Sunday, September 25, 2022

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.


This post first appeared on the AFP Community Blog.

Thursday, September 22, 2022

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.

Monday, September 12, 2022

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.


This post first appeared on the AFP Community Blog.