Heidi Splete

A pilot program aimed at teaching residents how to better counsel patients and families about childhood obesity is underway in five California-based residency programs.

The idea is to train pediatric and family medicine residents in strategies that can help patients make behavioral changes proven to reduce and prevent obesity. For example, the program gives the residents tips for helping individuals decrease their consumption of sugary beverages. Residents are armed with handouts on healthy beverage options and a visual aid that shows patients how much sugar is in a soda or sports drink.

The hope is that preparing future primary care physicians to effectively motivate lifestyle changes will help stem the prevalence rates of pediatric obesity, type 2 diabetes, and heart disease, Dr. Lydia Tinajero-Deck, the project's principal investigator, said in an interview.

The pilot, dubbed Fit for Residents, was developed by the University of California, Los Angeles, in collaboration with the American Academy of Pediatrics and American Academy of Family Physicians, said Dr. Tinajero-Deck, a pediatrician in the primary care department at Children's Hospital & Research Center in Oakland, Calif.

A pilot program aimed at teaching residents how to better counsel patients and families about childhood obesity is underway in five California-based residency programs.

The idea is to train pediatric and family medicine residents in strategies that can help patients make behavioral changes proven to reduce and prevent obesity. For example, the program gives the residents tips for helping individuals decrease their consumption of sugary beverages. Residents are armed with handouts on healthy beverage options and a visual aid that shows patients how much sugar is in a soda or sports drink.

The hope is that preparing future primary care physicians to effectively motivate lifestyle changes will help stem the prevalence rates of pediatric obesity, type 2 diabetes, and heart disease, Dr. Lydia Tinajero-Deck, the project's principal investigator, said in an interview.

The pilot, dubbed Fit for Residents, was developed by the University of California, Los Angeles, in collaboration with the American Academy of Pediatrics and American Academy of Family Physicians, said Dr. Tinajero-Deck, a pediatrician in the primary care department at Children's Hospital & Research Center in Oakland, Calif.

A pilot program aimed at teaching residents how to better counsel patients and families about childhood obesity is underway in five California-based residency programs.

The idea is to train pediatric and family medicine residents in strategies that can help patients make behavioral changes proven to reduce and prevent obesity. For example, the program gives the residents tips for helping individuals decrease their consumption of sugary beverages. Residents are armed with handouts on healthy beverage options and a visual aid that shows patients how much sugar is in a soda or sports drink.

The hope is that preparing future primary care physicians to effectively motivate lifestyle changes will help stem the prevalence rates of pediatric obesity, type 2 diabetes, and heart disease, Dr. Lydia Tinajero-Deck, the project's principal investigator, said in an interview.

The pilot, dubbed Fit for Residents, was developed by the University of California, Los Angeles, in collaboration with the American Academy of Pediatrics and American Academy of Family Physicians, said Dr. Tinajero-Deck, a pediatrician in the primary care department at Children's Hospital & Research Center in Oakland, Calif.

WASHINGTON — The health cost of obesity in the United States jumped over the past decade, from $74 billion in 1998 to approximately $147 billion today, based on data from a study conducted by the Centers for Disease Control and Prevention and the Research Triangle Institute. The data were presented at the CDC's inaugural Weight of the Nation conference on obesity.

“Obesity affects every body system,” Dr. Thomas R. Frieden, director of the CDC, said during opening remarks at the conference.

Obesity accounted for 6.5% of overall annual medical costs in the United States in 1998, but that proportion increased to 9.1% by 2006, said the study's lead author, Eric Finkelstein, Ph.D., of the independent Research Triangle Institute.

The annual cost of medical care per adult in the United States is 41% less for a normal-weight individual than for an obese individual, Dr. Finkelstein said. In this study, obesity was defined as a body mass index of 30 kg/m

If the obesity prevalence had remained the same between 1998 and 2006, 2006 medical costs in the United States would have been approximately $40 billion less, Dr. Finkelstein emphasized.

The study results were limited by the reliance on self-reports of body mass index, Dr. Finkelstein noted. The study examined only aggregate health costs and did not look at disease-specific costs, but “diabetes is one of the largest drivers of health care costs,” he said.

At a media briefing, Dr. Frieden said that the most effective strategies to reduce obesity may involve community intervention rather than clinical intervention. But physicians have a responsibility to encourage patients' weight-loss efforts in a clinical practice setting, he added.

The study was sponsored in part by the CDC.

To watch a video interview of Dr. Finkelstein, go to: http://www.youtube.com/watch?v=TwyTYVrnJjw

WASHINGTON — The health cost of obesity in the United States jumped over the past decade, from $74 billion in 1998 to approximately $147 billion today, based on data from a study conducted by the Centers for Disease Control and Prevention and the Research Triangle Institute. The data were presented at the CDC's inaugural Weight of the Nation conference on obesity.

“Obesity affects every body system,” Dr. Thomas R. Frieden, director of the CDC, said during opening remarks at the conference.

Obesity accounted for 6.5% of overall annual medical costs in the United States in 1998, but that proportion increased to 9.1% by 2006, said the study's lead author, Eric Finkelstein, Ph.D., of the independent Research Triangle Institute.

The annual cost of medical care per adult in the United States is 41% less for a normal-weight individual than for an obese individual, Dr. Finkelstein said. In this study, obesity was defined as a body mass index of 30 kg/m

If the obesity prevalence had remained the same between 1998 and 2006, 2006 medical costs in the United States would have been approximately $40 billion less, Dr. Finkelstein emphasized.

The study results were limited by the reliance on self-reports of body mass index, Dr. Finkelstein noted. The study examined only aggregate health costs and did not look at disease-specific costs, but “diabetes is one of the largest drivers of health care costs,” he said.

At a media briefing, Dr. Frieden said that the most effective strategies to reduce obesity may involve community intervention rather than clinical intervention. But physicians have a responsibility to encourage patients' weight-loss efforts in a clinical practice setting, he added.

The study was sponsored in part by the CDC.

To watch a video interview of Dr. Finkelstein, go to: http://www.youtube.com/watch?v=TwyTYVrnJjw

WASHINGTON — The health cost of obesity in the United States jumped over the past decade, from $74 billion in 1998 to approximately $147 billion today, based on data from a study conducted by the Centers for Disease Control and Prevention and the Research Triangle Institute. The data were presented at the CDC's inaugural Weight of the Nation conference on obesity.

