An article by Wei et al. reported the death of a child associated with an increased risk of incident atrial fibrillation (AF). The association was observed when the cause of death was both cardiovascular and non-cardiovascular diseases.1 These findings provide a valuable addition to the literature; however, some issues were not addressed by the authors.
First, several clinical risk factors are associated with incident AF, including concurrent medication, illegal drugs, obesity, sleep apnea, and hyperthyroidism.2-4 For example, we previously reported that insulin users had a higher risk of incident AF than non-users among the elderly patients’ cohort (1.58 odds ratio (OR); 95% confidence interval (CI): 1.37–1.82). Patients with dipeptidyl peptidase 4 inhibitor (OR 0.65; 95% CI: 0.45–0.93) intake had a lower risk of developing AF when compared with non-users.4 However, while associated evaluations were not presented, Wei et al. did not exclude individuals with these risk factors. Consequently, confounding effects may have contributed to the significant effects causing incident AF, thus, omitting these effects may improve study validation outcomes.
Second, the study initially enrolled 2,740,028 participants in the unexposed group and 64,216 participants in the exposed group at baseline, but missing data between groups (50.1% vs. 79.6%) were examined in further analyses. These missing data potentially affected data credibility in mediation analyses.5 Consequent...
An article by Wei et al. reported the death of a child associated with an increased risk of incident atrial fibrillation (AF). The association was observed when the cause of death was both cardiovascular and non-cardiovascular diseases.1 These findings provide a valuable addition to the literature; however, some issues were not addressed by the authors.
First, several clinical risk factors are associated with incident AF, including concurrent medication, illegal drugs, obesity, sleep apnea, and hyperthyroidism.2-4 For example, we previously reported that insulin users had a higher risk of incident AF than non-users among the elderly patients’ cohort (1.58 odds ratio (OR); 95% confidence interval (CI): 1.37–1.82). Patients with dipeptidyl peptidase 4 inhibitor (OR 0.65; 95% CI: 0.45–0.93) intake had a lower risk of developing AF when compared with non-users.4 However, while associated evaluations were not presented, Wei et al. did not exclude individuals with these risk factors. Consequently, confounding effects may have contributed to the significant effects causing incident AF, thus, omitting these effects may improve study validation outcomes.
Second, the study initially enrolled 2,740,028 participants in the unexposed group and 64,216 participants in the exposed group at baseline, but missing data between groups (50.1% vs. 79.6%) were examined in further analyses. These missing data potentially affected data credibility in mediation analyses.5 Consequently, the results should be interpreted with caution and not influence teaching or clinical practice before the findings are comprehensively replicated. We suggest performing sensitivity tests on parents of live-born children in 1991–2016, in the Danish Medical Birth Register, to improve study validation.
In conclusion, although we raised some concerns with Wei et al.1, we applaud the authors for their commendable work and hope this study will benefit readers, clinicians, and patients. We look forward to further work on the early prevention of incident AF and hope that early preventive approaches will benefit bereaved parents.
Contributors TKL, TYY and GPJ wrote the manuscript. GPJ contributed to the final version of the manuscript. TYY and GPJ supervised the project.
Funding None.
Competing interests None declared.
Patient consent for publication Not applicable.
Provenance and peer review: Not commissioned; internally peer reviewed.
References:
1. Wei D, Janszky I, Li J, et al. Loss of a child and the risk of atrial fibrillation: a Danish population-based prospective cohort study. J Epidemiol Community Health 2023;77:322-7.
2. Dai H, Zhang Q, Much AA, et al. Global, regional, and national prevalence, incidence, mortality, and risk factors for atrial fibrillation, 1990–2017: results from the Global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes 2021;7:574–82.
3. Fauchier L, Clementy N, Babuty D. Statin therapy and atrial fibrillation: systematic review and updated meta-analysis of published randomized controlled trials. Curr Opin Cardiol 2013;28:7-18.
4. Chen HY, Yang FY, Jong GP, et al. Antihyperglycemic drugs use and new-onset atrial fibrillation in elderly patients. Eur J Clin Invest 2017;47:388-93.
5. Tsvetanova A, Sperrin M, Peek N, et al. Missing data was handled inconsistently in UK prediction models: a review of method used. J Clin Epidemiol 2021;140:149-58.
While the data that this article studied and the results that were produced show a change in the mental health status and medication behaviors of Portugal, it does not support the change in mental health status captured in much of the literature around the world. When the COVID-19 virus was declared a pandemic, there was global unrest. It is natural for people to feel fear, anxiety, and panic in the face of an unknown pandemic (Usher, Durkin, & Bhullar, 2020). The article addresses some of the discrepancies between the literature coming out that has been showing increases in anxiety and depressive symptoms in the Discussion section. However, these discrepancies do not align with the data presented in the paper. Further explanation and research is needed as to why rates of some prescription medications to manage mental health symptoms are declining when there is evidence showing that mental illnesses have increase as a result of the pandemic.
The article discussed a reduction of prescriptions for anxiolytics, sedatives, and hypnotics in children, adolescents, and elderly women. These medications would address the symptoms of anxiety, stress, and other symptoms that a global pandemic may cause (Javed, Sarwer, Soto, & Mashwani, 2020). The authors suggested that perhaps people have been going to see the doctor less frequently due to quarantines and fear of contracting the virus. However, some of the medications are long-term, so it does not make sense that, duri...
While the data that this article studied and the results that were produced show a change in the mental health status and medication behaviors of Portugal, it does not support the change in mental health status captured in much of the literature around the world. When the COVID-19 virus was declared a pandemic, there was global unrest. It is natural for people to feel fear, anxiety, and panic in the face of an unknown pandemic (Usher, Durkin, & Bhullar, 2020). The article addresses some of the discrepancies between the literature coming out that has been showing increases in anxiety and depressive symptoms in the Discussion section. However, these discrepancies do not align with the data presented in the paper. Further explanation and research is needed as to why rates of some prescription medications to manage mental health symptoms are declining when there is evidence showing that mental illnesses have increase as a result of the pandemic.
