Important Implications For Population Health Research Articles

A reassessment of trends and rural–urban/regional differences in the total fertility rate in China, 2000–2020: analyses of the 2020 national census data

The decline in the total fertility rate (TFR) is a key driver of population change and has important implications for population health and social development. However, China’s TFR has been a considerable controversy due to a lack of high-quality data. Therefore, this study used the 2020 national population census of China (NPCC) data and reverse survival method to reassess temporal trends in the TFRs and to reexamine rural–urban differences and regional variations in TFRs from 2000 to 2020 in China. Overall, there were significant gaps between the estimated and reported TFRs before 2020, and the estimated TFRs based on the 2020 NPCC data remained higher than the reported TFRs from government statistics. Although TFRs rebounded shortly in the years after the two-child policy, they have shown a wavelike decline since 2010. Additionally, the estimated TFRs fluctuated below 1.5 children per woman in urban areas compared to above 1.8 in rural areas, but the rural–urban differences continued to decrease. Regarding geographic regional variations, the estimated TFRs in all regions displayed a declining trend during 2010–2020, especially in rural areas. Large decreases of over 25% in TFRs occurred in the north, east, central, and northwest regions. In addition to changing the birth policy, the government and society should adopt comprehensive strategies, including reducing the costs of marriage, childbearing, and child education, as well as promoting work-family balance, to encourage and increase fertility levels.

Expansion of Comprehensive Sexuality Education

School-based sex education has always been and continues to be controversial and mired in politics, and gaps persist in the content and skills that children and adolescents receive about sexual health. State policies dictate whether sex and HIV education are mandated, medically accurate, or include life skills such as providing consent to sexual activity, and these policies have important implications for population health. In this column, I review research findings about abstinence only versus sex education or comprehensive sexuality education, identify gaps in research and content related to sex education programs, review state sex education policies, and provide recommendations from professional organizations on expanding school-based programming to include comprehensive sexuality education.

Food security, food safety & healthy nutrition: are they compatible?

Food security, food safety, and healthy nutrition are key aspects of food systems with important implications for population health. Food safety addresses food-borne illness, and covers the handling, preparation and storage of food. Healthy nutrition is about the nutritional quality of diets. Food security encompasses both food safety and healthy nutrition, as well as a wider set of concerns related to food availability, access, utilization and stability. These three aspects of strong food systems are not only compatible, as important objectives and outcomes of food systems, but are complementary in principle, with important synergies existing between them in terms of their impact on population health outcomes. Yet tensions exist between food safety, healthy nutrition and the distinct aspects of food security. In practice, they are much less compatible, with political trade-offs between addressing them evident. This article critically assesses the compatibility of these concepts as a framework for achieving coherent food policy and global health.

Five year trends in the serve size, energy, and sodium contents of New Zealand fast foods: 2012 to 2016

BackgroundThe nutritional composition of foods and beverages consumed away from the home has important implications for population health. Our objective was to determine if the serve size, energy, and sodium contents of fast foods sold at chain restaurants in New Zealand (NZ) changed between 2012 and 2016.MethodsServe size and nutrient data were collected in annual cross-sectional surveys of all products sold at 10 major fast food chains. Changes over time may occur due to alterations in product availability or individual product reformulation. Linear regression adjusting for food group and chain was used to estimate overall changes in serve size and nutrients. Random effects mixed models were used to estimate reformulation changes on same products available for two or more years.ResultsAcross all products (n = 5468) increases were observed in mean serve size (+ 9 (3, 15) g, + 5%), energy density (+ 54 (27, 81) kJ/100 g, + 6%), energy per serve (+ 178 (125, 231) kJ, + 14%), and sodium per serve (+ 55 (24, 87) mg, + 12%). Sodium density did not change significantly. Four of 12 food groups (Desserts, Pizza, Sandwiches, and Salads) and four of 10 fast food chains (Domino’s, Hell Pizza, Pizza Hut, and Subway) displayed large, undesirable changes for three or more (of five) outcomes (≥10%; p < 0.05). One food group (Asian) and one chain (St Pierre’s) displayed large, desirable changes for two or more outcomes. The only significant reformulation change was a drop in sodium density (− 22 (− 36, − 8) mg/100 g, − 7%).ConclusionsThe serve size and energy density of NZ fast food products has increased significantly over the past 5 years. Lower sodium concentration in new and reformulated products has been offset by overall increases in serve size. Continued monitoring and development and implementation of Government-led targets for serve size and nutrient content of new and existing fast food products are required.