“Obesity affects every body system,” Dr. Thomas R. Frieden, director of the CDC, said during opening remarks at the conference.

Obesity accounted for 6.5% of overall annual medical costs in the United States in 1998, but that proportion increased to 9.1% by 2006, said the study's lead author, Eric Finkelstein, Ph.D., of the independent Research Triangle Institute.

The annual cost of medical care per adult in the United States is 41% less for a normal-weight individual than for an obese individual, Dr. Finkelstein said. In this study, obesity was defined as a body mass index of 30 kg/m

If the obesity prevalence had remained the same between 1998 and 2006, 2006 medical costs in the United States would have been approximately $40 billion less, Dr. Finkelstein emphasized.

The study results were limited by the reliance on self-reports of body mass index, Dr. Finkelstein noted. The study examined only aggregate health costs and did not look at disease-specific costs, but “diabetes is one of the largest drivers of health care costs,” he said.

At a media briefing, Dr. Frieden said that the most effective strategies to reduce obesity may involve community intervention rather than clinical intervention. But physicians have a responsibility to encourage patients' weight-loss efforts in a clinical practice setting, he added.

The study was sponsored in part by the CDC.

To watch a video interview of Dr. Finkelstein, go to: http://www.youtube.com/watch?v=TwyTYVrnJjw

Bacterial coinfections likely played a role in almost one-third of fatal cases of 2009 pandemic influenza A(H1N1) in the United States, based on data from 77 patients published online in the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

“These findings confirm that bacterial lung infections are occurring among patients with fatal cases of 2009 H1N1 and underscore both the importance of pneumococcal vaccination for persons at increased risk for pneumococcal pneumonia and the need for early recognition of bacterial pneumonia in persons with influenza,” the investigators wrote (MMWR 2009;58:1–4).

The investigators found evidence of concurrent bacterial infection in lung specimens from 22 of 77 patients (29%) with fatal cases of 2009 H1N1 infection. The specimens were submitted to the CDC by medical examiners and local health departments between May 1 and Aug. 20, 2009.

A total of 10 fatal cases were coinfections with Streptococcus pneumoniae, 6 were Streptococcus pyogenes, 7 were Staphylococcus aureus, 2 were Streptococcus mitis, and 1 was Haemophilus influenzae. Four of the fatal cases involved multiple pathogens. The age of the patients ranged from 2 months to 56 years, with an average age of 31 years. The 22 patients were divided evenly by sex. The average duration of illness was 6 days, based on data from 17 of the 22 coinfection cases for whom this information was available.

Medical history was available for 21 of the coinfection patients, and 16 of these had underlying medical conditions “that were known to increase the risk for influenza-related complications,” the investigators wrote. And 15 patients had conditions that were indications for vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23), the investigators added. Data were not available on the vaccination status of any of the 22 bacterial coinfection cases.

Although two early reviews of severe 2009 H1N1 cases this year showed no evidence of coinfection with bacterial pneumonia, the current results support findings from autopsy studies in previous pandemics, in which bacterial coinfections were found in the majority of the deaths attributed to influenza A infections, the investigators wrote.

The results were limited by incomplete patient information, a lack of specimens from unaffected lung tissue, and a limited evaluation of potential bacterial pathogens, they noted.

For the complete MMWR report, visit www.cdc.gov/mmwr

Bacterial coinfections likely played a role in almost one-third of fatal cases of 2009 pandemic influenza A(H1N1) in the United States, based on data from 77 patients published online in the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

“These findings confirm that bacterial lung infections are occurring among patients with fatal cases of 2009 H1N1 and underscore both the importance of pneumococcal vaccination for persons at increased risk for pneumococcal pneumonia and the need for early recognition of bacterial pneumonia in persons with influenza,” the investigators wrote (MMWR 2009;58:1–4).

The investigators found evidence of concurrent bacterial infection in lung specimens from 22 of 77 patients (29%) with fatal cases of 2009 H1N1 infection. The specimens were submitted to the CDC by medical examiners and local health departments between May 1 and Aug. 20, 2009.

A total of 10 fatal cases were coinfections with Streptococcus pneumoniae, 6 were Streptococcus pyogenes, 7 were Staphylococcus aureus, 2 were Streptococcus mitis, and 1 was Haemophilus influenzae. Four of the fatal cases involved multiple pathogens. The age of the patients ranged from 2 months to 56 years, with an average age of 31 years. The 22 patients were divided evenly by sex. The average duration of illness was 6 days, based on data from 17 of the 22 coinfection cases for whom this information was available.

Medical history was available for 21 of the coinfection patients, and 16 of these had underlying medical conditions “that were known to increase the risk for influenza-related complications,” the investigators wrote. And 15 patients had conditions that were indications for vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23), the investigators added. Data were not available on the vaccination status of any of the 22 bacterial coinfection cases.

Although two early reviews of severe 2009 H1N1 cases this year showed no evidence of coinfection with bacterial pneumonia, the current results support findings from autopsy studies in previous pandemics, in which bacterial coinfections were found in the majority of the deaths attributed to influenza A infections, the investigators wrote.

The results were limited by incomplete patient information, a lack of specimens from unaffected lung tissue, and a limited evaluation of potential bacterial pathogens, they noted.

For the complete MMWR report, visit www.cdc.gov/mmwr

Bacterial coinfections likely played a role in almost one-third of fatal cases of 2009 pandemic influenza A(H1N1) in the United States, based on data from 77 patients published online in the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

“These findings confirm that bacterial lung infections are occurring among patients with fatal cases of 2009 H1N1 and underscore both the importance of pneumococcal vaccination for persons at increased risk for pneumococcal pneumonia and the need for early recognition of bacterial pneumonia in persons with influenza,” the investigators wrote (MMWR 2009;58:1–4).

The investigators found evidence of concurrent bacterial infection in lung specimens from 22 of 77 patients (29%) with fatal cases of 2009 H1N1 infection. The specimens were submitted to the CDC by medical examiners and local health departments between May 1 and Aug. 20, 2009.

