Large Harvard Cohort Studies Show Eating Nuts Reduces All Cause and Cause Specific Mortality Dose Response Demonstrated Short Clever Video at NEJM Explains The Results A large epidemiologic study by researchers at Harvard published in the New England Journal of Medicine this month has confirmed previously published findings about the health benefits of eating nuts in combating chronic health diseases and in reducing deaths from all causes, especially when consumed several
times a week. In the Nurses Study and the Health Professionals Follow Up Study, investigators took frequent selfreported histories of nut consumption from over 76,000 women and 42,000 -Nuts continued on pg 2
Florida Epidemiologist Goes Public With Her Humor To Start A T-Shirt Company How’s this for an epidemiologist’s marriage vow? I promise I will always fail to reject you! Tammie Johnson an assistant professor at the University of North Florida with a sense of humor has decided to go public and is now marketing her brand of humor online emblazoned on t-shirts. How does it happen that one goes from being a relatively new faculty
member in epidemiology and biostatistics to becoming a new business entrepreneur? Johnson told the Monitor she started using humor to polish her teaching and presentation styles. “The material in epidemiology and biostatistics can be dry,” she said. Because of her sense of humor, unusual thoughts would pop into her head while teaching. She started using these ideas and joking around in a -Humor continues on page 2
In This Issue: -3Book Corner Interview with Michael Bracken -5New Humor Contest -7On the Light Side Revisited -10Social & Economic Status May Be a Death Sentence -12Jobs
Check our online Job Bank for more offerings http://tinyurl.com/cy6k3fu
November 2013 Volume Thirty Four Number Eleven
-Nuts continued from pg 1 "A striking dose response was demonstrated... “
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men and followed them up for an equivalent of over 3 million life years. A striking dose response was demonstrated when comparing persons who ate nuts with those who did not after controlling for potential confounding factors. The benefits in death reduction ranged from a low of 7% for those who consumed nuts less than once a week to 20% for those who consumed nuts 7 or more times per week. Nuts were also shown to be beneficial for reducing the risk of death against cancer, heart disease, and respiratory disease. Results were similar for peanuts and tree nuts. According to Ying Bao and colleagues, “We cannot rule out the possibility of confounding by unknown factors…a potential confounding effect would have to be quite large to meaningfully alter the observed associations in this study…it seems unlikely that such strong unmeasured confounding could explain the associations.” They identified the prospective design, large sample, and 30 years of followup with a high follow-up rate and repeated assessments of diet and lifestyle variables as strengths of the study. In a an entertaining video feature called Quick Take on the NEJM website, the NEJM editor seeks to explain the findings of the study and their significance for the average person. Readers of the Epidemiology Monitor can imagine some of the ridicule these findings might engender on late night TV shows and elsewhere because of epidemiology’s reputation for
controversial and sometimes contradictory findings on the risks or benefits of a wide variety of diet and other lifestyle factors. The video is a well-executed example of how scientific findings in epidemiology can be disseminated to both a lay and a professional audience and seeks to address some of the questions listeners may have. For example, this is how the video concludes: “If you include nuts in your regimen of sloth and gluttony, will you live longer than if you left nuts out? These kind of data can’t answer that question, but I would be nuts if I were to think that eating nuts alone would add years to my life.” Watch the video at: http://tinyurl.com/jvtad2s ■ -Humor continues from page 1 graduate biostatistics course to make her teaching more enjoyable. The things she made up were “really funny”, she said, and a close friend who is an accountant with an ongoing interest in business suggested she make t-shirts to capture her slogans and sayings. The result? She has just created an online t-shirt sales company at EpiStuff.com . At this site, a half-dozen different slogans or graphs are available for $22 each on shirts of different colors and sizes. ■
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Book Corner
An Interview With Michael Bracken, Yale University Epidemiologist and Author of Risk, Chance, and Causation A 19th century cartoon used as the image for the book cover of Risk, Chance, and Causation by Yale University’s Michael Bracken piqued our curiosity more than usual when we learn about new books. It shows the picture of a man, presumably Benjamin Perkins, the American who discovered a new treatment, applying electrophysical force with metal rods to a male patient’s face. The cartoon ridicules the claim graphically but also with these words: Grand exhibition in Leicester Square. Just arrived from America the Rod of Aesculapios. Perkinism in all its glory being a certain Cure for all Disorders. Red Noses, Gouty Toes, Windy Bowels, Broken Legs, Hump Backs. Just discover the grand Secret of the Philosophers Stone with the True Way of turning all metals into Gold. Pro Bono Publico
The Epidemiology Monitor questioned Mike Bracken about his new book, and here is what he had to say. Readers interested in reviewing the book for The Epidemiology Monitor should contact us at epimon@aol.com We will select a qualified reviewer who will get a free copy of the book in exchange for the review. Epi Monitor: The book has a humorous image on the cover for an epidemiology book. What is that image and why was it selected? Bracken: James Gilray is a famous satirical cartoonist working at the turn of the 18th century and in this
image he comments on an episode that relates to two themes in the book. A Yale (sorry to say) doctor Benjamin Perkins went to London to promote his metallic tractors that appeared to cure everything from gout to syphilis by using “electrophysical forces”.
