Building Governmental Public Health Capacity to Advance Health Equity: Conclusions Based on an Environmental Scan of a Local Public Health System.

Vast health inequities persist in cities across the United States. Although recommendations exist to guide governmental public health institutions seeking to advance population health equity, local contexts are likely to influence how these pursuits take shape. We review recommendations for pursuing equity that were developed from an environmental scan conducted in the city of New Orleans. The recommendations, which are based on perspectives provided by city and state public health leaders, leaders from other city governmental departments, and community-based health department partners, center around the enduring impact of systemic racism, working across sectors, and prioritizing community engagement.

Assessing Potentially Preventable Hospitalizations at the County Level: A Comparison of Measures Using Medicare Data and State Hospital Discharge Data.

This study examined the representativeness of the County Health Rankings and Roadmaps (CHR) measure of potentially preventable hospitalizations, which is derived from Medicare inpatient claims data, as an indicator of potentially preventable hospitalizations for adults aged ≥18 years. Potentially preventable hospitalizations were evaluated using rates of ambulatory care sensitive conditions (ACSCs). CHR rates of hospitalization for ACSCs based on Medicare data for 2010, Agency for Healthcare Research and Quality Prevention Quality Indicator #90 Overall Composite (PQI #90 Composite) rates of ACSCs based on hospital inpatient data for adults aged ≥18 years for 2011, and 2011 total mortality rates for adults aged ≥18 years for 212 counties in 3 US states were evaluated. Pearson correlation analyses were used to assess the linear association between the PQI #90 Composite and CHR rates of hospitalization for ACSCs as well as associations of these measures with total mortality. Steiger's Z-test was conducted to examine whether the PQI #90 Composite and CHR measures of health care quality were similarly correlated with total mortality. The age- and sex-adjusted PQI #90 Composite for adults ≥18 years was moderately correlated with the CHR rate of hospitalization for ACSCs. The PQI #90 Composite and CHR measures of hospitalization for ACSCs were similarly correlated with mortality. These findings suggest that in the absence of easily accessible, high-quality data for adults aged ≥18 years, the CHR measure of potentially preventable hospitalizations provides a modest but acceptable approximation of county-level disparities in potentially preventable hospitalizations for the US adult population.

Public health in pharmacy: improving vitamin D status in the U.S. population.

OBJECTIVES: To summarize the problem of vitamin D inadequacy in the United States and discuss how pharmacists can help improve vitamin D status in the population. SUMMARY: Vitamin D inadequacy has proven skeletal health effects and potential effects on other chronic conditions. The condition is present in many Americans. Adequate vitamin D intake is currently emphasized to prevent vitamin D inadequacy. However, overall dietary vitamin D intake and use of vitamin D supplements is relatively low in the United States. Pharmacists' health knowledge and placement in communities make them ideal resources for raising awareness on the benefits of vitamin D and providing nutrition information to prevent vitamin D inadequacy. However, pharmacists' ability to provide these services may be impeded in part by current limitations on compensation for health promotion activities. CONCLUSION: Health care reform is likely to expand pharmacists' scope of practice and services eligible for reimbursement. By promoting vitamin D in the communities they serve, pharmacists can take a lead role among health professionals in addressing vitamin D inadequacy.

The Black and White of infant back sleeping and infant bed sharing in Florida, 2004-2005.

Not using the infant back sleep position is an established risk factor for sudden unexpected infant death (SUID). Infant bed sharing may also increase SUID risk, particularly under certain circumstances. Both of these infant sleeping behaviors are disproportionately higher among Black mothers. We explored the relationship between not using the infant back sleeping and infant bed sharing, developed separate risk factor profiles for these behaviors, and identified maternal characteristics contributing to racial differences in their practice. Merged 2004-2005 birth certificate and Pregnancy Risk Assessment Monitoring System data for 2,791 non-Hispanic Black and White Florida women were evaluated using univariable and multivariable analyses to develop risk factor profiles for infrequent back sleeping and frequent bed sharing. Cross-product interaction terms were introduced to identify factors contributing to racial differences. Infrequent back sleeping and frequent bed sharing were reported by two-thirds of Black women and one-third of White women. There was no association between the infant sleeping behaviors when adjusted for race (adjusted odds ratio [aOR], 1.04; 95% CI, 0.83-1.31). The infant sleeping behaviors shared no common independent maternal characteristics. Father acknowledgement on the birth certificate was a strong contributor to racial differences in infrequent back sleeping while breastfeeding, trimester of entry to prenatal care, and maternal depression revealed notable racial differences for bed sharing. Behavior-specific and race-specific public health messages may be an important public health strategy for reducing risky infant sleeping behaviors and decreasing SUIDs.