Emerging Trends in Clinical Research: With Implications for Population Health and Health Policy.

Developments in clinical medicine have important implications for population health, and there is a need for interdisciplinary engagement among clinical medicine, the social sciences, and public health research. The aim of this article is to help bridge the divide between these fields by exploring major recent advances in clinical medicine that have important implications for population health. We reviewed the most cited articles published from 2010 to 2015 in 5 high-impact clinical journals and selected 5 randomized controlled trials and 2 related clinical practice guidelines that are broadly relevant to population health and policy. We discuss the following themes: (1) expanding indications for drug therapy and the inherent medicalization of the population as highlighted by studies and clinical guidelines supporting lower blood pressure targets or widespread statin use; (2) the tension in nutritional research between quantifying the impact of isolated nutrients and studying specific foods and dietary patterns, for example, the role of the Mediterranean diet in the primary prevention of cardiovascular disease; (3) the issue of high medication costs and the challenge of providing equitable access raised by the development of new and effective treatments for hepatitis C infection; (4) emerging clinical applications of research on the human microbiome as illustrated by fecal transplant to treat Clostridium difficile infections; and (5) the promise and limitations of precision medicine as demonstrated by the rise of novel targeted therapies in oncology. These developments in clinical science hold promise for improving individual and population health and raise important questions about resource allocation, the role of prevention, and health disparities.

The fertility of internal migrants to Kinshasa

The rapid population growth of many African cities has important implications for population health, yet little is known about factors contributing to increasing population, such as the fertility of internal migrants. We examine whether in-migrants to Kinshasa have different fertility patterns than lifetime Kinshasa residents, and identify characteristics of migrants that may explain differences in fertility. We also use detailed migration histories to examine whether fertility differs by features of migration. We use representative data from the PMA2020 Project for 2197 women in Kinshasa, including 340 women who moved to Kinshasa. We examine differences between migrants and non-migrants in fertility and other fertility-related characteristics. We also examine whether fertility differs by duration of residence in Kinshasa, number of lifetime moves, age at first migration, urban/rural classification of birthplace, and the distinction between intra-Kinshasa migration and migration to Kinshasa.. Migrants have significantly higher fertility than permanent Kinshasa residents, but the difference is relatively small in magnitude. This higher fertility appears due in part to patterns of contraceptive use among migrants. There is noteworthy heterogeneity among migrants: higher fertility among migrants is associated with longer duration in Kinshasa, more lifetime moves, urban-Kinshasa migration, older age at first migration, and moving to Kinshasa from outside (as opposed to intra-Kinshasa migration).

Cost per median overall survival month associated with abiraterone acetate and enzalutamide for treatment of patients with metastatic castration-resistant prostate cancer

Objective: To calculate costs per median overall survival (OS) month in chemotherapy-naïve patients with metastatic castration-resistant prostate cancer (mCRPC) treated with abiraterone acetate plus prednisone (AA + P) or enzalutamide. Methods: Median treatment duration and median OS data from published Phase 3 clinical trials and prescribing information were used to calculate costs per median OS month based on wholesale acquisition costs (WACs) for patients with mCRPC treated with AA + P or enzalutamide. Sensitivity analyses were performed to understand how variations in treatment duration and treatment-related monitoring recommendations influenced cost per median OS month. Cost-effectiveness estimates of other Phase 3 trial outcomes were also explored: cost per month of chemotherapy avoided and per median radiographic progression-free survival (rPFS) month. Results: The results demonstrated that AA + P has a lower cost per median OS month than enzalutamide ($3231 vs 4512; 28% reduction), based on the following assumptions: median treatment duration of 14 months for AA + P and 18 months for enzalutamide, median OS of 34.7 months for AA + P and 35.3 months for enzalutamide, and WAC per 30-day supply of $8007.17 for AA + P vs $8847.98 for enzalutamide. Sensitivity analyses showed that accounting for recommended treatment-related monitoring costs or assuming identical treatment durations for AA + P and enzalutamide (18 months) resulted in costs per median OS month 8–27% lower for AA + P than for enzalutamide. Costs per month of chemotherapy avoided were $4448 for AA + P and $5688 for enzalutamide, while costs per month to achieve median rPFS were $6794 for AA + P and $7963 for enzalutamide. Conclusions: This cost-effectiveness analysis demonstrated that costs per median OS month, along with costs of other Phase 3 trial outcomes, were lower for AA + P than for enzalutamide. The findings were robust to sensitivity analyses. These results have important implications for population health decision-makers evaluating the relative value of therapies for mCRPC patients.