“...providing the first known example of masking in a clinical trial..."
This is not unlike many of the numerous quack “treatments and cures” to which the public today falls victim. Our villain, Ben, is exposed by a Dr. John Haygarth who paints wooden tractors to look like metal and achieves the same successful cures. Thus, providing the first known example of masking in a clinical trial, demonstrating the placebo effect, and alluding to another theme in the book - how sources of bias are recognized and avoided. Epi Monitor: How did the idea for the book come about? Bracken: I hoped to write a book that explored for the public the work of epidemiologists. The public faces a tsunami of misinformation about the value of therapies and the risks of environmental and life-style exposures. At the same time, they are ill prepared to properly evaluate this information.
“I hoped to write a book that explored for the public the work of epidemiologists.”
Because epidemiology is not taught in schools (I think it should be but that’s a topic for another day) the public is never formally educated in -Bracken continues on page 4
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-Bracken continued from page 3 how to evaluate claims of therapeutic effectiveness and safety.
“Indeed how we conceive of causation is poorly understood.”
Risk Chance and Causation is an effort to make some of these concepts available to the general public and to hopefully help them navigate through this wave of hyperbole that constantly washes over them. Epi Monitor: How would you describe the book in just a few sentences? Bracken: We all take risks every day without giving much thought to the pros and cons, or weighing alternatives. We are exposed to events that may occur by chance although we attribute some cause to them. And we are exposed to other events that are not random although we think they are because we do not know a cause.
“...people will have a better chance of arming themselves against the onslaught of information they face.”
Indeed how we conceive of causation is poorly understood. Nowhere are these complexities more salient than in the context of health and disease and these are the issues the book is intended to explore Epi Monitor: What were your main aim(s) in writing the book? Bracken: We epidemiologists talk about risk and chance and causation continuously in our daily work, often without spending too much time analyzing them in depth. When we do give them serious thought, we realize what difficult concepts they are. How much more difficult it must be for the public to come to grips with these ideas.
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. introduce these ideas to the public in what I hope is an understandable way, and particularly in the context of how scientists investigate the origins and treatment of disease, which is the book’s subtitle. If the public understands how epidemiologists consider evidence, people will have a better chance of arming themselves against the onslaught of information they face. They can filter out information that is still hypothetical, not replicated or based on biased and unreliable studies from that which they should know about to be able to better protect their health. Epi Monitor: What is the main audience you are trying to communicate with? Bracken: The hardest part of writing the book was pitching the material to a non-specialist audience. Not being too technical while not dumbing it down and over-simplifying. After a lifetime writing papers for scientific journals it took some time to find the style I was hoping for and I’m not sure I was completely successful. Epi Monitor: How would you contrast your book with existing epidemiology textbooks? Bracken: Risk Chance and Causation is not a textbook. Epidemiology is well endowed with many superb texts and it was certainly not my goal to add another. You likely wouldn’t find a chapter entitled “Celebrity Trumps Science” in a standard text, but in my book it shows examples of -Bracken continues on page 6
My main goal for the book was to
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New Humor Contest Create The Funniest Marriage Vow For Epidemiologists and Win $500 Does your mind work in unexpected or humorous ways? Great! You are a candidate to compete in creating the funniest marriage vow for an epidemiologist in our humorous “marriage vow contest”. We were inspired to create the contest by the University of North Florida’s Tammie Johnson, a faculty member with a sense of humor she uses in her teaching. Johnson is recently married and in thinking of the vows she would exchange with her new husband, her sense of humor coined this vow: “I promise I will always fail to reject you.” Johnson is now marketing her humor with a new online T-shirt company. In collaboration with Johnson, the Epi Monitor will offer a $500 prize for the best slogan submitted to
epimon@aol.com before March 1, 2014. The goal is to coin a vow as funny or funnier than Johnson’s. And we confess our editor has a weakness for double entendres! The winner of the slogan contest will be picked by a panel of judges including epidemiologists selected by The Epidemiology Monitor. The winning slogan becomes property of The Epidemiology Monitor and will be used by Dr Johnson and her company to produce and sell Tshirts emblazoned with the winning entry.
