FDA chief, at UK, says 'It's fair to be critical' of failure to control e-cigarettes; voices concern about life expectancy, misinformation

By Melissa Patrick
Kentucky Health News

U.S. Food and Drug Administration Commissioner Dr. Robert Califf said Friday at the University of Kentucky, "It's fair to be critical of the FDA" regarding the agency's struggle to regulate electronic cigarettes.

Asked in a news-media interview what the FDA is doing to crack down on e-cigarette companies that defy FDA rules and continue to sell their products, with reports that the FDA is not enforcing the law to shut them down, Califf replied that this is a "tough issue." 

Robert Califf, M.D.

Califf said that while federal law requires the companies to submit an application to the FDA to determine if they can stay on the market, it turns out that there are 6.7 million vape products, which "no one expected." He said there were already a million synthetic nicotine products on store shelves by the time Congress passed a law to cover them.

"It's been a lot more labor-intensive than was expected," he said. "We're doing a complete evaluation now that will be out in December and enforcement is a big part of that. And I would just say, it's fair to be critical of the FDA in this regard.

"But in order for FDA to have enforcement, like taking things off the shelves, that involves other branches of government also. And so we've got to figure out how to adapt to a much more creative industry than we expected in terms of all the products that are developing and the way they're dealing with it." 

As a guest speaker at UK Healthcare's 60th Anniversary Symposium, Califf touched on a number of health-related topics very relevant to Kentucky, including tobacco use, decreasing life expectancies and the role of health-related misinformation.

He said Kentucky still has work to do on tobacco use, since it still has one of the top rates in the country (21.4% of adults) and is likely to lose about 8,000 people this year to tobacco-related illnesses.

"So we've got to work together to help people stop using tobacco or reduce their use of tobacco . . . and underneath that, we've got vaping, which is rising while the use of tobacco is declining," Califf said in the interview. "Those things are right in the core mission of the FDA." 

The FDA is working on a proposal to remove menthol from tobacco products to discourage smoking. The move has been long in coming because menthol cigarettes are the choice of most Black smokers. 

"Get rid of that and you're pretty much left with tobacco-flavored tobacco," he said. "That's going to, I think, be a disincentive for people to continue to use it. . . . Law prohibits us from eliminating tobacco products, you can't take them completely off the market."  

Life expectancy: Califf voiced grave concern that life expectancy, the most basic measure of population health, has decreased in the U.S. during the pandemic and is five years shorter than the average of other high-income countries. He pointed out that life expectancy is lower in the Appalachian region and the Southeast. 

"We've got very significant work to do if we're going to turn this around," he said, adding later, "It's something that I believe is an emergency that we need to take seriously, and it's something that is not sustainable."  

One of the ways to improve life expectancy, he said, is to improve health outcomes, which include things that we already know how to treat like obesity, low physical activity, cigarette smoking, high blood pressure and diabetes -- all conditions that plague Kentuckians. He also noted the widening disparities in health outcomes in rural people, compared to urban ones. 

"These are things that are not foreign objects to us, we understand them reasonably well," he said. "We're just not doing a good job of executing on the things that we already know."

He later told reporters that experts say it will be important to fix the underlying social determinants that impact health if we are ever going to move the needle on health outcomes, including things like fundamental economic and income distribution and the education system. 

"The good news for our health is, poor people can have really good health because you are talking about blood pressure, cholesterol level, use of tobacco, simple screening things that aren't very expensive. The most important drugs now are generic . . . so this is why I keep gravitating back to having a primary-care system that works." 

The role of the FDA in all of this would be in the regulation of food and nutrition and tobacco and digital products that would enhance better health outcomes, he said. 

He touched briefly on the increasing number of deaths caused by substance-use disorders, but did say that there is a great need for a non-addictive treatment for pain, which we don't have yet. 

Misinformation: Califf spent a fair amount of time talking about health misinformation, which he defined as when well-intentioned people get health information wrong and then influence a lot of people by sharing that bad information. He said it is largely driven by the widespread use of social media and the internet.

"I can't find a single expert who can put credibly put forth a strategy that will turn around the fact that we're losing the battle on misinformation right now," he said. 

Califf called on state health institutions and health professionals to actively work to dispel misinformation, most recently as it relates to the Covid-19 vaccinations and boosters. 

"We know that the most effective way to counter misinformation is through human interpersonal interaction with someone that you trust," he said "If we don't build this in as an active part of our medical education, what our doctors and nurses and pharmacists to in day to day work, we're going to lose." 

As for the FDA's role, Califf said one of the agency's missions is to provide people with reliable information about products, and the FDA will continue to put out reliable information. 

"We have a responsibility to try to do something about it, but it's overwhelming," said Califf, who is serving in his role as FDA commissioner for the second time. "The government can't fix this because there's so much mistrust of government that we need the private sector to pitch in. And we need the press to pitch in and be aware of when it's promoting misinformation and things that will affect people's health in a negative way." 

In 2020, Kentucky's life expectancy fell by 2 years, more than the U.S. drop of 1.8, and is now fourth from the lowest in the nation

Map by NBC News, adapted by Kentucky Health News

Kentucky Health News

One of the most striking measures of the pandemic is the decline in life expectancy from 2019 to 2020, the year the novel coronavirus hit; it declined more in Kentucky than it did in most other states.

Nationally, life expectancy declined from 78.8 years in 2019 to 77 in 2020, a drop of 1.8 years. Kentucky's decline was a full two years, from 75.5 to 73.5, according to a report from the National Center for Health Statistics. 

Kentucky's decline in life expectancy tied for 10th largest in the nation, with Indiana, Alabama, South Carolina and Michigan. The greatest decline, in New York, was three years, followed by the District of Columbia, Louisiana, New Jersey, Arizona, Mississippi, New Mexico, Illinois (2.2 years) and Texas.