Core state preconception health indicators: a voluntary, multi-state selection process.

This report describes the consensus-based selection process undertaken by a voluntary committee of policy/program leaders and epidemiologists from seven states to identify core state indicators to monitor the health of reproductive age women (aged 18-44 years). Domains of preconception health were established based on priority areas within maternal and child health and women's health. Measures (i.e., potential indicators) addressing the domains were identified from population-based, state level data systems. Each indicator was evaluated on five criteria: public health importance, policy/program importance, data availability, data quality, and the complexity of calculating the indicator. Evaluations served as the basis for iterative voting, which was continued until unanimous consent or a super majority to retain or exclude each indicator was achieved. Eleven domains of preconception health were identified: general health status and life satisfaction; social determinants of health; health care; reproductive health and family planning; tobacco, alcohol and substance use; nutrition and physical activity; mental health; emotional and social support; chronic conditions; infections; and genetics/epigenetics. Ninety-six possible indicators were identified from which 45 core indicators were selected. The scope of preconception care and the public health components to address preconception health are still under development. Despite this challenge and other measurement limitations, preconception health and health care indicators are urgently needed. The proposed core indicators are a set of measures that all states can use to evaluate their preconception health efforts. Furthermore, the indicators serve as a basis for improving the surveillance of the health of reproductive age women.

Self-report of depressive symptoms in African American and white women in primary care.

OBJECTIVES: Depressive symptoms are frequently seen among female patients in primary care. The majority of screening instruments are cumbersome for a busy clinic. METHOD: The effectiveness of a 2-item depression screening questionnaire was compared to the mental health section of the 36-Item Short Form Health Survey (SF-36). A total of 127 consecutive patients who presented for primary care service agreed to participate and completed the questionnaire. RESULTS: Of the final sample, 65.4% were African American and 44.9% of all women reported having depressive symptoms, with no significant difference in the prevalence of reported depressive symptoms between African American and white women (chi2 = 1.97, p = .16). The women reporting depressive symptoms were more likely to be in the lower-income group (chi2 = 9.02, p = .01); however, in stratified analysis this was only significant for the African American women (chi2 = 8.69, p = .01). Analysis of variance demonstrated that the women with depressive symptoms were more likely to score low on the mental health subscales of the SF-36 when adjusted for income (F = 58.32, P < .0001). Within race groups, the mean Mental Health Index scores were higher among African American women (t = -6.45, P <.0001) and White women (t = -3.59, P = .002) who reported depressive symptoms than among those who did not report depressive symptoms. The sensitivity and specificity of the 2-item depression symptom questions compared to the overall SF-36 mental health score were 70% and 77%, respectively. CONCLUSION: A simple 2-item questionnaire can be used to identify depressive symptoms in white and African American women in a primary care clinic.

Acute selenium toxicity associated with a dietary supplement.

BACKGROUND: Selenium is an element necessary for normal cellular function, but it can have toxic effects at high doses. We investigated an outbreak of acute selenium poisoning. METHODS: A case was defined as the onset of symptoms of selenium toxicity in a person within 2 weeks after ingesting a dietary supplement manufactured by "Company A," purchased after January 1, 2008. We conducted case finding, administered initial and 90-day follow-up questionnaires to affected persons, and obtained laboratory data where available. RESULTS: The source of the outbreak was identified as a liquid dietary supplement that contained 200 times the labeled concentration of selenium. Of 201 cases identified in 10 states, 1 person was hospitalized. The median estimated dose of selenium consumed was 41 749 microg/d (recommended dietary allowance is 55 microg/d). Frequently reported symptoms included diarrhea (78%), fatigue (75%), hair loss (72%), joint pain (70%), nail discoloration or brittleness (61%), and nausea (58%). Symptoms persisting 90 days or longer included fingernail discoloration and loss (52%), fatigue (35%), and hair loss (29%). The mean initial serum selenium concentration of 8 patients was 751 microg/L (reference range, < or =125 microg/L). The mean initial urine selenium concentration of 7 patients was 166 microg/24 h (reference range, < or =55 microg/24 h). CONCLUSIONS: Toxic concentrations of selenium in a liquid dietary supplement resulted in a widespread outbreak. Had the manufacturers been held to standards used in the pharmaceutical industry, it may have been prevented.

