is carried to humans from the bite of the Anophelels mosquito (Centers for Disease Control and Prevention, 2012). According to the World Health Organization (2011), there were 216 million cases of Malaria and 665,000 deaths due to Malaria in 2010 and 90% of the deaths are in Africa. According to the Centers for Disease Control and Prevention (2012), Africa is the most affected because it has right combination of climate, mosquite (Anopheles), parasite (Plasmodium falciparum), and scarce resources making Malaria the 5th leading cause of death from infectious disease and 2nd in Africa.
DDT, dichloro-diphenyl-trichlororoethane, is an organochlorine insecticide that is used for vector control and is very effective in controlling the mosquito population (International Programme on Chemical Safety, 1989). According to the International Programme on Chemical Safety (1989), DDT is a very stable, fat soluable compound that remains in the environment, and food chain, for a very long time.

DDT was developed during World War II to prevent lice, typus and eventually Malaria (Environmental Protection Agency, 2012). According to the Environmental Protection Agency (2012), throughout the 1940s and 1950s there was widespread use of DDT as a pesticide in the United States, not only for agricultural purposes, not also including residential neighborhoods, swimming pools and playgrounds to reduce the mosquito population. Carson (1962) published Silent Spring, which alleged that DDT was dangerous, not only to wildlife and the environment, but also to humans, which began the environmental movement in the United States. In 1972 the Environmental Protection Agency banned the use of DDT in the United States. At the Stockholm Conference (1972), the World Health Organization agreed phase out the use of DDT worldwide and replace it with other, less hazardous materials, as they become available. The World Health Organization continues to support the use of DDT for indoor spraying in high risk areas, such as in Africa (World Health Organization, 2011). According to the World Health Organization (2011) international funding for malaria control reached a peak of $2 billion in 2011.

Control of malaria with DDT
Using DDT as the primary insecticide, the National Malaria Eradication Program began in 1947 and by 1951 Malaria had been virtually eradicated from the United States (Centers for Disease Control and Prevention, 2012). While Malaria eradication has been successful in temperate climates, such as in the United States and Europe, the majority of Malaria cases are in the tropical and subtropical climates of Africa, India and South America and the most vulnerable groups are Children (Centers for Disease Control and Prevention, 2012).

The primary strategy for preventing Malaria worldwide is through vector control, which is the control of the anopheles mosquito population (World Health Organization, 2007). The Stockholm Convention is an agreement and process for reducing the impact of Malaria and phasing out the use of DDT under the guidance of the World Health Organization. DDT is still recommended for malaria control in high risk areas of Africa where Malaria is endemic (World Health Organization, 2011). According to the World Health Organization (2011), despite the environmental and safety concerns, DDT has the best residual efficacy of any of the 12 approved insecticides. In high transmission areas, indoor residual spraying and insecticide-treated nets are recommended by the World Health Organization (World Health Organization, 2007). As agreed upon by the parties of the Stockholm Convention, DDT is still used until less toxic alternatives can be developed. In some cases, the change from DDT to pyrethroids resulted in the reappearance of the
Anopheles, the major vector for Malaria.

Toxicity of DDT in humans and wildlife
Since DDT is a very stable compound that is fat soluble and virtually insoluble in water it is taken up in the atmosphere, water and soil and eventually by living organisms (Agency for Toxic Substances & Disease Registry, 2002). Carson’s (1962) initial concern was the impact that DDT would have on the environment and ultimately its effects on humans. DDT is highly toxic to the environment including fish and lowers the reproductive rates of birds by thinning the shells causing embryo deaths (Agency for Toxic Substances & Disease Registry, 2002). DDT is stored in the body fat of animals and humans and resides in human milk, creating concerns about the impact on children (World Health Organization, 2007). According to the Agency for Toxic Substances & Disease Registry, (2002), DDT is not acutely toxic, which is why it was thought to be safe for humans, but the primary effect on wildlife and humans that are exposed to DDT is on the nervous system, and the cause of death is respiratory failure. DDT is found in the body fat of humans and while the use of DDT has declined since the EPA ban, the levels of DDT found in body fat has decreased only slightly (Turusov, 2002).