Among other neighboring states, Arkansas' life expectancy fell 1.9 years, Tennessee 1.8, Missouri 1.8, West Virginia 1.7, Ohio 1.6, Virginia 1.5, and North Carolina 1.5.

Kentucky's 2020 life expectancy of 73.5 years ranks 47th in the nation. Below it are Alabama, 73.2; Louisiana, 73.1; West Virginia, 72.8; and Mississippi, 71.9.

Among other neighboring states, the 2020 life expectancy is 73.8 in Arkansas and Tennessee, 75 in Indiana, 75.1 in Missouri, 75.3 in Ohio, 76.1 in North Carolina, 76.8 in Illinois and 77.6 in Virginia. Hawaii has the highest life expectancy, 80.7, and had the smallest decline in 2020, only 0.2 years.

A healthier diet could add years to your life, study says: more than a decade in your 20s, and eight or nine years even at age 60

Graph by University of Bergen researchers, adapted by Kentucky Health News; click on it to enlarge.

A young adult in the U.S. can add more than a decade to their life expectancy by switching from a typical Western diet to a one that includes more legumes, whole grains, and nuts and less red and processed meat. Older people would also benefit from these changes, though not as much as younger individuals. 

Researchers at the University of Bergen in Norway used data from the Global Burden of Diseases study to build a model that can instantly estimate how various dietary changes affect life expectancy. The study is published in the journal PLOS Medicine, and the model is a publicly available tool called the Food4HealthyLife Calculator.

For young adults in the U.S., the model estimates that a sustained change from a typical Western diet to the optimal diet beginning at age 20 would increase life expectancy by more than a decade for women and men. Changing at age 60 years could still increase life expectancy by eight years for women and almost nine years for men, and even 80-year-olds could gain over three years.

The study estimated gains in life expectancy from eating more or less of various types of foods, and found that the largest gains came from eating more legumes, whole grains and nuts, and less red and processed meat.

“Research until now has shown health benefits associated with separate food groups or specific diet patterns but given limited information on the health impact of other diet changes,” said Lars Fadnes, lead author of the study. “Our modeling methodology has bridged this gap.”

Substance abuse drives decrease in life expectancy in U.S., Ky.

Charts from report show impact of drug overdoses; ages 45-54 showed an increase almost as steep.

By Al Cross
Kentucky Health News

Americans are dying younger, and Kentucky is a big part of that.

The most basic measurement of a population's health, life expectancy at birth, has decreased in the United States for three straight years, and in Kentucky for four. The leading cause is drug overdoses, but there are many other factors.

In 2000, Kentucky had a mortality rate of 425 deaths per 100,000 people; in 2017, the rate was 512 per 100,000, an increase of 20 percent. Most of that increase, 14.7 percentage points, occurred from 2010 to 2017, according to a study published in the Journal of the American Medical Association.

Eight states had greater increases: New Hampshire, 23.3%; West Virginia, 23%; Ohio, 21.6% Maine, 20.7%; Vermont, 19.9%; New Mexico, 17.5%; South Dakota, 15.5%; and Indiana, 14.8%.

For a larger version of any image, click on it.

The study calculated the "excess deaths" caused in 2010-17 by the increase in midlife mortality, defined as deaths of people aged 25 to 64. It said there were 1,524 excess deaths in Kentucky, 1,839 in Indiana, 3,179 in Pennsylvania (where the mortality rate rose 14.4%) and 4,730 in Ohio. The study report said higher midlife mortality in 2010-17 "was associated with an estimated 33,307 excess U.S. deaths, 32.8% of which occurred in four Ohio Valley states."

The report said, "The increase in opioid-related deaths is only part of a more complicated phenomenon and does not fully explain the increase in midlife mortality rates from other causes, such as alcoholic liver disease or suicides (85.2% of which involve firearms or other non-poisoning methods.) . . . Two recent studies estimated that drug overdoses accounted for 15% or less of the gap in life expectancy between the United States and other high-income countries in 2013 and 2014, respectively."

Other possible causes include high rates of tobacco use (including effects that linger despite lower smoking rates), obesity and socioeconomic factors: "substantial job losses in manufacturing and other sectors, contraction of the middle class, wage stagnation, and reduced inter-generational mobility. Income inequality widened, surpassing levels in other countries, concurrent with the deepening U.S. health disadvantage. . . . Increases in death rates were concentrated in areas with a history of economic challenges, such as rural U.S. areas and the industrial Midwest."

Dr. Steven H. Woolf

The study was done by Dr. Steven Woolf of Virginia Commonwealth University in Richmond and Dr. Heidi Schoomaker of Eastern Virginia Medical School in Norfolk.

"We found increases in 35 causes of death," Woolf told MedicalResearch.com. "An increase in mortality spanning 35 causes of death is difficult to blame on a single cause, such as the opioid epidemic or obesity. The pervasive trend suggests a systemic cause, something distinct that is causing this to occur in the United States and not other wealthy nations. . . . Job losses in manufacturing and other sectors, stagnant incomes, and widening income inequality could contribute to poor health in multiple ways and would explain the disproportionate impact we observed in the Rust Belt and other areas hit hard by the economy. This suggests that, while it is important to treat the 'symptoms' of this trend (addressing drug abuse, the obesity epidemic, etc.), social and economic policies to improve education, create good jobs, and invest in communities may be even more important in reversing this trend. If we fail to act, the trend is likely to continue, and that will mean that our children will live shorter lives than ours."

Fewer and fewer Kentuckians over the past decade have told pollsters that their general health is very good or excellent

The number of Kentucky adults who say they're in very good or excellent health has gradually declined over the last decade, from almost half to only two-fifths.

That was among the findings of the Kentucky Health Issues Poll, co-sponsored by the Foundation for a Healthy Kentucky. "The decline is largely among those adults living on higher incomes, although lower-income Kentucky adults consistently report poorer levels of health," the foundation said in a press release.

