Making the healthy choice the easy choice

*Seth will be giving you an update on Helsinki tomorrow, this is just a quick update on my seminar.

The Non-communicable Disease Training Seminar in Helsinki, Finland is fantastic! I highly recommend it to anyone who is interested in public health and population-based interventions for chronic diseases. It is based on the North Karelia Project that took a truly population-based approach to treat cardiovascular disease (CVD) in a population of lumberjacks and farmers that were dying at a young age of CVD. They were the folks who claimed, "Veggies are for rabbits" and said "I'll have some bread with my chunk of butter, kiitos (thank you)" who consumed 40 pounds of butter per year! Therefore, their diet (and tobacco use) contributed to their high cholesterol, blood pressure and mortality rates in the 1970s. Simple interventions - smoke-free workplace campaigns, margarine for butter, substituting skim milk for whole milk in schools, increased vegetable subsidies and consumption, and increased physical activity - made a dramatic difference for this community.

Who are we?
I am one of two people from the USA attending the seminar, which thankfully is held in English. There are 24 of us who come from all over he globe: Tanzania, Ethiopia, Thailand, Iran, Finland, Japan, UK, Australia, Bahrain, and the USA. The goal of the seminar is to discuss theories and share ideas for us to bring back to our countries or institutions in order to promote prevention. Specifically, the World Health Organization has emphasized four factors: tobacco, diet, exercise, and alcohol use. I've said it before, but let me re-emphasize, the global burden of cardiovascular disease is HUGE! Eighty percent of all CVD is in developing countries. The costs of pain and suffering from both chronic and infectious diseases are disproportionately affecting the poor. Many of the deaths from these causes are avertable - either preventable or treatable. Building cath labs is not going to solve this problem. Prevention is the only sustainable, affordable, and feasible public health intervention that has been shown to decrease this epidemic and decrease other chronic disease as well as delay or post-pone mortality so that people can live more healthy, productive lives and contribute to development and decreasing poverty in their countries. Often, the factors that contribute to disease are outside of the control of the individual and are deeply rooted in society (socioeconomic, cultural and environmental factors).
Get Healthy Before Wealthy
Some argue that helping get people out of poverty - for example, providing clean water, sanitation, and education - would improve their health so why bother with chronic disease management? Well, the truth is development is slow to decrease poverty and not real effective for improving health. If we help strengthen the health systems and make people healthier now, they in turn will do more to help improve development and decrease poverty.
In a nutshell
How to start a prevention program? First, involve the stakeholders, policymakers, and community as managers and directors of programs from the beginning. Then, use working groups to try to understand all the health and non-health existing resources and challenges in the community. Then, target the primordial, primary and secondary interventions using medical and social behavioral methods. Examples include individual behavorial changes like quitting smoking to lifestyle changes in the community, like smoke-free campaigns. Improving nutrition, encouraging physical activity, and improving medication adherence for treatment of disease are also important interventions. Finally, building infrastructure to treat the high risk people in the community.
"Make the healthy lifestyle the easy one."
Successful programs are those that are multi-dimensional, target the whole population, complement initiatives in place, are sustainable, and have adequate time and funding to complete the intervention(s). In all cases, making the healthy lifestyle or behavior the easier choice is key for a sustainable and effective intervention program. If only we could do this in the US too!
"Only those who see the invisible can do the impossible."

Where are all my charts?

Ah the joys of research!
I have been working a ton lately and have not had much time for traveling. Oh the real world...
As a Fogarty Scholar I am doing cardiovascular disease research in Peru and despite not blogging a lot about it, my fantastic readers, today is your lucky day - I have something to blog about that's related to work! My work usually consists of spending a lot of time on my computer plugging in equations into STATA, making tables, re-making the tables 50 times because we keep changing the the methods and research question, searching PubMed for references, reading PDFs and highlighting them on Skim (a much better PDF program than Adobe or Preview and it's free), writing manuscript drafts, and Skype-ing with my mentors in the states. In the past month, I have spent more time on buses going to a from work than I have spent eating and exercising combined (sad, I know). I often take the bus over an hour each way to Cayetano hospital, tracking down doctors on the medicine wards and shadowing them until the have time to talk with me for 20 minutes and then take the bus an hour back.