The article discussed a reduction of prescriptions for anxiolytics, sedatives, and hypnotics in children, adolescents, and elderly women. These medications would address the symptoms of anxiety, stress, and other symptoms that a global pandemic may cause (Javed, Sarwer, Soto, & Mashwani, 2020). The authors suggested that perhaps people have been going to see the doctor less frequently due to quarantines and fear of contracting the virus. However, some of the medications are long-term, so it does not make sense that, during a particularly stressful event, these medications would decrease. In addition, the authors noted that there was an increase in overall prescription trends throughout the COVID-19 pandemic, especially in older adults and the elderly. This trend though shows that patients have continued to see their doctors and get prescribed medications for other ailments. This demonstrates that it is possible for patients to continue to receive necessary medications for mental illnesses, despite the hurdles of the pandemic.
In addition to the anxiety and stress that the pandemic may cause, it can also increase rates of depression. During the pandemic, especially in the earlier stages of when doctors and researchers were trying to learn more about it, people spent time at home, away from others. This resulted in people feeling isolated and distanced from other people (Usher, Durkin, & Bhullar, 2020). The distancing from other is one of the issues that can cause an increase in depression. The study showed increasing rates of antidepressant prescriptions before the pandemic began, but then they started to decline, which contradicts the increasing depressive symptoms brought on by the pandemic (Gallagher et al., 2020). The authors saw a trend of a drop in antidepressant prescription rates in male and female children, male adolescents, adults, older adults, and the elderly. However, there was no impact on the rate of prescriptions for antidepressants in women during COVID-19. This is interesting because COVID-19 is not something that impacts one gender more than the other. Additional research would be warranted to explain the gap of prescription rates between genders during the pandemic.
Many different factors can explain the conflicting data, including country studied, rate of medication use before COVID-19, etc. As more information continues to come out about COVID-19 and its impacts on mental health, we’ll more fully understand these discrepancies.
References
Gallagher, M. W., Zvolensky, M. J., Long, L. J., Rogers, A. H., & Garey, L. (2020). The impact of covid-19 experiences and associated stress on anxiety, depression, and functional impairment in American adults. Cognitive Therapy and Research, 44(6), 1043–1051. https://doi.org/10.1007/s10608-020-10143-y
Javed, B., Sarwer, A., Soto, E. B., & Mashwani, Z. U. (2020). The coronavirus (COVID-19) pandemic's impact on mental health. The International journal of health planning and management, 35(5), 993–996. https://doi.org/10.1002/hpm.3008
Usher, K., Durkin, J., & Bhullar, N. (2020). The COVID-19 pandemic and mental health impacts. International journal of mental health nursing, 29(3), 315–318. https://doi.org/10.1111/inm.12726
The authors, Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al [1], present an article that, owing to a lack of rigor in the creation and application of ethno-racial categories, ends up employing an analysis method that, although intended to allow proving inequalities, ends up disguising or attenuating them.
Raj Bhopal published a seminal article in this journal in 2004 demonstrating the importance of ethnicity and race variables in epidemiology and public health. Bhopal pointed out that, at a minimum, researchers should explain their understanding of the concepts of race or ethnicity and the classification they use, even more so when we know that they need development in terms of geographic specificity, scope, and precision for different contexts [2]. Similar recommendations are made by Janeth Mosquera in her analysis about the use of the ethnic-racial category in the research published by the three most important scientific journals of Public Health in Colombia [3].
The paper does not present a comprehensive and helpful description of the categories that assist the reader in understanding the ethnic-racial composition of the Colombian population and correctly analyze the regularly available data for public health surveillance. The Colombian surveillance system employs the census ethnic-racial categories. Among these Census categories, the "white-mestizo" used by the authors is not defined and thus is not used for public health surveill...
The authors, Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al [1], present an article that, owing to a lack of rigor in the creation and application of ethno-racial categories, ends up employing an analysis method that, although intended to allow proving inequalities, ends up disguising or attenuating them.
Raj Bhopal published a seminal article in this journal in 2004 demonstrating the importance of ethnicity and race variables in epidemiology and public health. Bhopal pointed out that, at a minimum, researchers should explain their understanding of the concepts of race or ethnicity and the classification they use, even more so when we know that they need development in terms of geographic specificity, scope, and precision for different contexts [2]. Similar recommendations are made by Janeth Mosquera in her analysis about the use of the ethnic-racial category in the research published by the three most important scientific journals of Public Health in Colombia [3].
The paper does not present a comprehensive and helpful description of the categories that assist the reader in understanding the ethnic-racial composition of the Colombian population and correctly analyze the regularly available data for public health surveillance. The Colombian surveillance system employs the census ethnic-racial categories. Among these Census categories, the "white-mestizo" used by the authors is not defined and thus is not used for public health surveillance. Besides, the authors do not define "white-mestizo."
The authors employ an official database published by Colombian national sanitary authorities and provide a link to it. However, as systematic users of the cited source, we must point out that three of the model's explanatory variables are not available on the authors-cited open data platform. Therefore, it is necessary to warn the reader that micro-data on social security affiliation, household's socioeconomic stratum, and area of residence are not available. Consequently, the results are not reproductible with publicly available data. The authors should indicate how they accessed this data and the ethical implications if they exist.
Finally, it is crucial to recognize that the paper implicitly assumes homogeneity in the group's distribution, risk exposure, and events. Authors should discuss whether it is possible, with the available data, to have a syndemic approach, as proposed early on by Bambra and collaborators [4]. This kind of analysis accounts for structural differences within the country and how ethnic groups relate to each other in the territories.
References
1. Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al. Socioeconomic inequalities associated with mortality for COVID-19 in Colombia: a cohort nationwide study. J Epidemiol Community Health 2021;75:610-615; DOI:10.1136/jech-2020-216275
2. Bhopal R. Glossary of terms relating to ethnicity and race: for reflection and debate. Journal of Epidemiology & Community Health 2004;58:441-445; DOI:10.1136/jech.2003.013466
3. Mosquera Becerra J. Unveiling what is said in the colombian public health journals about race and ethnicity. Rev.CS 2015;16:109-2; DOI: https://doi.org/10.18046/recs.i16.1939
4. Bambra C, Riordan R, Ford J, et al. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health 2020;74:964-968; DOI:10.1136/jech-2020-214401
Frank’s essay contains several statements about 5G, its relation to the radiation protection science, and related to this, ICNIRP’s guidance and integrity more generally. ICNIRP considers this to be seriously inaccurate and in need of correction for the sake of both scientific accuracy and development of effective public health policy. However, due to journal word limits we must restrict our response to Frank’s misleading claims about ICNIRP’s integrity (for full response see https://www.icnirp.org/en/activities/news/index.html).