"Nationally and in Kentucky, the opioid epidemic continues to take a major toll on health and life expectancy across income levels," said Ben Chandler, president and CEO of the foundation. "Cancer, heart disease and diabetes also shorten lives and reduce quality of life in Kentucky. In many cases, these diseases are completely preventable. But it's often the case that social and financial circumstances make healthier choices far more difficult for people living on low wages."

In the poll, 40 percent of adults said their general health was excellent or very good. That was virtually the same as last year's 39 percent; the poll's error margin is plus or minus 2.5 percentage points. But in 2008, the share reporting excellent or very good health was 49 percent. It declined steadily through 2013, improved a bit through 2016, then fell in 2017.

In that year, 1,468 Kentuckians died of drug overdoses, the foundation noted, adding that "Kentucky also has the highest rates of cancer incidence and deaths, and some of the highest rates of heart disease and diabetes in the country."

The recent decline in reported health status has been steeper among people whose incomes are least double the federal poverty level. In 2008, 66 percent of higher-income people reported very good or excellent health; after six years ranging from 55 to 60 percent, the share has fallen the last three years, hitting a low of 49 percent in 2018.

Among people with incomes below 200 percent of the poverty level, reported health status has fluctuated relatively little; it hit a low of percent in 2017 but rose to 30 percent in 2018. The difference is not statistically significant, because that smaller sample has a larger margin of error.

"We have a dual issues of declining higher-income population health and the inability to improve health among those living on low incomes," Chandler said. "These facts must sharpen the focus of policymakers and health advocates to support what works for these populations. Those include smoke-free and tobacco-free laws and higher tobacco taxes, improving nutrition and increasing physical activity in schools, and reducing the cost and improving access to preventive health screenings and substance use treatment."

Seven counties in Southern Kentucky stand out as 'Bright Spots' in study, pointing the way to healthier communities

By Melissa Patrick
Kentucky Health News

Nine counties in Appalachian Kentucky have been recognized as "bright spots" when it comes to health, and seven of them adjoin in Southern Kentucky: Green, Adair, Russell, Wayne, McCreary, Pulaski and Lincoln. The other two counties were Lewis and Morgan.

"The Bright Spots project offers hope and a path forward to a healthier Appalachian Kentucky," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said in a news release. "Congratulations to the hardworking leaders in the nine Kentucky counties that have formed strong, cross-sector coalitions to address pressing health issues in their communities."

The study, which looked for Appalachian counties that had better than expected health outcomes given their resources, analyzed 19 health indicators in each of the 420 Appalachian counties and identified 42 as Bright Spots.

The goal of the research was to to identify successful activities, programs and policies that other struggling communities could replicate. A report is scheduled to be released later this year to identify them. The study was sponsored by the foundation, the Appalachian Regional Commission and the Robert Wood Johnson Foundation.

All the adjoining Bright Spots counties except Lincoln are served by the Lake Cumberland District Health Department. Its health education director, Tracy Aaron, told Kentucky Health News that improving the district's health has been a group effort, and each county has a health coalition made up of numerous organizations, agencies and individuals that meets monthly to choose what health issues they want to address and to then create plans to work on them.

"Our communities are rural and have limited resources, so we all work together to identify and leverage resources," she said in an e-mail. "Many times we may facilitate the discussion around health and improving the health of the community, but we are very fortunate to have dedicated organizations and individuals [working with us] as we continue to improve the health of people that live in Lake Cumberland."

McCreary and Wayne counties were part of a 10-county case study that took a deeper dive into what they were doing to improve the heath of their citizens, despite their many challenges. Both of these counties were named "Healthy Kentucky Policy Champions" by the foundation, citing the stuidies.

"What's happening in Wayne and McCreary counties is changing our understanding of what is possible for health in these and other Appalachian counties," Chandler said in the release announcing the awards. "They show us that there's always somewhere to start when working to improve health, and that dedicated individuals volunteering and working together with a few focused community leaders can change health outcomes for the better."

The report says Wayne County was one of three in the 10 case studies that stood out "for both the range of outcomes that were better than expected and the extent to which the outcomes exceeded expectations." The county performed better than expected on 16 of the 19 measured health outcomes, falling short in the areas of obesity, physically bad days and opioid prescriptions.

Cover page of report section on Wayne County

The Wayne County Health Department, part of the district health department, and the local office of the Cooperative Extension Service play "critical roles in improving community health," the report said.

It noted the department's program to increase access to healthy, local foods; its diabetes education work; and its strong HANDS (Health Access Nurturing Development Services) program, a voluntary home-visitation program for new and expectant parents, which the researchers say could be partly responsible for lower-than-expected rates of infant mortality and low birth weight.

"Wayne County’s strong community partnerships and social connections, integration of health services, and focus on healthy foods, are likely contributing to the better-than-expected health outcomes," the report says.

The county performed 36 percent better than expected for poisoning deaths, including drug overdoses; 34 percent better than expected for stroke deaths, 30 percent better than expected for heart disease hospitalization; 26 percent better than expected for the percentage of Medicare patients with depression; and 25 percent better than expected for years of potential life lost.

For example, the study found that 35.2 people per 100,000 in Wayne County actually died from a stroke, but when using a statistical model that factored in barriers to good health, the predicted stroke-death rate was 53.7 per 100,000. (The county's population is about 21,000.)

Cover page of report section on McCreary County

McCreary County, which has about 18,000 people, performed better than expected on 14 of the 19 measured health outcomes. It fell short in mentally bad days, suicide, diabetes, physically bad days and opioid prescriptions.

The report says the county has strong local volunteer organizations and emergency medical services, and a library that connects residents to health and social services.

Researchers found that the county performed 40 percent better than expected for injury deaths, 37 percent better than expected for stroke deaths; 34 percent better than expected for poisoning deaths; 19 percent better than expected for percentage of Medicare enrollees with depression; and 15 percent better than expected for years of potential life lost.