“I promise I will always fail to reject you.”
Readers may submit as many slogans as possible. In the event that the same slogan/vow is submitted by more than one person, the earliest submission will be the only valid entry for that slogan. ■
Training Courses for Public Health Professionals Cosponsored by Emory University (RSPH) & The Centers for Disease Control & Prevention (CDC) Atlanta, GA / Directed by Philip S. Brachman, M.D. Environmental Microbiology: Control of Foodborne & Waterborne Diseases / January 6-11, 2014 This is a course on the surveillance of foodborne and waterborne diseases designed for public health practitioners and other students interested in the safety of food and water. The course describes how information from surveillance is used to improve public health policy and practice in ways that contribute to the safety of our food and water. We focus on the micro organisms and chemical agents responsible for food and water-transmitted diseases. We study the diseases they cause, the pathogenesis, clinical manifestations, reservoirs, modes of transmission, and epidemiology. The transport, survival, and fate of pathogens in the environment, the concept of indicator organisms as surrogates for pathogens, and the removal and inactivation of pathogens and indicators by water and wastewater treatment processes will be analyzed.
Public Health Surveillance / May 19-23, 2014 This course is a comprehensive study on public health surveillance and includes discussions of the history and planning considerations, data sources and collection, analysis and interpretation, communication, evaluation, ethical and legal issues, state and local issues, and issues in developing countries as concerns public health surveillance.
Epidemiology in Action / June 9-20, 2014 This basic two-week course in epidemiology is directed at public health professionals and includes discussions of applied epidemiology and biostatistics, public health surveillance, field investigations, hands-on computer training using Epi-Info, and selected prevalent diseases. Epidemiologic case studies are worked on in the classroom.
Contact Person: Pia Valeriano, MBA Phone: 404.727.3485 / Fax 404.727.4590 / Email: pvaleri@emory.edu / Web: http://web1.sph.emory.edu/epicourses/
-Bracken continued from page 4
“...even being an aging skeptic didn't prepare me for some of the modern 'snake oil' sales personalities lurking on the internet...” epidemiology.
the misinformation the public is exposed to and then discusses the underlying evidence supporting (or, most likely, not supporting) the claim. It was one of the most enjoyable chapters to research and write because even being an aging skeptic didn’t prepare me for some of the modern “snake oil” sales personalities lurking on the internet and, surprisingly, even in the alumni magazines of some of our most prestigious universities. Other chapters less likely seen in epidemiology texts include an introduction to genetic causation and reflections on the poor predictability to the human condition of much animal research. Epi Monitor: Are there unique aspects to this book other than the cover?
“...I have tried to rehabilitate the enormous achievement of Joseph Goldberger's work on pellagra.”
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Bracken: Because of my own interests and from teaching evidence based medicine and health care the book melds these newer paradigms with more traditional themes in observational and classic epidemiology. I have never accepted that epidemiology should not, for example, include RCTs or that clinical epidemiology was somehow a distinct discipline. Epidemiologists have always been concerned about biased papers but evidence-based medicine (EBM) has highlighted the particular problems of bias in first published results (the winner’s curse) and even bias in entire bodies of literature.