DDT has been shown to cause cancer in certain animal species, but not in others (Agency for Toxic Substances & Disease Registry, 2002). According to the According to the Agency for Toxic Substances & Disease Registry (2002), while DDT has not been shown to cause disease in people with high exposure, epidemiological studies do point to higher health risk. Turusov (1973) exposed mice to six generations of DDT exposure and found increased liver tumors at all levels of DDT exposure. Cohn (2007) found that exposure to DDT early in life had a 5-fold increase in the risk of breast cancer. Salazar-Garcia (2004), found an increased odds ratio (2.48) for birth defects in male malaria workers with higher estimated DDT in their fat compared to workers with lower levels of DDT.

Alternatives to DDT
Alternatives to DDT include indoor residual spraying and insecticide treated bed nets (van den Berg, 2009). Although DDT is one of 12 insecticides approved for indoor residual spraying, the World Health Organization (2011) continues support the use of DDT in high risk areas. Pedercini (2011) simulated the effect of malaria control and management with DDT and non-DDT measures and indicated that DDT could be phased out, but not with a rapid phased approach. The most promising alternative, however, is the development of a malaria vaccine (RTS,S, 2011), which has shown promising results. Once Malaria is present, antimalarial drugs, such as doxycycline are used (Centers for Disease Control and Prevention, 2012).

Stakeholders
The primary stakeholders are the Environmental Protection Agency, the Centers for Disease Control and Prevention and the World Health Organization. The Environmental Protection Agency was formed in 1970 and banned the domestic production of DDT in 1972 (Environmental Protection Agency, 2012). At the request of congress, in 1975, the Environmental Protection Agency issued a new report, confirming their decision to ban DDT (Environmental Protection Agency, 1975). The Centers for Disease Control and Prevention (2012) and the U.S. Public Health Service made the eradication of Malaria a mission in 1946 and by 1951 had virtually succeeded in this mission. Today, the CDC continues to monitor and promote the prevention of Malaria in the United States and worldwide (Centers for disease Control and Prevention, 2012).

The World Health Organization (2008) recommends vector control through insecticide treated nets and indoor residual spraying (IRS) to control Malaria. The Stockholm Convention on Persistent Organic Pollutants in an international agreement that allows the use of DDT in high exposure areas of the world, primarily in Africa with the goal of phasing DDT as safer alternatives are developed. According to the van den Berg (209), DDT is only produced in India, China and North Korea.

Of course the high transmission areas, especially in Africa and the 300 million people affected by Malaria each year are also stakeholders.

Position Statement
To craft a position on this issue requires evaluating the benefit of better Malaria control but increased risk of altering the delicate balance of nature, including wildlife and humans vs. an increased incidence of Malaria, especially in Africa but reduced impact on the environment, including the risk of cancer. What a choice. If DDT was less effective, or if Malaria was less deadly, the choice would be much easier.

The critical question is whether or not DDT poses a serious health risk. Although the research may be equivocal as to the long term health risk in humans, there is plenty of studies that implicate DDT. Bouwman, van den Berg and Kylin (2011) reported that of 22 studies published in 2009 on the health effects of DDT, 12 showed significant health risks. It is the dose that makes the poison. DDT treatment is no longer needed in the United States, and should only be allowed in Africa under tightly monitored situations.
Widespread, outdoor use of DDT, without the consent of the population is irresponsible and unethical. It is inappropriate to use such a toxic chemical for pest control. If it is irresponsible, unethical and inappropriate to use DDT in the United States and Europe, the same should be true in Africa. The concern for their environment, food chain and long term health risks should be the same as ours. Sereda (2009) found DDT levels to be much higher in the breast milk of mothers exposed to indoor residual spraying.

The burden of proof should be on the companies that make DDT that it is safe. Approvals of pharmaceuticals are required to go through phases that insure efficacy and safety prior to the drug being approved by the Food and Drug Administration. The same standard should apply to DDT and other chemicals released into the environment.
Of course the high incidence of Malaria in Africa, especially in children cannot be overlooked. If the nations of the world want to improve health conditions in Africa, it is going to take more than DDT. It needs to start with improving the economic and political conditions of that impoverished continent. Yes, it is in the interest of all of us to make that happen. Until that is a reality, however, thoughtful and planned use of DDT with indoor residual spraying and insecticide treated nets in high risk areas, at least until safer treatments are available is necessary to reduce the impact of Malaria.

References
Bouwman, H., van den Berg, H., and Kylin, H. (2011). DDT and malaria prevention: Addressing the paradox. Environmental Health Perspectives. 119(6):744-747
Carson, R. (1962). Silent Spring. Houghton Miflin. Boston, MA. Retrieved from Amazon Kindle.