Frank’s essay accuses ICNIRP of unmanaged conflict of interests, and uses this accusation to attempt to throw doubt on ICNIRP’s scientific evaluations. However, ICNIRP has a very rigorous procedure to avoid conflicts of interest (https://www.icnirp.org/en/about-icnirp/commission/index.html), and Frank did not provide any evidence in support of his statement - he merely referred to ‘persistent allegations’ from the Swedish epidemiologist Lennart Hardell. For example, Frank repeats claims made by Hardell that “ICNIRP’s membership includes over-representation of vested interests, especially the giant multinational telecommunications firms who are heavily invested in the roll out of 5G systems internationally”, and no supporting evidence was provided by either author. To be clear, there are no industry r...
Frank’s essay contains several statements about 5G, its relation to the radiation protection science, and related to this, ICNIRP’s guidance and integrity more generally. ICNIRP considers this to be seriously inaccurate and in need of correction for the sake of both scientific accuracy and development of effective public health policy. However, due to journal word limits we must restrict our response to Frank’s misleading claims about ICNIRP’s integrity (for full response see https://www.icnirp.org/en/activities/news/index.html).
Frank’s essay accuses ICNIRP of unmanaged conflict of interests, and uses this accusation to attempt to throw doubt on ICNIRP’s scientific evaluations. However, ICNIRP has a very rigorous procedure to avoid conflicts of interest (https://www.icnirp.org/en/about-icnirp/commission/index.html), and Frank did not provide any evidence in support of his statement - he merely referred to ‘persistent allegations’ from the Swedish epidemiologist Lennart Hardell. For example, Frank repeats claims made by Hardell that “ICNIRP’s membership includes over-representation of vested interests, especially the giant multinational telecommunications firms who are heavily invested in the roll out of 5G systems internationally”, and no supporting evidence was provided by either author. To be clear, there are no industry representations within ICNIRP; people working for industry are not permitted to be ICNIRP members, and ICNIRP does not receive any funding or in-kind contributions from industry. Moving beyond funding, Frank claims that the “the most damning evidence adduced by Hardell is a table of the cross-appointments held by six members of the WHO Monograph Group, across five major international advisory panels on the health effects of non-ionising radiation”. However, this merely reflects the relatively small EMF research community together with the high public interest that has resulted in many national and international advisory boards. Frank does not tell the reader why this would in any way bias ICNIRP’s work. Thus, the essay’s accusations of industry influence are not only incorrect, but also lack appropriate scientific scholarship.
In conclusion, ICNIRP fully supports and contributes to critical debate related to the 5G rollout, but would like to stress the importance of approaching such debate with appropriate scientific scholarship in order to support effective, evidence-based public health measures that provide appropriate protection to the public. For ICNIRP it is imperative to avoid situations whereby personal interests of its members could affect the independence of ICNIRP’s guidance, and so has strong conflict of interest procedures, including transparent reporting of members’ declarations of interest.
Acknowledgements
Rodney Croft (1), Tania Cestari (2), Nigel Cridland (3), Akimasa Hirata (4), Guglielmo d'Inzeo (5), Anke Huss (6), Ken Karipidis (7), Carmela Marino (8), Sharon Miller (9), Gunnhild Oftedal (10), Tsutomu Okuno (11), Eric van Rongen (12), Martin Röösli (13), Soichi Watanabe (14).
Correspondence to: International Commission on Non-Ionizing Radiation Protection, Dr Gunde Ziegelberger, ICNIRP c/o BfS, Ingolstaedter Landstr. 1, 85764 Oberschleissheim, Germany. info@icnirp.org
Affiliations of ICNIRP Collaborators
1. ICNIRP and Australian Centre for Electromagnetic Bioeffects Research, Illawarra Health & Medical Research Institute, University of Wollongong, Australia
2. ICNIRP and Hospital de Clínicas de Porto Alegre, Brazil
3. ICNIRP and Public Health England, United Kingdom
4. ICNIRP and Nagoya Institute of Technology, Japan
5. ICNIRP and La Sapienza University Rome, Italy
6. ICNIRP and Institute for Risk Assessment, Utrecht University, The Netherlands
7. ICNIRP and Australian Radiation Protection and Nuclear Safety Agency (ARPANSA), Australia
8. ICNIRP and Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), Italy
9. ICNIRP
10. ICNIRP and Norwegian University of Science and Technology (NTNU), Norway
11. ICNIRP
12. ICNIRP and Health Council, The Netherlands
13. ICNIRP and Swiss Tropical and Public Health Institute, Basel, Switzerland
14. ICNIRP and National Institute of Information and Communications Technology (NICT), Japan
Hengartner et al. conducted a meta-analysis on suicide risk with selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants in adults (1). Although the pooled relative risks (RRs) of SSRI for suicide risk including suicide and suicide attempt in patients with depression and in patients with all indications did not reach the level of significance, the pooled RR (95% confidence intervals [CIs]) of any new-generation antidepressant for suicide risk in patients with depression and in patients with all indications were 1.29 (1.06-1.57) and 1.45 (1.23-1.70), respectively. The authors presented information on the different suicide risk between SSRI and other new-generation antidepressants , and I present additional information regarding the relationship.
First, Sharma et al. conducted a meta-analysis on the association of SSRI and serotonin-norepinephrine reuptake inhibitors with suicidality and other mental indicators (2). Although the pooled odds ratios (ORs) of antidepressant treatment for suicidality and aggression did not reach the level of significance in adults, the pooed ORs (95% CIs) of antidepressant treatment for suicidality and aggression were 2.39 (1.31-4.33) and 2.79 (1.62-4.81) in children/adolescents. The suicide risk differed in different generations, and suicide risk estimation should be conducted by stratification with generation and type of anti-depressants.
Second, Hengartner and Plöderl reported that odds ratios (OR...
