Soda Causes Cancer, Could it be?

A study done in Singapore has found that drinking 2 or more sodas per week is associated with nearly twice the risk of pancreatic cancer than staying soda free. The study was published this month in the journal Cancer Epidemiology, Biomarkers, & Prevention and reported on WebMD.

It's no surprise that the beverage industry is doing all it can to discredit the study; however, the methods used seem surprisingly sound. In fact, while the American Beverage Association claims that other studies have shown no association between soda and pancreatic cancer, a 2005 study out of Harvard School of Public Health found that soda (i.e. sugar sweetened beverage) consumption was associated with increased risk of pancreatic cancer in women, particularly those who were overweight.

Slimming Down School Milk: Did it have an impact?

Schools are getting smart and thinking more about where kids are getting their calories from in school. With childhood obesity continuing to rise (even though adult obesity seems to have slowed down), the implementation of sound school wellness policies is imperative to curbing unhealthy habit forming behaviors in kids' lives.

There is not a ton of data on how school nutrition policies have impacted student health or changed children's consumption of certain foods. (Though if you're interested, I've done a ton of research in this area on sugar-sweetened beverages). But now we have data on one common policy: switching school cafeterias over to serving kids lower-fat milk (1% or fat-free).

Have American Waistlines Stopped Growing?

Pam Belluck of the New York Times reported today that obesity rates have been seen to stabilize (for some groups like blacks and whites, but not Mexican-Americans) over the past 5 years. I've heard this data in several classes, and it does appear to be true. But this shouldn't be taken to mean that obesity rates are declining -- they certainly are not.

What puzzles me and other obesity researchers is: Why?

Mammography Screening Myths Exposed

The US Preventive Services Task Force (USPSTF) released "new" mammogram guidelines this week. The guidelines have received major backlash from the American Cancer Society and many cancer survivors.

Below is are some of the mammography screening myths floating around:

Can What You Eat Prevent Depression?

Did you know that eating a lot of processed foods (most of the foods in the center aisles) may be related to developing depression? A study recently reported by BBC News and passed along to a fellow colleague at Harvard School of Public Health (thanks Rachael!) has reached this conclusion -- and I am apt to agree.

Take-Home Message
Eat a diet rich in whole foods (fruits, vegetables, unprocessed meats, natural fats, and whole grains) and forgo the traditional diet of refined sugars and wheat, artificial fats, and *deli* meat and cheese.

Why should you? 
Because you can might not just impact your waist line, but also your mental health.

Gender and the HPV Vaccine

I need to take a minute to post about a non-school-health related topic: a recent study published in the British Medical Journal concluded that vaccinating males against HPV is not cost-effective. News outlets everywhere have reported on authors' conclusions.

However, are the underlying framework and assumptions of the study authors misguided?

William Saletan published a provocative (go-figure) post on Slate.com on the topic, and I think it is right on. If you have any interested in gender disparities and gender norms this is a very, very interesting topic right now!

Just as a refresher: the vaccine was developed and is currently being used to vaccinate girls. Check out a previous VH post on the male/female controversies of the HPV vaccine that I published earlier this year.

How Healthy is Your Breakfast Cereal?

Cereal is about as commonplace in the American home as peanut butter and jelly (unless you are allergic, I guess). At some point in our nations history, whole cereal grain breakfast that took minutes or hours to prepare were replaced by highly processed refined grain "cereals" that had loads of added sugar and went by the name of Cap'n and Lucky.

Until today's release of the Yale Rudd Center's Cereal Facts website, there was little way to know whether the cereal you were eating was healthy or all hype. Case in point: a friend posted a picture of Facebook with a Fruit Loops box reading "NOW WITH FIBER" on the front package (see yesterday's post for more on this...) which clearly illustrated food industry's widespread marketing of unhealthy food with their "healthy" components placed first, and foremost for consumers to see.

Research and Policymaking Merge in Public Health

How does a State know whether fluoridating its water supply will prove cost-effective in reducing tooth decay and its related health costs of their residents? Are mass media campaigns effective in discouraging smoking among young people?

These questions and others are posed in a Fall 2008 report by the Council of State Governments entitled "State Policy Guide: Using Research in Public Health Policymaking". 

The report indicates strong support for State governments to begin making public health decisions based on empirical evidence rather than the influence of lobbyists or in the interest of political expediency. The challenge of making evidence based decisions is directly addressed in the report, as is the need to distinguish public health policies directed at the population (i.e. community) level from medical care policies, which focus on treating or preventing disease in individual patients. 

Rating scales to evaluate the evidence for particular interventions are provided, as well as a step-by-step guide to drafting and reviewing proposed legislation on public health policy. 