Centers for Disease Control and Prevention. (2008). Toxic substances portal – DDT, DDE, DDD. Retrieved from: http://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=81&tid=20

Cohn, B.A., Wolff, M.S., Crillo, P.M., and Sholtz, R.I. ((2007). DDT and breast cancer in young women: New data on the significance of age at exposure. Environmental Health Perspectives. 115(10),1406-1414.

Environmental Protection Agency. (2012). DDT – A brief history and status. Retrieved from: http://www.epa.gov/opp00001/factsheets/chemicals/ddt-brief-history-status.htm

Environmental Protection Agency. (1975). DDT: A review of scientific and economic aspects of the decision to ban its use as a pesticide. Retrieved from: http://www.nal.usda.gov/speccoll/findaids/agentorange/text/01183.pdf

International Programme on Chemical Safety. (1989). DDT and its derivatives – environmental aspects. Retrieved from: http://www.inchem.org/documents/ehc/ehc/ehc83.htm

Pedercini, M., Movilla Blanco, S., and Kopainsky, B. (2011). Application of the malaria management model to the analysis of costs and benefits of DDT versus non-DDT malaria control. Plos One. 6(11),e27771

RTS-S Clinical Trials Partnership (2011). Results of Phase 3 trial of RTS,S/AS01 malaria vaccine in African children. The New England Journal of Medicine. 365,1863-1875.

Salazar-Garcia, F., Gallardo-Diaz, E., Ceron-Mireles, P., Loomis, D., and Borja-Aburto, V.H. (2004). Reproductive effects of occupational DDT exposure among male malaria control workers. Environmental Health Perspectives. 112,542-547.

Sereda, B., Bouwman, H., and Kylin, H. (2009). Comparing water, bovine milk, and indoor residual spraying as possible sources of DDT and pyrethroid residues in breast milk. Journal of Toxicology and Environmental Health. 72,842-851.

Stockholm Convention on persistent organic pollutants. (2001). United National Environment Programme. Retrieved from: http://pops.int/documents/convext/convext_en.pdf.

Turusov, V., Rakitsky, V., and Tomatis, L. (2002). Dichlorodiphenyltrichloroethane (DDT): uniquity, persistence and risks. Environmental Health Perspectives. 110(2), 125-128.

Turusov, V., Day, N., Tomatis, L., Gati, E., Charles, R. (1973). Tumors of CF-1 mice exposed for six generations to DDT. Journal of the National Cancer Institute. 51, 983-997.
U.S. Department of Health and Human Services. (2002). Toxicological profile for DDT, DDE and DDD. Retrieved from: http://www.atsdr.cdc.gov/toxprofiles/tp35.pdf

van den Berg, H. (2009). Global status of DDT and its alternatives for use in vector control to prevent disease. Environmental Health Perspectives. 117,1656-1663.

World Health Organization. (2007). The use of DDT in malaria vector control: WHO position statement. Retrieved from: http://www.who.int/malaria/publications/atoz/who_htm_gmp_2011/en/index.html

World Health Organization. (2011). World Malaria Report 2011. Retrieved from: http://www.who.int/malaria/world_malaria_report_2010/en/index/html

Nutrition labeling in restaurants

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The primary stakeholders for this issue are the restaurants, the patrons, or customers of the restaurants, restaurant groups, such as the National Restaurant Association, health advocacy groups, such as the American Heart Association, the American Diabetes Association, the American Cancer Society and consumer advocacy groups, such as the Center for Science in the Public Interest.

According to the Keystone Forum Report, “Away From Home Foods,” Americans spend 46% of their food budget and consume 32% of their calories on foods outside of the home.
In a review a review of 8 cohort studies, all but 1 found an association between out of home eating and body weight (Bezerra, 2012).

Food labels have been on packaged foods since 1994. The Nutrition Labeling Act of 1990, however, specifically exempted restaurants (FDA, 2012). Some restaurants, including many that should not be proud of the nutrition content of their food, provide nutrition information on their web sites, on their tray liners, or in a brochure. Displaying the nutrition information on a web site does not work for customers that do not have computer/internet access. Also, unless they are using a smart phone, that information is not available to them at the point of purchase. Having the information on the tray liner does not help in making the decision since it is after the purchase has been made. This information is useful, however, for diabetics that need to know the carbohydrate content of the food. Having the information in a brochure is only effective if the brochure is available and up to date. Therefore, the goal is to have nutrition information listed in the menu and on the menu boards along with the pricing.