Hengartner et al. conducted a meta-analysis on suicide risk with selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants in adults (1). Although the pooled relative risks (RRs) of SSRI for suicide risk including suicide and suicide attempt in patients with depression and in patients with all indications did not reach the level of significance, the pooled RR (95% confidence intervals [CIs]) of any new-generation antidepressant for suicide risk in patients with depression and in patients with all indications were 1.29 (1.06-1.57) and 1.45 (1.23-1.70), respectively. The authors presented information on the different suicide risk between SSRI and other new-generation antidepressants , and I present additional information regarding the relationship.
First, Sharma et al. conducted a meta-analysis on the association of SSRI and serotonin-norepinephrine reuptake inhibitors with suicidality and other mental indicators (2). Although the pooled odds ratios (ORs) of antidepressant treatment for suicidality and aggression did not reach the level of significance in adults, the pooed ORs (95% CIs) of antidepressant treatment for suicidality and aggression were 2.39 (1.31-4.33) and 2.79 (1.62-4.81) in children/adolescents. The suicide risk differed in different generations, and suicide risk estimation should be conducted by stratification with generation and type of anti-depressants.
Second, Hengartner and Plöderl reported that odds ratios (ORs) (95% confidence intervals [CIs]) of antidepressant treatment for suicides and suicide attempts were 2.83 (1.13-9.67) and 2.38 (1.63-3.61), respectively (3). By using the same database, Kaminski et al. reported that ORs (95% CIs) of antidepressant treatment for suicides and suicide attempts were 1.98 (0.71-5.50) and 1.63 (1.09-2.43), respectively (4). In case of rare events, the level of significance in OR differed by applying different analytical approaches. This means that marginal level of significance should be verified by further studies, and a meta-analysis with high quality of papers is recommended to confirm the association.
References
1. Hengartner MP, Amendola S, Kaminski JA, et al. Suicide risk with selective serotonin reuptake inhibitors and other new-generation antidepressants in adults: a systematic review and meta-analysis of observational studies. J Epidemiol Community Health 2021 Mar 8. doi: 10.1136/jech-2020-214611. [Epub ahead of print]
2. Sharma T, Guski LS, Freund N, et al. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ 2016;352:i65.
3. Hengartner MP, Plöderl M. Newer-generation antidepressants and suicide risk in randomized controlled trials: A re-analysis of the FDA database. Psychother Psychosom 2019;88(4):247-248.
4. Kaminski JA, Bschor T. Antidepressants and suicidality: A re-analysis of the re-analysis. J Affect Disord 2020;266:95-99.
The question “Why does Russia have such high cardiovascular (CV) mortality rates?”1 can be answered by a pathologist who practiced during the Soviet time.2 Since then, the quality of post mortem examinations has decreased especially during the 1990s: autopsies were sometimes made perfunctorily. The deterioration in anatomic pathology and the health care in general during the 1990s coincided with the increase in the registered CV mortality. A tendency to over-diagnose CV diseases is generally known to exist also for people dying at home and not undergoing autopsy. If a cause of death is not entirely clear, it has been usual to write on a death certificate: “Ischemic heart disease with cardiac insufficiency” or a similar formulation.2 Concerning the relatively high CV mortality in Russia, it should be commented that irregular treatment of hypertension,3 diabetes and other chronic diseases continues to be a problem. Considering the above, the differences between Norwegian and Russian cohorts1 can be better understood. The levels of serum lipids were comparable between Russia and Norway being slightly higher in the latter possibly due to better nutrition. Interestingly, N-terminal pro-b-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), and high-sensitivity C-reactive protein (hsCRP) were higher in Russia.1 It can be reasonably assumed that average levels of these markers inversely correlate with a nation’s health reflected by the life expecta...
The question “Why does Russia have such high cardiovascular (CV) mortality rates?”1 can be answered by a pathologist who practiced during the Soviet time.2 Since then, the quality of post mortem examinations has decreased especially during the 1990s: autopsies were sometimes made perfunctorily. The deterioration in anatomic pathology and the health care in general during the 1990s coincided with the increase in the registered CV mortality. A tendency to over-diagnose CV diseases is generally known to exist also for people dying at home and not undergoing autopsy. If a cause of death is not entirely clear, it has been usual to write on a death certificate: “Ischemic heart disease with cardiac insufficiency” or a similar formulation.2 Concerning the relatively high CV mortality in Russia, it should be commented that irregular treatment of hypertension,3 diabetes and other chronic diseases continues to be a problem. Considering the above, the differences between Norwegian and Russian cohorts1 can be better understood. The levels of serum lipids were comparable between Russia and Norway being slightly higher in the latter possibly due to better nutrition. Interestingly, N-terminal pro-b-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), and high-sensitivity C-reactive protein (hsCRP) were higher in Russia.1 It can be reasonably assumed that average levels of these markers inversely correlate with a nation’s health reflected by the life expectancy at birth. Indeed, elevated C-reactive protein is known to be associated with various inflammatory conditions. The natriuretic peptide (NP) plays an important role by opposing the vasoconstriction and sodium retention. A plasma NP elevation was found in essential hypertension, decreasing with effective antihypertensive therapy.4 Hs-cTnT is a biomarker for myocardial damage; but other conditions are also associated with its enhanced level: diabetes, COPD, decreased renal function, anaemia etc.5 The insufficient access to modern healthcare,1 higher consumption of alcohol and cigarettes in Russia vs. Norway (the data can be found in Wikipedia), as well as relatively poor quality of alcohol sold in Russia,6 have probably contributed to a higher morbidity. In conclusion, the valuable results by Dr. Iakunchykova and co-workers1 should motivate further search for associations between NT-proBNP, hs-cTnT and other markers with various pathological conditions.
REFERENCES
1. Iakunchykova O, Averina M, Wilsgaard T, et al. Why does Russia have such high cardiovascular mortality rates? Comparisons of blood–based biomarkers with Norway implicate non-ischaemic cardiac damage. J Epidemiol Community Health 2020;74:698–704.
2. Jargin SV. Cardiovascular mortality trends in Russia: possible mechanisms. Nat Rev Cardiol 2015;12:740.
3. Roberts B, Stickley A, Balabanova D, et al. The persistence of irregular treatment of hypertension in the former Soviet Union. J Epidemiol Community Health 2012;66:1079–82.
