Nation's Top Public Health Issues Reflect AAFP Initiatives

Some of the AAFP's health of the public initiatives got a boost in 2010 as the federal government looked at health care reform. Obesity and tobacco initiatives were particularly hot topics, and many new programs and regulations contain some of the same elements found in the AAFP's Americans in Motion-Healthy Interventions, or AIM-HI; Tar Wars; and Ask and Act programs.

In February, as part of the focus on health care reform, first lady Michelle Obama announced the launch of a campaign to fight childhood obesity. The Let's Move campaign is designed to support parents, provide healthier foods in schools, help kids be more physically active, and make healthy food affordable and available to "get us to our goal of solving childhood obesity in a generation," said Obama.

(Then) AAFP President Lori Heim, M.D., of Vass, N.C., pledged the AAFP's support for the Let's Move campaign. Heim noted that the AAFP would be undertaking a number of new activities related to the campaign, including providing family physicians with Web-based tools and services to help them aid patients and families struggling with childhood obesity.

Those resources are sorely needed, according to two reports issued by the Strategies to Overcome and Prevent, or STOP, Obesity Alliance. According to research conducted by Harris Interactive, even if primary care physicians had more time to discuss weight with their patients, many would "still be missing needed information about weight-loss tools and existing programs," said Richard Carmona, M.D., M.P.H., a former U.S. surgeon general and the health and wellness chair of the STOP Obesity Alliance.

However, family physicians in the AAFP's AIM-HI program already have those resources. The AIM-HI program is designed to

In May, the AAFP National Research Network released preliminary data from a study on the AIM-HI program. Results indicate that the program helps patients increase physical activity, make healthier choices, lose weight and maintain lifestyle changes. Researchers said they found a 10 percent increase in the number of patients who exercised at least 20 minutes a day three times a week and a nearly 42 percent increase in the number of patients who ate at least a half serving more of healthy foods each week from baseline to 10 months into the study.

AIM-HI provides a framework to quickly address how a patient's excess weight affects his or her health and then provides a plan to make improvements, said program participant Vance Blackburn, M.D., of Birmingham, Ala. "It's helped me develop an easier way to talk to patients about it."

Tobacco issues also were a flash point in 2010 as the FDA sought to define its power to regulate tobacco products, which Congress granted it in 2009. The agency took on the manufacturing industry for e-cigarettes in January after it blocked electronic cigarettes from entering the country.

In the meantime, the AAFP was ramping up its antismoking programs and announced the launch of a new pilot program that would train "office champions" to implement system changes that encourage the integration of tobacco cessation activities in daily office routines.

The program educates the office champions via an online training module, live teleconferences and a practice manual. "I can say from experience that changing the system in which you practice can help improve care on a consistent basis," said Saria Carter Saccocio, M.D., of Rome, Ga. She is a member of the Academy's Tobacco Cessation Advisory Committee.

At the same time, the AAFP was one of three dozen organizations calling on CMS to allow states to obtain federal Medicaid matching funds to cover the cost of tobacco cessation services provided by quitlines.

The letter noted that tobacco-related illnesses account for 10 percent to 15 percent of all Medicaid expenditures, and every state and two U.S. territories have tobacco cessation quitlines. However, some states do not have CMS approval for Medicaid coverage, which is required to receive federal matching funds to pay for quitline programs.

"Ensuring Medicaid coverage of tobacco cessation quitlines will improve access to these services, help more tobacco users to quit, help protect children and adults from secondhand smoke, and reduce the disease and premature death attributable to tobacco use," the letter said.

By November, the FDA was focused on rolling out new requirements for graphic warnings on cigarette packages and in tobacco ads. "Every pack will become a mini-billboard that tells the truth about smoking," said FDA Commissioner Margaret Hamburg, M.D., referring to the grim photos the FDA plans to require on the front of every pack of cigarettes.

The anti-tobacco message gained even more traction in December, when U.S. Surgeon General Regina Benjamin, M.D., M.B.A., released a report that stressed that damage from cigarette smoke -- including secondhand smoke -- is immediate.