Nutrition and Health

The Dietary Guidelines for Americans (USDA, 2010) recommend maintaining caloric balance to achieve a desirable weight; reducing sodium intake to 2,300 mg per day, and 1,500 mg for people over 50 or who have hypertension, diabetes or chronic kidney disease; consuming less than 10% of calories from saturated fat and < 300 mg of dietary cholesterol; and reduce trans fats, calories, alcohol and refined grains.

The Dietary Guidelines for Americans (USDA, 2010) also suggests selecting eating patterns that meet nutrient needs appropriate for calorie level, accounting for all foods and beverages and following food safety recommendations. Since such a large amount of food is eaten outside of the home, away from measuring bowls and scales, to meet these recommendations, providing nutrition information, not only in packaged foods, but also in restaurants is essential.

According to the National Center for Health Statistics (2012), the number of people in the United States living with a chronic disease that has dietary guidelines includes 16 million with coronary heart disease that must reduce fat, saturated fat, cholesterol and sodium, 7 million people with stroke, 5.7 million with heart failure and 76.4 million that must reduce sodium intake; 71.3 million with high cholesterol (LDL > 130 mg/dl) that must reduce saturated fat, trans fat and dietary cholesterol; 25.8 million with diabetes and another 79 million with pre-diabetes and must be aware of carbohydrates; and finally 149.3 million that are overweight (body mass index > 25) and another 75 million that are obese (Body mass index > 30).

In an effort to reduce the impact of obesity, the FDA published “Calories Count” and recommended point of sale labeling in restaurants to create an environment that is conducive to making better informed decisions (Food and Drug Administration, 2004). This environment includes having nutrition information readily available at the point of purchase, having the information on the menus and menu boards and having “Healthy symbols” next to the healthy selections (FDA, 2004). What information is needed? While getting the calories and possibly portion size on the menu is a very good start, additional information that is necessary for heart disease, stroke, hypertension, heart failure, high cholesterol and diabetes include fats, saturated fats, sodium and carbohydrates.

Laws Requiring Nutrition Labeling

The Nutrition labeling and Education Act of 1990 required that all packaged foods provide a standardized nutrition label and also provided guidelines for making health claims, such as “low fat” and “light” (FDA, 2012). The nutrition label is based on a standard 2000 calorie diet (FDA, 2012). The Food and Drug Administration has proposed Section 4205 of the Patient Protection and Affordable Care Act of 2010, which required restaurants with 20 or more locations to list calorie content on menus and menu boards, including drive through boards (Federal Register, 2011). Fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, fiber and protein information must be available upon request (Federal Register, 2011).

In 1996 New York City required quick serve chain restaurants with 15 or more outlets to provide calorie counts on their menu boards (Nestle, 2010). This was opposed by the New York Restaurant Associations, but the courts ruled in favor of the City and other cities and states have implemented similar laws (Rutkow, 2008), including San Francisco and Seattle (Center for Science in the Public Interest, 2008).

Stakeholders

Although the National Restaurant Association is opposed to the FDA proposal, they do have a Healthy Dining Finder application on their web site (Nestle, 2010). It is a search engine that can locate restaurants that have healthy food choices. The American Heart Association recently launched a new Restaurant Certification program, which is modeled after their Food Certification program which is used by food manufacturers. Subway is the first national chain to be certified by the American Heart Association (American Heart Association, 2012).