Contrasts in active transport behaviour across four countries: How do they translate into public health benefits?

ObjectiveCountries and regions vary substantially in transport related physical activity that people gain from walking and cycling and in how this varies by age and gender. This study aims to quantify the population health impacts of differences between four settings. MethodThe Integrated Transport and Health Model (ITHIM) was used to estimate health impacts from changes to physical activity that would arise if adults in urban areas in England and Wales adopted travel patterns of Switzerland, the Netherlands, and California. The model was parameterised with data from travel surveys from each setting and estimated using Monte Carlo simulation. Two types of scenarios were created, one in which the total travel time budget was assumed to be fixed and one where total travel times varied. ResultsSubstantial population health benefits would accrue if people in England and Wales gained as much transport related physical activity as people in Switzerland or the Netherlands, whilst smaller but still considerable harms would occur if active travel fell to the level seen in California. The benefits from achieving the travel patterns of the high cycling Netherlands or high walking Switzerland were similar. ConclusionDifferences between high income countries in how people travel have important implications for population health.

Ambient Fine Particulate Matter, Nitrogen Dioxide, and Term Birth Weight in New York City

Background The growing volume of studies addressing the association between air pollution and pregnancy outcomes remains inconclusive due to methodologic limitations. Using a unique community air pollution survey in New York City, we addressed this question with improved exposure assessment, a large number of births, freedom from confounding by socioeconomic status, and refined analytic methods. Aims We assessed the relationship between exposure to ambient pollutants, fine particulate matter (PM2.5) and nitrogen dioxide (NO2), and a term birth weight, considering trimester-specific and aggregate pregnancy exposure. Methods We included 252,967 singleton, term births to non-smokers, without congenital malformations, with known address, with birth dates in the years 2008-2010 restricted to avoid fixed cohort bias. Data from the New York City Community Air Survey were used to estimate exposure for all two week periods at all residences based on a network of 150 monitors. We examined term birth weight (37-42 weeks’ gestation), adjusting for maternal age, ethnicity, education, parity, insurance status, neighborhood socioeconomic indices, week of gestation, and calendar year using linear mixed models. Results An interquartile shift in PM2.5 in the three trimesters and over the entire pregnancy was associated with predicted birthweight decrements of 6.1, 3.3, 8.5, and 11.9 grams, respectively. For NO2, an interquartile shift in exposure for the three trimesters and total pregnancy predicted greater birthweight decrements of 11.3, 12.6, 13.6, and 11.2 grams, respectively. Conclusions Intra-urban and temporal sources of variation in PM2.5 and NO2 show a clear statistical association with a reduction in birth weight, adding to evidence from other studies that exposure to combustion pollutants may adversely affect fetal growth. The estimated effect, while modest at the individual level, would have important implications for population health if causal.

Abstract 186: Blends of Sesame and Rice Bran oils Lowered Blood Pressure and Lipids in Mild to Moderate Hypertensive Patients

Background and objectives: Sesame oil supplementation reduces blood pressure and lipids in hypertensives. Rice bran oil exhibits good control over lipids. The current study examines how modest variations in blends of sesame and rice bran oils (80% physically refined high oryzanol rice bran oil and 20% unrefined sesame oil), rich in antioxidants and unsaturated fatty acids, intake may affect blood pressure and lipids in hypertensives. Methods: In this prospective, randomized, open-label dietary intervention, 300 hypertensive patients (mean age, 57 years; 160% men; 140% women) were equally randomized for 60 days to one of the three groups: 1) calcium channel blocker 30 mg/d; 2) sesame oil blend (Vivo TM ) ; 3) sesame oil blend + calcium channel blocker 30mg/d. The patients except group 1 were supplied with sesame oil blend and instructed to use ∼35g of oil/day/person for cooking, salad preparation etc., Blood pressure was measured at baseline, and after 15, 30, 45 and 60 days, respectively. Lipid profile was measured at baseline and at the end of 60 days. Results: Calcium channel blocker or sesame oil blend or combination of calcium channel blocker and sesame oil blend induced significant fall of systolic/diastolic blood pressure [SBP -16.2mmHg, -14 mmHg and -36mmHg/DBP -12mmHg,-10.8mmHg and -23.8 mmHg, respectively vs baseline). Calcium channel blocker and sesame oil combination induced greater reduction and the dose of the drug was also reduced as there was remarkable fall in blood pressure. Total cholesterol, LDL cholesterol and triglycerides levels in the blood were significantly reduced while HDL cholesterol levels increased in sesame oil blend alone (18%, 26%, 12.6% and 9.5%, respectively vs baseline) or combination therapies (19.7%, 27%, 13.5% and 10.9% respectively, vs baseline). Conclusion: We have demonstrated, for the first time that dietary intervention with blends of sesame and rice bran oils lowers blood pressure and lipids in hypertensive individuals. Furthermore, our results suggest that the reduction of blood pressure and lipids will have important implications for population health and lowering the risk of stroke and ischaemic heart disease.