4. Hu W, Zhou PH, Zhang XB, Xu CG, Wang W. Plasma concentrations of adrenomedullin and natriuretic peptides in patients with essential hypertension. Exp Ther Med 2015;9:1901–908.
5. Wu W, Li DX, Wang Q, et al. Relationship between high-sensitivity cardiac troponin T and the prognosis of elderly inpatients with non-acute coronary syndromes. Clin Interv Aging 2018;13:1091–8.
6. Jargin SV. Vodka vs. Fortified Wine in Russia: Retrospective View. Alcohol Alcohol 2015;50:624–5.
We read with interest, intrigue and concern the findings reported in this short report. if the findings are validated from larger and multicentric data this may have huge implications in the way we trace and isolate the COVID-19 contacts. Pre symptomatic transmission from index cases 5 days prior to the onset of symptoms is a huge logistical nightmare in terms of containment strategies. This would imply at practical impossibility and futility of these strategy especially in setting of cluster or community transmission. This also highlights the virtues of basic but universal measures like physical distancing, hygiene and use of mask at all times under specific settings.
We read with great interest the report from Hamer and colleagues that examined the hypothesis that associations between television (TV) viewing and mortality from heart disease (HD) are due to confounding (1). They employed a negative control approach (2) and report evidence of associations between TV viewing and HD mortality (HR=1.09 [1.06, 1.12] per 1 hr/day increase in TV) and accidental deaths (the negative control outcome; HR=1.06 [0.98, 1.15]) after adjusting for age, sex, smoking, education, and prevalent HD (1)
The positive association between TV and accidental deaths was interpreted as evidence that the TV-HD mortality association was due to confounding. Although key study limitations were noted including a small number of accidental deaths and limited adjustment for confounding, the authors concluded that “observed associations between TV and HD are likely to be driven by confounding”. Although we agree that confounding is a worrisome threat to the internal validity of epidemiologic studies, we believe that the conclusion in the Hamer report is overstated.
A critical additional strategy to understand bias due to confounding, one that was not employed in the current study, is to examine relevant results from published studies conducted in different study populations using different methods. (2) We previously reported results in two studies that examined associations for accidental deaths and HD mortality with TV viewing (3) and leisure-time sitti...
We read with great interest the report from Hamer and colleagues that examined the hypothesis that associations between television (TV) viewing and mortality from heart disease (HD) are due to confounding (1). They employed a negative control approach (2) and report evidence of associations between TV viewing and HD mortality (HR=1.09 [1.06, 1.12] per 1 hr/day increase in TV) and accidental deaths (the negative control outcome; HR=1.06 [0.98, 1.15]) after adjusting for age, sex, smoking, education, and prevalent HD (1)
The positive association between TV and accidental deaths was interpreted as evidence that the TV-HD mortality association was due to confounding. Although key study limitations were noted including a small number of accidental deaths and limited adjustment for confounding, the authors concluded that “observed associations between TV and HD are likely to be driven by confounding”. Although we agree that confounding is a worrisome threat to the internal validity of epidemiologic studies, we believe that the conclusion in the Hamer report is overstated.
A critical additional strategy to understand bias due to confounding, one that was not employed in the current study, is to examine relevant results from published studies conducted in different study populations using different methods. (2) We previously reported results in two studies that examined associations for accidental deaths and HD mortality with TV viewing (3) and leisure-time sitting (predominantly TV viewing) (4), but these findings were not cited in the Hamer report. Our studies each examined 3-5 times more accidental deaths than the Hamer report, and adjusted for a much larger number of confounding factors. (3,4) We found significant positive associations with TV-HD mortality, but no evidence of association between accidental deaths and greater TV time (HR=1.01 [0.62, 1.64]; 7+ vs. < 1 hr/day) (3) or leisure-time sitting (HR=0.91 [0.76, 1.10]; 6+ vs. < 3 hr/d). (4) In context of the negative control outcome framework, our results provide no evidence that previously observed HD associations, or associations with several other causes of death, were due only to confounding. (3,4)
Many studies have reported positive associations between disease/mortality outcomes and TV, a prevalent leisure-time behavior that, as Hamer and colleagues note, is likely to displace time spent in more healthful physically active pursuits. We strongly support efforts to better understand these relationships, including careful consideration of bias and threats to validity. As we do so, it is critical that we consider the broad range of information available before drawing strong conclusions based on a single study.
References
1. Hamer M, Ding D, Chau J, Duncan MJ, Stamatakis E. Association between TV viewing and heart disease mortality: observational study using negative control outcome. Journal of Epidemiology and Community Health. 2020:jech-2019-212739.
2. Pearce N, Vandenbroucke JP, Lawlor DA. Causal Inference in Environmental Epidemiology: Old and New Approaches. Epidemiology. 2019;30(3):311-316.
3. Keadle SK, Moore SC, Sampson JN, Xiao Q, Albanes D, Matthews CE. Causes of Death Associated With Prolonged TV Viewing: NIH-AARP Diet and Health Study. American Journal of Preventive Medicine. 2015;49(6):811-821.
4. Patel AV, Maliniak ML, Rees-Punia E, Matthews CE, Gapstur SM. Prolonged Leisure Time Spent Sitting in Relation to Cause-Specific Mortality in a Large US Cohort. American Journal of Epidemiology. 2018;187(10):2151-2158.
Davis and colleagues must be commended for their concern about cancer outcomes in patients with mental disorders and for acknowledging the poor quality of research.(1) However, their statement “pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis “ deserve comment.
Firstly, patients with mental disorders, as all vulnerable populations, have poor access to care, considering either quantitatively or qualitatively, even more for specialized care, whatever it could be. Accordingly, a vertical approach only targeting patients with mental disorders would only be a partial and symptomatic solution A root cause analysis is a prerequisite to expect fixing a systemic failure.