A total of 10 fatal cases were coinfections with Streptococcus pneumoniae, 6 were Streptococcus pyogenes, 7 were Staphylococcus aureus, 2 were Streptococcus mitis, and 1 was Haemophilus influenzae. Four of the fatal cases involved multiple pathogens. The age of the patients ranged from 2 months to 56 years, with an average age of 31 years. The 22 patients were divided evenly by sex. The average duration of illness was 6 days, based on data from 17 of the 22 coinfection cases for whom this information was available.

Medical history was available for 21 of the coinfection patients, and 16 of these had underlying medical conditions “that were known to increase the risk for influenza-related complications,” the investigators wrote. And 15 patients had conditions that were indications for vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23), the investigators added. Data were not available on the vaccination status of any of the 22 bacterial coinfection cases.

Although two early reviews of severe 2009 H1N1 cases this year showed no evidence of coinfection with bacterial pneumonia, the current results support findings from autopsy studies in previous pandemics, in which bacterial coinfections were found in the majority of the deaths attributed to influenza A infections, the investigators wrote.

The results were limited by incomplete patient information, a lack of specimens from unaffected lung tissue, and a limited evaluation of potential bacterial pathogens, they noted.

For the complete MMWR report, visit www.cdc.gov/mmwr

BETHESDA, MD. — Family history continues to be an important tool for clinicians, but more research is needed before it can be declared an evidence-based strategy that improves outcomes for patients, according to a statement released after a conference on Family History and Improving Health sponsored by the National Institutes of Health.

“There's still a lot we don't know about how to collect and use family history effectively,” Dr. Alfred Berg of the University of Washington, Seattle, said at the start of the conference.

“The panel recognized that family history has an important role,” he added during a telebriefing after the conference. But it is unclear how this information can best be gathered and used to predict disease outcomes in primary care, he said.

The statement was compiled by an expert panel based on a review of the best available evidence on the role of family history in the diagnosis of common diseases seen by primary care clinicians. Dr. Berg served as chairperson of the panel.

Panelists heard from researchers who presented data on the usefulness of family history for risk assessment in clinical care settings, as well as in specific populations such as children and pregnant women.

In the statement, the panel acknowledged that “Family history was a core element of clinical care long before the evidence-based medicine paradigm was even proposed.” Consequently, the evidence to support the usefulness of family history for identifying common diseases is weak in several key areas, including defining the key elements of family history, linking results to clinical conditions, and evaluating potential benefits and harms.

Health care professionals in the United States have always asked patients about family history information, said Dr. Berg. The increase in the availability of genomic information and the shift toward electronic medical records provide interesting possibilities for ways to use family history more effectively to improve health outcomes, he added.

The statement includes a list of research questions that fall into three categories: structure or characteristics of a family history; the process of acquiring a family history; and outcomes of the acquisition, interpretation, and application of family history information.

One research question asks, “What are optimal ways to use family history in a primary care setting to identify individuals who can benefit from enhanced surveillance or referral to genetics services?”

The report is not designed to inform clinical practice, said Dr. Berg. But one of the goals of the conference is that the research agenda will generate the kind of information that eventually allows physicians to do a better job of collecting family history information, he said.

A State-of-the-Science statement is not an official policy or position statement of the National Institutes of Health or the federal government. The panel members had no relevant financial conflicts to disclose. The statement is available online at www.consensus.nih.gov

'There's still a lot we don't know about how to collect and use family history effectively.'

Source DR. BERG

BETHESDA, MD. — Family history continues to be an important tool for clinicians, but more research is needed before it can be declared an evidence-based strategy that improves outcomes for patients, according to a statement released after a conference on Family History and Improving Health sponsored by the National Institutes of Health.

“There's still a lot we don't know about how to collect and use family history effectively,” Dr. Alfred Berg of the University of Washington, Seattle, said at the start of the conference.

“The panel recognized that family history has an important role,” he added during a telebriefing after the conference. But it is unclear how this information can best be gathered and used to predict disease outcomes in primary care, he said.

The statement was compiled by an expert panel based on a review of the best available evidence on the role of family history in the diagnosis of common diseases seen by primary care clinicians. Dr. Berg served as chairperson of the panel.

Panelists heard from researchers who presented data on the usefulness of family history for risk assessment in clinical care settings, as well as in specific populations such as children and pregnant women.

In the statement, the panel acknowledged that “Family history was a core element of clinical care long before the evidence-based medicine paradigm was even proposed.” Consequently, the evidence to support the usefulness of family history for identifying common diseases is weak in several key areas, including defining the key elements of family history, linking results to clinical conditions, and evaluating potential benefits and harms.

Health care professionals in the United States have always asked patients about family history information, said Dr. Berg. The increase in the availability of genomic information and the shift toward electronic medical records provide interesting possibilities for ways to use family history more effectively to improve health outcomes, he added.

The statement includes a list of research questions that fall into three categories: structure or characteristics of a family history; the process of acquiring a family history; and outcomes of the acquisition, interpretation, and application of family history information.

One research question asks, “What are optimal ways to use family history in a primary care setting to identify individuals who can benefit from enhanced surveillance or referral to genetics services?”

The report is not designed to inform clinical practice, said Dr. Berg. But one of the goals of the conference is that the research agenda will generate the kind of information that eventually allows physicians to do a better job of collecting family history information, he said.

A State-of-the-Science statement is not an official policy or position statement of the National Institutes of Health or the federal government. The panel members had no relevant financial conflicts to disclose. The statement is available online at www.consensus.nih.gov

'There's still a lot we don't know about how to collect and use family history effectively.'

Source DR. BERG

BETHESDA, MD. — Family history continues to be an important tool for clinicians, but more research is needed before it can be declared an evidence-based strategy that improves outcomes for patients, according to a statement released after a conference on Family History and Improving Health sponsored by the National Institutes of Health.

“There's still a lot we don't know about how to collect and use family history effectively,” Dr. Alfred Berg of the University of Washington, Seattle, said at the start of the conference.

“The panel recognized that family history has an important role,” he added during a telebriefing after the conference. But it is unclear how this information can best be gathered and used to predict disease outcomes in primary care, he said.

The statement was compiled by an expert panel based on a review of the best available evidence on the role of family history in the diagnosis of common diseases seen by primary care clinicians. Dr. Berg served as chairperson of the panel.

Panelists heard from researchers who presented data on the usefulness of family history for risk assessment in clinical care settings, as well as in specific populations such as children and pregnant women.