I am excited to tell you about my new study: a retrospective chart review study looking at in-mortality after cardiovascular disease events. I am hoping to show a difference in in-hospital mortality between men and women and describe the factors that are strongly associated with mortality after a cardiovascular event in this population. My goal was to review 600 charts based on my sample size calculation and 10% missing charts, which meant we would review all the charts from 2005-2009. Luckily I have a partner-in-crime, the amazing Jennifer Milla.

She is a recent Peruvian medical school grad (so jealous), aka doctora, who is applying for residencies in Spain. We were supposed to start data collection 3 weeks ago but due to IRB delays and people being out of town when we needed their signature, we did not get approval to start until last week.

Soooo excited to have my first project stamp of approval!

That's when the trouble started... first, I did not exclude all the duplicate medical record numbers so in my list of 600 I only have 518 unique entires. Second problem, due to the large number of missing charts I'll be very happy if we get 450 (but realistically we will probably have around 400 - fingers crossed...). Third, our most recent pitfall is that the woman in charge of the charts, Senora Julia, refused to pull our charts last week and now will only give us 10 charts per day as it's "too much extra work" for her staff AND they will only look for them after 4:30pm! The hospital is not in the best neighborhood and leaving after dark is not a great idea for Jennifer or myself. Julia refuses to let us pull our own charts... oh how I wish they have electronic medical records! So at this rate we have officially completed 32 questionnaires and won't be done until July (and I'm leaving at the end of May) and that doesn't include the time it takes to enter the data. Oh well... we'll figure it out and we may just need to bribe someone so we can get it done. Welcome to the wonderful world of research!

Overall, it's a great experience and I find that I really only learn from my mistakes anyway (I hate how that works). I have enjoyed setting up my own project, writing protocols and ethics approvals in English and translating them to Spanish and then back to English again after they changed a dozen times. Thank goodness for Jennifer, who recently completed a thesis to graduate from medical school, who knew all the hoops we needed to jump through, like what little old lady behind the counter in the convenience store across the street from the University who you have to pay $1 to write the "official" cover letter presenting our protocol to the ethics boards and where the chief of medicine's office was and where he has coffee to track him down. Between our meetings and training Jennifer to do the chart abstraction my Spanish has really improved. We talk on the phone but we find text messaging and email to be a little easier as I still have a hard time discussing anything besides, "Where are you?" "What time are we meeting?" and "I'd like that chifa delivered, my address is...".
Learning what hoops to jump through in both the US and Peruvian systems had been very interesting and I find being flexible and having other projects to work on alongside is really the only thing keeping me sane yet a little crazy too because I am swamped with work right now. I enjoy going to rounds at the hospital in the AM and seeing a 39 year old patient who looked like she was in a concentration camp and weighed about 60 lbs. She has severe toxic thyroiditis where her body makes an anti-body to the TSH receptor and her thyroid is SUPER overactive and so her metabolism has increased and she is basically skin and bones. I don't think I will EVER see that again.
Medicine clinic waiting area

Basically, I am working on eight or so projects with four different groups/studies and have three IRB approvals (the bane of all researchers existence - especially in global health) and am waiting on one more for a total of four (the most that any Fogarty in Peru has had before me was two). I had one paper accepted in Diabetes Care and one abstract accepted, which I will be presenting at the World Congress of Cardiology in Beijing in June. The same abstract we are revised and are resubmitting next week to Atherosclerosis on carotid-intima media thickness in this population. I think it has been a very successful year and I'm happy to have accomplished most my goals, namely learning Spanish.
Cayetano
I'm standing in the middle of the street and on one side is the Cayetano University and hospital, on the other, a funeraria with a hearse parked in front. How morbid...



Adios!

Know your cardiovascular disease risk

I came across some interesting articles in my overwhelming literature search on what is known and not known about CVD in Latin America.

For busy physicians, there are four challenges in regard to a patient's CVD risk (Cooney et al. JACC 2009): 1) How do I identify people who are at increased risk of a cardiovascular event? 2) How do I weight the individual effects of all the causative risk factors when assessing a person’s risk? 3) How do I stratify that risk to determine who needs lifestyle advice and who needs additional medical therapy? 4) How do I ensure that I am not overmedicalizing those persons who are at low risk of an event?
There are various risk scoring systems that doctors use to answer these questions. The most well known is the Framingham risk score but it is unknown if it is a valid scoring system for different ethnic populations, say in Peru. That's one of my projects here.