Secondly, the term “pre-existing mental disorder” must be questioned as tobacco and alcohol cause both mental health problems and cancer. There is robust and accumulating evidence that cigarette smoking is a causal risk factor for anxiety, depression and, even severe mental illness such as bipolar disorder.(2) Cessation is associated with reduced depression, anxiety and, improved quality of life. While one can understand most patients are fooled by the immediate effects of smoking on perceived stress (decreasing cerebral pain from nicotine withdrawal), the fact that too many psychiatric setting remain smokehouses question the quality of care.(3) Similarly, in many experience, as a second line specialist for severe alcohol use disorders, many of patients referred t...
Davis and colleagues must be commended for their concern about cancer outcomes in patients with mental disorders and for acknowledging the poor quality of research.(1) However, their statement “pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis “ deserve comment.
Firstly, patients with mental disorders, as all vulnerable populations, have poor access to care, considering either quantitatively or qualitatively, even more for specialized care, whatever it could be. Accordingly, a vertical approach only targeting patients with mental disorders would only be a partial and symptomatic solution A root cause analysis is a prerequisite to expect fixing a systemic failure.
Secondly, the term “pre-existing mental disorder” must be questioned as tobacco and alcohol cause both mental health problems and cancer. There is robust and accumulating evidence that cigarette smoking is a causal risk factor for anxiety, depression and, even severe mental illness such as bipolar disorder.(2) Cessation is associated with reduced depression, anxiety and, improved quality of life. While one can understand most patients are fooled by the immediate effects of smoking on perceived stress (decreasing cerebral pain from nicotine withdrawal), the fact that too many psychiatric setting remain smokehouses question the quality of care.(3) Similarly, in many experience, as a second line specialist for severe alcohol use disorders, many of patients referred to me are treated with antidepressants. Antidepressants have modest, if any, useful effects in depressed drinkers but have a potential to aggravate drinking outcomes (pathological intoxication with marked lost control and, occasionally serious violence, even suicide or homicide).(4) This is a real issue in France: a) the use of alcohol, a most depressive agent, is a public health crisis as in England; b) in contrast to England psychotherapy is not reimbursed by the French mandatory healthcare scheme yet despite the success of the Improving Access to Psychological Therapies programme launched in 2008.
Last, even if a pre-existing mental disorder can to be the main concern, as in patients with schizophrenia, no one must overlook that these patients are 3.5 times more likely to die than the general population due to lung cancer, chronic obstructive pulmonary and cardiovascular diseases. For the main psychiatric cause of death, suicide, whose prevention remains a challenge, standardized mortality ratios is 52/100,000 person-years vs 75 for lung cancer.(5) In contrast, adequate treatment for smoking cessation, psychotherapy and nicotine replacement therapy with the belt and brace strategy (patches plus oral forms to suppress occasional craving, at increasing doses) is most effective, whether there are mental health disorders or not.
1 Davis LE, Bogner E, Coburn NG et al. Stage at diagnosis and survival in patients with cancer and a pre-existing mental illness: a meta-analysis. J Epidemiol Community Health 2020;74:84-94.
2 Vermeulen JM, Wootton RE, Treur JL et al. Smoking and the risk for bipolar disorder: evidence from a bidirectional Mendelian randomisation study. Br J Psychiatry. 2019. Online Sep 17. doi: 10.1192/bjp.2019.202.
3 Evins AE, Cather C, Daumit GL. Smoking cessation in people with serious mental illness. Lancet Psychiatry2019;6:563-564.
4 Braillon A. Alcohol Use Disorders and the Barrel of the Danaids. Alcohol Alcohol 2016;51:774.
5 Gatov E, Rosella L, Chiu M, et al. Trends in standardized mortality among individuals with schizophrenia, 1993–2012: a population-based, repeated cross-sectional study. CMAJ 2017;189:E1177–87.
Dear Editor,
The authors of “Effects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomized controlled studies” make a strong claim that PACE food labeling can increase consumer consciousness of calorie consumption and therefore caloric reduction, but perhaps this concept deters true understanding of "healthful eating" and may have larger health implications for those with disordered eating.
There is a growing knowledge that that not all calories are created equal. Different foods may not only have different effects on hunger and satiety but also insulin production, gut microbiome interactions, and de novo lipogenesis in the liver (1). While not all consumers need this level of understanding, but without a basic acknowledgement of food’s qualities- like fats, fiber, sugar, ect- the consumer is lead to believe that calories are the most important determinant in what makes food “healthful.” With PACE food labeling, a consumer is led to believe that an ice cream cone and a handful of nuts, both of which could amount to 200 calories, are “equal.” However, in this comparison, only the nuts are possibly advantageous to people with diabetes and cardiovascular disease (2).
Stripping foods down to solely their caloric energy through PACE food labeling could inadvertently foster unhealthy relationships with food. As stated in the article, PACE labeling could be use...
Dear Editor,
The authors of “Effects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomized controlled studies” make a strong claim that PACE food labeling can increase consumer consciousness of calorie consumption and therefore caloric reduction, but perhaps this concept deters true understanding of "healthful eating" and may have larger health implications for those with disordered eating.
There is a growing knowledge that that not all calories are created equal. Different foods may not only have different effects on hunger and satiety but also insulin production, gut microbiome interactions, and de novo lipogenesis in the liver (1). While not all consumers need this level of understanding, but without a basic acknowledgement of food’s qualities- like fats, fiber, sugar, ect- the consumer is lead to believe that calories are the most important determinant in what makes food “healthful.” With PACE food labeling, a consumer is led to believe that an ice cream cone and a handful of nuts, both of which could amount to 200 calories, are “equal.” However, in this comparison, only the nuts are possibly advantageous to people with diabetes and cardiovascular disease (2).
Stripping foods down to solely their caloric energy through PACE food labeling could inadvertently foster unhealthy relationships with food. As stated in the article, PACE labeling could be used to “help the public understand what a calorie means and therefore more able to decide whether the calories are ‘worth it.’” Through directing consumers to regard food as just calories to burn off through exercise, instead of fuel for a person’s body, perhaps consumers will come to regard food as punishment instead of its role as nourishment. Those who could be most affected from this way of thinking are the 30 million individuals living in the US with eating disorders (3,4). While obesity does affect more individuals than eating disorders, this is a population of individuals that should be considered when suggesting policymakers to consider implementation of this labeling system. Eating disorders are characterized by a pervasive thought pattern concerning both weight and food so implementing a labeling system that emphasizes food purging through the form of exercise can be detrimental to the mental health of these unique populations (5). Eating disorders have the highest mortality rate of any mental illness and 1 in 5 anorexia deaths are by suicide (6,7). Not only could PACE food labeling adversely affect those with eating disorders, but through fostering unhealthful relationships with food, they could potentially exacerbate the issue. On the other hand, reducing the risk and/or actual prevalence of obesity and all its related ailments, including psychological stress, is a worthy endeavor.