In the statement, the panel acknowledged that “Family history was a core element of clinical care long before the evidence-based medicine paradigm was even proposed.” Consequently, the evidence to support the usefulness of family history for identifying common diseases is weak in several key areas, including defining the key elements of family history, linking results to clinical conditions, and evaluating potential benefits and harms.

Health care professionals in the United States have always asked patients about family history information, said Dr. Berg. The increase in the availability of genomic information and the shift toward electronic medical records provide interesting possibilities for ways to use family history more effectively to improve health outcomes, he added.

The statement includes a list of research questions that fall into three categories: structure or characteristics of a family history; the process of acquiring a family history; and outcomes of the acquisition, interpretation, and application of family history information.

One research question asks, “What are optimal ways to use family history in a primary care setting to identify individuals who can benefit from enhanced surveillance or referral to genetics services?”

The report is not designed to inform clinical practice, said Dr. Berg. But one of the goals of the conference is that the research agenda will generate the kind of information that eventually allows physicians to do a better job of collecting family history information, he said.

A State-of-the-Science statement is not an official policy or position statement of the National Institutes of Health or the federal government. The panel members had no relevant financial conflicts to disclose. The statement is available online at www.consensus.nih.gov

'There's still a lot we don't know about how to collect and use family history effectively.'

Source DR. BERG

CHICAGO — A history of foodborne infections nearly triples the risk of inflammatory bowel disease, according to data from a population-based study of nearly 40,000 adults.

“We have seen increased incidence of both colitis and Crohn's disease in recent years,” said Dr. Henrik Nielsen of Aalborg (Denmark) Hospital. The pathogenesis of inflammatory bowel disease (IBD) remains uncertain. Previous studies have suggested a role for environmental factors, including infections, but few of these studies have included long-term follow-up data, he said at the annual Digestive Disease Week.

Dr. Nielsen and his colleagues used laboratory registries from 1991 to 2003 to identify 13,148 adults with a history of Salmonella or Campylobacter gastroenteritis, and 26,216 controls without a history of these infections.

During an average follow-up of 7.5 years, a first-time diagnosis of IBD was reported in 107 individuals with a history of Salmonella or Campylobacter infections, and in 73 controls. The risk of IBD was similar for both pathogens, and was independent of age and sex. In the group with the history of infections, the odds ratio for IBD was 2.9 during the entire follow-up period and 1.9 when the first year after infection was excluded.

The study could not prove causality because of its retrospective nature, but the results may contribute to a better understanding of the etiology of IBD, said Dr. Nielsen, who had no financial conflicts to disclose.

A related video is at www.youtube.com/Internal

CHICAGO — A history of foodborne infections nearly triples the risk of inflammatory bowel disease, according to data from a population-based study of nearly 40,000 adults.

“We have seen increased incidence of both colitis and Crohn's disease in recent years,” said Dr. Henrik Nielsen of Aalborg (Denmark) Hospital. The pathogenesis of inflammatory bowel disease (IBD) remains uncertain. Previous studies have suggested a role for environmental factors, including infections, but few of these studies have included long-term follow-up data, he said at the annual Digestive Disease Week.

Dr. Nielsen and his colleagues used laboratory registries from 1991 to 2003 to identify 13,148 adults with a history of Salmonella or Campylobacter gastroenteritis, and 26,216 controls without a history of these infections.

During an average follow-up of 7.5 years, a first-time diagnosis of IBD was reported in 107 individuals with a history of Salmonella or Campylobacter infections, and in 73 controls. The risk of IBD was similar for both pathogens, and was independent of age and sex. In the group with the history of infections, the odds ratio for IBD was 2.9 during the entire follow-up period and 1.9 when the first year after infection was excluded.

The study could not prove causality because of its retrospective nature, but the results may contribute to a better understanding of the etiology of IBD, said Dr. Nielsen, who had no financial conflicts to disclose.

A related video is at www.youtube.com/Internal

CHICAGO — A history of foodborne infections nearly triples the risk of inflammatory bowel disease, according to data from a population-based study of nearly 40,000 adults.

“We have seen increased incidence of both colitis and Crohn's disease in recent years,” said Dr. Henrik Nielsen of Aalborg (Denmark) Hospital. The pathogenesis of inflammatory bowel disease (IBD) remains uncertain. Previous studies have suggested a role for environmental factors, including infections, but few of these studies have included long-term follow-up data, he said at the annual Digestive Disease Week.

Dr. Nielsen and his colleagues used laboratory registries from 1991 to 2003 to identify 13,148 adults with a history of Salmonella or Campylobacter gastroenteritis, and 26,216 controls without a history of these infections.

During an average follow-up of 7.5 years, a first-time diagnosis of IBD was reported in 107 individuals with a history of Salmonella or Campylobacter infections, and in 73 controls. The risk of IBD was similar for both pathogens, and was independent of age and sex. In the group with the history of infections, the odds ratio for IBD was 2.9 during the entire follow-up period and 1.9 when the first year after infection was excluded.

The study could not prove causality because of its retrospective nature, but the results may contribute to a better understanding of the etiology of IBD, said Dr. Nielsen, who had no financial conflicts to disclose.

A related video is at www.youtube.com/Internal

Chicago — Children with Crohn's disease who received growth hormone in addition to corticosteroids showed significant improvements in symptoms after 12 weeks, based on data from 20 children aged 7-18 years with active Crohn's disease.

Previous studies have shown that growth hormone may reduce symptoms in adults with Crohn's disease and may improve growth in children, but the effect of growth hormone on intestinal inflammation in children with Crohn's is not well known, said Dr. Lee Denson of Cincinnati Children's Hospital Medical Center.

To assess the impact of growth hormone on symptoms in children with Crohn's, Dr. Denson and colleagues randomized 10 children with active disease to receive corticosteroids alone, or to receive 0.075 mg/kg per day of growth hormone (somatropin) in addition to corticosteroids.

After 12 weeks, 65% of the children who received growth hormone showed clinical remission of their Crohn's, compared with 20% of the children who did not receive growth hormone, a statistically significant difference. Growth hormone is not currently approved by the Food and Drug Administration to treat Crohn's disease, Dr. Denson reported at the annual Digestive Disease Week.

Endoscopic disease activity (measured using the Crohn's Disease Endoscopic Index of Severity) was lower in the growth hormone group. The difference between the groups was not significant. But 70% of the children in the growth hormone group achieved inactive mucosal disease at 12 weeks, compared with 50% of the children who didn't take growth hormone.