There We Go Again!

It's not often that one gets the opportunity to mix quotes from former President Ronald Reagan, Hall of Fame catcher Yogi Berra, and philosopher and cultural critic George Santayana all in the same paragraph. However, the words of these men resonated with me in the weeks preceding this late-June writing. Reagan's quip, used as the title for this column (I've replaced you with we), was made during a seemingly exasperating moment in his 1980 debate with President Jimmy Carter; Berra's famous line vu all over again (also used by Alan Cohen in his contribution to this issue) was allegedly made after New York Yankee teammates Roger Maris and Mickey Mantle hit consecutive home runs; and Santayana's caution that who cannot remember the past are condemned to repeat has been invoked repeatedly as a warning to those who ignore historical lessons. All of these words seem to apply appropriately to recent newsworthy events: the latest debacle in our financial sector, courtesy of J.P. Morgan Chase & Co.; the threat to repeat the 11th-hour drama and attendant uncertainty that characterized last year's debt ceiling standoff and budget debate; and the reemergence of efforts by congressional Republicans and those on the right to sacrifice our social safety net for tax breaks for our more affluent citizens. Although the attention directed to these events has been largely in terms of their implications for our financial and fiscal health, they can have important implications for population health and for health care delivery, more generally. Finally, as Inquiry was going to press, the Supreme Court issued its anxiously awaited ruling on the constitutionality of the Patient Protection and Affordable Care Act's (ACA) individual mandate. In rather dramatic fashion, the court voted 5-4 to uphold the individual mandate and the entire ACA. However, the court's decision has set the stage for subsequent deja vu moments as proponents and opponents of national health reform continue their defense and criticism of the ACA. I briefly discuss some of the implications of the court's ruling and leave a more complete discussion for a subsequent column. The Financial Sector Once Again Amid reports of a new round of trading in high-risk financial instruments by Wall Street investment houses, and the ongoing contentious debate over whether our financial institutions remain too big to fail and warrant greater oversight and more transparent transactions, the news of May 10 was especially jarring. J.P Morgan Chase & Co., the financial behemoth acclaimed for its enlightened management in the calamitous months preceding the Great Recession, had incurred a profound trading loss of $2 billion from highly speculative and risky transactions. The news grew worse over the next several days as it became clear that the initial loss would increase by at least 50% to approximately $3 billion, or perhaps as much as $9 billion, according to recent estimates. It is also noteworthy that this recent incident occurred on the heels of the collapse of Jon Corzine's MF Global, Inc., yet another victim of speculative trading. Several facts are particularly unsettling about the J.P. Morgan incident. First, despite the fallout of the 2008 financial crisis and efforts to fully implement the Dodd-Frank legislation regulating financial institutions, analysts who have repeatedly warned that the elements are in place for a future financial catastrophe appear to be prescient. In particular, with no firewall separating banks' commercial and investment activities and no vigorous oversight in the trading of highly speculative derivative securities (the Volcker Rule), Morgan's London office drew upon proprietary funds--government-backed savings deposits rather than its own resources--to finance what was essentially a cumulatively large hedge fund bet. As a result, Morgan placed its depositors and, ultimately, taxpayers at risk. …

A systematic review of fish-oil supplements for the prevention and treatment of hypertension

