The evidence is in: WIC improves maternal and child health

Food insecurity is increasingly recognized as a modifiable social determinant of health. The American Academy of Family Physicians has endorsed "sustained funding for evidence-based policies and programs to eliminate disparities in healthy food access, including ... the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC)." In a 2019 editorial about interventions to reduce maternal mortality, Drs. Katy Kozhimannil and Andrea Westby recommended postpartum screening for food insecurity. But how strong is the evidence that WIC improves maternal and child health?

Since 2012, American Family Physician's Implementing AHRQ Effective Health Care Reviews feature has summarized dozens of primary care-relevant systematic reviews from the Agency for Healthcare Research and Quality's Effective Health Care Program with accompanying clinical commentaries. A team of investigators in this program recently reviewed maternal and child outcomes associated with WIC and published a synopsis of their report in Annals of Internal Medicine. Investigators identified 82 studies that examined associations between WIC participation and maternal, birth, infant, and child health outcomes.

Based on direct evidence from 49 studies, they concluded that WIC participation likely reduces the incidence of preterm birth, low birth weight, and infant mortality. Lower strength of evidence suggested WIC is associated with less inadequate gestational weight gain and alcohol use and better diet quality during pregnancy, and it may increase child preventive care visits and immunizations. WIC was not associated with differences in breastfeeding rates or premature (before 4 months) introduction of solid foods. Children of families receiving WIC had better diet quality, increased household purchasing of healthy foods compared to less healthy foods and beverages, and higher cognitive development than WIC-eligible children not receiving benefits. There was insufficient evidence that WIC reduced childhood obesity or affected health status or risk of hospitalization.

The U.S. Department of Agriculture (USDA) found that food insecurity in households with children declined to its lowest rate in two decades in 2021, despite the negative impact of the COVID-19 pandemic on the economy. The nonpartisan Center on Budget and Policy Priorities observed:

About 10.2 percent of U.S. households were food insecure in 2021, meaning they struggled to afford enough food for an active, healthy life year-round. That the rate held steady during the pandemic — when accounting for statistical noise it’s not significantly different from the 10.5 percent rate for 2019 and 2020 — is a testament to robust relief measures policymakers enacted. These include Economic Impact Payments, an expanded Child Tax Credit, improved unemployment insurance, and expanded food assistance, along with [the Supplemental Nutrition Assistance Program]'s built-in ability to respond to increased need.

On the negative side, food insecurity increased from 2020 to 2021 in households without children and for women and older people living alone. Households headed by Black, Hispanic, and American Indian / Alaska Native persons were more likely to experience food insecurity than other households. Finally, the expiration of temporary pandemic emergency relief measures, such as free meals for all children attending public schools, may worsen food insecurity in low-income families.

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This post first appeared on the AFP Community Blog.

Malcolm Gladwell on trust in medicine and the devaluing of primary care

This week I'm back in Washington DC, attending and presenting educational sessions at the American Academy of Family Physicians FMX (Family Medicine Experience), the first in-person version of this conference since 2019. For me the highlight of this conference is usually the invited celebrity speaker, someone with an inspirational story outside of medicine: past speakers have included political pundits Mary Matalin and James Carville and Aron Ralston, who survived a canyoneering accident in which he had to cut off his own arm to save his life. But this year's speaker, the author and podcaster Malcolm Gladwell, topped them all. I've been a huge Gladwell fan since I read The Tipping Point, avidly listen to his Revisionist History podcast (and featured a past episode on philanthropy on this blog), and couldn't wait to hear what he had to say yesterday to an audience of family physicians who have spent the past two plus years fighting pandemic misinformation.