So, do you know your CVD risk? Framingham and other risk calculators have been developed based on people who are at risk for events and emphasize secondary prevention after disease has developed. For young people (<45 year) your Framingham risk will be low unless you have a genetic profile that predisposes you to CVD (high cholesterol or triglycerides) but primary prevention and modification of risk factors at this early stage is where we have the greatest opportunity for prevention of CVD and subclinical disease. The earlier the better.

Did you know that it is recommended to exercise at least 2 hours per week? That's it. That's only 30 minutes 4 times a day or 10 minutes 2-3 times per day. How many of us actually get 2 pathetic hours per week? How much time do you spend watching the Twins or Viking (or Packers) games? How much time do you spend in your car? The elephant in the room in the healthcare reform debates is our culture of inactivity and eating poorly. Walking 2 hours per week can lower your blood pressure more than popping a pill and it can decrease your risk of CVD and stroke by 25% not to mention it can help you lose weight.

Below are current recommendations based in risk and age. See where you fit and take the first step in lowering your risk now! It may be cutting down on smoking, it may be going for a walk or a longer walk but we can all do something to lower our risk and put me out of a job! :)

Arequipa and La Punta

Arequipa
A view of the main plaza in Arequipa with the Cathedral lit up at night.

Romina and I flew to Arequipa in the Southern Highlands of Peru on Friday in order to meet with Dr. Josefina Medina, a cardiologist and the principal investigator on the PREVENCION study. We departed the plane with a view of the full moon rising over the picturesque and dormant volcano, Misti. Dr. Medina is the sweetest Arequipenan woman that I have ever met and was very excited to show me all the technology that she has in her cardiology office. Thank goodness for Romina, my friend and translator, as my Spanish is improving but not sufficient to understand scientific meeting by myself. I was very impressed by Dr. Medina’s computer skills and by the wide array of cardiovascular prevention techniques that she uses in her clinic, including echocardiography, arterial pulse wave, sphygmography, and others.

La Punta
After our meeting we took a taxi on a winding mountain road with sheer cliffs down past Mollendo to La Punta, a small town on the beach where Romina’s family is from. We stayed at the Punta del Sur, the largest building in town besides the church. It didn’t take long for the gringos to become the talk of the town. Her uncle is a very prominent figure in the town and owns a lot of farm land and recently built the very nice hotel with solar panels for hot water which was a big bonus.
He drove us around in the back of his Toyota pickup truck up to the giant “Jesus Blanco” for a panoramic view of the beach and fertile green valley.


It was a stark contrast to the desert and dry brown mountains that we drove along.
Then, he took us along the beach and through his never-ending farms where he employs over 70 women to pick crops. Rice is his biggest crop and a close second are artichokes (photo below) since the value of sugar cane has dropped recently and export demands for artichokes have soared in the past few years. Next time you eat an artichoke heart, look at where it came from.


Next we went to the chicken coop where he keeps his prized roosters for cock fights.
There was even a cock ring where he trains these beautiful birds.
Photo of Josh and Tio (uncle) with the beautiful roosters.

Then he drove us through the valley to his prized possession – his bull. At nearly one ton it is an impressive animal and surprisingly friendly. He gave us kisses and let us rub his nose.

Later we went to lunch at this delicious restaurant with great views of the valley and river running though it where they catch fresh fish and crawfish. It was delicious until all of the gringos got sick the next day in which case I can only assume it was lunch.
Back to Arequipa
We returned to Arequipa and toured the city during the day. Since it is 7,800ft (2300m) above sea level, we undoubtedly felt a little altitude sickness upon our return and didn’t sleep much.
The city is nestled in the valley between towering, snow-capped mountains and it’s beautiful! The sky is always blue, the sun is always shining, the roof dogs are always barking, and the neighbor’s roosters are waking you up at sunrise. It’s weather and topography are similar to Arizona and nearby are the two deepest canyons in the world - Colca and Cotahuasi – that I will hike by the end of this year.