The American Heart Association (2012) has developed standards for healthy meals, including calories, total fat, saturated fat, cholesterol, trans fat, sodium and beneficial nutrients. Beverages are includes and include water, low fat or fat free milk or beverages containing less than 10 calories per serving, and does not include alcoholic beverages (American Heart Association, 2012). To verify compliance, the American Heart Association is performing secret shopper sampling of foods, which are tested in an accredited laboratory (American Heart Association, 2012).
In addition to the AHA program, Subway also markets Jason Fogle and other Fresh Fit Choices (USA Today, 2012). The Heart-Check mark is now on the Subway menu boards, but the information is listed at the bottom, making is somewhat difficult to interpret (USA Today, 2012). Many chain restaurants provide nutrition information in the restaurant or on their web site. Some restaurants are beginning to place the nutrition information in locations that are at least visible to the customer at the point of purchase. For restaurant chains in which the order is taken at the table, many are including nutrition information in the menu. Other health advocacy groups, such as the American Diabetes Association, American Cancer Society and LiveStrong provide nutrition information directly to the consumers. For example, the American Diabetes Association has “My Food Advisor” on their web site, but it is focus on preparing meals at home, not away from home (American Diabetes Association, 2012).A variety of ‘Apps’ are on the iPhone and Android markets that allow consumers to find nutrition information. This technology, however, only benefits customers that have “Smart phones” or “tablets” and use them at the time of purchase. The Center for Science in the Public Interest (2012) is a consumer advocacy organization that supports nutrition labeling in restaurants.

Research, Benefits and Next Steps

What does the research say about nutrition labeling in restaurants? While not all studies have shown positive results, there are indications that there is a benefit to requiring restaurants to provide better information about the nutritional value of their food. Polus (2011) found that a voluntary menu labeling program in full service restaurants reduced calories by 75 in 20% of the customers. Lunchtime calorie content was reduced at McDonalds, AuBonPain and KFC, but, ironically, increased at Subway (Dumanovsky, 2011). Roberto (2009) found that participants with calorie labels ordered foods with 14% fewer calories. Also, labeling and increasing the visibility of healthy foods improved health choices (Thorndike, 2011). While these studies are encouraging, not all of the research has been positive. In a literature review off calorie menu labeling in fast food restaurants, only 2 of 7 studies found a significant reduction in calories purchased (Schwatz, 2011).

Short term benefits will be a more informed and health conscious nation, resulting in a decrease in the prevalence of obesity, and better control of diabetes and heart disease. If the short term benefits can be sustained, the long term benefits will include a reduction in the risk and cost of many chronic diseases, such as heart disease, stroke, diabetes and hypertension.

Labeling at the point of service, either on the menu or the menu board should apply to all restaurants, not just the national chains. Food safety applies to all, so why should food health only apply to a few? Customers should be given the best chance for making the right decision, including information, pricing, appearance and display of the choices. Foods service workers, including the servers and preparers, should have training on health and nutrition. Finally, these measures to be adopted and practiced by all restaurants when they recognize the size and purchasing power of people with health related dietary guidelines, such as heart disease, diabetes and obesity. Since many customers are still voting with their forks, concurrent strategies for improving health literacy are also essential.

References

American Diabetes Association. (2012). My Food Advisor. Retrieved from: http://www.diabetes.org/mfa-recipes/log-in/recipes-for-healthy-living.html?loc=hpcarousel2_recipe-club_july2012

American Heart Association. (2012). Heart-Check meal certification program (Foodservice). Retrieved from: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/DiningOut/Heart-Check-Meal-Certification-Program-Foodservice_UCM_441027_Article.jsp

American Heart Association. (2012). Nutritional Criteria for Certified Meals. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/DiningOut/Nutritional-Criteria-for-Certified-Meals-at-Restaurants_UCM_441055_Article.jsp

Bezerra, I.N., Curioni, C., Sichieri, R., (2012). Association between eating out of the home and body weight. Nutrition Review. 70,65-79.

Center for Science in the Public Interest (2008). San Francisco Mayor Signs Menu Labeling Bill. Retrieved from: http://www.cspinet.org/new/200803261.html

Center for Science in the Public Interest. (2012). Nutrition labeling at fast food and chain restaurants. Retrieved from: http://www.phila.gov/health/pdfs/WhyMenu.pdf

Federal register. (2011). Food Labeling: Nutrition labeling of standard menu items in restaurants and similar retail food establishments. Retrieved from: https://www.federalregister.gov/regulations/0910-AG57/food-labeling-nutrition-labeling-of-standard-menu-items-in-restaurants-and-similar-retail-food-estab

Food and Drug Administration. (2012). Significant Dates in U.S. Food and Drug Law History. Retrieved from: http://www.fda.gov/aboutfda/whatwedo/history/milestones/ucm128305.htm
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Assessing Causality