The theme of his talk was that the decline in trust in medicine and public health that has manifested as tenacious resistance to Covid vaccination among certain demographics and/or areas of the country may have less to do with true anti-science sentiment and more to do with people having a hard time adjusting to strange new things. He shared several examples of this phenomenon in other fields: focus groups panning pilots of television sitcoms that ended up becoming classics (e.g., the Mary Tyler Moore Show, All In The Family, Cheers, and Seinfeld); the near rejection of the prototype of a mesh office chair that ended up earning billions of dollars for its inventor; and the Marines transforming its service from the misfits of the U.S. military to "the Few, the Proud" elite branch that we know today. Gladwell noted that trust in a profession doesn't always correlate with its effectiveness, and that pouring billions of dollars into amazing technological solutions to the pandemic (vaccines and antiviral treatments) while neglecting to support the family doctors whose job it is to persuade patients, based on preexisting trusting relationships, to accept these medical innovations was "nuts." (I made a similar point in an editorial in the Annals of Family Medicine last year). It's no wonder that many of our patients turned to the well established - but totally ineffective - drugs hydroxychloroquine and ivermectin instead.

Public health holds many stories of initial mistrust in effective interventions. Gladwell talked about how despite clear evidence showing that supplementing water or salt with iodine eliminated goiter, there was widespread public resistance to the idea ("I'll take my chances with the goiter"). The same thing happened when health officials proposed adding fluoride to water to prevent dental caries. This time, though, one official got clever and announced that fluoride would be added to the municipal water supply on a certain date, then when numerous people experienced adverse effects from drinking water on that date, mentioned that he had actually delayed the date but forgotten to tell anyone. So there is reason to hope that one day, receiving annual flu and Covid-19 vaccines will be less about one's partisan allegiances and more about following your doctor's common sense recommendation to protect yourself and others against severe illness and death.

Neurosyphilis, ocular syphilis, and otosyphilis are don't-miss diagnoses

When a patient with a history of migraine headaches presents with a "severe frontal headache and left-eye blurred vision and pain," neurosyphilis is unlikely to be foremost in the differential. Even after she mentions a two-month history of a diffuse maculopapular rash, clinicians may feel reassured because it doesn't involve the palms and soles. But syphilis, the great imitator, was in fact the eventual diagnosis in this patient, the subject of a case report published in Cureus.

In the August issue of American Family Physician, Dr. Jennifer Jones-Vanderleest reviewed detection and treatment of neurosyphilis, ocular syphilis, and otosyphilis, which can occur at any stage of syphilis regardless of immune status. Early neurosyphilis (within the first few years of infection) can present with "headache, dizziness, altered mental status, cranial neuropathies, motor and sensory deficits, meningitis, or stroke." Neurosyphilis is diagnosed with the combination of neurologic signs and symptoms and reactive syphilis serology and cerebrospinal fluid (CSF) tests. The 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines recommend that patients with neurosyphilis be treated with 18 to 24 million units of aqueous crystalline penicillin G per day for 10 to 14 days, administered as a continuous infusion or 3 to 4 million units intravenously every 4 hours. These patients should be tested for HIV and be offered HIV preexposure prophylaxis if HIV negative. After treatment, normalization of the serum RPR titer predicts normalization of CSF parameters; thus, repeated CSF sampling is not needed unless the patient is HIV positive and not receiving antiretroviral therapy.

As I discussed in a previous post, the incidence of syphilis in the U.S. has been rising steadily for the past two decades (beginning in my third year in medical school and continuing throughout my family medicine residency and practice) due to stagnant health department funding for contact tracers and the recent impact of the COVID-19 pandemic. Far from being ancient history, "in 2020, 133,945 cases of all stages of syphilis were reported, including 41,655 cases of primary and secondary syphilis," according to the CDC. Although a disproportionate number of cases occur in men who have sex with men, rates in women have increased sharply since 2016. A current review of the epidemiology, natural history, diagnosis and treatment of syphilis is available in the Journal of Lancaster General Hospital.

A draft recommendation statement from the U.S. Preventive Services Task Force (USPSTF) reaffirmed the importance of screening adolescents and adults at increased risk for syphilis infection. The USPSTF also recommends that all pregnant patients be screened for syphilis as early as possible in pregnancy. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend rescreening women at high risk for syphilis at 28 weeks of gestation and again at delivery to prevent congenital syphilis.