Where are the data to drive policy changes for preconception health and health care?

Improving preconception health is recognized as being crucial to improving reproductive health outcomes for women and infants. At the same time, there is increasing pressure on public health and clinical medicine programs to have evidence that documents positive health impact for continued support for program implementation and policy change. In the field of preconception health and health care, there is a growing body of evidence to support the implementation of public health programs and clinical practice. One current challenge is the unavailability of a comprehensive surveillance system providing data to demonstrate the need for such programs and to monitor the impact of programs and services. There is no single source of data or evidence for policy and financing support for preconception care; however, there are a number of related data resources that can be used to inform and support such programs. We describe national and state-level data sources from which data relevant to preconception health and health care can be extracted as well as steps that can be taken to improve the quantity and quality of preconception health data.

Influence of cardiovascular disease risk factors on the relationship between low bone mineral density and type 2 diabetes mellitus in a multiethnic US population of women and men: a cross-sectional study.

INTRODUCTION: Higher bone mineral density (BMD) has been reported among white women and men with type 2 diabetes mellitus (DM) compared with nondiabetic white individuals, but there is scant evidence for nonwhite persons. It is also not known whether cardiovascular disease (CVD) risk factors may confound any association between BMD and type 2 DM. OBJECTIVE: The present study examined the relationship between low BMD and type 2 DM in a multiethnic population of women and men while controlling for the influence of osteoporosis and CVD risk factors including body mass index (BMI), cigarette smoking, physical inactivity, total cholesterol and its components, blood pressure, and C-reactive protein. METHODS: Data collected from 4929 African American, Mexican American, and white women and men aged 50 to 79 years who participated in the household interview and clinical examinations during the Third National Health and Nutrition Examination Survey were analyzed. CVD risk factors associated with type 2 DM in this study population were included as covariates in gender-specific multiple logistic regression models assessing the relationship between type 2 DM and low BMD while controlling for osteoporosis risk factors. Gender- and race/ethnicity-specific mean BMD values at the total hip for young adults aged 20 to 29 years were used to establish race/ethnicity and gender-specific low BMD T-scores. RESULTS: The final study population included 2505 women and 2424 men. More women and men with type 2 DM than women and men without type 2 DM were nonwhite and had high BMI. Osteoporosis risk factors but not CVD risk factors were associated with low BMD in both women and men. Type 2 DM was not associated with low BMD among women (odds ratio [OR] = 0.77; 95% CI, 0.56-1.08). Based on a statistically significant interaction between type 2 DM status and race/ethnicity, white men with type 2 DM were less likely to have low BMD than were white men without type 2 DM (OR = 0.56; 95% CI, 0.37-0.86; P = 0.01). There was no significant BMD difference between diabetic and nondiabetic nonwhite men. CONCLUSION: CVD risk factors did not appear to influence the relationship between low BMD and type 2 DM in this study.

Can self-rated health identify US women and men with low bone mineral density? A cross-sectional population study.

BACKGROUND: Despite its simplicity, self-rated health (SRH) is a significant dimension of health assessment, with demonstrated means to identify individuals at increased risk of morbidity and mortality. OBJECTIVE: The aim of the present study was to assess whether SRH, age, and modifiable osteoporosis risk factors in a hypothetical screening situation could identify individuals with low bone mineral density (BMD). METHODS: Data were analyzed from a multiethnic sample of 4905 women and men aged 50 to 79 years from the Third National Health and Nutrition Examination Survey. Low BMD was assessed according to the World Health Organization definition using gender- and race/ethnicity-specific young adult mean values to calculate T-scores. Multiple linear regression analysis was used to determine whether BMD was lower among those with poorer SRH; multiple logistic regression analysis was used to determine whether poor SRH was associated with low BMD. RESULTS: The study population included 616 and 589 African American; 522 and 564 Mexican American; and 1312 and 1302 white women and men, respectively. The distributions of SRH responses differed for African American and Mexican American women and men compared with the distributions for same-gender whites, with significantly more white women and men reporting excellent or very good health (P < 0.05) and significantly greater proportions of African American and Mexican American women and men reporting poorer health (P < 0.05). Among women and nonwhite men, there was no evidence of an association between BMD and SRH. Linear trends of decreasing BMD with declining SRH were detected for all men with low or normal body mass index (P < 0.001) and overweight men (P < 0.001). When stratified by race/ethnicity, a linear trend of decreasing BMD with declining SRH was found for nonobese white men only (P-trend: <0.001). The likelihood of having low BMD among nonobese white men who reported excellent or very good health was two-thirds that of their male counterparts with poor SRH (P < 0.001). CONCLUSIONS: Independent of age and modifiable osteoporosis risk factors, poor SRH may be a relevant risk factor for low BMD among older nonobese white men. Further research is needed to determine whether SRH may be a useful risk assessment tool for low BMD in this group of men.