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To avoid misinterpretation of Bradford Hill’s guidelines for assessing causation, Greenland (2008) suggested reading directly from Hill (1965) rather than relying on a translation. The first criterion is the strength of the association by looking at the relative risk (Hill, 1965). Hill used the example of the chimney sweeps and scrotal cancer and smokers and lung cancer (Hill, 1965). The next criterion is consistency, by looking at the extent to which the observation has been repeated by different persons, in different places, circumstances and times (Hill, 1965). Hill (1965) again uses the example of smoking and lung cancer. The third criterion is specificity, which the degree to which the association is limited to specific people, groups, types, etc. (Hill, 1965). Hill (1965) points out that while specificity may reflect causation, the lack of specificity should not reject causation. The forth criterion is temporality, which means that the timing is correct, which is widely accepted as a requirement for causation (Hill, 1965). The fifth criterion is biological gradient, which is reflected by a dose-response relationship (Hill, 1965). The sixth criterion is plausibility, which means there is a biological explanation for the relationship (Hill, 1965). Hill (1965) warns us that this criterion is dependent on the biological knowledge of the day. The seventh criterion is coherence, which means that the cause-effect relationship is not in conflict with the known natural history of the disease (Hill, 1965). The eighth criterion is experiment, which is the extent to which the hypothesis has been tested (Hill, 1965). The final criterion is analogy, which the extent to which we would be willing to accept similar evidence (Hill, 1965). Hill (1965) points out no single criterion can be used to assess causality, but rather look at the evidence as a whole.
Mente, de Konning, Shannon and Anand (2009) conducted a systematic review of 146 prospective cohort studies and 43 randomized controlled trials for the evidence for a causal link between dietary factors and heart disease. This review specifically addressed the Hill guidelines in assessing causality. A modified algorithm was used to score each dietary factor based on the Bradford Hill guideline. This algorithm was based on strength of evidence, consistency, temporality and coherence. Another criterion, experiment, was added to assess whether or not a randomized, controlled trial had been conducted. Biological gradient was not included because many dietary factors have a j-shaped relationship, rather than a dose-response relationship. Also, plausibility, specificity and analogy were omitted. Plausibility was omitted because it had already been satisfied. Specificity was omitted because this analysis was specific to heart disease. Analogy was omitted due to subjectivity.

A scoring system for each criterion was established from 0-4. A score of 4 indicated strong evidence of causation. A score of 3 indicated moderate evidence of causation. A score of 2 or less indicated weak evidence of causation. In Table 1 the 1965 definition of each of the Bradford Hill Criteria are compared to the definition by Mente, et al. (2009). While the overall definition of each criterion is the same, Mente (2009) quantified the criteria where possible. For example, a strong association was defined as a relative risk of <=.83 or >=1.20, statistically significant at p<.05 and in the expected direction.
Dietary factors that met all four criteria included: Mediterranean Diet, high quality diet, vegetables, nuts, trans fatty acids and the glycemic index. Dietary factors that met 3 or the 4 criteria included: Prudent diet, Western diet, monounsaturated fats, fish, total and dietary folate, whole grains, total and dietary vitamin E, dietary beta carotene, total and dietary vitamin C, alcohol, fruits and vegetables, and fiber. Dietary factors that met 2 of the 4 criteria included omega 3 (marine and supplement), supplementary vitamin E, total fat, saturated and polyunsaturated fats. Dietary factors that only met 1 of the 4 criteria included meat, eggs and milk.

An alternative to the Bradford Hill guidelines is the “experiment” or randomized, controlled trial. Of the dietary factors that met all 4 criteria, the only one that has evidence from a randomized, controlled trial is the Mediterranean Diet.

Assessment of the causal link between dietary factors and heart disease is complex due to the multifactorial nature of the disease and the difficulty in accurately measuring dietary factors (Mente, 2009). Mente’s (2009) assessment, however, is consistent with the Dietary Guidelines for Americans and is a good tool for assessing the causality of dietary factors and heart disease(United States Department of Agriculture, 2010).

References
Greenland, S. (2008). Critical Review and Assessment of Causality. [dvd]. Laureate Education.

Hill, A.B. The environment and disease: Association or Causation? Proceedings of the Royal Society of Medicine. 58, 295-300.

Mente, A., de Konning, L., Shannon, H.S., and Anand, S.S. (2009). A systematic review of the evidence supporting a causal link betweek dietary factors and coronary heart disease. Archives of Internal Medicine. 169, 659-669.
USDA. (2010). Dietary Guidelines for Americans. Retrieved from: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ExecSumm.pdf