Microarray analyses of colon biopsies showed increases in some cellular components involved in neurophysiological function, cell signaling, and solute transport in children who took growth hormone that were not seen in biopsies from children who didn't take growth hormone, but the implications of these differences aren't fully understood.

In addition, 61% of the children who received growth hormone maintained their clinical response through 64 weeks, and differences in their predicted adult height after 48 weeks compared with baseline indicated catch-up growth.

“In the longer phase of the study, we found that most children who received growth hormone had a catch-up [in growth] and got back to where they would have been without the illness,” said Dr. Denson said. The growth hormone was well tolerated, and the results indicate the need for a larger multicenter study to assess the overall benefit of using growth hormone to treat Crohn's disease symptoms in children.

Dr. Denson has received grant and research support from Abbott Laboratories and Genentech Inc. This study was sponsored in part by Genentech.

Chicago — Children with Crohn's disease who received growth hormone in addition to corticosteroids showed significant improvements in symptoms after 12 weeks, based on data from 20 children aged 7-18 years with active Crohn's disease.

Previous studies have shown that growth hormone may reduce symptoms in adults with Crohn's disease and may improve growth in children, but the effect of growth hormone on intestinal inflammation in children with Crohn's is not well known, said Dr. Lee Denson of Cincinnati Children's Hospital Medical Center.

To assess the impact of growth hormone on symptoms in children with Crohn's, Dr. Denson and colleagues randomized 10 children with active disease to receive corticosteroids alone, or to receive 0.075 mg/kg per day of growth hormone (somatropin) in addition to corticosteroids.

After 12 weeks, 65% of the children who received growth hormone showed clinical remission of their Crohn's, compared with 20% of the children who did not receive growth hormone, a statistically significant difference. Growth hormone is not currently approved by the Food and Drug Administration to treat Crohn's disease, Dr. Denson reported at the annual Digestive Disease Week.

Endoscopic disease activity (measured using the Crohn's Disease Endoscopic Index of Severity) was lower in the growth hormone group. The difference between the groups was not significant. But 70% of the children in the growth hormone group achieved inactive mucosal disease at 12 weeks, compared with 50% of the children who didn't take growth hormone.

Microarray analyses of colon biopsies showed increases in some cellular components involved in neurophysiological function, cell signaling, and solute transport in children who took growth hormone that were not seen in biopsies from children who didn't take growth hormone, but the implications of these differences aren't fully understood.

In addition, 61% of the children who received growth hormone maintained their clinical response through 64 weeks, and differences in their predicted adult height after 48 weeks compared with baseline indicated catch-up growth.

“In the longer phase of the study, we found that most children who received growth hormone had a catch-up [in growth] and got back to where they would have been without the illness,” said Dr. Denson said. The growth hormone was well tolerated, and the results indicate the need for a larger multicenter study to assess the overall benefit of using growth hormone to treat Crohn's disease symptoms in children.

Dr. Denson has received grant and research support from Abbott Laboratories and Genentech Inc. This study was sponsored in part by Genentech.

Chicago — Children with Crohn's disease who received growth hormone in addition to corticosteroids showed significant improvements in symptoms after 12 weeks, based on data from 20 children aged 7-18 years with active Crohn's disease.

Previous studies have shown that growth hormone may reduce symptoms in adults with Crohn's disease and may improve growth in children, but the effect of growth hormone on intestinal inflammation in children with Crohn's is not well known, said Dr. Lee Denson of Cincinnati Children's Hospital Medical Center.

To assess the impact of growth hormone on symptoms in children with Crohn's, Dr. Denson and colleagues randomized 10 children with active disease to receive corticosteroids alone, or to receive 0.075 mg/kg per day of growth hormone (somatropin) in addition to corticosteroids.

After 12 weeks, 65% of the children who received growth hormone showed clinical remission of their Crohn's, compared with 20% of the children who did not receive growth hormone, a statistically significant difference. Growth hormone is not currently approved by the Food and Drug Administration to treat Crohn's disease, Dr. Denson reported at the annual Digestive Disease Week.

Endoscopic disease activity (measured using the Crohn's Disease Endoscopic Index of Severity) was lower in the growth hormone group. The difference between the groups was not significant. But 70% of the children in the growth hormone group achieved inactive mucosal disease at 12 weeks, compared with 50% of the children who didn't take growth hormone.

Microarray analyses of colon biopsies showed increases in some cellular components involved in neurophysiological function, cell signaling, and solute transport in children who took growth hormone that were not seen in biopsies from children who didn't take growth hormone, but the implications of these differences aren't fully understood.

In addition, 61% of the children who received growth hormone maintained their clinical response through 64 weeks, and differences in their predicted adult height after 48 weeks compared with baseline indicated catch-up growth.

“In the longer phase of the study, we found that most children who received growth hormone had a catch-up [in growth] and got back to where they would have been without the illness,” said Dr. Denson said. The growth hormone was well tolerated, and the results indicate the need for a larger multicenter study to assess the overall benefit of using growth hormone to treat Crohn's disease symptoms in children.

Dr. Denson has received grant and research support from Abbott Laboratories and Genentech Inc. This study was sponsored in part by Genentech.

WASHINGTON — The health cost of obesity in the United States jumped over the past decade, from $74 billion in 1998 to approximately $147 billion today, based on data from a study conducted by the Centers for Disease Control and Prevention and the Research Triangle Institute.

“Obesity affects every body system,” Dr. Thomas R. Frieden, director of the CDC, said during opening remarks at the agency's inaugural Weight of the Nation conference on obesity.

Obesity accounted for 6.5% of overall annual medical costs in the United States in 1998, but that proportion increased to 9.1% by 2006, said the study's lead author, Eric Finkelstein, Ph.D., of the independent Research Triangle Institute.

The annual cost of medical care per adult in the United States is 41% less for a normal-weight individual than for an obese individual. Prescription drugs are among the top contributors to the costs of obesity, Dr. Finkelstein said. In 2006, across all insurance payers, the average annual prescription drug cost for a normal-weight individual was $707, compared with $1,275 for an obese individual.