The report adds that local practices contributing to the overall health in McCreary County include intra-county cooperation and resource sharing, sustainable, community-focused nonprofit organizations, a strong integration of health services and systems, a shared value for health in the community and community engagement and dedicated local leaders.

Among other things, the report notes a strong health education program run by the district health department, which gives school-age children information on reproductive health, tobacco-use cessation and risky-behavior prevention. It also provides a health consultant for children and supports preventive initiatives like farmers' markets and smoke-free restaurants.

Among the other four Lake Cumberland counties named Bright Spots:

• Adair was 41 percent better than expected for poisoning and overdose deaths; 36 percent better than expected for unintentional injury deaths; and 26 percent better than expected for deaths from chronic obstructive pulmonary disease.
• Green scored 34 percent better than expected for poisoning and overdose deaths, and 31 percent better than expected for both years of potential life lost and opioid prescriptions as a percentage of Part D Medicare claims.
• Russell was 36 percent better than expected for heart-disease hospitalizations; 33 percent better than expected for opioid prescriptions as a percentage of Part D Medicare claims; and 18 percent better than expected for diabetes.
• Pulaski scored 39 percent better than expected for poisoning and overdose deaths; 26 percent better than expected for unintentional injury deaths; and 20 percent better than expected for stroke deaths.

The researchers report that while the counties in the case studies offered individual approaches to address their local health challenges, there were common themes, including: community leaders engagement, cross-sector collaborations, resource sharing, a commitment from local health care providers, active faith communities and grassroots initiatives to combat substance abuse.

In addition to a community of people with a shared value for health, the report says the Bright Spot communities also benefited from "anchor institutions," like schools, businesses, churches and hospitals that worked together to improve the health of their communities.

"The Bright Spots research is a roadmap for struggling Appalachian communities, showing how building strong coalitions and focusing resources in particular on reducing teen births and smoking, increasing physical activity and treating and preventing substance abuse can have an outsized impact on improving local health," Chandler said. "It also is a call to action for policy makers, funders and advocates to support laws and programs that are proven effective in addressing these issues."

The 10 case studies are at https://www.healthy-ky.org/res/images/resources/BrightSpotsCaseStudiesJuly2018.pdf. Data for all 420 Appalachian counties are at https://www.arc.gov/research/researchreportdetails.asp?REPORT_ID=144. The data can be mapped at https://healthinappalachia.org/.

This is the second report in the "Creating a Culture of Health in Appalachia: Disparities and Bright Spots" research initiative. The first report focused on health disparities in the region.

People with positive attitudes about aging live longer and have better health; Kentucky seniors' health is ranked 48th in nation

How you think about growing old can influence how well you age, says a growing body of scientific research and global data collected and analyzed by nonprofit journalism organization Orb Media. That's especially relevant in Kentucky, where seniors' health ranks 48th among the 50 states, according to America's Health Rankings.

"Individuals with a positive attitude towards old age are likely to live longer and in better health than those with a negative attitude. And those with a negative view of aging are more likely to suffer a heart attack, a stroke or die several years sooner," Jim Rendon and Olufemi Terry write for Orb. "Older people in countries with low levels of respect for the elderly are at risk for worse mental and physical health and higher levels of poverty."

Projected percentage of country population over 65 in 2050. Source: United
Nations World Population Prospects. (Orb Media graphic)

Why does it matter?

Orb reports that if population trends continue, by 2050 nearly one of six people in the world will be over 65, and close to half a billion will be older than 80. In 2050, seniors would make up nearly 16 percent of the world's population, compared to today's 8 percent.

In the U.S., the Census Bureau estimates that one in five people will be over the age of 65 by 2030, and by 2035, seniors will outnumber children younger than 18.

Those are the basic figures, reflecting quantity, but what about quality of life for those people? Research shows that a simple shift in attitude can make a difference in how well we age, especially in a world that often has negative views about growing older.

A World Health Organization analysis found that 60 percent of people surveyed across 57 countries reported relatively low levels of respect for older people. A separate Orb analysis found that the level of respect for seniors varied "significantly from country to country."

Of the 58 countries ranked in the Orb study -- in order of how they respect their elderly, with 1 being "very low" and 5 being "very high" -- the United States ranked 50th, scoring 3.29.

Becca Levy, a professor of epidemiology at the Yale School of Public Health, and a leading researcher in the field, has found "Those with positive views about old age live longer and age better," Orb reports. "They are less likely to be depressed or anxious, and they show increased well-being and recover more quickly from disability. They also are less likely to develop dementia and the markers of Alzheimer’s disease."

"In one study, Levy found that Americans with more positive views on aging who were tracked over decades lived 7.5 years longer than those with negative views," Orb reports, adding that studies in Germany and Australia have found similar results. In addition, other studies have shown that "the cells of those who have more positive views of the elderly actually aged more slowly than those who had negative views."

Levy told Orb that people with negative views of aging have higher levels of stress, which has been linked to a range of health problems. She added that those with more positive views of aging are also more likely to exercise, eat a balanced diet and go to the doctor. She also said people can decide for themselves how they think about aging, and that her research has found that people who who watch less TV, participate less in social media, and have more resistant personalities are more likely to hold more positive views of aging.

Study finds that maintaining five healthy habits could add a decade to your life, but only 8 percent of Americans follow all five

Harvard T.H. Chan School of Public Health photo

Americans could add about a decade to their lives, on average, if they maintained five healthy habits: not smoking, eating healthy, exercising regularly, maintaining a healthy weight and drinking in moderation, according to a new study.

It may sound easy enough, but the study also found that fewer people are adhering to these healthy habits: 8 percent between 2001 to 2006, down from 15 percent between 1988 to 1992. Researchers say the decline is "driven primarily by the increasing prevalence of obesity."