Coronary heart disease risk and bone mineral density among U.S. women and men.

AIMS: Low bone mineral density (BMD) has been shown to predict cardiovascular disease (CVD) and coronary heart disease (CHD) mortality in both women and men. The purpose of the current study was to determine whether a CHD risk assessment tool might be useful for identifying persons likely to have low BMD in a multiethnic population of women and men. METHODS: Cross-sectional data for 3881 women and men aged 50-74 years without overt CHD or stroke from the Third National Health and Nutrition Examination Survey (NHANES III) were used to explore the relationship between BMD and 10-year CHD risk, as estimated using the Framingham CHD risk prediction algorithm, in gender-stratified multiple logistic regression models. RESULTS: When compared with women who had a <10% CHD risk, women with a 10%-19% CHD risk were 45% more likely and those with a > or =20% CHD risk were 73% more likely to have low BMD. Similar increases in low BMD risk were not detected in men. CONCLUSIONS: In the United States, 10-year Framingham CHD risk assessment may be useful for identifying older women who should be evaluated for osteoporosis and referred for BMD measurement. The impact of such a screening strategy on fracture prevention needs further elucidation.

Relationship between bone mineral density and myocardial infarction in US adults.

Cardiovascular disease and osteoporosis have several common risk factors, and quite a few studies suggest a relationship between them. The objective of the present study was to explore the relationship between cardiovascular disease risk factors and bone mineral density in association with having had a previous myocardial infarction in a general population. This cross-sectional study was conducted using data for 5,050 women and men aged 50-79 years who participated in the Third National Health and Nutrition Examination Survey (NHANES III). Race/ethnic and gender-specific mean BMD values for young adults were used to determine race/ethnic and gender-specific T-scores to define osteoporosis and low BMD. Multiple logistic regression analysis revealed that subjects self-reporting a previous myocardial infarction had significantly higher odds (odds ratio 1.28, [95% confidence interval (CI), 1.01 to 1.63] p=0.04) of having low bone mineral density, when adjusting for cardiovascular disease and osteoporosis risk factors. Self-reported myocardial infarction was not significantly associated with low bone mineral density in women, (odds ratio 1.22, [95% CI, 0.80 to 1.86] p=0.37), but was significant in men, (odds ratio 1.39, [95% CI, 1.03 to 1.87] p=0.03). These findings demonstrate that male survivors of myocardial infarction have low bone mineral density. The pathophysiologic connection between the atherosclerotic and the osteoporotic processes needs further elucidation. It is also of importance to study the processes in both men and women.

Risk assessment and screening for low bone mineral density in a multi-ethnic population of women and men: does one approach fit all?

Screening for osteoporosis is currently recommended for all women aged 65 years and older in the USA. How to address screening of non-white women and all men is unclear. Osteoporosis risk assessment questionnaires have been designed and tested mostly among postmenopausal white women, and there is a lack of consensus on appropriate bone mineral density (BMD) cut-off values for defining osteoporosis in non-white persons. The objectives of the present study were to identify a set of risk factors from published population-based studies in white women and men and determine the ability of these risk factors to predict osteoporosis and low BMD in African-American (AA), Mexican-American (MA), and white women and men, and to assess the diagnostic accuracy of this set of risk factors for identifying osteoporosis separately in AA, MA, and white women and men by the use of data for 2,590 women and 2,391 men 50-79 years of age from the third National Health and Nutrition Examination Survey (NHANES III). We employed the World Health Organisation (WHO) definition of osteoporosis, using race/ethnic and gender-specific young adult mean values when calculating the T scores. Low body-mass index, low calcium intake, current cigarette smoking, and physical inactivity were independent risk factors identified from population-based studies. The presence of one or more risk factors was associated with having osteoporosis and low BMD in all groups. The strength of these associations was greater when two or more risk factors were present but varied with race/ethnicity, gender, and age. We conclude that this set of osteoporosis risk factors predicts osteoporosis in non-white women and men. Furthermore, as a risk assessment tool, this set of risk factors might be useful for reducing the number of unnecessary BMD tests performed in older women as well as identifying non-white men who do not require BMD testing.