WASHINGTON — The health cost of obesity in the United States jumped over the past decade, from $74 billion in 1998 to approximately $147 billion today, based on data from a study conducted by the Centers for Disease Control and Prevention and the Research Triangle Institute.

“Obesity affects every body system,” Dr. Thomas R. Frieden, director of the CDC, said during opening remarks at the agency's inaugural Weight of the Nation conference on obesity.

Obesity accounted for 6.5% of overall annual medical costs in the United States in 1998, but that proportion increased to 9.1% by 2006, said the study's lead author, Eric Finkelstein, Ph.D., of the independent Research Triangle Institute.

The annual cost of medical care per adult in the United States is 41% less for a normal-weight individual than for an obese individual. Prescription drugs are among the top contributors to the costs of obesity, Dr. Finkelstein said. In 2006, across all insurance payers, the average annual prescription drug cost for a normal-weight individual was $707, compared with $1,275 for an obese individual.

WASHINGTON — The health cost of obesity in the United States jumped over the past decade, from $74 billion in 1998 to approximately $147 billion today, based on data from a study conducted by the Centers for Disease Control and Prevention and the Research Triangle Institute.

“Obesity affects every body system,” Dr. Thomas R. Frieden, director of the CDC, said during opening remarks at the agency's inaugural Weight of the Nation conference on obesity.

Obesity accounted for 6.5% of overall annual medical costs in the United States in 1998, but that proportion increased to 9.1% by 2006, said the study's lead author, Eric Finkelstein, Ph.D., of the independent Research Triangle Institute.

The annual cost of medical care per adult in the United States is 41% less for a normal-weight individual than for an obese individual. Prescription drugs are among the top contributors to the costs of obesity, Dr. Finkelstein said. In 2006, across all insurance payers, the average annual prescription drug cost for a normal-weight individual was $707, compared with $1,275 for an obese individual.

The majority (88%) of postpartum women reported current use of at least one form of contraception, based on an analysis of data from more than 43,000 women.

Reducing the percentage of births within a year of a previous birth among women in the United States is one of the Center's for Disease Control and Prevention's Healthy People 2010 goals. Use of effective contraceptive methods after a recent pregnancy can help prevent unintended pregnancies, ensure adequate birth spacing, and reduce adverse maternal and infant outcomes, according to Maura Whiteman, Ph.D., and colleagues at the CDC.

The researchers reviewed data from the CDC's Pregnancy Risk Assessment Monitoring System from 2004 to 2006 from New York City and 12 states. The postpartum period was defined as 2–9 months after giving birth. The report is the first population-based study to examine differences in postpartum contraceptive use based on maternal characteristics (MMWR 2009;58:821–6).

Overall, 62% of of 43,887 postpartum women reported using highly effective contraceptive methods (such as sterilization, IUD, pill, patch, or ring).

Another 20% reported using moderately effective methods (such as condoms) and 6% reported using less effective methods (such as the rhythm method, sponge, or diaphragm), while 12% reported no postpartum contraception, they reported.

Women who were least likely to use at least one method of contraception included those who had no prenatal care, women aged 35 years and older, women who said they wanted to get pregnant sooner, and women who identified themselves as Asian/Pacific Islander.

Highly effective postpartum contraception use by age ranged from a low of 53% among women aged 35 and older to a high of 73% among women younger than 20 years.

When the data were broken down by race, highly effective postpartum contraception use ranged from a low of 35% among Asian/Pacific Islanders to a high of 71% among black women and American Indian/Alaska Native women.

In addition, women with Medicaid coverage prior to pregnancy were more likely to use highly effective contraception postpartum than women without Medicaid, while women with no prenatal care were less likely to use highly effective contraception postpartum than those who had any prenatal care.

The study was limited by several factors, including the use of self- reports, a lack of data from all parts of the United States, and a lack of data on several additional contraceptive methods such as spermicides, emergency contraception, and lactational amenorrhea.

But the results can help clinicians identify women who need more information about postpartum contraception, the researchers noted.

“Health care providers should consider encouraging postpartum women to use highly effective contraceptive methods to increase the proportion of pregnancies that are intended and promote healthy birth spacing,” they said.

The majority (88%) of postpartum women reported current use of at least one form of contraception, based on an analysis of data from more than 43,000 women.

Reducing the percentage of births within a year of a previous birth among women in the United States is one of the Center's for Disease Control and Prevention's Healthy People 2010 goals. Use of effective contraceptive methods after a recent pregnancy can help prevent unintended pregnancies, ensure adequate birth spacing, and reduce adverse maternal and infant outcomes, according to Maura Whiteman, Ph.D., and colleagues at the CDC.

The researchers reviewed data from the CDC's Pregnancy Risk Assessment Monitoring System from 2004 to 2006 from New York City and 12 states. The postpartum period was defined as 2–9 months after giving birth. The report is the first population-based study to examine differences in postpartum contraceptive use based on maternal characteristics (MMWR 2009;58:821–6).

Overall, 62% of of 43,887 postpartum women reported using highly effective contraceptive methods (such as sterilization, IUD, pill, patch, or ring).

Another 20% reported using moderately effective methods (such as condoms) and 6% reported using less effective methods (such as the rhythm method, sponge, or diaphragm), while 12% reported no postpartum contraception, they reported.

Women who were least likely to use at least one method of contraception included those who had no prenatal care, women aged 35 years and older, women who said they wanted to get pregnant sooner, and women who identified themselves as Asian/Pacific Islander.

Highly effective postpartum contraception use by age ranged from a low of 53% among women aged 35 and older to a high of 73% among women younger than 20 years.

When the data were broken down by race, highly effective postpartum contraception use ranged from a low of 35% among Asian/Pacific Islanders to a high of 71% among black women and American Indian/Alaska Native women.

In addition, women with Medicaid coverage prior to pregnancy were more likely to use highly effective contraception postpartum than women without Medicaid, while women with no prenatal care were less likely to use highly effective contraception postpartum than those who had any prenatal care.

The study was limited by several factors, including the use of self- reports, a lack of data from all parts of the United States, and a lack of data on several additional contraceptive methods such as spermicides, emergency contraception, and lactational amenorrhea.

But the results can help clinicians identify women who need more information about postpartum contraception, the researchers noted.

“Health care providers should consider encouraging postpartum women to use highly effective contraceptive methods to increase the proportion of pregnancies that are intended and promote healthy birth spacing,” they said.