Americans also have a shorter average life expectancy than almost all other wealthy nations, ranking 31st in the world for life expectancy in 2015, says a news release about the study.

At this time, 50-year-old American women can expect to live another 33 years and men another 30 years. The study predicts those numbers would jump to 43 years for men and 38 years for women who maintained all five healthy habits.It predicted the additional life expectancy of those who didn't adopt any of the habits would be 29 and 25.5, respectively.

"In other words, women who maintained all five healthy habits gained, on average, 14 years of life, and men who did so gained 12 years, compared with those who didn’t maintain healthy habits," the release says.

The study at the Harvard T.H. Chan School of Public Health, published in the journal Circulation, looked at 34 years of data from 78,865 women in the Nurses’ Health Study and 27 years of data from 44,354 men in the Health Professionals Follow-up Study.

The researchers found that those who had the five healthy habits were 74 percent less likely to die during the study period, compared to those who didn't follow any of the healthy habits -- and 82 percent were less likely to die from heart disease or stroke, and 65 percent less likely to die from cancer.

The study defined "regular" exercise as moderate or vigorous activity for at least 30 minutes a day. Moderate drinking was defined as no more than one alcoholic drink per day for women, and no more than two per day for men. And a "healthy" diet was scored by giving points to those who ate vegetables, fruits, whole grains, beans, fish and poultry and "good" fats. It also gave points to those with diets low in sugar, sodium and red meat.

The study found that adopting any one of the healthy lifestyles resulted in an increase in life expectancy, and that adopting all five produced the most additional years of life. (Click on chart for larger version.)

"This study underscores the importance of following healthy lifestyle habits for improving longevity in the U.S. population,” senior author Frank Hu, chair of nutrition at the Chan School, said in the release. “However, adherence to healthy lifestyle habits is very low. Therefore, public policies should put more emphasis on creating healthy food, built, and social environments to support and promote healthy diet and lifestyles.”

County Health Rankings show movement among some counties; rankings are blunt instruments meant to spur local action

By Melissa Patrick
Kentucky Health News

The latest County Health Rankings report for Kentucky shows little change among the top and bottom quarters of the standings, but a good deal of movement among counties in the middle -- in both directions.

The rankings look at health outcomes, gauged by life expectancy and measures of quality of life; and health factors, such as access to physicians and areas to exercise, tobacco use, children living in poverty, violent crime, long commutes and other environmental factors.

The rankings compare a state's counties against each other without comparison to national data, so when one county moves up, another moves down.

In health outcomes, 18 of the state's 120 counties moved up at least 10 notches since last year, and another 18 moved down by at least 10 slots. In health factors, about 10 counties improved at least 10 notches and 11 dropped by at least 10.

Most counties showed some shift in the rankings, but the differences may be so small they they are statistically insignificant. So, the University of Wisconsin Population Health Institute emphasizes a county's quarter (statistically, a "quartile" of 30 counties) as the best overall indicator of its health status. The rankings should be viewed more as a general categorization of a county's health status than to make specific comparisons with counties that are relatively close in the rankings.

The bottom quartile for both health outcomes and factors continues to be almost entirely Appalachian counties, with the only exceptions being Fulton County, in the Mississippi Delta at the state's western tip, which falls into the bottom quartile for both measures. In northern Kentucky, Bracken County was in the bottom quartile for outcomes, and Carroll County was in the bottom for health factors.

Oldham and Boone, two of Kentucky's wealthiest counties, continue to be the top two for health outcomes, as they have been since the rankings began in 2011. No. 3 Shelby County, which borders Oldham, has been in the top five since 2013. Adjoining Spencer County is ranked fourth. It adjoins Bullitt County, which ranked fifth. All of these counties are either in or near major metropolitan areas, which typically have better access to medical care as well as higher incomes.

Bullitt has shown considerable improvement recently. It jumped to sixth in outcomes 2016, from 27th in 2015, and was in the top 10 last year.

Breathitt, Wolfe and Owsley counties, in that order, have been the bottom three in outcomes for the past three years. Leslie and Perry counties make up the rest of the bottom five this year. All are in the East Kentucky Coalfield.

Oldham and Boone are also the top two counties in health factors, and have been since 2015. They have been in the top five since 2011. Woodford, Campbell and Spencer are currently ranked third, fourth and fifth, respectively.

The bottom five counties for health factors are Clay, Harlan, Knox, Leslie and McCreary, all in the eastern coalfield.

A few counties show big changes

Since 2011, some counties have seen big improvements in their rankings, while others have declined and others seem to bounce back and forth, perhaps because they are small and thus more likely to have their rankings changed from year to year.

Hickman is an example of how a county's rankings can fluctuate, and why it's important to look at multi-year trends. Last year, the Mississippi River county ranked 23rd in outcomes, up 53 spots from the initial 2011 report -- but it fell 20 notches this year, to 43rd. Its health-factor ranking also fell 20 places, to 57th, after improving to 23rd in 2016.

Henderson County also saw a surge of improvement in both of last year's rankings, only to drop back to some of its lowest rankings in outcomes and factors this year. The northwestern county dropped 31 outcome spots, to 70th from 39th last year, and 15 factor spots, to 55th from last year's 40th.

One of this year's success stories is Garrard County, which saw a 25-notch jump in outcomes, moving to 39th from 64th last year -- its worst ranking for this measure since the rankings began. The southern Bluegrass county also saw an improvement in its health-factor ranking, to 38th from 54th last year. It had ranked between 51st and 65th in health factors since 2013.

Christian County improved 22 notches in factors and and 18 places in outcomes over last year.

Bracken saw the greatest drop in health outcomes this year, falling 43 notches to 98th from last year's 55th. Nevertheless, it showed an improvement of 10 notches in the health-factor ranking, to 33rd.

Metcalfe County dropped 30 notches in outcomes, and 18 places in factors; Webster dropped 24 spots in outcomes and 13 spots in factors.