I wonder how much attention to evidence-based policy making is currently happening at the local and State level. Have other sectors of government (apart from health) been making evidence-based policies or is this something new altogether?

It is imperative that we elect and promote individuals with a strong ability to identify and critique the public health literature so that informed public health policies can be implemented. At the least, we must expect our policymakers to surround themselves with people who are public health experts and can inform the content that goes in to the legislation. This guide is a good first step -- a call to action of sorts. 

Next Steps:

• Are evidence-based public health policies being made in your State? 
• What are the risks/rewards of being the first State to adopt a new public health policy? Can these decisions still be evidence-based?
• Who will keep local and State governments accountable for their public health policies?

A Question of Sustainable Screening

This month my first first-author publication was published in the Journal of Women's Health! I am extremely excited as it was the product of a two-year effort and became a really insightful article with the help of some really intelligent colleagues and collaborators. While I want to share with you highlights from the article, I'd also like to share some reflections on what I learned through the process.

The article examined what factors predict mammography re-screening (in the past 2 years) among Latinas living in California. This paper began as a study of all Latinas, but by the final iteration it focused on Latinas had at least one mammogram. Here are some of the major findings and considerations:

• Multiple factors influence mammography screening; those screened were older (60+ years), more educated, had health insurance, and reported having a 'usual source of care'.
• The most common reasons for not having a recent mammogram were cost, inconvenience, and lack of knowledge.
• Latinas who interviewed in Spanish were more likely to have been recently screened than those who interviewed in English (suggesting language might not be such a barrier to preventive health care use once access is attained).
• Increasing access to mammography screenings (both by reducing the cost and increasing the convenience) will likely improve re-screening among Latinas.

This was an incredible learning experience; one that I am so thankful to have had prior to graduate school and dissertation defenses. Nonetheless, there are a few key 'lessons learned' that I'd like to share. I hope these will serve as a reminder for myself and provide some comfort to others who will likely endure the same challenges and frustrations.

1. Listen. Embrace opportunities to invite in others to be a part of the publication process. I was so grateful to connect with collaborators at the CA Department of Public Health who were running mammography screening programs. It gave us a lot more confidence in our understanding of the problem and the interpretation of our data. 
2. Persist. Publishing this article was  a roller coaster ride. At first you think that your idea is the greatest one yet. Then, either through reviewers' comments or constructive criticism, you begin to doubt. It takes courage to work through the tough issues that need to be dealt with to improve the paper.
3. Revise! As focused as I thought the paper was when we began, there was way too much in there for a 2500 word article. Revisions focused the paper and resulted from thoughtful critique from reviewers and coauthors.
4. Relax. Once you submit that article there is no point in checking the website every day to see if the status of the article has changed (I never did that...). Enjoy the waiting because once you get the manuscript back your next few weeks are shot.

I am looking forward to working on some more publications, but I'm excited to have this blog so I can discuss public health issues that interest me any time. 

If you could publish in any area -- magazine, newspaper, journal -- what would you write about?

Mouthwash: Friend or Foe?

There is something about that tingling, burning sensation of Listerine that always keeps me coming back. I just don't "feel" like that other stuff is working. However, according to a recent study published in the Dental Journal of Australia using mouthwash containing large amounts of alcohol is associated with greater risk for developing oral cancer.

A possible link between mouthwash use and oral cancer was brought to my attention while riding the T Tuesday morning by Metro. I did a quick PubMed search and found several articles -- even REVIEW articles -- on the issue that date back to 1991. This is not a new idea, however this finding is quite controversial. I decided to review 3 articles on the subject (I was limited by those journals subscribed to by HSPH at this point).

#1

 The first article, a 1996 review in the American Journal of Epidemiology, proposed a spurious (non-causal) association between mouthwash use and oropharyngeal cancer. The authors (one of whom worked for Procter and Gamble; the work was sponsored by a Pfizer company) argued that alcohol and tobacco use likely accounted for the association between mouthwash use and oral cancer. For example, consider that smokers are more likely than nonsmokers to use mouthwash to eliminate their bad breath, and that smoking is strongly associated with oral cancer -- it is. While it may seem that mouthwash was linked to cancer, really it may have just been the tobacco use.

#2

In 2003, an article was written and published in the Journal of the American Dental Association (this study was also financially supported by a Pfizer company) to review the literature examining the mouthwash-oral cancer relationship. Nine studies were considered - six showed no association between mouthwash use and oral cancer, and three showed a positive association. In addition, this article re-analyzed data from a large population-based National Cancer Institute study with nearly 1500 cases and a similar number of controls. The re-analysis showed that mouthwash had the same moderate effect on both "true"/mucosal and "pseudo"/nonmucosal cases of oral cancer; whereas other known risk factors (alcohol and tobacco use) for mucosal type oral cancer were quite strongly and predictably related to "true" cases, but not to the "pseudo" cases.  Of course, confidence intervals are not presented.