The majority (88%) of postpartum women reported current use of at least one form of contraception, based on an analysis of data from more than 43,000 women.

Reducing the percentage of births within a year of a previous birth among women in the United States is one of the Center's for Disease Control and Prevention's Healthy People 2010 goals. Use of effective contraceptive methods after a recent pregnancy can help prevent unintended pregnancies, ensure adequate birth spacing, and reduce adverse maternal and infant outcomes, according to Maura Whiteman, Ph.D., and colleagues at the CDC.

The researchers reviewed data from the CDC's Pregnancy Risk Assessment Monitoring System from 2004 to 2006 from New York City and 12 states. The postpartum period was defined as 2–9 months after giving birth. The report is the first population-based study to examine differences in postpartum contraceptive use based on maternal characteristics (MMWR 2009;58:821–6).

Overall, 62% of of 43,887 postpartum women reported using highly effective contraceptive methods (such as sterilization, IUD, pill, patch, or ring).

Another 20% reported using moderately effective methods (such as condoms) and 6% reported using less effective methods (such as the rhythm method, sponge, or diaphragm), while 12% reported no postpartum contraception, they reported.

Women who were least likely to use at least one method of contraception included those who had no prenatal care, women aged 35 years and older, women who said they wanted to get pregnant sooner, and women who identified themselves as Asian/Pacific Islander.

Highly effective postpartum contraception use by age ranged from a low of 53% among women aged 35 and older to a high of 73% among women younger than 20 years.

When the data were broken down by race, highly effective postpartum contraception use ranged from a low of 35% among Asian/Pacific Islanders to a high of 71% among black women and American Indian/Alaska Native women.

In addition, women with Medicaid coverage prior to pregnancy were more likely to use highly effective contraception postpartum than women without Medicaid, while women with no prenatal care were less likely to use highly effective contraception postpartum than those who had any prenatal care.

The study was limited by several factors, including the use of self- reports, a lack of data from all parts of the United States, and a lack of data on several additional contraceptive methods such as spermicides, emergency contraception, and lactational amenorrhea.

But the results can help clinicians identify women who need more information about postpartum contraception, the researchers noted.

“Health care providers should consider encouraging postpartum women to use highly effective contraceptive methods to increase the proportion of pregnancies that are intended and promote healthy birth spacing,” they said.

WASHINGTON — Adding epinephrine to epidural bupivacaine and fentanyl significantly reduced the breakthrough pain of women in labor, based on supplemental pain relief data from a randomized study of 107 women with uncomplicated singleton pregnancies.

Previous studies have shown that epinephrine enhances the analgesic effects of local anesthesia during labor, but the effect of epinephrine added during the epidural infusion has not been well studied, noted Dr. Philip E. Hess of Harvard Medical School, Boston.

In this study, Dr. Hess and his colleagues enrolled women in active labor who were at least 7 cm dilated. The average age of the women was 32 years. All the patients received a standard epidural with bupivacaine and fentanyl, and then were randomized to receive or not to receive 1.66 mcg/mL epinephrine (1:600,000) as part of the epidural solution. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“The primary outcome was the need for the treatment of breakthrough pain,” Dr. Hess said during an oral review of posters. Overall, the mean number of boluses of supplemental pain medication was significantly lower in the epinephrine group compared with the control group (1.16 vs. 0.74), and the bolus rate was significantly lower in the epinephrine group compared with the controls.

But there were no significant differences in the duration of labor or in the occurrence of side effects (including hypotension, nausea, and vomiting) between the two groups. Pain scores were recorded every 15 minutes during labor using the visual analog scale. The results suggest that adding epidural epinephrine at the beginning of labor significantly reduced the need for extra anesthesia to manage breakthrough pain, noted Dr. Hess, who said he had no conflicts to disclose.

WASHINGTON — Adding epinephrine to epidural bupivacaine and fentanyl significantly reduced the breakthrough pain of women in labor, based on supplemental pain relief data from a randomized study of 107 women with uncomplicated singleton pregnancies.

Previous studies have shown that epinephrine enhances the analgesic effects of local anesthesia during labor, but the effect of epinephrine added during the epidural infusion has not been well studied, noted Dr. Philip E. Hess of Harvard Medical School, Boston.

In this study, Dr. Hess and his colleagues enrolled women in active labor who were at least 7 cm dilated. The average age of the women was 32 years. All the patients received a standard epidural with bupivacaine and fentanyl, and then were randomized to receive or not to receive 1.66 mcg/mL epinephrine (1:600,000) as part of the epidural solution. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“The primary outcome was the need for the treatment of breakthrough pain,” Dr. Hess said during an oral review of posters. Overall, the mean number of boluses of supplemental pain medication was significantly lower in the epinephrine group compared with the control group (1.16 vs. 0.74), and the bolus rate was significantly lower in the epinephrine group compared with the controls.

But there were no significant differences in the duration of labor or in the occurrence of side effects (including hypotension, nausea, and vomiting) between the two groups. Pain scores were recorded every 15 minutes during labor using the visual analog scale. The results suggest that adding epidural epinephrine at the beginning of labor significantly reduced the need for extra anesthesia to manage breakthrough pain, noted Dr. Hess, who said he had no conflicts to disclose.

WASHINGTON — Adding epinephrine to epidural bupivacaine and fentanyl significantly reduced the breakthrough pain of women in labor, based on supplemental pain relief data from a randomized study of 107 women with uncomplicated singleton pregnancies.

Previous studies have shown that epinephrine enhances the analgesic effects of local anesthesia during labor, but the effect of epinephrine added during the epidural infusion has not been well studied, noted Dr. Philip E. Hess of Harvard Medical School, Boston.

In this study, Dr. Hess and his colleagues enrolled women in active labor who were at least 7 cm dilated. The average age of the women was 32 years. All the patients received a standard epidural with bupivacaine and fentanyl, and then were randomized to receive or not to receive 1.66 mcg/mL epinephrine (1:600,000) as part of the epidural solution. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“The primary outcome was the need for the treatment of breakthrough pain,” Dr. Hess said during an oral review of posters. Overall, the mean number of boluses of supplemental pain medication was significantly lower in the epinephrine group compared with the control group (1.16 vs. 0.74), and the bolus rate was significantly lower in the epinephrine group compared with the controls.