The report charges Kentucky counties to take this data and turn it into action, and offers specific strategies to do so on its What Works for Health website. Some of the suggestions include ways to invest in education, ways to improve employment along with improved family and social supports, ways to increase access to comprehensive sex education in both schools and communities and ways to increase social connections in communities.

The report also reminds counties to look at the health outcomes and health factors in their communities related to the racial and ethnic backgrounds of their residents, noting that these numbers are often masked when we only look at the differences based on place. For example, the report notes that 14 percent of babies born to black mothers in Kentucky are born with a low birthweight, compared to 8 percent of babies born to white mothers or 7 percent born to Hispanic mothers.

Click here to view an interactive map of your county's rankings, with details for each measurement.

Appalachians die sooner than 20 years ago, and region has a higher infant-death rate than U.S.; both attributed to smoking

By Melissa Patrick
Kentucky Health News

People who live in Appalachia are dying sooner than two decades ago, and the region has a higher infant death rate compared to the rest of the nation. A new study blames both largely on the region's high smoking rate, as well as its other bad health habits.

“What this report shows is the extreme damage that tobacco is causing our people, and how we are getting hammered by it worse than any other place in this country," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky.

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The study, published in the academic journal Health Affairs, compared infant mortality and life expectancy disparities in Appalachia to the rest of the United States between 1990 and 2013, using national vital statistics data.

It found that Appalachia and the rest of the nation had similar rates for infant morality and life expectancy in the 1990s, but by 2013 infant mortality was 16 percent higher in Appalachia, and adults in the region were living 2.4 fewer years than people who lived in the rest of the country: 76.9 and 79.3 years, respectively.

The study attributes these widening gaps to "persistent or increasing disparities in general living standards and health-risk behaviors such as adult smoking, smoking during pregnancy, obesity, physical inactivity, and heavy consumption of alcohol."

Heart disease, lung cancer and other respiratory diseases were among the leading causes of death in the Appalachian region during the study period, all conditions that can be caused by smoking.

"We are the cancer-mortality capital of the nation right now, and we just cannot let that stand," Chandler said. "If we truly want to change Kentucky’s health statistics, the single most effective thing we can do is to reduce our smoking rates."

Kentucky has the highest smoking rate in the nation, 26 percent of adults. But smoking affects children, even those who don't smoke. Smoking during pregnancy is a risk factor for both birth defects and SIDS, according to the federal Centers for Disease Control and Prevention.

While the number of Kentucky mothers who smoked during pregnancy dropped from 26 percent in 2006 to almost 20 percent in 2015, this is still significantly higher than the national rate of 8 percent. Overall smoking rates and pregnancy smoking rates are highest in the state's Appalachian counties.

The report says the higher rates of birth defects and Sudden Infant Death Syndrome deaths in Appalachia accounted for 60 percent of the difference in infant mortality between the region and the rest of the country in 2009-13. Other contributors included diabetes, kidney diseases, suicide, unintentional injuries (such as traffic accidents) and drug overdoses.

There could be other causes for the increasing disparity. The researchers said it is possible that more affluent, healthier Appalachian residents may have migrated to more urban and affluent areas of the U.S., thus increasing the health and economic inequalities between the region and the rest of the nation.

They called for policies that address the region's high smoking rates, high unemployment rates, low education levels, poor access to health care, high obesity rates, transportation and housing issues, and try to increase access to healthy foods, to decrease the current gaps in health outcomes.

“Given the national gains in life expectancy, seeing the increasing disparity between Appalachia and the rest of the United States should serve as a wake-up call,” Rebecca Slifkin, co-author of the study said in a news release. “Many of the reasons for the disparities we observe are due to differences in social determinants of health. We really need new investments to ensure that health is not determined by where one lives. As a society, we invest huge sums in medical care to extend an individual’s life; imagine the gains we could make if similar resources were devoted to public health.”

The study used the 2008 Appalachian Regional Commission definition of Appalachia, which covers 428 counties in 13 states, 54 in Kentucky.

Life expectancy in 13 U.S. counties declined from 1980 to 2014; eight of them are in one contiguous area of Eastern Kentucky

Map by The Washington Post, based on data from University of Wisconsin Institute for Health Metrics and Evaluation

A knot of eight Eastern Kentucky counties (Owsley, Lee, Leslie, Breathitt, Clay, Powell, Estill and Perry) had the greatest decline in life expectancy in the United States from 1980 to 2014.

In other words, babies born in those counties today are expected, on average, to live shorter lives than their parents, based on recent death certificates. That was true in only five other counties: two in Alabama and one each in Oklahoma, Mississippi and Tennessee.

The numbers are in a study by the University of Wisconsin Institute for Health Metrics and Evaluation, published Monday in the journal JAMA Internal Medicine.

The study blamed the declines in life expectancy on poverty, health risks such as smoking and obesity, physical inactivity, and lack of access to health care.

The greatest decline in the U.S. was in Owsley County, where life expectancy in 2014 was 70.2 years, down from 72.4 in 1980. That made it the lowest in Kentucky and sixth lowest in the nation.

"Owsley County Judge-Executive Cale Turner didn’t seem surprised by the findings," Bill Estep reports for the Lexington Herald-Leader. "He ticked off drags on life expectancy the county faces, including a debilitating drug abuse problem; one of the highest poverty rates in the nation; historic lack of access to health care; and high rates of diabetes. Turner said many county residents received better access to health care in recent years with an expansion of Medicaid under the Affordable Care Act. The law hadn’t been in effect long enough to be measured under the study."

Wellness coalition in Perry County, where life expectancy is state's lowest, gets funding from Foundation for a Healthy Ky.

The Foundation for a Healthy Kentucky has funded the Perry County Wellness Coalition's three-year plan to encourage fitness and better nutrition in school-age children, "Kids on the Move!"

