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HealthWrap: Focus on multi-morbidity, and the latest news in public health and prevention

In the latest edition of The Health Wrap, Associate Professor Lesley Russell reviews an important new publication on multi-morbidity, and also reports on discussions on multi-morbidity, prevention and mental health from the recent Public Health Prevention Conference 2018.

Beneath her column are links to some recommended new reading and “tweets of note”, sharing resources on tobacco control and the social determinants of health.

And do make sure to follow @WePublicHealth this week, where @LRussellWolpe is covering #HealthBudget18 and related news.


Multi-morbidity – an emerging global priority

There’s a new buzz word in health policy: multi-morbidity. The term is certainly not new – it’s been in use for at least a decade – but there is growing recognition that patients with multi-morbidity are the norm rather than the exception.

Multi-morbidity is sometimes seen as distinct from co-morbidity in that there is no primary or index condition, although more work needs to be done on this definition. Frailty is a related concept in ageing populations.

The UK Academy of Medical Sciences recently published a seminal report Multimorbidity: a priority for global health research, which addresses the growing issue of multi-morbidity as a global health challenge. The report highlights key evidence gaps, calls for standardised definitions and reporting systems, and recommends a series of research priorities.

The Lancet editorial in response highlights the need to update healthcare systems to cope with the increasing burden of multi-morbidity. The changes must include:

  • A shift from a specialised to a generalised healthcare workforce
  • Changing payment models
  • Technologies to support patients’ self-management
  • Integrating care both virtually and physically.

In a February 2018 blog, Greg Fell, who is Director of Public Health at Sheffield in the UK (well worthwhile following him on twitter @felly500), lays out, in a fairly cryptic way, what he thinks needs to be done to address this in the NHS.

There are some lessons here for Australia too; in particular, the importance of not ignoring mental health. Fell also details the research that has been done to date on identifying clinically relevant multi-morbidity clusters. Some of this work on understanding patterns and identifying common clusters of chronic diseases has been done in Australia.

The real problem is that most research and treatment is focused on the prevention and management of chronic conditions in isolation. That doesn’t represent reality.

Professor Andrew Wilson, in his presentation at last week’s Public Health Prevention Conference, made the point that risk factors for chronic disease travel together, and this calls a more coordinated approach to prevention. He said:

It’s no longer about single diseases or single risk factors, yet the prevention community is increasingly siloed into people who work in specific areas, such as smoking prevention, physical activity or diet.

But we have got to recognise that these things travel together – they are not independent associations. We have to start to think about these things as collective issues rather than individual problems.”

Writing at Croakey, Professor Stephen MacMahon and Dr Brendon Neuen, from The George Institute for Global Health, also highlighted the need to develope a better understanding of “the causes and consequences of the tidal wave of multimorbidity” in order to respond effectively and transition to more people-centred health systems, characterised by high-value, integrated, and generalist care.

Patients with multi-morbidity present a challenge to the healthcare workforce as it is currently educated and constructed.

The conundrum is best summed up by Richard Smith, former editor of the British Medical Journal: “Doctors and patients are heading in opposite directions… Patients increasingly have multiple conditions, while doctors are specialising in not just organ systems but in parts of organs.”


Former PM Julia Gillard speaks out on prevention and mental health

Former Prime Minister Julia Gillard, in her role as Chair of the board of beyondblue, was a keynote speaker at the Public Health Prevention conference. She talked about the “alarming gap” in access to services, with around half of Australians with a mental health condition not getting access to support or treatment.

She made the point that multi-morbidity – the fact that people with mental illness are more likely to have other chronic physical conditions, leading to reduced life expectancy – makes the need to “bridge the gap” even more urgent.

She highlighted the need to think about the whole-of-life needs of people and not to wait until things go wrong. Under the current fragmented and under-resourced mental health system/s too often help is not available until a crisis point is reached. This highlights the need for a better focus on prevention and the involvement of workplaces, schools and families.

In particular, Gillard highlighted the work beyondblue has been doing with two initiatives. The organisation has designed, trialled and evaluated New Access – a program that provides early intervention support for people with mild to moderate anxiety and depression. This approach is now being commissioned by a number of Primary Health Networks. She also talked about the Way Back Support Service, which provides psychosocial support to people who have attempted suicide (who are at highest risk of later dying by suicide) and their families.

Gillard’s focus on prevention and mental health echoes that in a report Investing to Save: The economic benefits for Australia of investment in mental health reform, which was released this month by Mental Health Australia and KPMG. The report highlights three core areas for action:

  1. Support for individuals with mental health issues to gain and maintain employment, and to maintain the mental health and wellbeing of the workforce.
  2. Minimise avoidable emergency department presentations and hospitalisations.
  3. Invest in promotion, prevention and early intervention.

I noted that in his weekly Update, MHA CEO Frank Quinlan chose to highlight Recommendation 2.1 of this report (Housing First for 15-24 year olds) which found that “For every $1 spent on Housing First models, $3 is generated in the short term (1-2yrs) and $6.70 is generated in the longer term (3+yrs) – this is supported by a strong evidence base that Housing First models work.”