Other examples of methodology concepts arising from the EBM paradigm include protocol registration, outcome reporting bias, citation bias and the science of systematic reviewing and metaanalysis, which have all been to differing degrees adopted by epidemiologists. These themes are all discussed in the book with reference to why the public should be cautious of many of the health claims and risks they read about. Finally, without taking anything away from the remarkable work of everybody’s hero, John Snow, I have tried to rehabilitate the enormous achievement of Joseph Goldberger’s work on pellagra. Unlike Snow, he includes experimental as well as observational methods. Goldberger is truly (with apologies to Gilbert and Sullivan) the very model of a modern major epidemiologist. Epi Monitor: How long did it take you to write the book? Bracken: I was writing daily for about 12 weeks to draft 80% of it while on sabbatical at my home outside Oxford, which may explain the large number of references to British epidemiology. But in other respects Risk Chance and Causation gestated over 45 years. I have drawn on many examples from my own career which, as for most epidemiologists, has been rewarded by a rich variety of personal experiences and acquaintance with fascinating -Bracken continues on page 9
On The Light Side Revisited “If it’s not fun, it’s not epidemiology!” One of our favorite slogans attributed to Darwin Labarthe in the Mentorship Guide of the American Heart Association
The discovery of the humorous slogans being used by a University of North Florida Assistant Professor Tammie Johnson and her launch of a new online T-shirt company (see article this issue) reminded us of “On The Light Side”, a regular column in The Epidemiology Monitor several years ago. Also in connection with that column, the Monitor ran several humor contests which were much enjoyed by our readers. We have decided to launch a new contest inspired by a double entendre marriage vow (see related article in this issue). Among the earlier contests were the following:
1. A Double Entendre Slogan Contest The winning slogan was: Epidemiologists prefer close associations Submitted by Andy Penziner The first runner up slogan was: Excite an epidemiologist—cause an effect Submitted by Ginger Stefanchik The second runner up was: If you’ve got the time and the place, I’m the person Submitted by Barbara McArthur
We initiated the contest by saying— Since birds come in flocks and fish in schools, what collective term best describes epidemiologists? Some of the most promising suggestions were: An outbreak of epidemiologists A case of epidemiologists A cluster of epidemiologists A doll of epidemiologists
“Epidemiologists prefer close associations."
There were several others. An interesting note we received at the time from Donald Peterson read as follows: “Collective nouns have been favorites of mine for some time. I’ve enjoyed streams of urologists, rashes of dermatologists, pots of pediatricians, etc. If epidemiology is what epidemiologists do, then it follows that a ‘do’ of epidemiologists might be an appropriate collective noun. This has an active, positive, and constructive connotation…Besides ‘do’ is shorter than ‘doll’ “
"Old Epidemiologists Never Die... ...They Just Don't Count Any More.”
3. A Complete The Sentence Contest Old epidemiologists never die… A biostatistician Carleen Thompson won this contest with her slogan: Old epidemiologists Never Die… They just don’t count any more. We received more than 200 sentence completions from 50 of our readers.
2. A Collective Term Contest -Light Side continues on page 8
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“Epidemiologists in Health Care Reform--A Low Risk Investment”
-Light Side continued from page 7
6. A Bogus Headlines Contest
4. The Tip of the Iceberg Metaphor Contest
For this contest, we invited readers to invent headlines with double entendres involving epidemiology and health. To get the creative juices flowing, we primed the pump with the following bogus headline:
Michel Thuriaux working in Papua New Guinea wrote to say that the “tip of the iceberg” metaphor did not fit well with his work in the tropics. He asked if we could ask our readers to suggest an equivalent metaphor for “iceberg” less obviously limited to polar or subpolar climes. We received many inventive metaphor suggestions. The winner was Daniel Fife for his entry—Front of the parade. Other clever suggestions— The fin of the shark, The ears of the hippopotamus, Tail of the elephant, Hump of the camel, First raindrops of the rainstorm, and many others.
5. A Health Care Reform Slogan Contest
“New Study of Obesity Looks For Larger Test Group”
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New Study of Obesity Looks for Larger Test Group The winning headline in our contest submitted by Ken Satin was: Electric Field Study Results Shocking with a subheadline reading Experts Methodology Not Well Grounded
7. The Best Epidemiology “To Do” List We kickstarted this contest with a sample to do list for a race car driver. It went like this: 1. Go fast. 2. Turn left.
Coming at the time of the Clinton efforts to reform health care and with everyone lobbying for their favorite provisions, we asked readers to devise a catchy slogan that could compete with the Harry and Louise commercial by capturing the role of epidemiology and its importance in health care reform. We received more than 125 slogans.