"The message from this report for Americans is simple, there is no safe level of exposure to tobacco smoke," said HHS Secretary Kathleen Sebelius during a December news conference.

"We have known that smoking causes a lot of problems, disease and cancer," said Benjamin during the news conference. "We had not known how. I believe it's very important that every American know exactly what's happening with their body, particularly people who are trying to stop smoking. They need to know there is a biological reason it's hard to quit so they don't give up."

Benjamin also noted that physicians play a vital role in helping their patients kick the habit. "Patients who have been advised to quite smoking by their doctors have a 66 percent higher rate of success," she said.

2010 also saw some further developments in the controversy surrounding the 2009 release of new breast cancer screening guidelines from the U.S. Preventive Services Task Force, or USPSTF.

The task force revised its recommendations in November 2009, recommending "against routine screening mammography in women aged 40 to 49 years." That created considerable controversy considering that it was an abrupt departure from previous recommendations, and the USPSTF had to clarify that the recommendation was against routine screening mammograms. The decision to have a mammogram for women in their 40s should be based on a discussion between a women and her doctor, said family physician Ned Calonge, M.D., M.P.H., chairman of the USPSTF.

The AAFP stood behind the USPSTF recommendations and the evidence-based process used to develop them, and, in January, the Academy released its own updated breast cancer screening recommendations that stressed the communication between family physicians and their patients.

The AAFP's updated recommendations advise family physicians to discuss with all women the potential benefits and harms of screening tests and develop a plan for early detection that minimizes potential harms. These discussions should include information about the evidence regarding each type of screening test, the risk of breast cancer and individual patient preferences.

"What we feel is important, especially between the ages of 40 and 50, is that there should be a conversation between the patient and her physician," Heim told AAFP News Now. "It's not about not doing something. The focus is about doing something, and the first thing to do is have a discussion. That discussion could drive further action."

Concerns about the revised USPSTF breast cancer screening guidelines were still evident, however, during the AMA House of Delegates' annual meeting. Delegates adopted a measure directing the AMA to "encourage government panels and task forces dealing with specific disease entities to have representation by physicians with expertise in those diseases."

2010 also seemed to be the year that concerns about the safety of medications erupted based on a number of events.

The year started with a massive recall of OTC medications manufactured by McNeil Consumer Healthcare. McNeil recalled more than 500 lots of OTC products, including Benadryl, Rolaids, variations of Motrin and Children's Motrin, and numerous variations of Tylenol and Children's Tylenol, because of chemical contamination.

The manufacturer said the products contained trace amounts of a chemical called 2,4,6-tribromoanisole, a degradant of 2,4,6-tribromophenol, which is a pesticide and flame retardant used to treat wooden pallets. The company expanded the recall in May, this time recalling children's and infants' liquid pain relief products because of manufacturing deficiencies that could affect quality, purity or potency.

The ongoing problems prompted the FDA to launch a company-wide investigation of McNeil's drug manufacturing practices "to determine whether similar problems exist throughout the company and what additional steps the agency must take to ensure that these problems do not recur." McNeil subsequently closed its Fort Washington, Pa., manufacturing facility where the recalled products were made and said it would not reopen the plant without notifying the FDA.

But OTC products were not the only focus of the FDA's scrutiny. In July, two committees that advise the FDA on medications voted to recommend that the agency remove rosiglitazone, which is marketed as Avandia, from the market. At the time, committee members noted that the diabetes drug, which is manufactured by GlaxoSmithKline, had been linked to an increased risk for cardiovascular events.

The FDA decided to allow continued marketing of the medication on the condition that the package label be revised to include additional warnings and that additional restrictions be put in place. Shortly thereafter, the FDA announced the new restrictions on the medication, which would require additional steps for physicians who continue to prescribe it.

The FDA said it would restrict use of the drug to patients with type 2 diabetes who cannot control their diabetes on other medications. "The drug will be available to patients not already taking it only if they are unable to achieve glycemic control on other medications," said the FDA's Hamburg at a September news conference.

FDA Principal Deputy Commissioner Joshua Sharfstein, M.D., added that patients already using rosiglitazone could continue to use the medication if they appeared to be benefiting from it and they acknowledged that they understood the risks.