In conclusion, while the authors of this article review a novel and potentially helpful way to combat the growing obesity epidemic, further studies need to be done to compare PACE against current public health education programs and to investigate potential harm to those with eating disorders prior to policy making.
1) Mozaffarian, D.(2017). Foods, obesity, and diabetes—are all calories created equal?, Nutrition Reviews, Issue Suppl_1 Volume 75, Pages 19–31
2) Allen, L. (2008). Priority Areas for Research on the Intake, Composition, and Health Effects of Tree Nuts and Peanuts, The Journal of Nutrition, Volume 138, Issue 9, Pages 1763S–1765S
3) Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358.
4) Le Grange, D., Swanson, S. A., Crow, S. J., & Merikangas, K. R. (2012). Eating disorder not otherwise specified presentation in the US population. International Journal of Eating Disorders, 45(5), 711-718.
5) Dell'Osso, L., Abelli, M., Carpita, B., Pini, S., Castellini, G., Carmassi, C., & Ricca, V. (2016). Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive-compulsive spectrum. Neuropsychiatric disease and treatment, 12, 1651–1660.
6) Smink, F. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports,14, 406-414.
7) Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry, 68, 724-731.
An article by Wei et al. reported the death of a child associated with an increased risk of incident atrial fibrillation (AF). The association was observed when the cause of death was both cardiovascular and non-cardiovascular diseases.1 These findings provide a valuable addition to the literature; however, some issues were not addressed by the authors.
Show MoreFirst, several clinical risk factors are associated with incident AF, including concurrent medication, illegal drugs, obesity, sleep apnea, and hyperthyroidism.2-4 For example, we previously reported that insulin users had a higher risk of incident AF than non-users among the elderly patients’ cohort (1.58 odds ratio (OR); 95% confidence interval (CI): 1.37–1.82). Patients with dipeptidyl peptidase 4 inhibitor (OR 0.65; 95% CI: 0.45–0.93) intake had a lower risk of developing AF when compared with non-users.4 However, while associated evaluations were not presented, Wei et al. did not exclude individuals with these risk factors. Consequently, confounding effects may have contributed to the significant effects causing incident AF, thus, omitting these effects may improve study validation outcomes.
Second, the study initially enrolled 2,740,028 participants in the unexposed group and 64,216 participants in the exposed group at baseline, but missing data between groups (50.1% vs. 79.6%) were examined in further analyses. These missing data potentially affected data credibility in mediation analyses.5 Consequent...
While the data that this article studied and the results that were produced show a change in the mental health status and medication behaviors of Portugal, it does not support the change in mental health status captured in much of the literature around the world. When the COVID-19 virus was declared a pandemic, there was global unrest. It is natural for people to feel fear, anxiety, and panic in the face of an unknown pandemic (Usher, Durkin, & Bhullar, 2020). The article addresses some of the discrepancies between the literature coming out that has been showing increases in anxiety and depressive symptoms in the Discussion section. However, these discrepancies do not align with the data presented in the paper. Further explanation and research is needed as to why rates of some prescription medications to manage mental health symptoms are declining when there is evidence showing that mental illnesses have increase as a result of the pandemic.
Show MoreThe article discussed a reduction of prescriptions for anxiolytics, sedatives, and hypnotics in children, adolescents, and elderly women. These medications would address the symptoms of anxiety, stress, and other symptoms that a global pandemic may cause (Javed, Sarwer, Soto, & Mashwani, 2020). The authors suggested that perhaps people have been going to see the doctor less frequently due to quarantines and fear of contracting the virus. However, some of the medications are long-term, so it does not make sense that, duri...
The authors, Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al [1], present an article that, owing to a lack of rigor in the creation and application of ethno-racial categories, ends up employing an analysis method that, although intended to allow proving inequalities, ends up disguising or attenuating them.
Raj Bhopal published a seminal article in this journal in 2004 demonstrating the importance of ethnicity and race variables in epidemiology and public health. Bhopal pointed out that, at a minimum, researchers should explain their understanding of the concepts of race or ethnicity and the classification they use, even more so when we know that they need development in terms of geographic specificity, scope, and precision for different contexts [2]. Similar recommendations are made by Janeth Mosquera in her analysis about the use of the ethnic-racial category in the research published by the three most important scientific journals of Public Health in Colombia [3].
The paper does not present a comprehensive and helpful description of the categories that assist the reader in understanding the ethnic-racial composition of the Colombian population and correctly analyze the regularly available data for public health surveillance. The Colombian surveillance system employs the census ethnic-racial categories. Among these Census categories, the "white-mestizo" used by the authors is not defined and thus is not used for public health surveill...
Show MoreFrank’s essay contains several statements about 5G, its relation to the radiation protection science, and related to this, ICNIRP’s guidance and integrity more generally. ICNIRP considers this to be seriously inaccurate and in need of correction for the sake of both scientific accuracy and development of effective public health policy. However, due to journal word limits we must restrict our response to Frank’s misleading claims about ICNIRP’s integrity (for full response see https://www.icnirp.org/en/activities/news/index.html).
Frank’s essay accuses ICNIRP of unmanaged conflict of interests, and uses this accusation to attempt to throw doubt on ICNIRP’s scientific evaluations. However, ICNIRP has a very rigorous procedure to avoid conflicts of interest (https://www.icnirp.org/en/about-icnirp/commission/index.html), and Frank did not provide any evidence in support of his statement - he merely referred to ‘persistent allegations’ from the Swedish epidemiologist Lennart Hardell. For example, Frank repeats claims made by Hardell that “ICNIRP’s membership includes over-representation of vested interests, especially the giant multinational telecommunications firms who are heavily invested in the roll out of 5G systems internationally”, and no supporting evidence was provided by either author. To be clear, there are no industry r...