We wondered what a succinct to do list for an epidemiologist would be. The winning entry came from Carol McPherson. Her list was equally elegant and apropos
The winning slogan was Epidemiology in Health Care Reforn—A Low Risk Investment The winner was Del Aguila.
A close runner up was submitted by R. DiGiacomo.
1. Follow people around until they die. 2. Count them.
1. Find cause. 2. Make change. ■
-Bracken continues from page 6 characters, many of whom have become dear friends. I hope this more personal approach makes the subject matter more accessible for the intended non-specialist reader.
claims about what makes humans healthy or sick. This book should be required reading for all in the media who try to explain health studies to the public."—Nigel Paneth, University Distinguished Professor, Michigan State University
Reviews To Date Here is what reviewers have said about the book so far as seen from the book jacket. “Risk, Chance, and Causation is remarkable for a text covering such technical and scientific subject matter…Bracken provides his audience with an engaging, entertaining and educational read.”— Audrey F. Saftlas, University of Iowa
“The book is very enjoyable to read, and the author has successfully diversified the cold scientific topics with anecdotal material and popular quotes.”—John P. A. Ioannidis, Stanford University "This book is a great read for almost anyone, from the interested lay reader to the experienced epidemiologist. We are quickly drawn into to the foundation of epidemiologic science and thinking by way of stories, cautionary tales and numerous examples, from both history and current events. Whether you are a practitioner, teacher, student, or you just happen to pick up the book, you will be certain to find Bracken’s stories compelling and even eye-opening."— Kay Dickersin, Johns Hopkins Bloomberg School of Public Health "Using a great range of examples, Michael Bracken provides a masterful guide to identifying the many false
"This book is a credit to epidemiology and an exciting and joyful read for lay and learned readers alike.”—Geir W. Jacobsen, Norwegian University of Science and Technology The book is available on Amazon: http://tinyurl.com/m37uzw4 ■
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“This book is a credit to epidemiology...”
Social And Economic Status May Be A Death Sentence In America, Says Congressional Hearing
"...25% of all deaths in Virginia would be averted if everyone had the death rate of Virginia's five most affluent areas"
“The lower people’s income, the earlier they die and the sicker they live,” said Steven Woolf, Director of the Center on Society and Health at the Virginia Commonwealth University in testimony before the a Senate committee earlier this month. The hearing was called by the US Senate Committee on Health, Education, Labor, and Pensions and its Subcommittee on Primary Health and Aging. The hearing was entitled “Dying Young: Why Social and Economic Status May Be A Death Sentence in America.” Key Points
"Cutting a health program to save money may save nothing... “
Among the key points made by Woolf are that economic policy is not just economic policy—it’s health policy. Second, Woolf noted that relieving economic hardship for Americans is a smart way for Congress to control medical spending. To illustrate his point, Woolf reported that 25% of all deaths in Virginia would be averted if everyone had the death rate of Virginia’s five most affluent areas. Given that possibility said Woolf, “no form of health care reform, and no treatments by doctors and hospitals, can rival that kind of effect.” In a final takeaway message for Congress, Woolf stated “…health is affected not only by what’s in your bank account but also, perhaps most importantly, by policies that put people on the road to economic success, such as helping our young people get a good education.”
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The hearing was called in part to provide evidence for not slashing spending in future budget negotiations for education reform, job training, urban renewal, and other safety net programs. In closing, Woolf emphasized that “Cutting a program to save money may save nothing if it makes people sicker and thereby drives up the costs of health care.” Harvard Epidemiologist Also testifying at the hearing was Harvard University social epidemiologist Lisa Berkman. She discussed life expectancy in the United States and reported on the findings from a recent National Academy of Science panel which found that the US ranked at the bottom of 21 developed countries. Of even greater concern, said Berkman, is the gap between the risk of death for those at the bottom versus those at the top in the US. She reported on increasing mortality gaps over the years and said “the fact that the size of the risks varies so much suggests that such large inequalities are not inevitable or innate, and gives hope that there are ways to reduce the burden of illness for our most vulnerable citizens.” Cause of Health A third speaker at the hearing was the University of Wisconsin’s David Kendig. He reminded the congressmen that “health is -Death continues on page 11
-Death continued from page 10
and how much they could improve.
produced by many factors including medical care and health behaviors and, importantly, components of the social and physical environment in which we live in like income, education, social support, and the structure of our neighborhoods. The bottom line is that we will not improve our poor performance unless we balance our financial and policy investments across this whole portfolio of factors.