But there were no significant differences in the duration of labor or in the occurrence of side effects (including hypotension, nausea, and vomiting) between the two groups. Pain scores were recorded every 15 minutes during labor using the visual analog scale. The results suggest that adding epidural epinephrine at the beginning of labor significantly reduced the need for extra anesthesia to manage breakthrough pain, noted Dr. Hess, who said he had no conflicts to disclose.

WASHINGTON — Curbing the obesity epidemic in America requires community intervention, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, said at the CDC's Weight of the Nation conference.

“The only way on a societal basis to reduce the prevalence of obesity is through community action, not through individual clinical interventions,” Dr. Frieden said in a press conference.

“We got to this stage in the [obesity] epidemic because of a change in our environment,” he said. “Only a change in our environment again will allow us to get back to a healthier place.”

To help communities respond to the obesity epidemic, the CDC launched Common Community Measures for Obesity Prevention. As part of this project, the CDC convened a panel of experts in a variety of areas including nutrition, urban planning, and physical activity, as well as obesity prevention (MMWR 2009:58 [RR-7]:1-26).

“We can't wait for the best possible evidence, we have to act on the best available evidence,” said Dr. William Dietz, director of the CDC's Division of Nutrition, Physical Activity, and Obesity. Dr. Dietz presented the CDC's recommendations at a press conference.

The panel agreed on 24 strategies, which fall into six categories:

▸ To promote the availability of affordable healthy foods and beverages (example: adding grocery stores in underserved areas).

▸ To support healthy food and beverage choices (example: limiting ads for unhealthy food and beverages).

▸ To encourage breast-feeding (example: encouraging workplaces to support breastfeeding moms).

▸ To encourage physical activity or limit sedentary activity in children and adolescents (example: requiring physical education in schools).

▸ To create safe communities that support physical activity (example: enhancing infrastructure to support walking and biking).

▸ To encourage communities to organize for change (example: participating in coalitions and partnerships to address obesity).

The panel chose strategies that are likely to have a broad reach and a long-term, meaningful impact on health, according to the full report. And the panel deemed the strategies reasonable for a community to implement.

“I think there is a responsibility to physicians and the medical profession generally to be active in their communities promoting prevention,” said Dr. Frieden. It is often physicians who encourage community actions and influence policy makers, he emphasized.

It is often physicians who encourage community actions and influence policy makers.

Source DR. FRIEDEN

WASHINGTON — Curbing the obesity epidemic in America requires community intervention, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, said at the CDC's Weight of the Nation conference.

“The only way on a societal basis to reduce the prevalence of obesity is through community action, not through individual clinical interventions,” Dr. Frieden said in a press conference.

“We got to this stage in the [obesity] epidemic because of a change in our environment,” he said. “Only a change in our environment again will allow us to get back to a healthier place.”

To help communities respond to the obesity epidemic, the CDC launched Common Community Measures for Obesity Prevention. As part of this project, the CDC convened a panel of experts in a variety of areas including nutrition, urban planning, and physical activity, as well as obesity prevention (MMWR 2009:58 [RR-7]:1-26).

“We can't wait for the best possible evidence, we have to act on the best available evidence,” said Dr. William Dietz, director of the CDC's Division of Nutrition, Physical Activity, and Obesity. Dr. Dietz presented the CDC's recommendations at a press conference.

The panel agreed on 24 strategies, which fall into six categories:

▸ To promote the availability of affordable healthy foods and beverages (example: adding grocery stores in underserved areas).

▸ To support healthy food and beverage choices (example: limiting ads for unhealthy food and beverages).

▸ To encourage breast-feeding (example: encouraging workplaces to support breastfeeding moms).

▸ To encourage physical activity or limit sedentary activity in children and adolescents (example: requiring physical education in schools).

▸ To create safe communities that support physical activity (example: enhancing infrastructure to support walking and biking).

▸ To encourage communities to organize for change (example: participating in coalitions and partnerships to address obesity).

The panel chose strategies that are likely to have a broad reach and a long-term, meaningful impact on health, according to the full report. And the panel deemed the strategies reasonable for a community to implement.

“I think there is a responsibility to physicians and the medical profession generally to be active in their communities promoting prevention,” said Dr. Frieden. It is often physicians who encourage community actions and influence policy makers, he emphasized.

It is often physicians who encourage community actions and influence policy makers.

Source DR. FRIEDEN

WASHINGTON — Curbing the obesity epidemic in America requires community intervention, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, said at the CDC's Weight of the Nation conference.

“The only way on a societal basis to reduce the prevalence of obesity is through community action, not through individual clinical interventions,” Dr. Frieden said in a press conference.

“We got to this stage in the [obesity] epidemic because of a change in our environment,” he said. “Only a change in our environment again will allow us to get back to a healthier place.”

To help communities respond to the obesity epidemic, the CDC launched Common Community Measures for Obesity Prevention. As part of this project, the CDC convened a panel of experts in a variety of areas including nutrition, urban planning, and physical activity, as well as obesity prevention (MMWR 2009:58 [RR-7]:1-26).

“We can't wait for the best possible evidence, we have to act on the best available evidence,” said Dr. William Dietz, director of the CDC's Division of Nutrition, Physical Activity, and Obesity. Dr. Dietz presented the CDC's recommendations at a press conference.

The panel agreed on 24 strategies, which fall into six categories:

▸ To promote the availability of affordable healthy foods and beverages (example: adding grocery stores in underserved areas).

▸ To support healthy food and beverage choices (example: limiting ads for unhealthy food and beverages).

▸ To encourage breast-feeding (example: encouraging workplaces to support breastfeeding moms).

▸ To encourage physical activity or limit sedentary activity in children and adolescents (example: requiring physical education in schools).

▸ To create safe communities that support physical activity (example: enhancing infrastructure to support walking and biking).

▸ To encourage communities to organize for change (example: participating in coalitions and partnerships to address obesity).

The panel chose strategies that are likely to have a broad reach and a long-term, meaningful impact on health, according to the full report. And the panel deemed the strategies reasonable for a community to implement.

“I think there is a responsibility to physicians and the medical profession generally to be active in their communities promoting prevention,” said Dr. Frieden. It is often physicians who encourage community actions and influence policy makers, he emphasized.

It is often physicians who encourage community actions and influence policy makers.

Source DR. FRIEDEN