More on Funding of Biomedical Research

In this post, I tap on a burning issue that is immensely important to people like me who are working full time in biomedical research; funding. Despite the hurdles it faces to improve care, clinical medicine generates direct income (and profit) through the patient care it delivers. Such income pays physicians, nurses, hospital teams, overheads etc… Unlike clinical medicine, biomedical research is mechanism that requires tons of money, but it is always viewed as a national investment for future economic growth.

The National Institutes of Health (NIH), the largest funding organization of biomedical research in the world, describes the impact of its work on US economy, and states that:

It directly supported almost half million jobs in medical research in 2012
For every $1 of NIH funding, about $2.21 is generated in local economic growth.
Let’s look at just one example. The U.S. government’s $4 billion investment in the Human Genome Project spurred an estimated $965 billion in economic growth from 1988-2012; a 178-fold return on investment, after adjusting for inflation.

NIH isn't the only US governmental agency that funds biomedical research. Other major agencies include Department of Defense, Department of Homeland Security, and Department of Agriculture, among many others.

However, who decides the dollar amount to be spent by these agencies is the legislative arm in the US; the Congress. Due to the major budget cuts in 2010:

NIH budget was decreased by ~14%
Department of Defense budget was decreased by ~12%
Department of Agriculture budget was decreased by ~20%
What is very shocking is that the Department of Homeland Security budget for biodefense was almost shut down, and decreased by ~91%.

A striking example showing the projected difference between healthcare spending on Parkinson’s Disease versus the research and development (R&D) spending on Parkinson’s Disease is shown in the below figure. While the current funding limits are maintained, the healthcare cost of the 1.5 million Americans with Parkinson’s Disease, with annual incidence of 60k new cases, will jump from $8 billion to $18 billion per year. 

Figure adapted from 10th annual Investment in Research 2012 report by Research!America.

Federal spending on R&D doesn't only support direct biomedical research in the US. In addition to support training programs (predoctoral, doctoral, and postdoctoral levels) and research centers, it also supports research globally through USAID and the NIH’s Fogarty International Center.

More detailed figures can be found in 10th annual Investment in Research 2012 report by Research!America. 

Caloric Content in Restaurant Meals is in Excess of What We Actually Need

To follow up on my latest post, I read another paper was published simultaneously with the paper I discussed in JAMA Internal Medicine studied the food served in restaurants from a different angle. Investigators from the Human Nutrition Research Center on Aging (HNRCA) of Tufts University in Boston studied the energy content in the most commonly purchased foods in a random sample of independent and small-chain restaurants.

Inclusion criteria for a restaurant were: to be a “sit-down” restaurant, within 15 miles from downtown Boston, have a online menu with no nutrition labels. Restaurants were classified according to the number of employees (small <10 employees, large ≥10 employees), and the type of food served (Mexican, American, Chinese etc…), and then randomly selected according to these two categories. The research team led by Dr. Susan Roberts, The director of the Energy Metabolism Laboratory at the HNRCA, selected the 5 most popular entrée choices and their standard side dishes from each restaurant. They included 157 meals representing 42 meal categories from 9 restaurants in the present study.

Due to my inexperience in nutrition labeling and nutrition research methods, the next part is very interesting to me. The authors used the Bomb Calorimeter to estimate the energy content in each meal using the kilocalorie (kcal) as the measuring unit. The food must be grounded into fine powder. I found the following very interesting (and fun) interactive flash video explaining how the Bomb Calorimeter works. 

I embedded this video from its original source in McGraw-Hill.

Back to the paper! So the analysis of the energy content in the sample meals offers interesting results. To set the stage, the authors used the US federally-referenced daily energy requirement (as stated in the CFR Title 21, Volume 2§101.9(d)(9)(i)) to compare their results to it. This value is 2,000 kcal per day.