These two studies with their industry backing leave me wanting...let's hope #3 wraps things up.

#3

I can make this quick. The final article was published online (2008) ahead of the Oral Oncology print yet featured no new evidence since the 2003 review. The author suggested there is no epidemiological evidence that mouthwash causes oral cancer.

Summing It Up:

•  None of these studies address issues of reverse causation. It is likely (think about it...) that the onset of oral health issues (cancer, lesions, etc) result in greater use of mouthwash, and not the other way around.
• Studies do not differentiate between alcohol-based and other mouthwash types, weakening the claim that it is the alcohol-based mouthwashes that are the culprit.
• There is no clear relationship between quantity or frequency of mouthwash use and greater risk of oral cancers.
• More rigorous studies are needed to suggest that the relationship is not a result of recall bias, under-estimation of tobacco or alcohol use, and other potential confounders.

I'll stick with my mouthwash of choice -- for now. Of course, if you are really interested in oral health issues check out the source articles for yourself!

PS. If someone can send me that Australian journal article I'd love to take a look!

Update: So I took a look at the Australian Dental Association article, which suggested that there is sufficient evidence to implicate high-alcohol content mouthwashes in the development of oral cancer. However, the studies they cited were not recently published, leading me to believe that the evidence upon which they base their claims are the same ones that these previous lit reviews reject. It is possible that high-alcohol containing mouthwash is dangerous for certain vulnerable groups. However, more rigorous scientific evidence should be produced to support that hypothesis.

Biking for Health

It really was not until we moved to California that I was introduced to a bike culture. Many people we met were committed to traveling by bike; they rode everywhere  - to school, to work, even to sporting events. The roads were wide, the bike lanes were well marked and well maintained (no debris, no dangerous obstacles to maneuver around) and young and old partook in this type of activity. Was it exercise? Yes! Did it necessarily feel like it? No! For many, riding was a lifestyle, not an exercise routine. 

A recent study (reported in the press here) examined modes of transportation across several countries and rates of obesity. Countries where more people walked, cycled, or took mass transit to get around found lower rates of obesity. Obviously this study gives us no insight into why this is the case. While I don't expect that we can just start building bike lanes everywhere and expect communities to up and start riding bikes overnight, I see great promise in each place that I have lived to put in bike lanes to make it easier to get around without needing a car. Especially in the suburbs, where owning a car is assumed to be necessary. 

How do public health professionals, especially in suburban communities, change these transportation norms? What might be the impact for community health? 

R. Shephard provides an excellent article discussing the "active commuting" debate. Another study by scholars in Scotland examined adolescents' walking and biking commuting behaviors (to school, obviously) with regards to distance as a potential barrier. The authors found that adolescents were more likely to walk or bike to school if they lived within 2.5 miles, living farther than that was considered a sufficient barrier to active commuting. I wonder what that threshold would be in active cities in the US. This is a ripe area for future research and public health activity.

Defining "Risk": Statins and Heart Disease

The front page of CNN.com today read "Study: Cholesterol drugs can help low-risk patients." This is a perfect example of the medicalization of health. Rather than advocating high-risk prevention strategies for those at higher risk of developing disease, we now have "medical creep"  -- where even moderate risk of heart disease makes someone a good candidate for medical intervention. 

Dr. W. Douglas Weaver, president of the American College of Cardiology was quoted as saying, "This takes prevention to a whole new level, because it applies to patients who we now wouldn't have any evidence to treat." 

This is great news for Big Pharma -- not mainstream America. Note: cholesterol lowering drugs like AstraZeneca's Crestor (used in the study cited and funder of the research) or Lipitor by Pfizer are laden with awful side effects: headache, diarrhea, muscle pain and even depression, insomnia, and ulcers. Who needs that?

What is the alternative to pharmaceutical intervention? Hmmm...let me think...a healthier diet, regular exercise, and quitting smoking. And the side effects of such a drastic lifestyle change?  Side effects may include lowered risk of diabetes, stroke, cancer, and depression. 

While the choice of pill or persistence may seem obvious to me, the barriers to sustainable lifestyle change are great. Choosing persistence may seem more expensive or too restrictive (who is to say I can't eat another slice of mom's apple pie?). But the truth is we all have the power to make change in our life that will improve our health. The result may be 10 more years of healthy life or 10 more days. How do you measure the worth of your days and years?

My choice: a healthier lifestyle.  I will leave the statins for those who truly need them.