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May 15, 2014

Bad News, Good News

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

I have written a couple of times about how discouraged I was to learn that Perry County, Kentucky, has the shortest life expectancy for women and the third shortest for men in the country. Perry County is a medical hub in Eastern Kentucky. The medical community is sizable and sophisticated.  In the eight years I lived there in the 1990s, I never considered going anywhere else for medical care.  Medical school deans have recently come from China to see the University of Kentucky Center of Excellence in Rural Health, a model rural health professions program.  But in the last 20 years, health in the region has been deteriorating, as in so much of Appalachia.  From this I concluded that we can't reverse the health effects of poor living conditions just through medical care.

I began arguing for a major emphasis on health promotion, on keeping people healthy instead of trying to fix them after they've gone fat, diabetic, and hypertensive with clogged arteries.  I'll admit I don't have a crystal clear notion of how to do that, but I'd start on the problem.

That what we're doing isn't working was, for me, the bad news.  Then I got some really good news.  It was published in the journal, Science, presenting an approach to improving health that works, really works.  By that I mean an intervention that seems to help fix multigenerational, poverty-related poor health in a way that medical care does not. The finding was a surprise.  The project started out as an educational intervention.  It is turning out that the subjects are growing up healthier than their peers.

The 30-year follow-up of the Abecedarian Project at the University of North Carolina-Chapel Hill is fascinating, to say the least.  The project was begun as an early childhood education intervention in 1972 with 2-month-old kids from very disadvantaged backgrounds.  Half the children, the control group, got excellent but conventional day care for the next five years.  The other half of the children, the intervention group, got day care that sounds like “high intensity parenting,” as well as built-in clinic visits.  Each caregiver had as few as three children in her care, six to eight hours per day, five days per week.  They were constantly picked up, talked to and played with. The cost was about $70,000 per child for the whole five years, in current dollars.  Though the kids got all the recommended clinic care, no one thought of it as a health project.

Through the school years the intervention group performed about a year ahead of the control group and, as adults, more have gone to college, and have done better, job-wise.

The fascinating aspect of this report for me, though, lies in the difference in the health of the members of these two groups, now in their mid-30s.  The average blood pressure for men in the group that got ordinary day care (that is, the control group) is in the hypertensive range.  The average blood pressure for men in the intervention group is normal.

Adult obesity is significantly more common in the control group.  People who are obese in their 30s were on their way at birth and certainly by their first birthday.  The authors speculate that parents in the intervention group were advised regarding their child's weight during the pediatric visits that were built into the intervention program.  It will take a different study to sort out the clinical/nutritional from the educational causal factors if that seems necessary.  Personally I'd go for both smart and healthy.

A quarter of the men in the control group have “metabolic syndrome”—that is excess abdominal fat and high blood sugar.  A few years ago we'd have called them “prediabetic.”  None in the intervention group has “metabolic syndrome.”  This early intensive intervention project seems to have shown a way to prevent the disease package that is responsible for the rising death rates across much of the country.  Medical care hasn't been able to do that.

The numbers of alumni of the Carolina Abecedarian Project that can still be found for follow-up are small.  The statistical methods applied to the results of these most recent reports were stringent and carefully crafted in recognition of those small numbers.

Granted, this insight isn't of much help to the millions of folks, no longer infants, who are at high risk for the obesity/hypertension/diabetes package of disease that goes with socioeconomic disadvantage, but it strikes me as a start, an opening where we've had none except the suggestion, “eliminate poverty and health will improve.”

If early, highly interactive care can prevent the obesity/diabetes/hypertension that plagues the disadvantaged populations of this country, rural and urban, that is a big deal.  It will be a strain to afford it, considering how much we're already spending on heart attacks, diabetic kidney failure and leg amputations caused by our failure to prevent this epidemic.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

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