(Note: Julia Gillard’s speech does not appear to be publicly available).


More recommendations from Medicare Benefits Schedule Review

An announcement on April 29 indicated that the Minister for Health has accepted 38 new recommendations from the work of the MBS Review. They include a new item to support the delivery of dialysis in very remote areas to improve access for Aboriginal and Torres Strait Islander people with kidney disease.

This move has been welcomed as a lifeline for the growing health crisis of Indigenous kidney disease. Rates of end-stage kidney disease are astronomically higher among Indigenous people, up to 50 times that for non-Indigenous people. Many of these people must move from their communities in order to receive needed dialysis treatment with devastating impacts on health and wellbeing, survival rates and culture. Such community-based services that exist have had to rely on private donations and fundraising to provide care because of inadequate government funding.

Now Medicare will cover some of the costs of dialysis delivered by nurses, Indigenous practitioners and Indigenous health workers in remote areas, “in a primary care setting”.

However, the accompanying fact sheet provides no details about this new item, which will be introduced by November 1. The effectiveness of this item in overcoming current barriers to accessing community-based services will depend on the details of its implementation and applicability. It is estimated that this item will initially cover 470 patients.


A California push for cancer warning labels on coffee

My Croakey colleague Dr Ruth Armstrong has been travelling in the United States, and she tweeted some travel and public health commentaries and some great photos for @WePublicHealth.

Her tweets included a photo of a warning about the cancer risks of coffee from a California chain diner. This raised considerable interest – after all, Aussies in the US are always on the hunt for a decent cup of coffee, regardless of the hazards involved.

I have no legal training, so I hope my explanation of this lawsuit is accurate. Here’s how I see it.

At the end of March, a judge of the California Superior Court in Los Angeles issued a preliminary decision in a case first filed in 2010 by the non-profit, little known Council for Education and Research on Toxics (try Googling it – nothing comes up!) against some ninety companies that make or sell coffee.

The case was brought under the California Safe Drinking Water and Toxic Enforcement Act of 1986 (known as Proposition 65) and asked for warning labels about the dangers of acrylamide in coffee and damages for the harms done in the failure to provide these warnings.

California has a list of chemicals that are possible causes of cancer – one of them is acrylamide, which is created when coffee beans are roasted. It is also found in potatoes, baked goods, burnt toast and tobacco smoke. Under Proposition 65, businesses must give customers “clear and reasonable warning” about the presence of high levels of cancer-causing chemicals.

The preliminary decision found that companies like Starbucks, 7-Eleven and gas stations had failed to meet the burden of proof that the levels of acrylamide in coffee are safe and that the heath benefits of coffee outweigh any risks.

The defendants have until April 10 to file objections to the proposed decision. The cost implications could be substantial; the law allows for fines of US$ 2,500 for each time a consumer is exposed to a chemical without warning.

No wonder then that some companies affected have already simply agreed to provide warning notices like the one Ruth saw. And earlier, in 2008, companies like Heinz, Frito-Lay and Kettle Foods had agreed to reduce levels of acrylamide in their potato chips and French fries. But the fact is that this decision puts public health experts and Proposition 65 – both aimed at safeguarding the health of Californians – at odds. And it is confusing to the public.

Studies have linked acrylamide at high doses to cancers in rats and mice, but a 2014 research review found “no statistically significant association between dietary acrylamide intake and various cancers”. On the other hand, there is considerable consensus about the health benefits associated with drinking moderate amounts of black coffee.

The real problem with coffee (so-called) is that something like a Starbucks venti white chocolate mocha has 580 calories, 22 grams of fat and 79 grams of carbohydrate (mostly sugar).

The perfect segue into the next issue…


Obesity and a sugar tax

Lots on this issue recently – perhaps there’s hope that, finally, the Turnbull Government will be brave enough to include something on tackling this important and costly public health issue in the upcoming Budget? (Not holding my breath, not taking bets.)

Last week’s Four Corners’ episode (described as a stunning expose of food, nutrition and health politics in Australia) highlighted the clear need for a national, comprehensive strategy to reduce obesity, including a sugar-sweetened beverage (SSB) tax.

There is evidence that the political and economic power of Big Food can be overcome with the right approaches. A recently published evaluation of the impact of the LiveLighter ‘Sugary Drinks’ campaign in Victoria showed reduced consumption of SSBs among adults in the target age range. A sugar tax is a good start for tackling the obesity problem. Some 28 jurisdictions have such a tax already in place and Australia is sadly lagging in its implementation.

As Rosemary Stanton said in a recent tweet: “Campaign against sugary drinks works and adding a sugar tax would make it even more effective. Why don’t we do it? The fact that the drinks industry doesn’t want it is good enough reason to know it would be effective.”

The issues are bigger than the sugar tax, however, as Dr Phillip Baker and Professor Mark Lawrence wrote for The Conversation, and republished at Croakey:

What the program highlighted was as important as what it did not. It showed a clear need for a sugar-sweete