Show MoreHengartner et al. conducted a meta-analysis on suicide risk with selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants in adults (1). Although the pooled relative risks (RRs) of SSRI for suicide risk including suicide and suicide attempt in patients with depression and in patients with all indications did not reach the level of significance, the pooled RR (95% confidence intervals [CIs]) of any new-generation antidepressant for suicide risk in patients with depression and in patients with all indications were 1.29 (1.06-1.57) and 1.45 (1.23-1.70), respectively. The authors presented information on the different suicide risk between SSRI and other new-generation antidepressants , and I present additional information regarding the relationship.
First, Sharma et al. conducted a meta-analysis on the association of SSRI and serotonin-norepinephrine reuptake inhibitors with suicidality and other mental indicators (2). Although the pooled odds ratios (ORs) of antidepressant treatment for suicidality and aggression did not reach the level of significance in adults, the pooed ORs (95% CIs) of antidepressant treatment for suicidality and aggression were 2.39 (1.31-4.33) and 2.79 (1.62-4.81) in children/adolescents. The suicide risk differed in different generations, and suicide risk estimation should be conducted by stratification with generation and type of anti-depressants.
Second, Hengartner and Plöderl reported that odds ratios (OR...
Show MoreThe question “Why does Russia have such high cardiovascular (CV) mortality rates?”1 can be answered by a pathologist who practiced during the Soviet time.2 Since then, the quality of post mortem examinations has decreased especially during the 1990s: autopsies were sometimes made perfunctorily. The deterioration in anatomic pathology and the health care in general during the 1990s coincided with the increase in the registered CV mortality. A tendency to over-diagnose CV diseases is generally known to exist also for people dying at home and not undergoing autopsy. If a cause of death is not entirely clear, it has been usual to write on a death certificate: “Ischemic heart disease with cardiac insufficiency” or a similar formulation.2 Concerning the relatively high CV mortality in Russia, it should be commented that irregular treatment of hypertension,3 diabetes and other chronic diseases continues to be a problem. Considering the above, the differences between Norwegian and Russian cohorts1 can be better understood. The levels of serum lipids were comparable between Russia and Norway being slightly higher in the latter possibly due to better nutrition. Interestingly, N-terminal pro-b-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), and high-sensitivity C-reactive protein (hsCRP) were higher in Russia.1 It can be reasonably assumed that average levels of these markers inversely correlate with a nation’s health reflected by the life expecta...
Show MoreWe read with interest, intrigue and concern the findings reported in this short report. if the findings are validated from larger and multicentric data this may have huge implications in the way we trace and isolate the COVID-19 contacts. Pre symptomatic transmission from index cases 5 days prior to the onset of symptoms is a huge logistical nightmare in terms of containment strategies. This would imply at practical impossibility and futility of these strategy especially in setting of cluster or community transmission. This also highlights the virtues of basic but universal measures like physical distancing, hygiene and use of mask at all times under specific settings.
We read with great interest the report from Hamer and colleagues that examined the hypothesis that associations between television (TV) viewing and mortality from heart disease (HD) are due to confounding (1). They employed a negative control approach (2) and report evidence of associations between TV viewing and HD mortality (HR=1.09 [1.06, 1.12] per 1 hr/day increase in TV) and accidental deaths (the negative control outcome; HR=1.06 [0.98, 1.15]) after adjusting for age, sex, smoking, education, and prevalent HD (1)
The positive association between TV and accidental deaths was interpreted as evidence that the TV-HD mortality association was due to confounding. Although key study limitations were noted including a small number of accidental deaths and limited adjustment for confounding, the authors concluded that “observed associations between TV and HD are likely to be driven by confounding”. Although we agree that confounding is a worrisome threat to the internal validity of epidemiologic studies, we believe that the conclusion in the Hamer report is overstated.
A critical additional strategy to understand bias due to confounding, one that was not employed in the current study, is to examine relevant results from published studies conducted in different study populations using different methods. (2) We previously reported results in two studies that examined associations for accidental deaths and HD mortality with TV viewing (3) and leisure-time sitti...
Show MoreDavis and colleagues must be commended for their concern about cancer outcomes in patients with mental disorders and for acknowledging the poor quality of research.(1) However, their statement “pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis “ deserve comment.
Firstly, patients with mental disorders, as all vulnerable populations, have poor access to care, considering either quantitatively or qualitatively, even more for specialized care, whatever it could be. Accordingly, a vertical approach only targeting patients with mental disorders would only be a partial and symptomatic solution A root cause analysis is a prerequisite to expect fixing a systemic failure.
Secondly, the term “pre-existing mental disorder” must be questioned as tobacco and alcohol cause both mental health problems and cancer. There is robust and accumulating evidence that cigarette smoking is a causal risk factor for anxiety, depression and, even severe mental illness such as bipolar disorder.(2) Cessation is associated with reduced depression, anxiety and, improved quality of life. While one can understand most patients are fooled by the immediate effects of smoking on perceived stress (decreasing cerebral pain from nicotine withdrawal), the fact that too many psychiatric setting remain smokehouses question the quality of care.(3) Similarly, in many experience, as a second line specialist for severe alcohol use disorders, many of patients referred t...
Show MoreDear Editor,
Show MoreThe authors of “Effects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomized controlled studies” make a strong claim that PACE food labeling can increase consumer consciousness of calorie consumption and therefore caloric reduction, but perhaps this concept deters true understanding of "healthful eating" and may have larger health implications for those with disordered eating.
There is a growing knowledge that that not all calories are created equal. Different foods may not only have different effects on hunger and satiety but also insulin production, gut microbiome interactions, and de novo lipogenesis in the liver (1). While not all consumers need this level of understanding, but without a basic acknowledgement of food’s qualities- like fats, fiber, sugar, ect- the consumer is lead to believe that calories are the most important determinant in what makes food “healthful.” With PACE food labeling, a consumer is led to believe that an ice cream cone and a handful of nuts, both of which could amount to 200 calories, are “equal.” However, in this comparison, only the nuts are possibly advantageous to people with diabetes and cardiovascular disease (2).
Stripping foods down to solely their caloric energy through PACE food labeling could inadvertently foster unhealthy relationships with food. As stated in the article, PACE labeling could be use...
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