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This post first appeared on the AFP Community Blog.

Hot topics in health policy

Last night, in a short talk to medical students and residents on "Health Policy in Family Medicine," I outlined three paths to become involved in the health policy space as a family physician, paralleling the ways that policy has intersected with my own career:

1. Clinical guidance and practice guidelines. How do research findings make their way into clinical practice recommendations? Where evidence is lacking or inconclusive, how are the judgment calls made and who gets to make them? Examples include my experiences as a medical officer for the U.S. Preventive Services Task Force, a guideline panelist for the American Academy of Family Physicians and collaborating specialty groups, and a member of the HHS Secretary's Advisory Committee on Breast Cancer in Young Women.

2. Advocacy for patients and population health. Advocacy can take many forms: interpersonal (e.g., lobbying local, state, or federal officials), writing opinion pieces, or serving as a source for a news story. I consider Common Sense Family Doctor and my Twitter account to be my main advocacy platforms, though on occasion I've written editorials in high-profile publications such as JAMA. During the COVID-19 pandemic, I spent a good deal of time pushing back against vaccine hesitancy and anti-vax sentiments in my community and online.

3. Advocacy for health professionals and primary care. While at Georgetown, I directed a health policy fellowship that trained recent family medicine residency graduates in research that demonstrated the value (and financially undervalued nature) of primary care. I continue to support the Robert Graham Center's work by publishing an ongoing series of Policy One-Pagers in American Family Physician.

Health policy isn't an abstract subject for me. In my medical career, I've seen firsthand the benefits to patients of the 2003 Medicare Modernization Act (which provided prescription drug coverage to millions of older adults), the 2010 Affordable Care Act (which extended access to affordable health insurance to tens of millions and provided consumer protections and guaranteed preventive services to all), and this year's Inflation Reduction Act, which allows Medicare to negotiate the prices of a limited number of expensive drugs, caps Medicare patients' out-of-pocket insulin costs at $35 per month and their total prescription out-of-pocket costs at $2000 per year. In addition, the IRA extended enhanced health insurance marketplace subsidies that were set to expire this year through 2025, which will preserve the affordability of private plans for lower-income patients who are self-employed or work for small employers that don't offer health care benefits. This legislation will make a major difference in many of my patients' lives by making it easier for me to provide them with the best care possible.

Diabetes is an increasingly common pregnancy complication

My clinical experiences suggest that more pregnant patients have been developing diabetes over the past several years, and it turns out this is a national phenomenon. A recent report from the Centers for Disease Control and Prevention documented a precipitous rise in the rate of gestational diabetes in the U.S. from 2016 to 2020, based on data collected from birth certificates. In 2020, gestational diabetes affected 7.8% of all pregnancies, reflecting a 13% increase since 2019 and a 30% increase since 2016. Prevalence increased with increasing age (2.5% in patients younger than 20 years and 15.3% in those aged 40 or older) and increasing pre-pregnancy body mass index (BMI). Both factors are likely driving the overall rise in gestational diabetes; the median age at which U.S. women gave birth reached an all-time high of 30 years in 2019 and only 2 in 5 women with a live birth in 2020 had a normal BMI prior to pregnancy.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes in asymptomatic pregnant patients at or after 24 weeks of gestation. Although the USPSTF did not identify a preferred test, a previously discussed study suggested that the two-step approach (a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test is positive) "produces equivalent benefits, and fewer harms, than the one-step approach."

Adverse outcomes associated with gestational diabetes include gestational hypertension, preeclampsia, shoulder dystocia, macrosomia, and Cesarean delivery. Gestational diabetes also confers a 7-fold greater maternal risk of developing type 2 diabetes later in life and 1.5 times greater risk of the child being overweight in childhood or adolescence. Management of gestational diabetes begins with glucose self-monitoring and lifestyle modifications, followed by oral medication or insulin if target blood glucose levels are not achieved.