Fish oils are widely believed to promote cardiovascular health by lowering blood pressure (BP) but the evidence supporting this is not conclusive. We aimed to systematically review existing evidence. We undertook a systematic review of randomized controlled trials and crossover trials that evaluated the effectiveness of fish-oil supplements. We included trials enrolling adults who were given fish-oil supplements with at least 8 weeks' follow up. Effects on systolic and diastolic BP were assessed using meta-analysis. Meta-regression was undertaken to explore the relationship between dose of fish oil and BP outcomes. We included 17 studies, with a total of 1524 participants. We explored the effects of fish-oil supplements in both normotensive and hypertensive participants with BP 140/85 mmHg at least. Meta-analyses were performed using the inverse-variance method. Data from eight studies in hypertensive participants found a statistically significant reduction in systolic and diastolic BP; 2.56 mmHg (95% CI 0.58 to 4.53) and 1.47 mmHg (95% CI 0.41 to 2.53), respectively. Nine studies in normotensive participants showed a non-significant reduction in both systolic and diastolic BP. Meta-regression showed no significant relationship between dose of fish oil and the effect on BP. The small but statistically significant effects of fish-oil supplements in hypertensive participants in this review have important implications for population health and lowering the risk of stroke and ischaemic heart disease. Their modest effects, however, mean that they should not be recommended as an alternative to BP-lowering drugs where guidelines recommend treatment.

Maternal calcium supplementation and cardiovascular risk factors in twin offspring

There is evidence that maternal calcium supplementation may result in lower offspring blood pressure. We hypothesized that maternal calcium supplementation also influences other cardiovascular risk factors. In the Tasmanian Infant Health Study, supplements reportedly taken in pregnancy were recorded. Twin children of 147 participating mothers were seen at mean age 9 years. Blood pressure was measured in all 294 children and fasting blood samples taken from 230 (78%) for glucose and insulin, triacylglycerol, total cholesterol (T-C) and HDL cholesterol (HDL-C). LDL cholesterol (LDL-C) was calculated. Children of supplemented mothers (n = 110, 77 had venipuncture) had lower geometric mean triacylglycerol, T-C, and LDL-C than other children. After adjustment for potential confounding factors, geometric mean ratios were 0.86 (95% CI: 0.75, 0.98), 0.94, (95% CI: 0.90, 0.99) and 0.90, (95% CI: 0.83, 0.98) respectively. The association with T-C and LDL-C was seen principally among children with BMI > 17.5: estimated ratios 0.85 (95% CI: 0.79, 0.92) for total cholesterol and 0.79 (95% CI: 0.70, 0.90) for LDL cholesterol (P for interaction 0.001 and 0.009 respectively). There was no significant association between maternal calcium supplementation and child size at birth and follow up, blood pressure, fasting glucose or insulin or HDL-C. Maternal calcium supplementation may confer health benefits on twin offspring, especially if they are relatively fat. Calcium availability could permanently programme lipid metabolism during fetal life, directly or by influencing maternal lipid profile. Our findings need to be replicated in other studies and in singletons. If confirmed, our findings could have important implications for population health.

Dietary essential fatty acids and brain function: a developmental perspective on mechanisms.

Brain development is a complex interactive process in which early disruptive events can have long-lasting effects on later functional adaptation. It is a process that is dependent on the timely orchestration of external and internal inputs through sophisticated intra- and intercellular signalling pathways. Long-chain polyunsaturated fatty acids (LCPUFA), specifically arachidonic acid and docosahexaenoic acid (DHA), accrue rapidly in the grey matter of the brain during development, and brain fatty acid (FA) composition reflects dietary availability. Membrane lipid components can influence signal transduction cascades in various ways, which in the case of LCPUFA include the important regulatory functions mediated by the eicosanoids, and extend to long-term regulation through effects on gene transcription. Our work indicates that FA imbalance as well as specific FA deficiencies can affect development adversely, including the ability to respond to environmental stimulation. For example, although the impaired water-maze performance of mice fed a saturated-fat diet improved in response to early environmental enrichment, the brains of these animals showed less complex patterns of dendritic branching. Dietary n-3 FA deficiency influences specific neurotransmitter systems, particularly the dopamine systems of the frontal cortex. We showed that dietary deficiency of n-3 FA impaired the performance of rats on delayed matching-to-place in the water maze, a task of the type associated with prefrontal dopamine function. We did not, however, find an association over a wider range of brain DHA levels and performance on this task. Some, but not all, studies of human infants suggest that dietary DHA may play a role in cognitive development as well as in some neurodevelopmental disorders; this possibility has important implications for population health.