The mean energy content of all food categories of all the samples and all restaurants was 1327 kcal, which is already >66% of daily energy requirement reference value. The Italian meal categories had the highest mean energy content of 1755 kcal, and the Vietnamese meal categories had the lowest mean energy content of 922 kcal. Interestingly, some of the sample meals provided even more than 100% of the daily energy requirement. This includes; the Mexican Classic Nachos providing 2165 kcal, and the Italian Fettuccini Alfredo [yummy!!] providing 2270 kcal. The authors also found that 75% of individual sampled meals contained at least 50% of the daily energy requirement.

Overall, this study provides overwhelming evidence that “dining out” entails consuming food with energy content more than what our bodies need. One should pay more attention to how many calories are in the meals ordered in restaurants, regardless of its type (fast-food, small chain, or even independent), or cuisine. But this can’t be done without data. Restaurants should provide nutrition labels on their menus to help diners decide what to eat, and advocate for healthy choices.

The study authors concluded:

A national requirement for accurate calorie labeling in all restaurants may discourage menus offering unhealthy portions and would allow consumers to make informed choices about ordering meals that promote weight gain and obesity.

PS: If you are interested to know how many calories your need based on your BMI and Physical Activity Level (PAL), check this link from the Food and Agriculture Organization of the United Nations. 

Soduim Content in Foods is Almost Constant!

No doubt that sodium is an important risk factor for hypertension. The American Heart Association estimates that there are 78 million adults in the US (1 in 3) have high blood pressure. In a workshop organized by the National Heart, Lung, and Blood Institute (NHLBI) on sodium and blood pressure, the report stated

“There is an abundance of scientific evidence demonstrating a direct relationship with sodium intake and blood pressure”.

I came across an interesting article published in JAMA Internal Medicine this week titled “Changes in Sodium Levels in Processed and Restaurant Foods, 2005 to 2011”. Dr. Stephen Havas from Northwestern University Feinberg School of Medicine, and his colleagues collected the sodium content data in processed food from the nutrition facts label in 2005, and recollected the same data for the same food products in 2011.

The main finding with their analysis is that the sodium content in the 402 processed food products declined by only 3.5% over 6 years. On the other hand, the sodium content in 78 fast-food restaurants’ products increased by 2.6%. Table 1 in their paper shows that Caesar salad dressing and Turkey breasts are the top 2 food categories, with highest sodium content in 2005 to 2011. Canned tuna fish, canned tomato, sliced turkey breast, and vegetable soup had the highest decline of the sodium content by about 22%, from 2005 to 2011. For the rest of the processed foods, the sodium content either remained constant or changed by ±2%.

Among the restaurant foods, the sodium content in the French fries increased by 27% from 2005 to 2011. Cheese pizza’s sodium content increased by about 12% in the same period.

The authors outlined in Table 3 the names of some companies that committed to reduce sodium levels in their products. For example, the Domino’s Pizza committed to decrease the sodium content in the smart pizza slice for schools by a third. Wal-Mart committed to reduce sodium by 70% in fresh steaks and roasts.

The authors concluded that 

“It is clear from this analysis that reductions in sodium content in both processed and restaurant foods are both inconsistent and slow”

I think it is a time for the local, state and federal government to look into new ways to enforce sodium content reduction in processed and restaurant foods to alleviate the burden of preventable diseases (like hypertension). This could be similar to what Mayor Michael Bloomberg did by prohibiting the sale of soda cans more than 16 ounces. Although there has been a resistance against the implementation of this bill, public health advocates has long way to go. 

Eating Fish is Associated with Decreased All-Cause Mortality in Older Adults

Mozaffarian and his colleagues published a paper recently in the Annals of Internal Medicine analyzed data from 2692 U.S. adults aged 74 years (±5 years) without prevalent cardiovascular diseases at baseline, who participated in the National Heart, Lung, and Blood Institute (NHLBI)-funded cohort, The Cardiovascular Health Study (CHS). The investigators measured the blood circulating levels of 3 types of long-chain omega-3 polyunsaturated fatty acids (omega-3 PUFAs); eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA). These were measured from the blood that was collected from the participants in 1992. They then followed them longitudinally for 16 years (1992 through 2008) to evaluate the relationship with total and cause-specific mortality and incident fatal or nonfatal CHD and stroke.