The wellness coalition will receive $144,450 from the foundation this year, matched by $124,944 from the community, to increase access to physical activity and provide healthier food options and nutrition education. Perry County has the lowest life expectancy in Kentucky.

"Our children are the most valuable resource we have," said Gerry Roll, executive director of the Foundation for Appalachian Kentucky, which is serving as fiscal agent for the coalition. "It's the best investment we can make as a community partner."

The health coalition will work with local schools to implement physical activity and nutrition-policy changes, collaborate with local farmers' markets for a strong farm-to-school component, and coordinate with other community agencies to create a lasting and collective impact.

The project also will implement best-practices nutrition and exercise programs in schools, support community gardens, summer feeding programs, and a "Farmacy" program to increase the purchase of healthier produce at farmers' markets and local grocery stores, among other changes to be coordinated by the agencies in the coalition.

The Appalachian Regional Healthcare hospital in Hazard will be the administrative hub for the coalition, providing leadership and sharing its expertise in promoting community health. "We have already begun these efforts by providing fitness fairs and health screenings to over 20 schools in our service area and reaching a little more than 2,500 middle school and high school age kids this year alone," said Hazard ARH Community CEO Dan Stone said.

The coalition is among seven Kentucky communities funded by the foundation's "Investing in Kentucky's Future" initiative, which is spending $3 million over five years to fund communities working to improve the health of their school-aged children. The other groups are in Breathitt, Clinton, Grant, Jefferson and McLean counties, and in Boyd and Greenup counties. Perry County was in the original announcement and recently completed its detailed plan. It shares with Breathitt and Wolfe counties the state's lowest life expectancy, 70 years.

Kentucky's life expectancy, a basic measure of health status, is 76; it fluctuates as many as 9 years from county to county

By Danielle Ray

Kentucky Health News

A life lived in Kentucky is expected to vary up to nine years in length depending on the county in which it's spent.

Life expectancy is perhaps the most basic measure of a community's overall health. Health researchers say life expectancy is driven by a complex web of factors that influence health: opportunities for education and jobs, safe and affordable housing, availability of nutritious food and places for physical activity, and access to health care, child care and social services.

The state average is 76 years. Twenty-four of 120 Kentucky counties exceed that figure, mostly in the counties near Louisville, Lexington, Frankfort, Bardstown, Elizabethtown, Owensboro and Bowling Green, with a few exceptions. Oldham County has the state's highest life expectancy, 79 years. Nine counties (Fayette, Jessamine, Scott, Garrard, Shelby, Bullitt, Meade, Boone, and Calloway) share a life expectancy of 78.

Differences become more apparent moving east along the Bert T. Combs Mountain Parkway and down its KY 15 extension. In general, the starkest comparisons in the state exist between the metropolitan areas of Louisville and Lexington versus southeastern Kentucky counties. Only one Eastern Kentucky county, Morgan, has a life expectancy equal to the state’s. Others range from 70 (Perry, Breathitt and Wolfe counties) to 75, mostly found in counties in northeastern Kentucky.

Eastern Kentucky counties are not the only ones with below-average numbers. Other counties ouitside that region with life expectancies of 74 or below are Fulton, Webster, Muhlenberg, Gallatin, Carroll, Casey, Monroe, Metcalfe, Cumberland and Clinton.

The numbers are on a Kentucky life expectancy map released Monday by researchers at the Virginia Commonwealth University Center on Society and Health and the Robert Wood Johnson Foundation. It shows that chances to lead a long and healthy life can vary dramatically by county.

“Health differences between communities are rarely due to a single cause,” the researchers said in a press release. “The health differences shown in these maps aren’t unique to one area. We see them in big cities, small towns, and rural areas across America,” said Derek Chapman, the VCU center’s associate director for research.

The map is the latest effort by the Robert Wood Johnson Foundation to raise public awareness of the many factors that shape health, particularly social and economic factors.

Another is the County Health Rankings, done annually by the University of Wisconsin Population Health Institute. The rankings don’t provide a comprehensive explanation for life expectancy, but they provide helpful correlations.

For example, Harlan County, with a life expectancy five years below the average, ranks 117^th in overall health outcomes and last in health factors. The county has rates of smoking, obesity and teen births that are higher than statewide. It also has less access to exercise opportunities. The rankings show that the county's unemployment rate is nearly 14 percent, more than double the state's. In addition, 43 percent of Harlan County children live in poverty, compared to the statewide figure, 26 percent.

The complete rankings are available at the County Health Rankings web site.

The state Department for Public Health says it and partners have several efforts underway to tackle the many factors that shape health:

•          Promotion of farmers’ markets and their acceptance of federal food assistance benefits such as SNAP, WIC and Senior Farmers’ Market Nutrition Program Vouchers, incentive programs to help with affordability and community outreach.

•          Promotion of walking and walkability by providing communities with targeted training and technical assistance to develop pedestrian plans.

•          Protecting youth from tobacco exposure through the “100 percent Tobacco Free Schools” program, which provides guidance to districts that wish to reduce tobacco use by students and staff.

Experts say local efforts are needed, too. “We must build a society where everyone, no matter where they live, the color of their skin, their financial or family situation, has the opportunity to lead a productive, healthy life,” said RWJF President and CEO Risa Lavizzo-Mourey.  “There’s no one-size-fits-all solution. Each community must chart its own course, and every person has a role to play in achieving better health in their homes, their communities, their schools and their workplaces.”

Women in small-town America aren't living as long as before; alcohol, drugs, food, housing, jobs, education, pollution to blame

By Trudy Lieberman
Rural Health News Service

Those of us who grew up in small rural communities in the 1950s and '60s expected to have longer life spans than our parents.