This colonial city is build of white volcanic rock, called sillar, and has largely withheld the test of time and numerous earthquakes. The Catedral de Arequipa is the largest building in town and forms one side of the popular Plaza de Armas. It was built in the 1544 and was reconstructed in 1844 after suffering much damage from fires and earthquakes. Recently, in 2001, a cathedral tower fell after a earthquake but has been restored. The streets are narrow and many are for pedestrians only and are lined with small tiendas (stores), cafes, and restaurants, while other restaurants have balconies that overlook the Catedral, Plaza and its central fountain.
Nearby is the Monastario de Santa Catalina (St. Catherine‘s Convent) that was established in 1580 shortly after the Spanish conquest. My proper name is Catherine Ann, after my great grandmother Catherine Youngquist and I believe she was named after this saint. I might start telling people my name is Catalina since when I say “Katie” everyone says “Que?” since it’s not a common name here.



At its peak, over 200 nuns and their servants lived in this city and since the nuns took vows of isolation it because a city-within-a-city. Currently 20 nuns still reside in a private part of the convent and the rest has been open to the public for 40 years. The narrow streets are beautifully painted with reds, blues, and whites, and flowers and fruit trees line the courtyards and streets. The nuns are famous for their baking and I enjoyed a delicious alfadore in the café after wandering this tranquil little city for over an hour.
I met my friends for another delicious meal at Tradicion – rocotta rellena (stuffed red peppers) and queso helado (yummy fresh ice cream) while a very talented band played traditional Peruvian music.



On our last night there were fireworks on this large bamboo structure in the main plaza but before the lit the big structure a man holding a bamboo toy on a stick with fireworks was in the street. My friend Jenni got caught on fire from sparks flying.


Romina and I about to board the plane back to Lima after a wonderful long weekend. I miss it already!

"Why study global health?"

Many of you are thinking this while others are thinking, "Why do you have to go to Peru to study cardiovascular disease?" or "Why are you doing research if you are going to be a doctor?" Many have thought it but few were bold enough to ask and I respect that. So today I had to answer those questions as I was selected to be interviewed by an organization who was making a PR video for the Fogarty International Center. This is what I said:

I think global health research is important for many reasons, including humanitarian, understanding domestic diseases, and globalization. As we get better at treating infectious diseases people live longer and develop chronic diseases. Specifically, major risk factors for cardiovascular disease, such as age, smoking, family history, high blood pressure, high cholesterol, and diabetes, are increasing in prevalence leading to cardiovascular disease becoming the leading cause of death in Latin America. Most risk factors (except advancing age, family history and ethnicity) may be modified using various interventions and treatments.

The prevalence of diabetes mirrors the increased prevalence of obesity in the US. Genetics and environmental factors play a significant role in the development of diabetes and cardiovascular disease but defining these in developing countries is important. However, as with most governments, policy leader need to see the facts and data that this is actually a problem in their area or country in order to make create change.


Graph from PRB.

Fact: $1 of every $3 Medicare dollars is spent on diabetes in the US yet chronic disease attracts only 5% of the entire World Health Organization budget. In the US, global health research has seen a large grassroots movement that started with idealistic students and health care professionals. My goal is to do good scientific research this year to advance our understanding of cardiovascular disease in Peru, help raise awareness on an individual level, and generalize the results to populations in other areas. The rest I'll leave up to the politicians.
The burden of chronic disease is shifting to developing countries that do not have the resources, primary care medical infrastructure and awareness of policy makers and individuals to effectively manage this problem. Therefore, I feel that it is our duty as global citizens to help reduce the burden of poverty and inequalities in health. Join the ProCor mailing list to get updates: >. Also an interesting site of WHO statistics.

Quotes of the week:
"It's a bold new move to completely embrace that chronic diseases are and will be the biggest burden in the developing countries." Dr. Cristina Rabadan-Diehl, director National Heart, Lung, and Blood Institute

"It pays to listen to the people suffering from the disease." Dr. Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases.
"Humanitarian reasons are like relationships, you know, they come and go, you can always find another one." Dr. Anthony Fauci explaining why we need global health research.

"The more tools you have in the toolbox, the better prepared and useful you'll be." Dr. Steven Reynolds, MPH, who works on HIV in Uganda

"In battle no plan remains in tact." Dr. Pierce Gardner emphasizing how important it is to be flexible this year with regards to our projects.

"Luck comes to the prepared mind." Dr. Larry Laughlin and old friend of my mentor, Dr. David Williams.