The authors found that the individual levels of EPA, DPA, and DHA, and their total levels (omega-3 PUFA) were associated with lower total mortality across three robust models of adjusted Cox proportional hazards models (age, gender, various demographic and co-morbid conditions, and dietary factors):

       The participants in the higher quintile of the total omega-3 PUFAs had 27% lower risk 

       The participants in the higher quintile of EPA had 17% lower risk 

       The participants in the higher quintile of DPA had 23% lower risk

       The participants in the higher quintile of DHA had 20% lower risk

All results were statistically significant with narrow 95% confidence internals.

For cause-specific mortality, and using the same adjustment models of the total mortality risk data, total omega-3 PUFAs, and most of the individual levels of the three subtypes, were associated with cause-specific mortality. Total omega-3 PUFAs was associated with: 

       35% lower risk from cardiovascular mortality

       40% lower risk from coronary heart disease mortality

       45% lower risk from arrhythmic coronary heart disease (CHD) mortality

       28% lower risk from non-arrhythmic CHD mortality

       40% lower risk from stroke mortality

       28% lower risk from total fatal and nonfatal CHD mortality

       17% lower risk from nonfatal myocardial infarction mortality

       25% lower risk from total fatal and nonfatal stroke mortality

       37% lower risk from Ischemic stroke mortality

This data strongly suggests that fish consumption or fish oil supplementation would reduce both total mortality and cause-specific mortality in older adults. The steepest dose-response relationship between the circulating blood levels of omega-3 PUFAs and the decreased risk came from as low as 400 mg per day dietary intake, or two servings of fatty fish per week. This will lead to an average increase of about 2 more years of life in those with higher levels compared to those with lower levels.

My opinion:

This conclusion is supported by the robust statistical analyses with adjustment to many confounders, as well as a quantification of the omega-3 PUFAs rather than the amount of fish intake from Food Frequency Questionnaires (FFQ) or similar tool. Despite some limitations in this paper, it is a landmark paper in supporting increased fish intake to decrease the risk of mortality in older adults. 

Does Epidemiology Matter?

Dr. Michael Lauer, the director of the Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute (NHLBI), recently wrote an editorial in JAMA¹ calling for “creative transformation” of epidemiology research in the United States.  He states:

“…Yet today, despite these extraordinary contributions, the value of epidemiology is questioned. Critics cite excess expense, repudiated findings, studies that offer small incremental knowledge, inability to innovate at reasonable cost, and failure to identify research questions with the greatest merit. At a time of unprecedented budgetary constraints, these critics wonder what epidemiology has done for medical science lately…”.  

Dr. Lauer's comments are crucial especially with the recent budget sequestration to limit United States' federal spending to meet the deficit targets that will likely affect the already decreased funding medical research from the National Institutes of Health (NIH). NIH Director, Dr. Francis Collins, MD, PhD, stated that the NIH already lost 20% of its purchasing power for medical research. Furthermore, such cuts will force the NIH to fund 2300 fewer grants in 2013. Such automatic cuts will be "devastating". Of course I don't have to mention the accompanying economic crisis worldwide. 

Dr. Lauer sums the needed actions into the following key elements:

“… Such transformations will likely include refocused scientific questions, centralized and integrated governance, different types of exposure and outcome measures, and embedded clinical and policy trials…”  

The driving passion behind initiating this academic epidemiology blog is to discuss the latest findings from epidemiologic research of mainly non-communicable diseases that would be of interest to epidemiologists, epidemiologists-in-training, and practicing physicians. Our main focus will be directed towards discussing groundbreaking findings that affects clinical practice, policy-making and lifestyle. 

Dr. Lauer concluded his JAMA editorial: 

“These transformations will also ensure that epidemiology will have much to give, whether lately or later.”

I am sure we will!


References:

1.       Lauer, M. S. (2012) Time for a creative transformation of epidemiology in the United States.   JAMA 308, 1804-1805