The trends were in our favor. White women born in 1900 could expect to live, on average, just shy of 49 years; white men 46.6 years. Those were our grandparents and our neighbors. By 1950, life expectancy had climbed to 72 years for white women born that year and 66.5 for white men. By 2000, life expectancy was still increasing, with female babies expected to live to nearly 80 and males to almost 75.

America was on the rise, jobs were plentiful, antibiotics kept us from dying of strep throat, and polio vaccine kept us out of the iron lung. We thought things would only keep getting better. So I was dismayed to read a story in The Washington Post in April that blew holes in those childhood expectations.

The Post found “white women have been dying prematurely at higher rates since the turn of this century, passing away in their 30s, 40s, and 50s in a slow-motion crisis driven by decaying health in small town-America.”

That “small town America” was where I grew up. I contrasted the Post’s findings to the claims made by all those politicians who have told us we have the best health care in the world and who point to gobs of money lavished on the National Institutes of Health to find new cures and to hospitals promoting their latest imaging machines.

The Post found that since 2000, the health of all white women has declined, but the trend is most pronounced in rural areas. In 2000, for every 100,000 women in their late 40s living in rural areas, 228 died. Today it’s 296.

If the U.S. really has the best healthcare, why are women dying in their prime, reversing the gains we’ve made since I was a kid? After all, mortality rates are a key measure of the health of a nation’s population.

Post reporters found, however, that those dismal stats probably have less to do with health care – which we like to define today as the latest and greatest technology and insurance coverage albeit with high deductibles – and more to do with what health experts call “the social determinants of health,” such basics as food, housing, employment, air quality, and education.

Landmark studies examining the health of British civil servants who all had access to health insurance under Britain’s National Health Service have found over the years that those at the lowest job levels had worse health outcomes. Some of those outcomes were related to things like work climate and social influences outside work like stress and job uncertainty.

In its analysis, the Post found that the benefits of health interventions that increase longevity, things like taking drugs to lower cholesterol and the risk of heart disease, are being overwhelmed by increased opioid use, heavy drinking, smoking and obesity.

Some researchers have speculated that such destructive health behaviors may stem from people’s struggles to find jobs in small communities and the “dashed expectations” hypothesis. White people today are more pessimistic about their opportunities to advance in life than their parents and grandparents were. They are also more pessimistic than their black and Hispanic contemporaries.

A 42-year-old Bakersfield, California, woman who was addicted to painkillers for a decade explained it this way: “This can be a very stifling place. It’s culturally barren,” she said. There is no place where children can go and see what it’s like to be somewhere else, to be someone else. At first, the drugs are an escape from your problems, from this place, and then you’re trapped,” she told Post reporters.

I recently heard U.S. Surgeon General Dr. Vivek Murthy talk about his upcoming report on substance use. About 2.2 million people need help, he said, but only about one million are actually getting it. Murthy wants his report to have consequences as far reaching as the 1964 surgeon general’s report linking tobacco use to lung cancer. In 1964, Murthy noted, 42 percent of Americans smoked; today fewer than 17 percent do.

The Post story concludes that the lethal habits responsible for increasing mortality rates are cresting in small cities where the biggest manufacturer has moved overseas or in families broken by divorce or substance abuse or in the mind and body of someone doing poorly and just barely hanging on.

The Surgeon General has taken on an enormous task, but his efforts just might help the nation move its life expectancy trends back in the right direction.

What do you think is causing poor health in your community? Write to Trudy at trudy.lieberman@gmail.com.

Rural Health News Service is funded by a grant from The Commonwealth Fund and distributed by the Nebraska Press Association.

Health reform should make Medicaid and Medicare more interested in preventing chronic diseases in young, expert says

Dr. Wayne Myers

While some rural areas may not have enough doctors (or those who accept Medicaid patients) to treat new patients generated by federal health reform, the key to healthy living is more education, not more physicians, rural medical expert Dr. Wayne Myers opines in The Rural Monitor. As an example, Myers points to Hazard and Perry County, where he once worked. The Appalachian county leads the nation in shortest average life span for women (72.65 years) and is third shortest for men (66.52 years) despite having an abundance of doctors and health facilities. The reason, Myers says, is bad habits that lead to unhealthy lives, something no amount of medical attention can cure.

"In Perry County, as in much of America, medical care is losing to unhealthy behavior," Myers writes. "Clinicians aren’t trained, nor is our clinical system structured, to accomplish changes in long-term cultural behavior, or to respond to the needs of groups of people. Certainly the 15-to-20-minute acute-care visit is a poor situation to try to work with a person on diet, level of activity, his/her addictions. We can’t modify family and social patterns with tools developed to treat strep throat, sprained ankles or breast cancer."

Myers, who headed the federal and Kentucky rural-health offices, said the solution is education at the local level, with "a lot more health educators, community health nurses and nutrition educators" that are trained within the community. Areas with community colleges can build partnerships with schools to receive training, he suggests. His hope is that the Patient Protection and Affordable Care Act will provide the resources and motivation necessary to bring about changes.

As the law generates enrollees, the Center for Medicare and Medicaid Services’ "book of business will shift from old people on Medicare toward younger people on Medicaid," he writes. "When the main business of CMS was Medicare, the rational business strategy was to seek the most economical quality care for those with only a few years to live. As the business shifts toward Medicaid and subsidized private insurance customers, the rational business strategy for CMS shifts toward preventing chronic disease. From an insurer’s point of view, a 70-year-old obese hypertensive diabetic is a self-limited problem. She’ll die soon. A 30-year-old with the same diagnoses will be a very long-term financial drain.  It will be good business for CMS to keep their 'covered lives' healthy."

This, he said, is kind of forward thinking we need to ensure young Americans get healthy. "We need new approaches to keeping people healthy, instead of trying to heal them after they get sick," Myers writes. "Clinicians can’t change the way people live and raise their kids, even if some of the choices the parents make turn out to be pretty dangerous for the kids. These are sensitive life and death issues. We need to tackle them." (Read more)