Letters to the Editor

Screening Question for Alcohol Abuse

TO THE EDITOR: I would like to thank the authors of "Problem Drinking and Alcoholism: Diagnosis and Treatment"¹ for highlighting problem drinking and alcoholism. These problems are common: 7 percent of adults in the United States meet criteria for a current diagnosis of alcohol abuse or dependence, and 15 percent have had at least one episode of very heavy drinking in the past 30 days.

This article¹ makes it clear that the problems associated with alcohol abuse are often hidden, yet profoundly damaging to patients, their families, and the community. A study² showed that brief intervention has been shown to reduce emergency department visits and hospital stays significantly, even four years later. This study also found that intervention resulted in a reduction in mortality that was significant at three years, but not at four years, and that there was a substantial reduction in health care and societal costs at all follow-up times.²

If a problem is serious but hidden, and if intervention before the patient has symptoms that are obvious to the physician makes a difference in patient-relevant outcomes, then physicians must screen for it.

Simpler screens are easier to use and more likely to become part of our office, hospital, and emergency department routines. We have developed³ and validated⁴ a single question that is 86 percent sensitive and 86 percent specific in identifying patients with past-month hazardous drinking and/or current alcohol abuse or dependence: "When was the last time you had more than X (five for men, four for women) drinks in one day?" The criterion we used for a "positive screen" was any time in the last three months.

Further work is needed to make brief interventions part of routine family practice but, we believe, this screening question is a very useful first step.

DANIEL C. VINSON, M.D.
M231 Family and Community Medicine
University of Missouri­Columbia
Columbia, MO 65212

REFERENCES

1. Enoch M, Goldman D. Problem drinking and alcoholism: diagnosis and treatment. Am Fam Physician 2002;65:441-8.
2. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26:36-43.
3. Taj N, Devera-Sales A, Vinson DC. Screening for problem drinking: does a single question work?
   J Fam Pract 1998;46:328-35.
4. Williams R, Vinson DC. Validation of a single screening question for problem drinking. J Fam Pract 2001;50:307-12.

Physicians Should Be Educated on the Benefits of Breastfeeding

TO THE EDITOR: This letter is in response to the article published in American Family Physician, "Initial Management of Breastfeeding."¹ This article stresses the importance of breastfeeding and suggests ways "in which family physicians can facilitate the early initiation and long-term success of breastfeeding in their patients."¹ One of the keys noted in this article¹ to improve breastfeeding rates relies on the breastfeeding education of medical professionals.¹ I agree that breastfeeding education for all health care professionals that provide care for new mothers and their infants is an important aspect of encouraging breastfeeding in American families.

Breastfeeding is undoubtedly beneficial to the baby, mother, and society at large. Infants who are breastfed are less likely to develop common childhood illnesses, such as otitis media, lower respiratory tract infections, bacterial meningitis, chronic constipation, allergies and asthma, and infantile eczema.¹ Women who breastfeed also gain health benefits, including reduced postpartum bleeding, earlier return to prepregnant weight, reduction in postmenopausal hip fractures, and decreased risk of developing some types of cancer.² Finally, the cost of formula feeding over breastfeeding is another consideration; a single family could potentially save over $400 during a child's first year of life breastfeeding instead of formula feeding.²

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend exclusive breastfeeding during the first six months of life, and they advise continued breastfeeding during months 6 to 12.^1,2 Despite these strong recommendations, the number of women in the United States who choose to initiate and continue breastfeeding is significantly below the breastfeeding goals set by Healthy People 2010.³ These objectives state that by 2010, 75 percent of new mothers will initiate breastfeeding, 50 percent of these women will breastfeed until their babies are five to six months old, and 25 percent will continue breastfeeding until their babies are one year of age.³ In 1998, only 64 percent of new mothers initiated breastfeeding at birth, and just 29 percent of mothers continued to breastfeed at six months.⁴

Despite the many benefits derived from breast milk compared with formula, many health care professionals are not encouraging mothers to breastfeed. A study⁵ conducted by the AAP found that only 65 percent of pediatricians recommend exclusive breastfeeding for the first month after birth and only 37 percent encourage breastfeeding for the entire first year. Most of these pediatricians stated that they needed more education on breastfeeding and had not attended a presentation on breastfeeding in the previous three years.⁶ This lack of proper breastfeeding education of health care professionals who provide care for infants may be directly contributing to the poor breastfeeding rates in the United States.

It is vital that the training curriculum of physicians and advanced practice nurses include breastfeeding education. This education should include why breastfeeding is optimal for infants and ways for physicians to assist their patients with breastfeeding. Improved education of health care practitioners is vital to attaining the infant nutrition goals set by Healthy People 2010.

SHANNON COURTNEY WONG
108 Red Sunset Place
Carrboro, NC 27510

REFERENCES

1. Sinusas K, Gagliardi A. Initial management of breastfeeding. Am Fam Physician 2001:64:981-8.
2. American Academy of Pediatrics. Breastfeeding and the use of human milk. Work Group on Breastfeeding. Pediatrics 1997;100:1035-9.
3. United States Department of Health and Human Services. Healthy People 2010: Vol II. Objectives for improving health (part B). Retrieved May 2002, from www.health.gov/healthypeople/document/ tableofcontents.htm#Volume2.
4. Philipp BL, Merewood A, O'Brien S. Physicians and breastfeeding promotion in the United States: a call for action. Pediatrics 2001;107:584-7.
5. Schanler RJ, O'Connor KG, Lawrence RA. Pediatricians' practices and attitudes regarding breastfeeding promotion. Pediatrics 1999;103:E35.

Correction

The answer block for the "Clinical Quiz" in the January 1, 2002 issue (page 133) gave an incorrect answer for Question 5, pertaining to the article "Medical Care for Obese Patients: Advice for Health Care Professionals," on page 81. The correct answer to this question is B. The question is reprinted below.

Q5. Which one of the following statements about extremely obese patients is incorrect?

A. They are less likely to receive some types of preventive care.

B. Encouraging self-acceptance is not recommended because it is likely to decrease their motivation to lose weight.

C. They may avoid physician visits because of concerns about their weight.

D. Shortness of breath may be of cardiac or respiratory origin.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.