UK research project will create strategies to improve respiratory health for those living in Appalachian Kentucky

Public health researchers at the University of Kentucky will undertake a five-year long research project called "Community-Engaged Research and Action to Reduce Respiratory Disease in Appalachia," Sarah Noble writes in a UK press release.

Funded by the National Institutes of Health's National Institute of Environmental Health Sciences, the project will involve creating strategies to improve respiratory and environmental public health. Kentuckians living in Appalachian counties have the state's highest rates of serious respiratory illness.

"Adults in Appalachian Kentucky are 50 percent more likely to develop asthma or chronic obstructive pulmonary disease than the overall U.S. population," Noble writes. "As many as one in five adults in the region have received a diagnosis of asthma, and rates of COPD are nearly two-and-a-half fold the incidence of the disease in other parts of the country.

Although studies show associations between respiratory health problems and environmental contaminants, data doesn't yet include individual-level assessments or behavioral risk factors common in the area—such as smoking, poor diet and insufficient physical activity. The "Community Response to Environmental Exposures in Eastern Kentucky" project will fill those gaps.

The CREEEK project will include three steps. A community-based assessment will "identify the relationships between indoor air pollutants, behavioral and social determinants and the effects these factors have on risk of respiratory disease," Noble writes. That information "will be shared with local stakeholders in an effort to increase understanding of the environmental exposures present in the region," then the project will put in place "an environmental public health action strategy and will evaluate that strategy's ability to impact short-and long-term outcomes for respiratory health."

Newspapers' data analysis finds that Kentucky's seniors on Medicare are among the sickest in U.S.; local data available

Red counties are over 21%. For map with data, click here.

The top 10 Kentucky counties with the highest percentage of seniors on Medicare who have six or more chronic conditions are also in the nation's top 50 for sick seniors, according to government data analyzed by USA Today and The Courier-Journal. Nine of the top 10 counties are in Appalachia.

"That's not surprising," Fran Feltner, director of the University of Kentucky Center of Excellence in Rural Health, told The C-J's Laura Ungar. "And when you're having breathing problems, high blood pressure problems and other problems, to me it seems like you're waging a daily battle against the chronic diseases. It's hard to fight the battle ... and as you get older, it's harder."

The top 10 Kentucky counties ranked by percentage of the 65-and-older Medicare population with six or more chronic conditions are Clay, 27.1 percent; Breathitt, 26.3 percent; Johnson, 26.2 percent; Knott, 25.1 percent; Perry, 24.6 percent; Letcher, 24.2 percent; Bell, 24 percent; Floyd, 23.8 percent; Wolfe, 23.7 percent; and Taylor, 23.6 percent. Taylor County (Campbellsville) is not in Appalachia but borders three non-coal Appalachian counties.

Beve Cotton (C-J photo by Mark Mahan)

Beve Cotton, 81 and with a long list of chronic diseases, is one of those seniors. He lives in Manchester, the seat of Clay County, which ranks 12th among more than 3,100 counties nationally for the percentage of seniors on Medicare with six or more chronic conditions, Ungar reports.

"I'm a mess," said Cotton, who gets around in a power chair and wears a full set of dentures after losing all his teeth. "I'm not able to do things. I'm an accomplished cook, but I can't do that anymore ... I can't drive. My legs don't cooperate. ... It's very hard."

Ungar reports that Clay County, population 21,147, has many of the factors that combine to cause poor health.: "Nearly 38 percent of residents live below the poverty level, compared with a state average of 19 percent, according to the Census Bureau. Median household income is about $22,000 a year, about half the state average.Access to health care, especially specialists, is limited, and there are few well-stocked grocery stores or safe places to exercise. Smoking and obesity rates are sky-high."

Carmen Webb, who directs the senior center in Manchester, told Ungar that many seniors struggle with being able to afford staples, let alone healthy food and also the high cost of transportation, making it difficult to get to doctors appointments to manage their illnesses.