They found that if each state had the highest level of all the determinants that any state had already achieved, then even the healthiest state New Hampshire could improve mortality by 24% and the least healthy West Virginia by 46% by working on reducing smoking rates, increasing insurance, increasing high school and college graduation rates, increasing median family income, and increasing employment.
"New Hampshire could improve mortality by 24% and the least healthy West Virginia by 465..."
How Healthy We Could Be Dr Kendig is one of the colleagues who helped create the County Health Rankings (www.countyhealthranking.org) and he discussed modeling state mortality rates
Readers interested in learning more about the testimonies and the discussion at the hearing can view the hearing at : http://tinyurl.com/lato73m â–
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Post-doctoral Fellowship in Cancer Care Quality The University of North Carolina at Chapel Hill seeks candidates for a two-year post-doctoral fellowship in our Cancer Care Quality Training Program, an NCIfunded R25T multidisciplinary research training program. Qualified individuals must have completed a Ph.D., M.D., or equivalent degree and must be a U.S. citizen or have permanent resident status. Applications should include a curriculum vita, a twopage personal statement, a five-page fellowship plan, and three letters of recommendation. Applications must be submitted online. Please see the Postdoctoral Research Associate Posting for details: https://unc.peopleadmin.com/postings/34362
2300 Holcomb Bridge Rd, Ste 103-295 Roswell, GA 30076
First Class U.S. Postage PAID Permit #1040 Leesburg, FL 34748
Editor & Publisher Roger H. Bernier, Ph.D., MPH Director of Operations Linda P. Bernier, Ph.D.
Applications are due February 1, 2014. Interviews begin March 1, 2014. Fellowship begins in summer 2014. For more information on the Cancer Care Quality Training Program or the application package, visit: http://www.sph.unc.edu/hpm/ccqtp. The University of North Carolina at Chapel Hill is an Equal Opportunity Employer. Women and minorities are strongly encouraged to apply and self-identify on their application.
University of Pennsylvania Clinician Educator in Epidemiology and Biostatistics The Division of Infectious Diseases in the Department of Medicine at the Perelman School of Medicine at the University of Pennsylvania seeks candidates for an Assistant Professor position in the non-tenure clinician-educator track. Applicants must have an M.D or M.D./Ph.D. degree and have demonstrated excellent qualifications in education, research, and clinical care. Advanced training in epidemiologic research methods is also highly desirable. Board Certified or Board Eligible is requirement for the position. We expect the candidate to have skills in clinical epidemiology and biostatistics and to spend approximately 20% time providing patient care and teaching and 80% time performing patient-oriented research. We anticipate this individual will develop with independent funding, a cutting edge patient oriented research program focused on antimicrobial resistance and healthcare-acquired infections. We seek candidates who embrace and reflect diversity in the broadest sense. The University of Pennsylvania is an equal opportunity, affirmative action employer. Apply for this position online at: http://tinyurl.com/p44ode4
Division of Intramural Population Health Eunice Kennedy Shriver National Institute of Child Health and Human Development On September 6, 2013, the Eunice Kennedy Shriver National Institute of Child Health and Human Development announced the reorganization of the former Division of Epidemiology, Statistics and Prevention Research to what is now known as the Division of Intramural Population Health Research, which comprises three intramural branches Biostatistics and Bioinformatics, Epidemiology, and Health Behavior along with the Office of the Director. Throughout its 50-year history, the Division made substantial contributions to understanding the etiology of diseases that affect reproductive-aged individuals, pregnant women and children, and to the prevention and treatment of such diseases and reduction of risk-related behaviors. Building upon this legacy, the Division of Intramural Population Health Research seeks to understand how best to ensure the health and well being of populations, including some of the most vulnerable subgroups such as fetuses and children. Future etiologic research will be grounded within the conceptual framework of health, allowing an even more complete understanding of factors that influence health. The Division will continue to design and implement innovative behavioral and epidemiological research along with the development of novel methods for answering lingering data gaps affecting the health of the populations we serve. Dr. Germaine M. Buck Louis will continue to serve as the Division’s Director. More information about the Division of Intramural Population Health may be found at: http://tinyurl.com/l2earax