The global burden of lung disease Living to 100 in a California town The gluten-free fad The statin controversy

issue 5.02

FROM THE DEPARTMENT OF EPIDEMIOLOGY SUMMER 2014 MAILMAN SCHOOL OF PUBLIC HEALTH – COLUMBIA UNIVERSITY Sandro Galea, MD, DrPH Gelman Professor and Chair Department of Epidemiology

EDITOR Barbara Aaron Administrative Director

EDITOR / WRITER Elaine Meyer Associate Director of Communications

CONTRIBUTING EDITORS Dana March, PhD Assistant Professor of Epidemiology

Joshua Brooks Senior Health and Epidemiology Fellow

CONTRIBUTING WRITERS Amina Foda Patches Magarro Catherine Richards, PhD Stephanie Shiau Christopher Tait Kaitlin Ugolik

ASSOCIATE DESIGNER Kristen Byers Web Developer / Graphic Designer

DESIGNER Jon Kalish

ON THE COVER: The smoggy skyline of Beijing, China. A lone tree in the foreground in the shape of human lungs symbolizes the negative effect of air pollution on the public. Read more about how this and other factors can be addressed through a public health approach on page 10. CONTENTS

3 Publication highlights

FEATURES

10 The global burden of lung disease

16 Place and health: into the blue zone

20 Does your brain really do better off grain?

24 Changing the statins quo

27 Symposium report: Encouraging urban health has multiple benefits

29 Grand rounds report: Sticks and bones may break my heart

30 In the news

33 Faculty publications

DEPARTMENT OF EPIDEMIOLOGY 1 chair’s message

Colleagues,

The Institute of Medicine defines public health as “what we, as a society, do collectively to assure the conditions for people to be healthy.”1 Epidemiology, as the science of public health, then has a particular responsibility to provide data that can guide the improvement of those conditions.

The summer issue of 2x2 synthesizes new research that is concerned with the creation of these conditions. We highlight articles that look at the relationship between lung disease and economic development, how place influences longevity, whether a gluten-free diet is really better for everybody, how new statin guidelines might change treatment for heart disease, and the inextricable link between urban planning and promoting health.

These stories illustrate how epidemiological research examines the conditions that can improve population health on the broadest scale. I hope you find them interesting and informative.

Warm regards,

1) Institute of Medicine. The Future of Public Health. National Academy Press; Washington, D.C.: 1988

2 publication highlights

hey have been called “suicide who are either similar to the reader outbreaks,” “suicide epidemics,” (i.e., another teenager) or revered T or “copycat suicides”—when by him or her (e.g., a celebrity),” the multiple suicides occur in a commu- authors write. nity in a short period of time, usually The authors controlled the study among teenagers and young adults. so that nothing about the suicides Suicide clusters are somewhat of a they examined would have led to mystery: why does a suicide lead to varying coverage in the comparison an “outbreak” of many more in some groups—such as how graphic or public communities but not in others? a suicide was. To help answer that question, Although the study does not prove a group of researchers at Columbia causality, the authors suggest theo- University, led by Dr. Madelyn Gould, a ries for why media coverage could professor of epidemiology in psychiatry, influence suicides. Repeated coverage examined the influence of media cover- may normalize suicide in the eyes of age in the initiation of suicide clusters, young, vulnerable people, according in a study published in Lancet Psychia- to one theory, or it may “prime” latent try last month. Although research has thoughts in already suicidal youth, shown that press reports are associated according to another theory. with suicide spikes nationally, no study Media guidelines on how to cover had yet examined how they might influ- suicide, which have been published by ence suicide clusters. the World Health Organization, among Dr. Gould and her colleagues exam- other sources, can be helpful. ined the period between 1988-1996 “In light of the extensive use of looking at news reporting in various social media by teens, we hope our communites around the country in the current findings will stimulate research aftermath of the first suicide of a clus- on social media’s impact on suicidal ter. They compared this to coverage in behavior. We also would recommend Does news communities that saw just one suicide. that our suggestions for responsible They found that there were signifi- reporting about suicidal individuals be reporting cantly more news stories in cluster applied by all who generate suicide-re- communities than in isolated suicide lated stories via social media, which encourage communities, suggesting an associ- would include teens, as well as media ation between reporting on suicides professionals,” the authors say. suicide and suicide clusters. Newspapers in the cluster communities gave more Gould MS, Kleinman MH, Lake AM, Forman J, outbreaks? prominent and detailed coverage of Basset Midle J. (2014). Newspaper coverage suicidal individuals, such as front-page of suicide and initiation of suicide clusters in Study has implications for placement, photography, headlines teenagers in the USA, 1988-96: A retrospec- how media covers teen suicides containing the word “suicide,” specifi- tive, population-based, case-control study. cation of the method used, and a more Lancet Psychiatry. published online May 2, detailed description of the person and 2014, 7-16. the2x2project.org how he or she committed the act. the2x2project.org/media-suicide-clusters The researchers only observed the association in the coverage that focused on a suicidal individual—as related media coverage opposed to stories that covered sui- cide more generally. This “supports USA Today the theory that the media effect usat.ly/1iQsvqP operates through the mechanism of identification with a model…. [T]he Live Science models with the most effect are those bit.ly/1nR3C4M

DEPARTMENT OF EPIDEMIOLOGY 3 PUBLICATION HIGHLIGHTS

n states where they experience and whites is greater, health problems more systematic disadvantage are worse than in states where blacks Ithan whites, blacks have worse occupy a lower socioeconomic status cardiovascular health than they do but there is less inequality. in states where opportunity is more “While inequality does track with evenly distributed, according to a socioeconomics of U.S. states, there study published in the journal Social is considerable variation; for example, Science & Medicine. states like Maine and New York have While past research has looked higher rates of inequality than would at the effects of self-reported experi- be expected given their economic pro- ences of discrimination on health at an files,” says Dr. Keyes. individual level, this study is one of the As for whites, they reported better first to examine how unfair treatment cardiovascular health in states where at an institutional level contributes there was more structural racism. to health, according to the authors, “These results raise the provoca- Dr. Katherine Keyes, an assistant tive possibility that structural racism professor of epidemiology, Dr. Mark may not only harm the targets of Hatzenbuehler, assistant professor of stigma but also benefit those who sociomedical sciences, and Dr. Alicia wield the power to enact stigma and Lukachko, a postdoctoral alumna of discrimination,” write the authors of the Psychiatric Epidemiology Training the study. Program, all from Columbia Universi- Structural racism did not appear to ty’s Mailman School of Public Health. influence health when it came to job To determine what the researchers status. Black Americans in states with call “structural racism,” which they greater parity in terms of the relative define as “the systematic exclusion of percentage of blacks and whites in blacks from resources and mobility in high status executive or managerial society,” they looked at the percentage positions actually were at higher odds Racial inequality of blacks compared to the percentage of a heart attack than those in states of non-Hispanic whites in each of the with a greater disparity. and matters of 50 U.S. states on several measures: This is not the first time researchers holding a college degree, employ- have observed this. Epidemiologist the heart ment, incarceration, and participation Dr. Sherman James found that blacks in the state’s political system. in high status positions cope with Structural racism predicts worse Blacks were more likely to report structural racism like the pressure to cardiovascular health for blacks having had a heart attack in the past assimilate and defy negative racial year in states where there was greater stereotypes by putting forth extraor- inequality in the number of blacks dinary levels of effort, often at the versus whites employed, well edu- expense of their health. He called this cated, and politically represented. In phenomenon John Henryism, invoking states where the gulf between blacks an American folk figure who worked and whites in prison was larger, they himself to death while he was suc- were also more likely to have had a cessfully competing against a steam heart attack in the past year. Across powered machine. the United States, blacks are jailed “People with high levels of [John or put in prison from two to 14 times Henryism] and inadequate resources the2x2project.org more frequently than whites. have a much higher prevalence of Interestingly, the results indicate health disorders… because they drive 2x2.ph/racism-inequality-heart-health that structural race inequality plays a themselves toward reaching specific larger role than socioeconomic status goals at the expense of their health, in determining health outcomes. In often without realizing they are doing states where on average blacks occupy so,” says research that emerged from a higher socioeconomic status, but a 2006 symposium on the subject. the gap in opportunity between blacks “While many recognize that

4 SUMMER 2014 : ISSUE 5.02 A lithographic composite of thirteen scenes pertaining to African-American history c.1897.

disparities in civil engagement, incarceration, and employment are problematic on a social level, this is among the first of studies to Structural racism show an association between these structural forms of inequality and health,” says Dr. Keyes. “Our results suggest that improving may not only social conditions at a very macro level, which is logistically difficult but has been done many times before, may have positive health harm the targets benefits for those Americans with the highest levels of many chronic adverse health events.” of stigma but also

Lukachko A, Hatzenbuehler ML, Keyes KM. Structural racism and myocardial benefit those who infarction in the United States. Soc Sci Med. 2014 Feb;103:42-50. doi: 10.1016/j. socscimed.2013.07.021. PMID: 24507909 [PubMed - indexed for MEDLINE] wield the power to enact stigma and discrimination.

DEPARTMENT OF EPIDEMIOLOGY 5 PUBLICATION HIGHLIGHTS

stay in hospital intensive with the non-critical care hospital pop- care could put patients at ulation. However, the absolute risk of A unique risk of having psychi- receiving a new psychiatric diagnosis atric troubles such as depression or in the first three months after being post-traumatic stress disorder, accord- discharged was small. ing to a new study published in the The results are consistent with Journal of the American Medical Asso- smaller cohort studies, some of which ciation from researchers at Columbia were done in the U.S., according to Dr. University, University of Pittsburgh, Wunsch. The instances of post-inten- Ohio State University, and Denmark’s sive care psychiatric diagnosis could Aarhus University Hospital. even be higher in the U.S. because “A large percentage of the critically overall rates of diagnoses of psychi- ill population had no history of atric illnesses are higher here than in diagnoses such as depression or Western European countries. treatment for depression yet had There are no standards for screen- substantially increased rates of ing for depression, anxiety, and PTSD this diagnosis and prescriptions for when discharging patients, according psychoactive medications in the year to Dr. Wunsch, who practices in the after the critical illness,” the paper surgical intensive care unit at Colum- says. “However, the largest increase bia University Medical Center. in risk occurred in the first few months “We certainly see patients who by after the critical illness, suggesting the end of their stay in intensive care that the risk may be transient.” are severely depressed,” she says. She “In the community of providers has also met patients months or years of critical care, there’s an increasing after their stay in an ICU who say they awareness that this is a likely issue for have PTSD from the experience. people after intensive care,” says Dr. Hannah Wunsch, an assistant professor Wunsch H, Christiansen CF, Johansen MB, of epidemiology and anesthesiology at Olsen M, Ali N, Angus DC, Sørensen HT. ICU stay Columbia’s Mailman School of Public Psychiatric diagnoses and psychoactive Health. However, there had not been medication use among nonsurgical critically may lead to good population level research on this ill patients receiving mechanical ventilation. issue before, she says. JAMA. 2014 Mar 19;311(11):1133-42. doi: psychiatric The investigators analyzed data 10.1001/jama.2014.2137. from Denmark’s National Registry of diagnosis Patients, one of the most comprehen- sive repositories of patient information Depression, PTSD most common because all of that country’s hospitals are included. They looked at 24,179 intensive care patients who had been admitted to a hospital between 2006- 2008 with an “unanticipated critical illness” and had received mechani- cal ventilation. They compared this group of patients to two other groups: general population controls and a the2x2project.org population of patients who stayed in a 2x2.ph/intensive-care-mental-health hospital but were not critically ill. The intensive care cohort was at a 20-fold increased likelihood of receiv- ing a new psychiatric diagnosis or psychoactive medication compared to the general population in the first IMAGE: POLLOBARBA FOTÓGRAFO few months after critical illness, and at a 2-3 fold increased risk compared

6 SUMMER 2014 : ISSUE 5.02 PUBLICATION HIGHLIGHTS

s the rate of overdosing on a state-by-state basis, they found prescription opioids like Oxy- big differences among states: nine A contin and Vicodin has risen states reported significantly fewer dramatically across the U.S. since the opioid prescriptions after launching early 1990s, states have tried to reign their drug monitoring programs, 14 in over-prescription of these popular reported no change, and eight states painkillers. A new study suggests that reported significant increases. some states may have made major Over the 10-year period, Colorado headway, while others seem to be had the greatest decrease in opioids having more difficulty. dispensed associated with its pre- Published in the March/April scription drug monitoring program, issue of Public Health Reports, the followed by Texas and Wyoming. study examined the influence of pre- Connecticut had the largest increase. scription drug monitoring programs PDMPs that are overseen by (PDMPs), which exist in some form state health departments appeared in all 50 states, on the rates of opioid to be more effective than those analgesics dispensed over the years administered by other government 1999-2008. In such programs, an agencies, such as a state bureau of agency houses an electronic data- narcotics or a board of pharmacy, base tracking controlled substances according to the authors. “It indicates dispensed throughout the state. a public health approach is more Authorized individuals like doctors effective than alternatives, such as the and pharmacists can consult the data- law enforcement and criminal justice base to monitor whether patients are approaches,” says Dr. Li. “doctor shopping”—getting painkillers “While data through 2008 show and other drugs from multiple doctors. state prescription drug monitoring Law enforcement can also seek access programs have greatly expanded and to track suspicious prescribing activity rates of opioids dispensed are stabi- The divided by medical providers. lizing, there exists considerable room Dr. Guohua Li, Finster Professor of to improve the overall effectiveness states of opioids Anesthesiology and Epidemiology; Dr. of state PDMPs, such as increasing Charles Dimaggio, associate professor interstate data sharing and making U.S. states vary widely in success of epidemiology; Dr. Hannah Wunsch, prescription drug-dispensing informa- of monitoring prescription painkillers assistant professor of epidemiology tion accessible by healthcare providers and anesthesiology; and doctoral in real time,” says Ms. Brady. trainee Ms. Joanne Brady, of Colum- bia’s Mailman School of Public Health Brady JE, Wunsch H, Dimaggio C, Lang BH, the2x2project.org and College of Physicians & Surgeons, Giglio J, Li G. Prescription drug monitoring examined quarterly data from the U.S. and dispensing of prescription opioids. Public 2x2.ph/opioid-monitoring Drug Enforcement Administration. Health Rep. 2014 Mar;129(2):139-47. PMID: The annual number of prescriptions 24587548 [PubMed - in process] for the painkillers fentanyl, hydroco- done, hydromorphone, meperidine, methadone, morphine, and oxycodone from the 2x2 project archive nearly tripled between 1991 to 2010, from about 76 million to nearly 210 When the prescription becomes the problem million, according to the National Insti- tute on Drug Abuse. 2x2.ph/1gr2Ire When averaged together, state prescription drug monitoring pro- Are doctors overprescribing opioids? grams were associated with only a small decline in morphine milligram 2x2.ph/1eBaI4U equivalents of opioids. However, when the research team looked on

DEPARTMENT OF EPIDEMIOLOGY 7 PUBLICATION HIGHLIGHTS

n March of last year, at the 20th at 18 months. When she came in five Conference on Retroviruses and months later, she reported that the IOpportunistic Infections (CROI) child had not been on treatment since in Atlanta a group of researchers the last visit. Yet tests showed the announced that a child in Mississippi child had no detectible viral load. who underwent viral control post- A year later at the 21st CROI, antiretroviral therapy (ART) had researchers reported that the been cured of HIV. The story took the Mississippi baby had been off ART media by storm, with headlines in for almost two years with no rebound the New York Times, CNN, and PBS’s of HIV. The researchers also reported News Hour, among other places. But on a second infected child who was some experts were skeptical and started on antiretroviral treatment asked whether the results had been at four hours of age and had no released prematurely. detectable replication of HIV, though Was the Mississippi baby really the child remained on treatment. cured of HIV? In order to better under- A recent review that I published with stand the case, it is important to define Dr. Louise Kuhn, professor of epidemi- what a cure entails in the field of HIV ology in the Gertrude Sergievsky Center research. An eradication cure involves at Columbia, highlights important completely eliminating HIV-infected issues in the treatment of HIV-infected cells from the body so that the virus is infants raised by the Mississippi baby. BY STEPHANIE SHIAU, no longer present. The only example Though starting treatment at PhD CANDIDATE of what experts consider an eradi- birth may bring the possibility of a cation cure is “the Berlin patient,” functional cure, there are diagnostic reported in 2009. The patient, Timothy challenges. Early initiation depends Brown, received a stem cell transplant on early diagnosis of HIV-infected from a donor who had a genetic muta- infants. HIV testing will have to occur Was a baby tion that protects the immune system not only at birth to detect infections from the HIV virus. Since then, Brown that occur in utero but again later to cured of HIV? has shown no signs of HIV and been detect infections that occur during off treatment for six years. delivery and in the early postnatal What the ‘Mississippi baby’ The Mississippi baby, on the other period. There also are limited safe means for care and treatment hand, is an example of a “functional and effective treatment formulations of HIV-infected infants cure,” which involves treating indi- available for newborns. viduals so that the virus decreases Though the case of the Mississippi to such levels that it does not cause baby has brought optimism around disease and can be controlled without the possibility of a functional cure in continued antiretroviral treatment. HIV-infected infants, more research the2x2project.org The Mississippi baby’s functional is needed. In the meantime, aiming cure came about almost by accident. to provide treatment for HIV-infected 2x2.ph/hiv-mississippi-baby The infant was born to a mother who children who are not receiving it was not diagnosed before birth—the should continue, and prevention of optimal time to prevent HIV trans- mother to child transmission should Related media coverage mission from a mother to child. As a remain a priority. result, her baby was started on a more Mail & Guardian aggressive therapeutic regimen at 30 Shiau S, Kuhn L. Antiretroviral treatment in hours after being born rather than a HIV-infected infants and young children: novel bit.ly/P9dgSa more typical regimen. After starting issues raised by the Mississippi baby. Expert treatment the child’s viral load came Rev Anti Infect Ther. 2014 Mar;12(3):307-18. doi: Medpage Today down even though the mother missed 10.1586/14787210.2014.888311. PMID: 24506199 scheduled appointments for her child bit.ly/1g6aTZH

8 SUMMER 2014 : ISSUE 5.02 PUBLICATION HIGHLIGHTS briefs

Universities should embrace Park features associated Genetic testing for epilepsy implementation science with body mass index brings hope and challenge

The nature of the relationship between The size and cleanliness of a neighborhood In the past 20 years, there has been a dra- academic institutions and the “real” world park has a strong association to the body matic increase in the discovery of genes has long been debated, with some arguing mass index (BMI) of the neighborhood’s res- that play a role in epileptic disorders. This that the university does not do enough idents, according to a study by Dr. Andrew has paved the way for increased clinical work to improve society. Rundle, associate professor of epidemiol- genetic testing of people who have epi- Drawing on the work they have done to ogy, Dr. Gina Lovasi, assistant professor of lepsy, in order to clarify the diagnosis, implement HIV treatment and prevention epidemiology, both at Columbia’s Mailman inform treatment, and improve prognosis. programs in resource-limited settings School of Public Health, and colleagues. Although the availability of genetic test- at ICAP, Dr. Wafaa El-Sadr, university Looking at New York City, the researchers ing has distinct advantages, it also raises professor of medicine and epidemiology determined size by measuring the propor- complex issues, such as how to educate at Columbia’s Mailman School of Public tion of a zip code that was park space and physicians about when and how to test Health, Dr. Jessica Justman, associate measured cleanliness by looking at a “park and how to ensure affected individuals and professor of medicine and epidemiology cleanliness index,” determined by the city’s their families can make informed choices at Columbia, and Ms. Neena M. Philip, a Department of Parks and Recreation. about testing and receive support after program coordinator, argue in the New After adjusting for other characteristics receiving the results, says Dr. Ruth Ottman, England Journal of Medicine that academic like homicides and walkability, they found professor of epidemiology at Columbia’s institutions should expand their core mis- that residents with lower BMI were more Gertrude H. Sergievsky Center, and col- sion to include the pursuit of a wider range likely to live in neighborhoods with larger and leagues, in Nature Reviews Neurology. of research. In particular, the university cleaner parks than residents with high BMI. Moreover, the genes do not always should embrace “implementation science,” “As urban planners and public health tell the full story. Not all epilepsies can be which focuses on how new discoveries are officials consider ways to enhance and detected with genetic tests, and conversely, translated into treatments and programs design neighborhoods, efforts should be sometimes people have genetic variants and how these treatments and programs given to creating safe and clean physical associated with epilepsies while not actually are brought to scale. activity environments that encourage use showing signs of the disorder. On the other “Academic institutions have an oppor- among nearby residents,” the authors say. hand, the advantages of genetic testing tunity to embrace societal challenges more include hastening and clarifying the diagno- fully by placing value not only on discov- Stark JH, Neckerman K, Lovasi GS, Quinn J, sis, assisting with reproductive decisions, ering the ‘what’ but also on elucidating the Weiss CC, Bader MD, Konty K, Harris TG, Rundle and helping people to plan for the future. ‘how’ and bringing to action discoveries A. The Impact of Neighborhood Park Access and “Genetic testing has the potential to rev- with broad benefits,” the authors say. Quality on Body Mass Index Among Adults in olutionize care for epilepsy, but we need to New York City. Prev Med. 2014 Apr 2. pii: S0091- address the challenges involved to ensure El-Sadr WM, Philip NM, Justman J. Letting HIV 7435(14)00120-0. doi: 10.1016/j.ypmed.2014.03.026. services are delivered in the most effective, transform academia--embracing implementation [Epub ahead of print] sensitive, and equitable manner possible,” science. N Engl J Med. 2014 May 1;370(18):1679-81. the researchers say. doi: 10.1056/NEJMp1314777. No abstract available. PMID: 24785205 Poduri A, Rosen Sheidley B, Shostak S, Ottman R. Genetic testing in the epilepsies—develop- ments and dilemmas. Nat. Rev. Neurol. advance online publication 15 April 2014; doi:10.1038/ nrneurol.2014.60

DEPARTMENT OF EPIDEMIOLOGY 9 The global burden of lung disease

Smoking, pollution major factors that could be controlled through a public health approach

BY ELAINE MEYER

the2x2project.org

2x2.ph/global-lung-disease

10 Beijing, China IMAGE: CHRIS ASTON

n rural Kentucky, a These experiences represent the global increased dramatically with industrializa- scope of lung diseases, which are a heavy tion, the development and marketing of middle-aged woman burden in low, middle, and high-income cigarettes, and the drop in deaths from who used to smoke visits countries alike. They are among the leading other diseases. I causes of death in the world, according to A delicate and complex system, the her doctor complaining a recently released report by the Forum lungs are the only internal organs that are of shortness of breath. In of International Respiratory Societies. Yet constantly exposed to the environment. because they often manifest in initially less When people regularly breathe in toxins, Beijing a young man walks dramatic symptoms like a cough or head- their lungs over time can experience to work in a haze of smog ache, and because they are associated with inflammation, scarring, and infection. cigarettes, lung diseases often are ignored Because the damage accumulates grad- with a splitting headache. or written off as a smoker’s problem. ually, people do not always make the In Nairobi, Kenya, a young “Some of these things seem like back- connection between hazardous air expo- ground noise. I think that’s part of the sures and diseases like lung cancer, chronic woman hunches over a problem,” says Dr. Neil Schluger, a pro- obstructive pulmonary illness or COPD, stove, breathing in toxic fessor of medicine, epidemiology, and acute respiratory tract infection, and tuber- environmental health sciences and chief culosis—four of the leading causes of death fumes and coughing as she of the pulmonary, allergy and critical care in the world. cooks her family’s dinner medicine division at Columbia University. Since becoming chief scientific officer According to Dr. R. Graham Barr, a of the World Lung Foundation, Dr. Schluger over charcoal. professor of medicine and epidemiology has been working to draw attention to lung at Columbia, “The bottom line is that the diseases and the central role that is played amount we spend on research diagnosis by the air we breathe. “Although molecu- and treatment in lung disease is miniscule larly lung diseases are different from each compared to cardiovascular disease or other, they are all exacerbated by pollution nonsmoking related cancer.” and tobacco,” he says. Diseases of the lung have existed since In March, he and Dr. Ram Koppaka, a Greek and Roman times, but they have senior advisor at the Centers for Disease

DEPARTMENT OF EPIDEMIOLOGY 11 An estimated 4.3 million people die Control and Prevention published a think ailments among factory workers, spotlight each year as a result of exposure to piece in the Annals of the American the Chinese government’s failure to check household air pollution, a big part of Thoracic Society, articulating the problem: the pace of industrialization and develop- which comes from rudimentary cook “The lung diseases that account for the ment. Where that pace once evoked fear stoves that burn dirty fuels like coal, greatest global morbidity and mortality are on the part of economic competitors like animal dung, straw, and agricultural preventable to a very significant degree.” the U.S., China is increasingly becoming waste, according to WHO. “A new approach is required that an exemplar of the problems wrought by goes beyond simply developing new treat- unrestrained development seen in many ments for each of the major respiratory middle-income countries, like India, Egypt, disorders.” and Pakistan. “There’s such a rush to develop economically that government Outdoor air pollution regulations on things like air pollution or Last October what became dubbed as the sale of cigarettes sometimes become sec- “Airpocalypse” hit Harbin, China, a city of ondary,” says Dr. Schluger. 10 million in the northeastern part of the According to WHO, one in eight of total country. A thick, grey cloud of pollution global deaths in 2012—7 million people— rendered visibility so low that people walk- were linked to air pollution. With the global ing side by side reported they could not trend toward urbanization, the problem will see each other. Schools closed, highways likely get worse. shut down, and authorities urged people to In their paper, Drs. Schluger and Kop- stay home. The air quality score index went paka say that “Governments must be above 500—which is the highest possible held accountable…for protecting the lives number on that scale and 20 times the level of their citizens at least as much as they of particulate matter considered safe by the protect the commercial interests of large World Health Organization (WHO). industries.” They cite ways that high-in- IMAGE: BEN GREY Catastrophic levels of air pollution come countries have reduced pollution and other related consequences, such as at its source, such as mandating lead- heavy traffic, contaminated farmland, and free gasoline, encouraging fuel-efficient

12 SUMMER 2014 : ISSUE 5.02 According to WHO, one in eight of total global deaths in 2012—7 million people— were linked to air pollution.

vehicles, traffic planning, and air filtering “We’ve seen a lot of effort in the past Nearly six million deaths are linked to methods at factories. that has not resulted in improved health tobacco each year. Government air quality standards have because the interventions weren’t that While high-income countries began made a difference, as the U.S. has shown clean at the end of the day. Burning these snuffing out cigarette advertising many with the Clean Air Act, passed in 1963. By fuels in a way that reduces exposure is a decades ago, cigarette companies the 1990s, air pollution in most American really hard problem,” says Dr. Jack. redirected their efforts toward nations cities had declined or plateaued. “Those He is currently conducting an intervention with growing middle classes and fewer of us who live in high income cities, we study in Ghana that compares giving people anti-tobacco regulations. In China, which breathe much cleaner air than our grand- “the latest and greatest biomass stoves” has nearly one-third of the world’s smok- parents and our parents did,” says Dr. with giving them liquefied petroleum gas, ers, the state-run tobacco company China Darby Jack, assistant professor of envi- which is cleaner than the fuels they usually National Tobacco Corporation has not ronmental health sciences at Columbia’s use. “Those are sort of the two options: set cigarette taxes at any meaningful Mailman School of Public Health. clean fuels or clean combustion. Our study level. As a result, smoking runs cheap is designed to look at both of those side by in cost—74 cents a pack—but costly in Household air pollution side. Most of those studies have just looked health—an estimated 1 million people die Around 3 billion people, especially in at the clean cook stoves,” he says. of tobacco-related causes each year, a nations in sub-Saharan Africa, South and Based on disappointing results from number that is expected to triple by 2050. East Asia, the Middle East, and Latin Amer- previous studies of stoves, he believes the In Africa, smoking rates are rising ica, heat their homes with open fires and solution will likely come from clean fuels but amidst dedicated marketing efforts by cig- cook using leaky stoves that burn dirty acknowledges that money is a big obstacle. arette companies to target a continent that fuels like coal, animal dung, straw, and “It’s much more expensive,” he says. has been called “Big Tobacco’s last fron- agricultural waste. Soot from these sources tier.” Tobacco companies employ locals Smoking penetrates deeply into the lungs and can in their factories and deploy marketing lead to pneumonia in children and COPD New York City residents are used to breath- strategies, such as selling cigarettes indi- in adults. An estimated 4.3 million people ing smoke-free air in restaurants, bars, vidually-wrapped to increase affordability die each year as a result of exposure to stores, and other public spaces, and are for those who do not have much spending household air pollution, a big part of which accustomed to a pack of cigarettes priced money—such as children. is from cooking on these kinds of stoves, at upwards of 14 dollars. Here, smoking Dr. Schluger says that tobacco compa- according to WHO. may no longer seem mainstream. But in nies, not individuals, should primarily be This is the cost of living in a low or other parts of the world, the number of held responsible for smoking rate spikes: middle-income country, where sources of smokers is climbing, a result of population “By no means should we treat people who clean fuel from electricity and natural gas growth and marketing efforts of tobacco use tobacco and have lung disease as if are often not available, and stoves are not companies. The total number of smokers it’s their fault. The tobacco industry says fuel-efficient. around the world has risen from 721 million this all the time: ‘people choose to do it.’ Several initiatives have sprung up to to 967 million since 1980, although rates of Let’s face it: it’s not a fair fight. The tobacco promote the design of more efficient, smoking have declined worldwide over that industry is spending billions of dollars on cleaner burning stoves, but it has proven period, according to a study in the Jour- advertising, which is extremely effective.” difficult because of limited budgets. nal of the American Medical Association. In the U.S., New York City has been a

DEPARTMENT OF EPIDEMIOLOGY 13 Projected global increase in cancer-related costs per year

These two stacked bar graphs depict the projected increase in cancer-related costs in 2030 compared with 2010 for the top 10 most prevalent cancers. The graph on the left shows the absolute increase in cancer-related costs along the x-axis. The graph on the right shows the relative, or percent, increase in cancer-related costs along the x-axis. Along the y-axis for both graphs is a list of the top 10 most prevalent cancers, ordered from top to bottom in ascending order according to the cancer associated with the lowest projected absolute annual increase in related costs. The largest absolute increase in cancer-related costs is projected to occur with lung cancer, with a large proportion of the increase occur- ring due to medical costs and income losses.

DATA SOURCE: INSTITUTE FOR HEALTH METRICS AND EVALUATION. GBD CAUSE PATTERNS. GBD 2010, RELEASED 3/2013. HTTP://WWW.HEALTHMETRICSANDEVALUATION.ORG/GBD/VISUALIZATIONS/GBD-CAUSE-PATTERNS

Originally published on the GRAPH website, at cugraph.org

14 SUMMER 2014 : ISSUE 5.02 Tuberculosis requires more attention, investment

Drug companies, governments, and other sources under-invest in tuberculosis compared to other global diseases, especially given the emerging threat of new strains of multi-drug resis- tant tuberculosis, says Dr. Neil IMAGE: KEVIN SCHOENMAKERS Schluger in the Financial Times: “The biggest challenge is for people to realize how much TB is out there. The rate is going down leader, with a hefty increase on cigarette 2 percent a year but that is too Promoting global public health taxes and bans on smoking at indoor and slow for eradication to happen outdoor public spaces. Since the ban was Despite the challenges implementing the for decades to come.” enacted in 2003, the percent of active smok- tobacco treaty, Drs. Schluger and Koppaka ers has decreased in New York City from 21 urge WHO to pass a similar treaty to address Read more to 14, and the city now has the lowest rate air pollution and occupational exposure. of lung cancer deaths in the New York state, “We do not underestimate the difficulty ff Big pharma balks at according to the American Cancer Society in reducing the impact of the important investment in TB of New York and New Jersey. drivers of lung disease in the world,” they on.ft.com/1dOsIho “Mayor Bloomberg saved more lives say. “These drivers arise to a great degree from lung disease than any physician in because of poverty (e.g., due to a lack of ff Stubborn new TB strain New York or any hospital because of what access to clean burning fuels and efficient threatens to reverse progress he did to decrease tobacco use in the city,” stoves for cooking) because of a lack of on.ft.com/ObAA0i says Dr. Schluger. “Individuals can say, ‘I’m government oversight and regulation ff TB, disease of the poor, not going to smoke,’ but they need help (regarding the sale of tobacco products or now threatens rich from the government,” he adds. worker safety), or a combination of both.” on.ft.com/1dOsW81 That help is more forthcoming in some The centrality of public health inter- countries than others. In 2013, the WHO ventions cannot be underestimated. Dr. “The [U.S.] president’s budget ratified the Framework Convention on Schluger says: “When I think of the global proposal, with stunning short-sight- Tobacco Control, which sets a universal burden of lung disease, these public health edness, calls for a $45 million cut standard for regulating tobacco production, and population approaches could be so for USAID’s TB program,” writes Dr. sales, advertising, distribution, and taxes. much more effective than waiting for Gerald Friedland, adjunct professor of “Almost every country in the world has people to get sick and treating them.” epidemiology at Columbia’s Mailman signed it, almost no country has adopted School of Public Health. Read more in all of its measures,” says Dr. Schluger. the Hill. [bit.ly/1fEOsNA]

IMAGE: DR. RAY BUTLER, CDC

DEPARTMENT OF EPIDEMIOLOGY 15 Place and health: into the blue zone Lessons for living to 100 from Loma Linda, California

BY PATCHES MAGARRO

COMMUNICATION IN EPIDEMIOLOGY & HEALTH FELLOW the2x2project.org

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A view of Loma Linda and the Loma Linda University Medical Center.

IMAGE: COSMIN COSMA

16 magine, at the age of 100, mowing the lawn and walking Imiles per day with neighbors in their nineties. If it seems impossible to live long enough to reach the triple digits, let alone arrive at the century mark in good health, simply consider life in Loma Linda. Mountain biking in Loma Linda. Loma Linda, California, is a small city about 60 miles east of Los Angeles. It is also home Outside of the U.S., there are other certain behaviors in the absence to a relatively large number of blue zones. Nicoya, Costa Rica, of other confounding factors. The has exceptionally hard water, rich authors of the paper examined data centenarians and is therefore in calcium and magnesium. The from a large sample of over 34,000 the only recognized “blue zone” radon-enriched thermal baths of Icaria, Adventists over the course of 12 years, Greece, are credited with contributing and found that California Adventists’ in the United States, where to longevity: residents of the island life expectancies exceed that of any the average individual life span are four times more likely to reach the other natural population. age of 90 than Americans and at avoid- But there is good news for those is much greater than other ing chronic disease as they age. who are not planning to convert to American cities. However, the remarkable longevity the Adventist religion. “It seems likely of Loma Linda’s residents is uniquely that the effects of these particular inspiring because their lifestyle can variables on life expectancy can be be adopted almost anywhere. While applied to Adventist and non-Adven- genetics are a factor, up to 80 percent tist populations. There is no reason of longevity depends on decisions to suspect that Adventists are biolog- people make about their lifestyles, ically different in their responses to which could translate into enjoying environmental exposures.” good health until nearly 90 years old. Dan Buettner, author of The Blue About half of Loma Linda’s 23,000 Zones: Lessons for Living Longer From residents are practicing Seventh Day the People Who’ve Lived the Longest, Adventists, which sets the city apart has studied Loma Linda and other from otherwise analogous places longevity hot spots across the globe. in the U.S. The Adventists eschew One key recommendation he makes smoking and encourage staying lean, for anyone looking to make healthier engaging in regular physical activity, choices comes from another blue zone, eating nuts, and sticking to a vegetar- Okinanwa, Japan. The people of Oki- ian diet. And in addition to a focus on nawa form personal networks called God, they promote strong social and moais that provide support through- family ties and volunteerism. out their lives, and he stresses how important such groups are for making A Matter Of Choice? successful changes. “We know that Adopting the Adventist lifestyle social behaviors are as contagious as could add up to 10 years to a person’s catching a cold…we’re setting up this lifespan. A paper published in 2001 network that has the right contagion in the Archives of Internal Medicine flowing through it,” Mr. Buettner says. explored this very possibility. Due The “right contagion” flowing through to their lifestyle choices, Adventists moais includes walks and plant-based provide an opportunity to study pot luck dinners.

IMAGE: RUSSEL BRENNAN

17 Dr. Ellsworth Wareham

The Picture Of Health At 100 starting his day with breakfast around 9 or ends up climbing them several times a day, 10 o’clock, which always includes a banana which adds to his daily activity. He is an Dr. Ellsworth Wareham of Loma Linda is and one other fruit, nuts, and a whole grain avid reader, but “Never fiction. I’m too lazy a walking—and driving!—billboard for an cereal such as Grape Nuts or Shredded for fiction.” Adventist lifestyle program. He will turn Wheat. He then will do chores around the He eats two meals per day, and has the 100 this October. Dr. Wareham is impres- house and care for his yard. He still mows second in the late afternoon. Mrs. Ware- sive because of his age, but even more so his own lawn. He is able to go up and down ham prepares vegetables and legumes. because of his vitality. When speaking by a flight of stairs with ease, and finds that he “Occasionally she’ll make one of those telephone, it is difficult to picture a cen- meat analogs—you know what I mean, tenarian on the other end of the line: his fake meat,” he says. As a vegan who never voice is clear and steady, his mind sharp, really cared for dairy products, he admits, and his conversation full of details of a life “If I digress…I may have a piece of salmon.” that sounds more like that of a person in Dr. Wareham Maybe there will be salmon on the their 60s or 70s than of a man planning his menu when his five children, eight grand- 100th birthday celebration. He claims to is impressive children and three great-grandchildren have no aches or pains and hasn’t had a come to celebrate his centennial this year. cold or flu in years, maybe decades. because of If more Americans put a plant-based diet At the age of 95, Dr. Wareham retired and active lifestyle on their own menu, from a very long career as a heart sur- his age, but Loma Linda might not be the only blue geon. When asked what he had been up to zone in the United States, a place where recently, he elaborated on his activities the even more centenarians still mow their lawns. prior day. He drove alone about 70 miles each way to attend a bris for a friend’s son. so because It was his first time at such an occasion. Even after so many years, he is still having of his vitality. new experiences. Most days are less event- ful. He resides with his wife of 64 years, Barbara. He says he is leisurely about IMAGE: PATRICK STRATTNER FOR NEW YOU MAGAZINE

18 SUMMER 2014 : ISSUE 5.02 Epidemiology Matters

Epidemiology Matters is a digital space intended to be a forum for an ongoing epidemiology conversation, providing up-to-date resources useful to trainees and practicing epidemiologists alike. The site is anchored around the book, Epidemiology matters: a new introduction to methodological foundations, with supplementary materials.

ff HIGHLIGHTS OF CURRENT ARTICLES, REPORTS AND BOOKS ff CURATED READING LISTS ORGANIZED BY TOPIC ff RESOURCES ORGANIZED BY EPIDEMIOLOGIC METHOD ff SUPPLEMENTARY MATERIAL AND EXERCISES

epidemiologymatters.org Does your brain really do better off grain?

BY KAITLIN UGOLIK Experts question the science behind gluten-free diets

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20 SUMMER 2014 : ISSUE 5.02 mericans are 1 percent of adults currently affected. Gluten-free may not be However, most Americans on a gluten- increasingly adopt- free diet do not have celiac disease. In healthy for those who ing a gluten-free a 2013 survey conducted by the Food don’t have celiac disease A Marketing Institute, only 2 percent of diet, spurred by claims that shopper respondents said they bought Though increasingly trendy, a glu- gluten-free foods because they had a celiac avoiding this protein, found in ten-free diet can actually be harmful sensitivity; 59 percent said they simply for people who do not have celiac wheat and other grains, might believed gluten-free foods to be healthier. disease. “Unlike gluten-containing The reasons for the increase are not cure various ailments or even products, gluten-free substitutes entirely understood, but one unintended are not enriched with iron and could prevent diseases such as consequence is clear to anyone who has lead to the development of vitamin walked down the aisles of a grocery store Alzheimer’s and dementia. deficiencies,” says Dr. Benjamin Leb- recently, where there is a “gluten-free” wohl. Read more in the Daily Beast. Eliminating gluten is typically recom- label on everything from boxes of crackers thebea.st/RZMJYy mended for people with celiac disease, a to milk cartons. The idea that gluten-free condition in which the small intestine’s abil- is healthy has spread rapidly, championed ity to absorb nutrients is inhibited by the by celebrity doctors including Dr. Mehmet gluten protein. Incidences of celiac disease Oz and Dr. David Perlmutter, a Florida are rising in the U.S.—a 2012 study from physician and author of the 2013 book the Mayo Clinic found that the number of Grain Brain: The Surprising Truth About U.S. adults with the disease has increased Wheat, Carbs and Sugar — Your Brain’s four-fold over the last 50 years, with about Silent Killers.

DEPARTMENT OF EPIDEMIOLOGY 21 Gluten free products now fill the shelves.

Researchers who study gluten and glucose levels, which may be caused by a celiac disease caution that if you don’t have number of things from diabetes to stress to the condition, it would be wise to steer diet, may be correlated with dementia. clear of this fad, which bans everything In an interview, Dr. Perlmutter said the “It’s a difficult and from beer to bagels. point he is making is that “lifestyle choices “We don’t take the decision to start a affect the brain” and emphasized that he expensive and gluten-free diet lightly,” says Dr. Benjamin does not view a gluten-free diet as a silver Lebwohl, Herbert Irving Assistant Professor bullet. The impact of changes in diet and socially isolating of Epidemiology at Columbia, who focuses exercise on brain health has been “left out” on outcomes in celiac disease. “It’s a dif- of much of the public conversation about diet,” and when it ficult and expensive and socially isolating disease prevention, says Dr. Perlmutter, so diet,” and when it comes to using it as a pre- the idea that people could have some con- comes to using it ventative measure for diseases other than trol over the trajectory of their brain health celiac, the science just isn’t there, he says. is empowering for many. “There is no pill as a preventative Experts further warn that questionable for memory, there is no dementia or Alzhei- claims are being made by people who mer’s treatment, but lifestyle choices are measure for stand to benefit lucratively. hugely impactful in terms of preventing this One of the most controversial of glu- and even reversing it,” he says. diseases other than ten-free proponents is Dr. Perlumtter, Grain Brain cites various studies to whose Grain Brain which has made the make its case. One is a case series of 13 celiac, the science New York Times bestseller list and has patients conducted by the Mayo Clinic in been published in 15 countries. The book 2006 that showed a potential association just isn’t there argues that eating foods with high glyce- between gluten and dementia. However, mic indexes, which happen to be some of the researchers noted that the study was the most gluten-rich foods, increases the small, their results did not display a causal chances of developing neurological disor- relationship, and that more research was ders like Alzheimer’s and dementia. needed to determine the nature of the asso- The book’s prescription of a gluten-free ciation. Dr. Perlmutter points to another diet relies in part on recent studies show- study released in January from the Journal ing that some people without celiac disease of Neurology, Neurosurgery and Psychiatry IMAGES / LEFT: ALEX ABBOUD, have neurological responses to gluten, which found that a Mediterranean-style RIGHT: ALEXIS O’TOOLE including migraines, “brain fog” and trou- diet that is higher in omega-3 fat and lower ble controlling their muscles, and that high in carbohydrates than the typical American

22 SUMMER 2014 : ISSUE 5.02 diet dramatically improved cognition. during a single day on dementia risk. While themselves are causing the neurological But many researchers aren’t sure that there is better evidence to suggest that symptoms, according to Dr. Lebwohl. science has reached the point where exercise is more effective than diet in stav- For those with a gluten intolerance, such connections can so confidently be drawn ing off dementia, Dr. Crane thinks that the symptoms could potentially be caused by a between diet and cognitive health. Dr. Paul media views exercise as boring. failure to absorb vitamin B-12, which plays K. Crane, a co-author of one of the cited “You can’t sell walking,” he says. a key role in brain functioning. studies, which was published last August in Dr. Armin Alaedini, an assistant pro- “In those who have celiac disease, the the New England Journal of Medicine, wor- fessor of medical sciences at Columbia’s management decision is clear: they need ries that Dr. Perlmutter is one of a growing department of medicine, who studies to go on a gluten-free diet. In those who group of public figures stretching the find- the links between bacterial and dietary don’t have the disease, it’s still very tempt- ings of a study to fit a cure-all narrative. proteins and the development of immune ing, and I often agree with going on a strict The problem with Dr. Perlmutter and processes, has also seen his findings gluten-free diet to see what happens to other gluten-free proponents is that they stretched to tout the gluten-free diet as a neurological symptoms,” Dr. Lebwohl says. sometimes extrapolate diet advice from preventative measure. But “on the other side of things, the more studies that do not directly relate to the “There is very little data to suggest that common neurological symptoms a lot of research questions the authors set out to gluten proteins interact directly with the people report…the reason for that is com- answer, says Dr. Crane, who is an associate brain,” said Dr. Alaedini, who has studied pletely unknown at this point.” professor at the University of Washington’s the impact of gluten proteins in patients For instance, a study by Dr. Lebwohl department of medicine studying Alzhei- with autism and schizophrenia. and others of migraine headaches in people mer’s disease and cognitive functioning. But that has not stopped commentators with gluten intolerance found no meaningful His paper describes a potential link who reviewed his articles from claiming correlation between the severity of migraines between high blood glucose levels over otherwise. “I noticed articles talking so and the duration of a gluten-free diet. time and dementia. It did not discuss definitively about a role for gluten for Ultimately, experts agree that not whether the high blood glucose levels in which we really didn’t have that kind of evi- enough is known about the way gluten his subjects were connected to eating glu- dence,” he said. impacts the brain—or even whether ten-rich foods with high glycemic indices, However, there is evidence that some restricting gluten may negatively impact which tend to cause a short-term jump in patients with and without celiac disease people without celiac disease—to support blood glucose. This didn’t stop the media exhibit neurological issues, with one of a gluten-free diet as a preventative mea- and other researchers from reporting that the most common being “gluten ataxia,” sure for any disease, let alone dementia. the study was making recommendations or difficulty moving the limbs after con- “Even though it makes for a great for a low glycemic diet, which Dr. Crane suming gluten. While this is hard to ignore, story, it doesn’t make for great science,” himself refuses to make. researchers aren’t sure that gluten proteins Dr. Alaedini said. “I think a lot of these links are awfully speculative, and a lot more research is needed,” Dr. Crane says. Last fall, a group of European doctors also championed a low glycemic diet based on a study they published in the journal Neurology. The study found that adults with high blood sugar levels had a smaller hippocampus volume and more memory problems than those with lower blood sugar. However, the doctors studied glu- cose levels, not glycemic index impact, Dr. Crane points out. “Their exposure data was pretty similar to my exposure data, [which was] not at all about glycemic indices in the diet,” Dr. Crane says. In fact, very little research has been done on the relationship between glycemic Gluten-free recipes have proliferated online. indices and neurological problems, and scientists have not determined the impact of multiple swings in blood glucose levels

DEPARTMENT OF EPIDEMIOLOGY 23 Changing the statins quo

The controversy around the new cholesterol treatment guidelines

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BY CHRIS TAIT

COMMUNICATION IN EPIDEMIOLOGY & HEALTH FELLOW, MPH ‘14

24 onsidering that one in After the last time the ACC/AHA guidelines were updated, in 2001, there three Americans will was a three-fold increase in the number die of cardiovascular of Americans for whom statin therapy C was recommended. Critics of the 2013 disease, and that 60 per- recommendations worry the number of cent will have either a heart Americans taking statins will double from 36 million to 72 million patients—one-third attack or a stroke at some of adults over the age of 40. However, stud- point in their lives, preven- ies find that statins reduce cholesterol in many patients who have not had success tive measures have become with a heart healthy diet and exercise, increasingly valued among and are credited with saving thousands of lives from premature cardiovascular patients and doctors. But death, according to a 2013 meta-analysis how to go about preventing published in the Journal of the American Medical Association. ABOUT CHOLESTEROL cardiovascular disease has Since 2001, the body of evidence sur- Cholesterol, which is waxy and has a been a controversial issue. rounding the effectiveness of statin therapy fatty appearance, is found in every cell has greatly expanded, largely through ran- of the body and serves several important That controversy ramped up in November, domized clinical trials, which are the gold functions, such as enabling the body to with the American College of Cardiology standard in medical research. According to produce hormones and contributing to the (ACC) and the American Heart Associa- the ACC/AHA panel, the research suggests structure of cell walls. Cholesterol is also tion (AHA)’s new cholesterol guidelines, that four groups distinguished by age and found in certain foods. Having too much which were developed to help clinicians clinical risk factors would benefit from sta- of a type of cholesterol called low-density determine when they should prescribe a tin-therapy and that statins safely reduce lipoprotein (LDL) in the blood puts one at particular cholesterol-lowering medication incidence of cardiovascular disease events, greater risk of heart disease. known as a statin to treat high cholesterol. like heart attacks and strokes. Drawing At the center of the debate has been one on this research, the ACC and AHA made of the major changes in recommendations, available an online risk calculator to help a reformulation of how a patient’s risk for physicians estimate their patients’ 10-year cardiovascular disease is calculated. This risk for cardiovascular disease based on change, informed by the latest scientific traditional clinical and lifestyle risk factors. research, is meant to identify people Supporting clinicians say the tool is whose overall health will improve from user-friendly and will help foster important statin use while reducing the number of conversations between patients and doc- those who are less likely to benefit, accord- tors who are deciding on an appropriate ing to the ACC/AHA committee. medication regimen. But months after the release, the new Opponents, however, challenge the guidelines remain strongly contested by calculator, on the grounds that it greatly members of the medical community who overestimates one’s cardiovascular dis- worry that the recommendations may ease risk, potentially resulting in millions result in over-prescription of statins and being unnecessarily prescribed to statin may be more of a boon for drug companies therapy. Some experts, like Dr. Peter than patients. Alagona, Pennsylvania State University’s Statins like Lipitor and Crestor are a program director for diagnostic cardiology, group of drugs that reduce the amount of express concerns about the impact of the cholesterol produced by the liver. They are new guidelines on payments for medical commonly prescribed for patients at risk of treatment. He wonders whether patients heart attack and stroke as well as a number who fall outside of the new guidelines but of other adverse cardiovascular conditions. whose doctors recommend they stay on While the prevalence of heart disease has statin therapy would be denied reimburse- remained relatively steady throughout the ment from their insurance companies. past decade, the use of statin medication And in a New York Times op-ed pub- to prevent it has escalated dramatically— lished immediately after the release of the about ten-fold over the past 20 years. guidelines, Dr. John Abramson, professor

DEPARTMENT OF EPIDEMIOLOGY 25 Critics worry that the risk calculator will cause physicians to prescribe statins to patients who previously weren’t on the medication

of primary care at Harvard Medical School, ■■ Anyone with a history of cardio­ discussion balancing scientific evidence criticized the ACC/AHA panel for their vascular disease with individual values, context, and ulti- alleged ties to the pharmaceutical industry, ■■ Those with elevated LDL cholesterol mately the preferences of the patient. which he said would stand to benefit more ■■ Anyone with diabetes between ages 40-75 This component of the guidelines than anyone should statin prescriptions ■■ Those without diabetes, with elevated should quell critics’ fears that the risk cal- increase according to projections. Dr. cholesterol, aged 40-75, with a ≥ 7.5 culator will be used in an overly simplistic Abramson argues that drug treatment in percent 10-year risk of cardiovascular fashion. “The decision to prescribe statins general provides false reassurances that disease according to the risk calculator is not automatic. Risk discussion with a discourage patients from making lifestyle physician needs to take place for those in changes to treat and prevent against car- The controversy is centered on those this group,” says Dr. Stone diovascular disease. in the fourth group. Critics worry that the And while a “heart healthy lifestyle” is Dr. Neil Stone, who chaired the panel risk calculator will cause physicians to pre- always the primary recommendation for that developed the 2013 guidelines and scribe statins to patients who previously those susceptible to cardiovascular disease, who is a professor of cardiology at North- weren’t on the medication. which includes a balanced diet and regular western University’s Feinberg School Dr. Stone says most critics of the new exercise, lifestyle changes may not always of Medicine, attributes the contentious guidelines did not appreciate additional be enough for those at highest risk, espe- debate to one particular component of the recommended steps put out by the panel, cially in the short term. new guidelines. which address how to proceed in treating Dr. Stone believes that some of the Previously, physicians were recom- patients in this particular group. The new media reporting has obscured his commit- mended a statin if their LDL or “bad” recommendations are more comprehen- tee’s recommendations: “Translating to cholesterol- and non-HDL cholesterol sive in using the latest evidence to ensure physicians means getting the word out on targets were above a certain threshold. that the decision to begin statin therapy what we actually said. It’s unfair for them Subsequently, they were recommended to will prove to be beneficial he says. In fact, to have to hear misconceptions about what get their LDL level down to 70 milligrams some patients who were previously on wasn’t said.” per deciliter, sometimes meaning taking statins according to the old guidelines may statins in conjunction with other medica- be encouraged to adopt lifestyle changes tions, even though this has never been before seeking medication, pending a dis- proven to prevent cardiovascular disease. cussion with their physician, according to Because evidence from recent random- Dr. Stone. ized clinical trials does not provide enough Dr. Stone also says that the guidelines support for treatment based on these do not unquestionably prescribe statin ther- targets, the new guidelines identified four apy to patients in this group, but rather call groups of patients on whom physicians for a collaborative decision-making process should focus their efforts to reduce cardio- between the physician and patients that vascular disease events: provides an opportunity for a pragmatic

26 SUMMER 2014 : ISSUE 5.02 symposium report BY ELAINE MEYER

Encouraging urban health has multiple benefits Urban+Health symposium

hen it comes to urban “It’s certainly my impression that health is one of those universal values—across cultures, across countries. How do we then take advantage of that?” asked Dr. planning, we tend Sandro Galea, Gelman Professor of Epidemiology and chair of the department to look at competing of epidemiology at Columbia’s Mailman School of Public Health, in reference to W urban planning. interests: environmentalism “When you look at the political context—politicians, communities, societies— versus economic development often health is a very important value, but it is not the only value. People also care about issues like economic development, the environment, equity issues,” or affordability versus gentrifi- said Karen Lee, MD, senior adviser on the built environment and healthy housing cation. But a building and design at the New York City Department of Health and Mental Hygiene. “Finding syn- ergies and co-benefits has been a critical part in terms of advancement of these approach that prioritizes health issues in communities.” can act as an entry point for She pointed to the multiple benefits of New York City’s “pedestrianization” of Times Square, Herald Square, and Union Square where the city converted promoting many other interests automobile lanes to pedestrian plazas with more walking space and seating. In at the same time, said speak- addition to reducing traffic injuries and encouraging more physical activity, the urban makeovers have conferred economic benefits. In Union Square there has ers at a daylong symposium of been a 49 percent drop in vacant storefronts, and for the first time, Times Square the Mailman School of Public became one of the top ten retail areas in the world. In a similar vein, FRESH (Food Retail Expansion to Support Health) program has incentivized the building Health’s Urban+Health program, of grocery stores in parts of the city that were formerly food deserts, creating co-organized with the Graduate both new jobs and proximity to healthy food for residents. In China, the economic effects of heavy air pollution has fueled concern School of Architecture, Plan- from a government that historically has been lax on environmental regulation. ning, and Preservation (GSAPP), “Businesses are paying a premium to send people to China because of air pollution concerns,” said Dr. Carlos Dora, coordinator of the interventions which took place April 22 at for healthy environments unit, part of the department of public health and the GSAPP Studio-X space environment at the World Health Organization. “We’re going to use air pollution as an entry point” to address issues like chronic disease and climate change, he downtown. added. A recent WHO study reported that one in eight people die because of air pollution globally. By reducing use of cars, dense urban living promotes sustainability more than green suburban living, said Vishaan Chakrabarti, the Marc Holliday Associate Professor of Real Estate Development GSAPP, and a partner at SHoP Architects. Cities also promote a factor that he calls “public joy.” This can be seen in the The Columbia University many urban centers across the U.S. that are “creating extraordinary pieces of Epidemiology Scientific Symposium public landscape, public architecture, culture, waterfronts.” People are seeking (CUESS) series brings the best a walkable urban lifestyle free of long office commutes, which affords them minds in epidemiology and other “something that’s critical for health and joy, which is more time,” he said. “Most disciplines together for a full day of young people today are looking at that 20th century technology of that suburban discussions on the most pressing house and that office park and trying to find a different way.” health questions of our time. Illustrating Chakrabarti’s point that cities are home to all kinds of creative endeavors, Dr. Natalie Jeremijenko, an associate professor of art at New York

27 SYMPOSIUM REPORT

Cities also promote a factor that he calls “public joy.” This can be seen in the many urban centers across the U.S. that are “creating extraordinary pieces of public landscape, public architecture, culture, waterfronts.”

the2x2project.org University’s Steinhardt School of Culture, Education, and Human Development, spoke about her work as an artist and scientist who creates sustainable projects 2x2.ph/urban-health-benefits for urban environments. At her Environmental Health Clinic at NYU, she works with clients on projects to address their environmental health concerns. These include a Butterfly Bridge in Washington, which elevates the insects above traffic to protect them from untimely fates on car windshields She has also created various air collection devices like “solar chimneys” to collect air pollutants and filter the air. She has tried to work with New York’s Metropolitan Transportation Authority to put a device on one of the system’s air Read more about the symposium vents but “for security reasons, I’ve been told that I can’t have access to it, which is a great way to say what the MTA is doing provides no filtration whatsoever.” 2x2.ph/breaking-ground-urban-health She also runs an urban farm, which is “the only non-technology we have for improving urban air quality.” Watch video / courtesy of GSAPP Such projects buttress the idea that the marriage of urban design and health can address a variety of concerns and provide a variety of benefits. As Dr. Gina youtu.be/b7NMm6FkM2U Lovasi, an assistant professor of epidemiology at Columbia’s Mailman School of Public Health, said: “Cities that support health are going to be supporting our other social and economic goals and the kinds of lives we want to live.”

Deans Linda P. Fried of the Mailman School and Mark Wigley of the School of Architecture, Planning and Preservation discuss their shared vision for urban health

28 grand rounds report BY AMINA FODA, MPH ‘15

Sticks and bones may break my heart How early physical and sexual abuse shape lifelong cardiovascular risk

t has long been clear that The “elephant in the room” in this area of research is child abuse, said Dr. Rich-Edwards, who is an associate professor of medicine and epidemiology at people in a low socioeconomic Harvard’s Medical School and School of Public Health. group are at heightened risk of Dr. Rich-Edwards has found a strong association between low socioeco- I nomic status and women who reported being raped or abused as children. As poor health, compared to those part of the Nurses’ Health Study, she introduced an investigation into physical, with more resources. What is sexual, and emotional abuse during childhood and adolescence and how those experiences predict the likelihood of diseases in adulthood, including diabetes, less clear is why. That relation- cardiovascular disease, and hypertension. She found that as the cumula- ship is the “black box that needs tive measure of child abuse increased, the likelihood of these diseases also increased. Those who experienced “severe” physical and sexual abuse during to be opened” said Dr. Jan- childhood and adolescence were about two times more likely to have food et-Rich Edwards, the featured addiction, which is often associated with obesity as an adult. The good news is that over the last ten years rates of abuse have been on speaker at February’s Columbia the decline. Dr. Rich-Edwards hopes that awareness of the data will help lower University Epidemiology Grand the rates even further and provide opportunities for early interventions to improve women’s health. Rounds (CUEGR).

The Columbia University Epidemiology Grand Rounds (CUEGR) is a monthly series that hosts global leaders in epidemiology to share their work with faculty, students, and the Columbia community at large.

29 in the news

According to a new study by Dr. W. Ian Lipkin, John Snow Professor of MERS comes to the Epidemiology, director of the Center for Infection and Immunity at Columbia’s Mailman School, and professor of neurology at College of Physicians & U.S.; camels implicated Surgeons; Dr. Thomas Briese, associate professor of epidemiology at Colum- as the source bia; and colleagues, camels are the major source of Middle East Respiratory Syndrome, or MERS, a viral disease that was first detected in Saudi Arabia in 2012 and is responsible for nearly 100 deaths. Dr. Lipkin talked to various media outlets after two cases appeared in the U.S. last month, saying he is confident that “we have MERS under control.”

Watch more on the Wall Street Journal. › on.wsj.com/1n4tKpo

Read more on the LA Times. › lat.ms/1nS6z5x

Read more in the New York Times. › nyti.ms/1ncpCEp

IMAGE: CHARLES ROFFEY

30 IN THE NEWS

Dr. Ernest Drucker, adjunct professor of epidemiology at Columbia’s Mailman War on drugs not School, is part of a group of academics who have authored a London School of Economics report saying the “singular approach” of the War on Drugs isn’t working working. Dr. Drucker points to one of the costliest byproducts of the war: the system of mass incarceration. Read more in the Daily Beast. › thebea.st/1nXblft

In response to the city of Baltimore’s plan to welcome a Las Vegas-style Anticipating the health casino, Dr. Silvia Martins, associate professor of epidemiology at Columbia’s Mailman School, who has researched the effect of gambling on the health effects of a new casino of young people in disadvantaged neighborhoods says that: “Just because in Baltimore you live in a disadvantaged Baltimore neighborhood, you’re not more likely to be impulsive, but there would likely be less prevention strategies in place to control those who are impulsive.” Read more in the Baltimore Sun. › bsun.md/1iSDaVL

In the wake of measles outbreaks on both the East and West coasts this Measles outbreak past winter, there are fears that a growing trend of vaccine refusal may be driving the infections. “Measles is extremely transmissible, so you really points to declining need a very high level of immunization to protect people, so the complacency vaccine coverage there is the fact that we don’t see the threat quite the way we did 50 years ago or perhaps even 25 years ago,” Dr. Stephen Morse, professor of epidemiology at Columbia, told PBS in March. Watch the full interview on PBS › to.pbs.org/1omxcQV and read more in Salon. › bit.ly/1gm07KT

The president’s budget for the National Institutes of Health is slowing down the Worries about an pace of current research and could deter young researchers from entering health fields, says Dr. Neil Schluger, a professor of medicine, epidemiology, and envi- NIH dry spell ronmental health sciences and chief of the pulmonary, allergy and critical care medicine division at Columbia University. “We really are in the process of losing a generation of people who otherwise might have pursued careers in research.” Read more in Genetic Engineering and Biotechnology News. › bit.ly/1fmkhbA

The nation of Guinea is currently trying to contain an Ebola epidemic, and How big is the it is unclear how far the deadly virus will spread. “It’s not as well contained as we would have hoped. I anticipate we will lose many people, but it will be Ebola threat? a self-limited outbreak,” Dr. Ian Lipkin said. Read more in Business Insider. › read.bi/1iam6Hh and National Geographic. › bit.ly/1kx4cjg

The reason Ebola is unlikely to lead to widespread epidemics, says Dr. Stephen Morse, is that there are no natural reservoirs for the disease outside of Africa. Read more in Popular Mechanics. › bit.ly/1e9pzDA

31 IN THE NEWS

A new Centers for Disease Control and Prevention study reports a large gap Lifespan more about in longevity in the U.S. based on the demographics of where people live. where you live than your “We have been far too tolerant of some of the health gaps that have charac- terized the U.S. health landscape for many decades,” says Dr. Sandro Galea, genes Gelman Professor and chair of the department of epidemiology at Columbia’s Mailman School of Public Health. Read more in USA Today. › usat.ly/1rNkBCN

New York City health commissioner Dr. Mary Bassett, who is also an associate NYC health professor of clinical epidemiology at Columbia’s Mailman School of Public Health, plans to continue the previous administration’s campaign to improve commissioner promotes public health, with an added emphasis on listening to communities. “We have community-based to engage with communities to make sure that they understand that we in gov- approach ernment aren’t trying to do things to them but do things with them,” she says. Read and listen to more on WNYC. › bit.ly/1iambL1

Members of the American military who responded to the Fukushima nuclear Health effects of meltdown last year in Japan are claiming that radiation exposure has put them at risk for future health problems. But Dr. Lydia Zablotska, adjunct assistant Fukushima professor of epidemiology at Columbia’s Mailman School of Public Health, says exposure levels estimated by the government were “miniscule” and cannot be linked to specific health problems. “It could be genetics, smoking or radiation—and the leukemia would look exactly that same,” she said. Read more in the Huffington Post. › huff.to/1kpzPeD

32 SUMMER 2014 : ISSUE 5.02 faculty publications APRIL – JUNE 2014

Ablah E, Hesdorffer DC, Liu Y, Paschal Arora N, Papapanou PN, Rosenbaum M, Benito-León J, Romero JP, Louis ED, Ber- Brinton LA, Scoccia B, Moghissi KS, West- AM, Hawley S, Thurman D, Hauser WA; Jacobs DR Jr, Desvarieux M, Demmer RT. mejo-Pareja F. Faster cognitive decline in hoff CL, Niwa S, Ruggieri D, Trabert B, The Prevalence of Epilepsy in Rural Periodontal Infection, Impaired Fasting elders without dementia and decreased risk Lamb EJ. Long-term Relationship of Ovu- Kansas Study Group. Prevalence of epi- Glucose and Impaired Glucose Tolerance: of cancer mortality: NEDICES Study. Neu- lation-Stimulating Drugs to Breast Cancer lepsy in rural Kansas. Epilepsy Res. 2014 Results from The Continuous National rology. 2014 Apr 9. [Epub ahead of print] Risk. Cancer Epidemiol Biomarkers Prev. Feb 13. pii: S0920-1211(14)00014-X. doi: Health and Nutrition Examination Survey 2014 Apr;23(4):584-93. doi: 10.1158/1055- Besser A, Weinberg M, Zeigler-Hill V, 10.1016/j.eplepsyres.2014.01.001. [Epub 2009-2010. J Clin Periodontol. 2014 Apr 9965.EPI-13-0996. Neria Y. Acute Symptoms of Posttrau- ahead of print] 8. doi: 10.1111/jcpe.12258. [Epub ahead matic Stress and Dissociative Experiences Callahan LF, Cleveland RJ, Shreffler J, of print] Abu Daya H, Lebwohl B, Smukalla S, Among Female Israeli Civilians Exposed Hootman JM, Mielenz TJ, Schoster B. Lewis SK, Green PH. Utilizing HDL Levels Bafeta A, Trinquart L, Seror R, Ravaud to War: The Roles of Intrapersonal and Evaluation of active living every day in to Improve Detection of Celiac Disease in P. Reporting of results from network Interpersonal Sources of Resilience. J adults with arthritis. J Phys Act Health. Patients With Iron Deficiency Anemia. Am meta-analyses: methodological system- Clin Psychol. 2014 Mar 11. doi: 10.1002/ 2014 Feb;11(2):285-95. doi: 10.1123/ J Gastroenterol. 2014 May;109(5):769-70. atic review. BMJ. 2014 Mar 11;348:g1741. jclp.22083. [Epub ahead of print] jpah.2011-0317. doi: 10.1038/ajg.2014.30. doi: 10.1136/bmj.g1741. Bild DE, McClelland R, Kaufman JD, Carmo RA, Melo AP, Dezanet LN, de Ahmad Khan F, Verkuijl S, Parrish A, Chik- Baldwin MR, Reid MC, Westlake AA, Blumenthal R, Burke GL, Carr JJ, Post Oliveira HN, Cournos F, Guimarães wava F, Ntumy R, El-Sadr W, Howard AA. Rowe JW, Granieri EC, Wunsch H, Dam WS, Register TC, Shea S, Szklo M. Ten- MD. Correlates of hepatitis B among Performance of symptom-based tubercu- TT, Rabinowitz D, Goldstein NE, Maurer Year Trends in Coronary Calcification in patients with mental illness in Brazil. losis screening among people living with MS, Lederer DJ. The feasibility of mea- Individuals without Clinical Cardiovas- Gen Hosp Psychiatry. 2014 Mar 12. pii: HIV: not as great as hoped. AIDS. 2014 suring frailty to predict disability and cular Disease in the Multi-Ethnic Study S0163-8343(14)00064-4. doi: 10.1016/j. Mar 27. [Epub ahead of print] mortality in older medical intensive care of Atherosclerosis. PLoS One. 2014 Apr genhosppsych.2014.03.001. [Epub ahead unit survivors. J Crit Care. 2014 Jan 6. pii: 17;9(4):e94916. doi: 10.1371/journal. of print] Ahmed FS, Jiang XC, Schwartz JE, Hoff- S0883-9441(14)00004-5. doi: 10.1016/j. pone.0094916. eCollection 2014. man EA, Yeboah J, Shea S, Burkart KM, Castaldi PJ, Dy J, Ross J, Chang Y, Washko jcrc.2013.12.019. [Epub ahead of print] Barr RG. Plasma sphingomyelin and lon- Brackbill RM, Cone JE, Farfel MR, GR, Curran-Everett D, Williams A, Lynch gitudinal change in percent emphysema Barnes DM, Hatzenbuehler ML, Hamilton Stellman SD. Chronic physical health DA, Make BJ, Crapo JD, Bowler RP, Regan on CT. The MESA Lung study. Biomarkers. AD, Keyes KM. Sexual orientation dispari- consequences of being injured during the EA, Hokanson JE, Kinney GL, Han MK, 2014 Mar 21. [Epub ahead of print] ties in mental health: the moderating role terrorist attacks on World Trade Center Soler X, Ramsdell JW, Barr RG, Foreman of educational attainment. Soc Psychiatry on September 11, 2001. Am J Epidemiol. M, van Beek E, Casaburi R, Criner GJ, Lutz Alagaili AN, Briese T, Mishra N, Kapoor Psychiatr Epidemiol. 2014 Feb 26. [Epub 2014 May 1;179(9):1076-85. doi: 10.1093/ SM, Rennard SI, Santorico S, Sciurba FC, V, Sameroff SC, de Wit E, Munster VJ, ahead of print] aje/kwu022. Epub 2014 Feb 20. PMID: Demeo DL, Hersh CP, Silverman EK, Cho Hensley LE, Zalmout IS, Kapoor A, Epstein 24561992 [PubMed - in process] MH. Cluster analysis in the COPDGene JH, Karesh WB, Daszak P, Mohammed Baumgartner JN, Kaaya S, Karungula H, study identifies subtypes of smokers OB, Lipkin WI. Middle East Respiratory Kaale A, Headley J, Tolley E. Domestic Bradshaw PT, Ibrahim JG, Khankari N, with distinct patterns of airway disease Syndrome coronavirus infection in drom- Violence Among Adolescents in HIV Pre- Cleveland RJ, Abrahamson PE, Stevens and emphysema. Thorax. 2014 Feb 21. edary camels in Saudi Arabia. MBio. 2014 vention Research in Tanzania: Participant J, Satia JA, Teitelbaum SL, Neugut AI, doi: 10.1136/thoraxjnl-2013-203601. [Epub Mar 25;5(2). pii: e01002-14. doi: 10.1128/ Experiences and Measurement Issues. Gammon MD. Post-diagnosis physical ahead of print] mBio.01002-14. Matern Child Health J. 2014 Apr 17. [Epub activity and survival after breast cancer ahead of print] diagnosis: the Long Island Breast Cancer Chadeau-Hyam M, Vermeulen RC, Hebels Aleksandrova K1, Jenab M, Bue- Study. Breast Cancer Res Treat. 2014 May DG, Castagné R, Campanella G, Porten- no-de-Mesquita HB, Fedirko V, Kaaks R, Beasley A, White KO, Cremers S, West- 1. [Epub ahead of print] gen L, Kelly RS, Bergdahl IA, Melin B, Lukanova A, van Duijnhoven FJ, Jansen E, hoff C. Randomized clinical trial of self Hallmans G, Palli D, Krogh V, Tumino R, Rinaldi S, Romieu I, Ferrari P, Murphy N, versus clinical administration of subcu- Brady JE, Wunsch H, Dimaggio C, Lang Sacerdote C, Panico S, de Kok TM, Smith Gunter MJ, Riboli E, Westhpal S, Overvad taneous depot medroxyprogesterone BH, Giglio J, Li G. Prescription drug MT, Kleinjans JC, Vineis P, Kyrtopoulos K, Tjønneland A, Halkjær J, Boutron-Ru- acetate. Contraception. 2014 Feb 7. pii: monitoring and dispensing of prescrip- SA; on behalf of the EnviroGenoMark- ault MC, Dossus L, Racine A, Trichopoulou S0010-7824(14)00036-5. doi: 10.1016/j. tion opioids. Public Health Rep. 2014 ers project consortium. Pre-diagnostic A, Bamia C, Orfanos P, Agnoli C, Palli D, contraception.2014.01.026. [Epub ahead Mar;129(2):139-47. Transcriptomic Markers of Chronic Lym- Panico S, Tumino R, Vineis P, Peeters PH, of print] Braunstein ED, Rosenberg R, Gress F, phocytic Leukemia Reveal Perturbations Duell EJ, Molina-Montes E, Quirós JR, Beelen R1, Stafoggia M, Raaschou-Nielsen Green PH, Lebwohl B. Development and 10 years before diagnosis. Ann Oncol. Dorronsoro M, Chirlaque MD, Barricarte O, Andersen ZJ, Xun WW, Katsouyanni validation of a clinical prediction score 2014 Feb 22. [Epub ahead of print] A, Ljuslinder I, Palmqvist R, Travis RC, K, Dimakopoulou K, Brunekreef B, Wein- (the SCOPE score) to predict sedation out- Khaw KT, Wareham N, Pischon T, Boeing Chang CL, Torrejon C, Jung UJ, Graf K, mayr G, Hoffmann B, Wolf K, Samoli E, comes in patients undergoing endoscopic H. Biomarker patterns of inflammatory Deckelbaum RJ. Incremental replacement Houthuijs D, Nieuwenhuijsen M, Oudin A, procedures. Aliment Pharmacol Ther. and metabolic pathways are associated of saturated fats by n-3 fatty acids in Forsberg B, Olsson D, Salomaa V, Lanki T, 2014 May 11. doi: 10.1111/apt.12786. [Epub with risk of colorectal cancer: results from high-fat, high-cholesterol diets reduces Yli-Tuomi T, Oftedal B, Aamodt G, Nafstad ahead of print] the European Prospective Investigation elevated plasma lipid levels and arterial P, De Faire U, Pedersen NL, Ostenson into Cancer and Nutrition (EPIC). Eur J Epi- Bray BC, Lee GP, Liu W, Storr CL, Ialongo lipoprotein lipase, macrophages and CG, Fratiglioni L, Penell J, Korek M, Pyko demiol. 2014 May 4. [Epub ahead of print] NS, Martins SS. Transitions in Gambling atherosclerosis in LDLR-/- mice. Athero- A, Eriksen KT, Tjønneland A, Becker T, Participation During Late Adolescence sclerosis. 2014 Apr 3;234(2):401-409. doi: Allegranzi B, Conway L, Larson E, Pittet Eeftens M, Bots M, Meliefste K, Wang M, and Young Adulthood. J Adolesc Health. 10.1016/j.atherosclerosis.2014.03.022. D. Status of the implementation of the Bueno-de-Mesquita B, Sugiri D, Krämer 2014 Mar 18. pii: S1054-139X(14)00061-5. [Epub ahead of print] World Health Organization multimodal U, Heinrich J, de Hoogh K, Key T, Peters doi: 10.1016/j.jadohealth.2014.02.001. hand hygiene strategy in United States A, Cyrys J, Concin H, Nagel G, Ineichen A, Chang SC, Glymour MM, Walter S, Liang [Epub ahead of print] of America health care facilities Am J Schaffner E, Probst-Hensch N, Dratva J, L, Koenen KC, Tchetgen EJ, Cornelis Infect Control. 2014 Mar;42(3):224-30. doi: Ducret-Stich R, Vilier A, Clavel-Chapelon Briese T, Chowdhary R, Travassos da Rosa MC, Kawachi I, Rimm E, Kubzansky LD. 10.1016/j.ajic.2013.11.015.. F, Stempfelet M, Grioni S, Krogh V, Tsai A, Hutchison SK, Popov V, Street C, Tesh Genome-wide polygenic scoring for MY, Marcon A, Ricceri F, Sacerdote C, RB, Lipkin WI. Upolu virus and Aransas a 14-year long-term average depres- Argos M, Parvez F, Rahman M, Rakibuz- Galassi C, Migliore E, Ranzi A, Cesaroni Bay virus, two presumptive bunyaviruses, sion phenotype. Brain Behav. 2014 Zaman M, Ahmed A, Hore SK, Islam T, G, Badaloni C, Forastiere F, Tamayo are novel members of the family Ortho- Mar;4(2):298-311. doi: 10.1002/brb3.205. Chen Y, Pierce BL, Slavkovich V, Olopade I, Amiano P, Dorronsoro M, Katsoulis myxoviridae. J Virol. 2014 Feb 26. [Epub Epub 2014 Feb 12. C, Yunus M, Baron JA, Graziano JH, Ahsan M, Trichopoulou A, Vineis P, Hoek G. ahead of print] H. Arsenic and Lung Disease Mortality in Chen LY, Strain EC, Alexandre PK, Long-term Exposure to Air Pollution and Bangladeshi Adults. Epidemiology. 2014 Briese T, Mishra N, Jain K, Zalmout IS, Alexander GC, Mojtabai R, Martins SS. Cardiovascular Mortality: An Analysis of May 5. [Epub ahead of print] Jabado OJ, Karesh WB, Daszak P, Moham- Correlates of nonmedical use of stim- 22 European Cohorts. 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DEPARTMENT OF EPIDEMIOLOGY 33 Bangalore S, Eunus M, Ahmed A, Islam of Club Rhumatismes et Inflammations. J, Tjonneland A, Olsen A, Overvad K, Fedirko V, Romieu I, Aleksandrova K, T, Rakibuz-Zaman M, Hasan R, Argos M, Influence of gender on response to ritux- Chang-Claude J, Boeing H, Steffen A, Pischon T, Trichopoulos D, Peeters PH, Levy D, Sarwar G, Ahsan H. A prospective imab in patients with rheumatoid arthritis: Trichopoulou A, Lagiou P, Sarantopoulou Romaguera-Bosch D, Bueno-de-Mesquita study of arm circumference and risk of results from the Autoimmunity and Rit- M, Palli D, Berrino F, Tumino R, Vineis HB, Dahm CC, Overvad K, Chirlaque MD, death in Bangladesh. Int J Epidemiol. 2014 uximab registry. Rheumatology (Oxford). P, Mattiello A, Bueno-de-Mesquita HB, Johansen C, Bidstrup PE, Dalton SO, Apr 7. [Epub ahead of print] 2014 May 11. 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