Cotton, who grew up in Manchester, told Ungar that he depends on others for rides, frequently to doctors' appointments, including many at the Veterans Affairs Medical Center in Lexington, about 100 miles away. Webb noted that public transportation in the area costs $1.50 per mile.

Feltner added that many seniors in the area don't know how to prevent chronic disease, some have fatalistic attitudes and because many of them are on multiple medications, they face the dangers of drug interactions and side effects, Ungar reports.

Experts say that such high levels of illness hurts communities, "hastening a downward economic spiral locally and requiring huge portions of Medicare budgets," Ungar writes. It also overtaxes the medical communities in rural counties even thinner.

"These patients need to be seen frequently by doctors, and they need much longer visits. ... These folks need intense care," Dr. Michael Karpf, executive vice president for health affairs at UK, told Ungar. "Given the shortage of primary care in Appalachia, this kind of patient just exacerbates that shortage."

"The real issue is prevention — weight control, exercise, food habits," Karpf said. "But it's hard. Fast food is cheaper than wholesome, healthy food, and (the way people eat) is partly cultural. Those things are hard to change. It's a generational process."

Clay County 4th and 5th graders participate in UK research of circadian rhythms and obesity, little studied in children

The University of Kentucky recently partnered with over 100 fourth and fifth grade students in two Clay County schools to study the relationship between circadian rhythms and weight in children.

Sydney Sester, a fifth grade student at Manchester Elementary School, said in a UK news release that in addition to learning more about science and helping others by contributing to research, participating in the study showed her the importance of maintaining a healthy weight and eating well.

"It made me want to be more responsible with food and be patient with what I eat and only eat when I'm hungry," she said.

The project, "Circadian Rhythm Parameters and Metabolic Syndrome Associated Factors in Young Children," also known as the Clay County Clock Study, is led by Dr. Jody Clasey, associate professor of kinesiology and health promotion, and Dr. Karyn Esser, professor of physiology.

The research team says it hopes to learn about the relationship between circadian rhythms, eating, and activity behaviors and the incidence of overweight and obesity in children.

And while the team is in the process of analyzing the data, Esser told a group at the 10th annual Center for Clinical and Translational Science conference in March that early data show 33 percent of the students in the study are considered obese, their initial blood pressure measurements are on the high end of normal, and the students are less active on weekends and nights than during the school week.

The data was gathered through electronic devices that the students wore for seven days to measure activity, heart rate and skin temperature. The students also kept a daily journal to record their sleep and eating activities each day.

Previous studies have shown that disrupting an adult's circadian rhythm is associated with increased risk for metabolic disease, which is a combination of chronic health conditions that puts a person at a higher risk of heart disease and diabetes. Similar research with children has been limited.

Esser noted that "Clay County and many of the counties in Appalachia have a much higher rate of these chronic diseases."

She also said that while it is known that light exposure affects the body clock, recent findings show that the time that we do activities, like exercising and eating, also contribute to circadian health, and that this is also likely true in children.

This research "could not only influence an individual, but school start times, activity intervention, just so many different areas from personal practice or behavioral choices to public policy, all for the metabolic or physiological good of the individual or collective body," Clasey said.

Community health groups, with focus on prevention, fight to be part of new setup for lowering health costs, improving outcomes

The Patient Protection and Affordable Care Act is forcing doctors and hospitals to collaborate on lowering health-care costs while improving health outcomes. Community health groups that focus on preventive care are battling to be included as part of the solution, Laura Ungar reports for The Courier-Journal and USA Today.

One way physicians and hospitals are coming together to "reduce the duplication of services and keep large groups of patients well" is by forming accountable care organizations. Community health groups are having to fight for a "seat at the table" in these "doctor-dominated boards of ACOs," Ungar writes.

Such groups often offer less expensive, non-medical solutions for preventive health, according to a 2014 report by a North Carolina physicians' coalition. Some ACOs are beginning to include them as partners, but Bo Bobbitt, a Raleigh health-care lawyer who was lead author of the report, told Ungar, "The bad news is that the gap between the medical system treating illness and disease and the community health system was larger than we had feared."

Jose Pagan, a health economist who directs the New York Academy of Medicine's Center for Health Innovation, told Ungar that another key challenge is that doctors and hospitals are going to keep working to keep the money flowing their way. "If you go to a surgeon for a solution, they're not going to give you massage therapy," he says. "There's going to be progress, but it's going to be very slow."

Traditionally U.S. health care has focused its attention on "costly medical intervention," Ungar reports, instead of lifestyle changes, with only 3 percent of the $2.6 trillion health-care budget being spent public health and prevention, despite preventable chronic conditions accounting for 75 percent of medical care, according to a 2012 Institute of Medicine report.

"Compared to even the best medical therapy, we can decrease heart attacks, strokes and deaths by between 35 percent and 45 percent by changing lifestyle," Paul Rogers, a Louisville cardiologist at one of KentuckyOne Health System's healthy lifestyle centers, told Ungar.

For example, losing about 10 percent of weight reduces cardiac risks significantly, and losing 15 to 20 percent begins to reverse diabetes, lowers blood pressure, improves sleep and improves cholesterol level, Rogers said.

Another challenge for community-based programs is that little money goes into research on wellness programs, "and without studies, few will invest in their programs," Ungar notes.

Some members of Congress don't see nutrition, physical fitness or stop-smoking campaigns as health funding and gripe about the "nanny factor," Georges Benjamin, a physician who is executive director of the American Public Health Association, told Ungar.

As a result, "annual funding authorized by the ACA for the Prevention and Public Health Fund was supposed to hit $2 billion starting in 2015 but won't reach that level until at least 2022," Ungar reports.

Lifestyle changes are known to help chronic conditions, and Ungar gives many examples in the article. Here is one: Kevin French, 57, a construction contractor in Louisville, told Ungar that he began having chest pain and had to have two stents implanted in his heart in 1993.  And through cardiac rehab, he learned that his previous eating habits, which included lots of fast food, lack of exercise and smoking, played a big part in his heart problems. But with the help of the healthy lifestyle center, he said he  has "basically changed everything" about  his lifestyle and that's "improved not only his health but his family's as well."

Clinton, Beshear, Humana chief and others discuss Medicaid expansion, other changes in health systems, and chronic illness

By Melissa Patrick and Al Cross
Kentucky Health News

The economic advantages from expanding Medicaid under federal health reform should outweigh any ideology that is holding states back from participating in it.

At least that was the consensus of a panel discussion about economics and health care led by former President Bill Clinton on Jan. 27, the last day of the Clinton Foundation's fourth annual Health Matters Activation Summit in Coachella Valley, Calif.

Gov. Steve Beshear, the leadoff panelist, said the Patient Protection and Affordable Care Act is a "transformative tool" to help change the dire health statistics in Kentucky, and while the decision to expand the Medicaid program to people with incomes up to 138 percent of the federal poverty level was "morally the right thing to do," it was economically the right thing to do, too.

Citing figures from a PriceWaterhouse Coopers study that predicted Medicaid expansion would bring money and jobs to Kentucky by expanding health care, he also said it would help create a healthier workforce to compete for jobs and this would give Kentucky an economic advantage over the surrounding states that didn't expand Medicaid.

"We are going to go past them pretty fast, from an economic standpoint," the governor said.

The study Beshear cited is being replicated to give a fresh forecast of the expansion's economic impact now that the state has a year's experience -- a year in which Medicaid enrolled more people than the first study said would enroll by 2020, and two-thirds as many health jobs were created as the predicted number for 2020. Republicans have voiced doubt that the expansion will pay for itself once the state has to pay for part of it: 5 percent in 2017, rising to the law's cap of 10 percent in 2020.

Clinton, a Democrat, said Republican-run states that had used Republican consultants for their Medicaid studies had found that expansion would pay for itself. Laughing, Clinton said the reports weren't well read because they didn't say what the Republicans had wanted them to say, and the consultants replied that "Yes, they were Republicans, but they also believed in arithmetic."

Trevor Fetter, president and CEO of Texas-based Tenet Healthcare, said that as a provider and member of the Texas business community, "It is a big mistake not to expand Medicaid, not to offer this access." He said many in Texas are "trapped" because the state hasn't expanded Medicaid and they make too much to qualify for it and too little to qualify for the federal subsidies for private insurance.

Meredith Rosenthal, professor of health economics and policy at the Harvard School of Public Health, said, "The most compelling argument for those who resist coverage expansion is an economic one," especially because health care is the largest employer in most communities.

The most talkative panelist was Bruce Broussard, president and CEO of Louisville-based insurer Humana Inc. He said expansion "is a good thing" because it allows access to insurance for people as they move or change jobs, decreases the burden of stress on the under-served and will save businesses money because it costs less to take care of healthy people than sick ones.

In discussing the health-care industry's new focus on patient outcomes, Broussard said outcomes will improve as the U.S. shifts from model built around treating episodic conditions to one that treats chronic conditions.

"It's not about the insurance, it's not about the treatment. It's how do we help people stay healthy no matter where they are in their journey," he said to a round of applause.

Experts say rising levels of chronic disease among baby boomers are a major concern. Clinton asked the panel to name the one thing we need to do that isn't being done now to deal with chronic conditions like diabetes.

Broussard said yearly health assessments "would help people make better health decisions." It is important to tell them what their current health is, relative to where it should be. "When people know their numbers, they make more effective decisions," he said.

Rosenthal said, to a room full of applause, "The biggest thing you could do to prevent diabetes in this country is to look at the agriculture policy." Clinton suggested working directly with all of the stakeholders involved in food production and distribution to create change.

The discussion shifted to the role of transparency and interoperability (different systems working together) in health-care finance as a way to improve health outcomes and decrease costs. Michael Peterson, president of the Peter G. Peterson Foundation, said "We are spending 3 trillion dollars a year without any regard to cost or quality."

Broussard said, "I think interoperability will bring transparency, better data analytics and will empower the consumer."

Beshear said Kentucky has already shifted to a pay-for-performance model by switching Medicaid to managed care, in which insurance companies are paid a flat fee per person as an incentive to limit costs.

"We want people to learn how to take care of themselves and to take responsibility for themselves and stay well," he said. "And if we are successful in doing that, we will bend this cost curve."

As for the reform law, Beshear said that while there is still work to do, "We've got to get past this talk of we're going to throw the whole baby out with the bath water" and make it work.

"The ACA is not going anywhere as far as I'm concerned," he said. "It is going to stay and we are going to implement it and we are going to better the lives of our people."

Are nutrition rules for schools and day-care centers too much regulation, or steps in the right direction, toward better health?

Commentary by Melissa Patrick
Kentucky Health News

The Paducah Sun's editorial on Jan. 20 said the Obama administration has overstepped its bounds by expecting child day-care centers to follow stricter nutrition standards. The newspaper also called for relaxation of the requirements of the 2010 Healthy, Hunger-Free Kids Act, as Republicans hope to to when the law comes up for reauthorization this year. (The editorial is behind a paywall.)

The editorial does what any good editorial should do: stirs up a bit of controversy and makes you think a bit harder. Do you agree with the editorial's views that these nutrition standards impose "too much regulation," or are you thinking,"We have to try something to combat obesity and the best place to change health behaviors is with children?"

What most everyone probably agrees on is that we have a problem: too many fat, unhealthy children who will become fat, unhealthy adults, perpetuating a chronic health epidemic that is sweeping across Kentucky and the nation. "The heaviest children are getting even heavier" and "overweight or obese preschoolers are five times more likely than normal-weight children to be overweight or obese as adults," says the Obesity Society website.

Nationwide, one in five children is overweight and more than one in three adults are obese, according to the Centers for Disease Control and Prevention. Kentucky leads the nation in both adult and child obesity, ranking fifth for adult obesity; first for high-school obesity; eighth in obesity of 10- to 17-year-olds; and sixth in obesity among 2- to 4-year-olds in low-income families, according to the States of Obesity report. These statistics don't even include the number of adults or children who are simply "overweight."

The World Health Organization says chronic disease is the leading killer in our world, with two-thirds of all deaths worldwide a result of conditions such as heart disease, cancer, diabetes and respiratory infections in 2012. Kentucky, once again, leads the way in each of these conditions.

Kentucky ranks eighth in the nation for heart-disease deaths; 17th for diabetes; fifth for high blood pressure; and first for smoking, lung cancer and lung cancer deaths.

The editorial says, "The food police are on the march again." Is it too much regulation, or could these "police" represent a concerned government trying to solve a major health-crisis that is only getting worse?

In making the day-care proposal, Agricuture Undersecretary Kevin Concannon wrote, "Providing children access to nutritious food early in life helps instill healthy habits that can serve as a foundation for a lifetime of healthy choices.”

The Department of Agriculture proposal calls for new nutritional guidelines for child and adult day-care programs, after-school programs and people who live in shelters that are part of USDA's Child and Adult Day Care Food Programs.

The guidelines would follow the Healthy, Hunger-Free Kids Act guidelines followed in schools, which require more fruits and vegetables, more whole grains, less fat and sugar, and limit calories according to age.

What seems to aggravate Sun Editor Jim Paxton the most are the proposal's suggestions to ban on-site frying and the qualification of tofu, a soybean curd, as a meat alternative. It said that while the program was originally set up to combat malnutrition, it now has decided "a little starvation is not a bad thing; ergo, tofu instead of fried chicken."

The editorial suggests that day-care facilities could no longer have french fries or fried chicken, but it fails to mention that both items could be offered with a more healthful preparation in the oven. And tofu, a cheap, low-fat protein source, would be added as an option, not a requirement.

The recommended way to lose weight is to decrease calories, eat healthful foods, and increase activity. The nutritional requirements suggested in this program include two of these efforts.

The editorial reminds us that some students are "turning up their noses at the new offerings," that "student participation in school meal programs is down," and says pre-school programs are concerned that the same thing will happen to them.

However, schools say they are tweaking their menus to find healthful foods that the kids like and purchase newer whole grain products that don't taste any different than the processed grains the kids are used to.

So, is it too much regulation or a new way to improve the health of children that will take time and tweaks to perfect?

The editorial says the Sun supports nutrition education and healthy choices on the school menu, but that the "primary responsibility for combating childhood obesity lies with parents and the rules they set in the home."

But what the editor fails to consider is that one out of three adults, many whom are parents, are obese, and are the ones responsible for teaching these lessons.

Too much regulation or a step in the right direction? You decide.

Health issues facing Appalachia, focus of CDC director's tour, could be a forewarning of where the country is heading

The chronic health issues of Appalachia, the focus of a recent tour by the head of the federal Centers for Disease Control and Prevention, are really no different than the chronic health issues the entire country faces; they are simply more concentrated in one area, Laura Ungar writes for The Courier-Journal and USA Today.

"It's about proportion and intensity rather than something unique that's happening there," Jesse Roman, chairman of the Department of Medicine at the University of Louisville, told Ungar. "The problem is larger and more visible there, but they're not alone."

Ungar describes the health challenges of one couple in Appalachia, 48-year-old Alisha Blankenbeckler and her husband, Tony. Alisha has diabetes, bowel and bladder problems and is on oxygen. Her condition makes it hard to take care of her husband who has heart disease and hip problems since being struck by lightening in 2010. He takes 11 pills a day; she takes 30.

"Dying is something I think about every day," Alisha told Ungar.

This story, Ungar reports, is common in the Appalachian region, which is considered one of the nation's unhealthiest regions.

Heart disease prevalence is 84 percent higher in the region than the national average, diabetes is 47 percent higher, and lung cancer kills at a rate 83 percent higher. The region has the highest-in-the-nation smoking rates, with nearly a third of adults smoking cigarettes, and Kentucky has the highest number of deaths caused by cancer.

"We're in the stroke belt, the diabetes belt, the coronary valley. We get all those labels," Fran Feltner, director of the University of Kentucky Center of Excellence in Rural Health at Hazard, told Ungar. "We're in a sad state here."

Some experts say Appalachia "may be a harbinger of where the country is headed if we don't rein in epidemics like obesity," Ungar writes. Obesity spawns "diabetes, heart disease and many cancers and spanning all socioeconomic levels/."

CDC Director Tom Frieden recently toured Eastern Kentucky to "find out more about the underlying causes of the region's ills and how to treat them -- and in the process gain traction against the rising burden of chronic disease that ails the nation," Ungar reports.

"The Appalachian region is just like the rest of the U.S. — only more," Frieden said on the tour. "We want to help an entire community and a whole nation."

Ungar writes, "Appalachia, like some blighted urban areas and Native American reservations, mixes several ingredients of poor health: doctor shortages and access-to-care problems; stressful, unhealthy lifestyles; low education levels; and insidious poverty."

Alisha Blankenbeckler told Ungar that at times she has had to stretch her insulin by taking less than the prescribed amount and once needed to go to the hospital but didn't because she had no insurance or money to pay the bill. She recently got insurance through the state's Medicaid expansion, and her husband is on Medicare, but that doesn't guarantee access to all the care they need because of required Medicare co-payments, medical equipment that is not covered, and gas to get to the doctor. The couple gets disability benefits of $1,427 a month.

Though more than half a million Kentuckians have enrolled in health insurance through the Affordable Care Act, "access to health care is difficult in Appalachia," Roman told Ungar.  "And there seems to be something about culture — a sense of fatalism, that whatever happens, happens."

Ungar writes that Friden and Benjamin Sommers, assistant professor of health policy and economics at the Harvard School of Public Health "say improving the health of Appalachia and like communities will not be easy, because it depends on changing seemingly intractable socioeconomic disparities and personal health habits."

Frieden said that while outreach and health education is crucial, he will "listen and take cues from local communities about how best to attack their particular health problems. If he finds an effective program, he said, he will replicate it and fit it to other communities."

Saint Joseph Hospital Foundation and Verizon team up to help certain patients with chronic diseases monitor their health

Verizon and the Saint Joseph Hospital Foundation have teamed up to help select patients who have a chronic disease manage their condition from home, according to a press release from KentuckyOne Health, St. Joseph's parent organization.

The program will help patients age 50 and older monitor and manage their health with new technologies after being discharged from Saint Joseph Hospital and Saint Joseph East in Lexington, and Saint Joseph Mount Sterling.  It will also be available to some patients who have certain health issues by referral from their primary care provider or patients can enroll in the program if they have been treated for congestive heart failure, acute myocardial infarction, chronic obstructive pulmonary disease (COPD), coronary artery bypass graft surgery, diabetes, hypertension, hyperlipidemia as well as some other concerns.

The goal is to enroll 300 patients in the first year of the program, according to the release.

Funding to create this program came from a $125,000 grant from the Verizon Foundation and in-kind donations of technologies, which includes 4G LTE powered smartphones and tablets, from Verizon Wireless. Grant funds will purchase biometric devices to better self-manage the participants conditions and share that information with their team of health care providers. 

Patients will use the smartphones and tablets for six months to access pre-loaded health apps, such as Glucose Buddy and Fooducate, according to the release. The grant will also provide items such as digital weight scales, blood pressure monitors, FitBit activity trackers, CalorieKing Calorie, Fat and Carbohydrate Counter book and digital food scales/nutritional calculators.  Some will get glucose test strips. Individualized health-coaching will also be available.

"Verizon is also supplying all of the technology protective gear for the devices, the data plans to allow that technology to work, plus funding for a part-time dietitian and research assistant for the program," the release says.