Prevention of gestational diabetes includes counseling on appropriate weight gain goals based on pre-pregnancy BMI, which can generally be achieved by averaging "350 to 450 calories per day above the previous intake (e.g., two slices of bread with half an avocado, ¾ cup of Greek yogurt or 1 cup of blueberries with two hard-boiled eggs)." Additionally, "patients should be encouraged to engage in moderate aerobic activity most days of the week for at least 20 to 30 minutes at a time, for a total of at least 150 minutes per week." The USPSTF recommends offering behavioral counseling interventions for healthy weight and weight gain in pregnancy; effective interventions generally started at the end of the first trimester and varied in duration and intensity (from 15 to 120 minutes and from 1 to more than 12 total contacts).

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This post first appeared on the AFP Community Blog.

Preventive services mandate can be improved, but eliminating it isn't the answer

Over the past 12 years since the Affordable Care Act became law, individuals, business groups, and state officials who object to one or more of its provisions have filed a lengthy list of mostly unsuccessful lawsuits seeking to have part or all of it declared unconstitutional by the courts. The latest legal challenge involves the requirement that private health insurers cover without patient cost-sharing all evidence-based preventive services, defined as more than 100 services recommended by the Advisory Committee on Immunization Practices, the U.S. Preventive Services Task Force, Bright Futures, or the Women's Preventive Service Initiative. When I went to my family doctor last month and received screening tests for colorectal cancer, high blood pressure, and cholesterol, these tests were all covered under the ACA's preventive services mandate. When I take my kids to receive their school-required vaccinations, those shots are fully covered too. The same goes for the costs of clinicians counseling pregnant patients about healthy weight and weight gain to prevent complications such as gestational diabetes, and similar counseling for to midlife women (aged 40 to 60 years) to maintain weight or limit weight gain to prevent obesity.

Why would anyone have a problem with requiring insurers to cover preventive services? Some employers have religious or ideological objections to paying for birth control and sterilization, preexposure prophylaxis for HIV prevention, or testing for sexually transmitted diseases. Others might oppose the increased employer or government contribution to insurance premiums that may result from mandating that these services be covered, though in reality the types of health care that drive up premiums tend to be pricey procedures and medications such as the Alzheimer's drug Aduhelm, whose initial projected price of $56,000 per year drove the highest-ever increase in Medicare premiums from 2021 to 2022.

Ensuring that patients can afford preventive services is only the first step toward getting them done. Only about two-thirds of eligible adults are up-to-date on colorectal cancer screening, for example, and a much lower percentage of current or past heavy smokers over age 50 have been offered or received lung cancer screening. Behavioral health preventive services such as screening for depression, intimate partner violence, and unhealthy alcohol use can be difficult to fit into clinical practice workflows that rely on dysfunctional electronic health records (systems that are optimized for billing rather than patient care).

The narrow focus of the ACA's preventive services mandate on health care services also leaves out other private and public programs that can have large benefits on disease prevention and care. For example, the final report of the National Clinical Care Commission included population-level diabetes prevention recommendations involving the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, and the Department of Housing and Urban Development. A related analysis article in Health Affairs bemoaned the fragmented state of US health care and policy that has stalled progress in preventing and controlling type 2 diabetes:

At the population level, fragmentation and lack of shared population health goals across stakeholders mean that there is no ownership for large segments of the population who are at risk for or have diabetes. Payers carry the liability for the health service costs of their beneficiaries and can track utilization. Enrollee churn reduces payers' incentives to take on long-term responsibility or investments in higher-quality preventive services for which returns are only realized in the long term. ... Similarly, the movement of people between health systems undermines incentives for long-term, high-value care.

So you'll get no pushback from me if you observe that there are lots of flaws and loopholes in the preventive services mandate (beginning with the fact that it doesn't even apply to half of Americans who are either publicly insured or uninsured). But getting rid of it is throwing the baby out with the bathwater: an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans.