By Dianna Douglas

Imagine your doctor says he plans to increase your oral medication to control your diabetes. You do not like taking pills. Should you:
A. Not rock the boat with your doctor and agree to take the increased dosage?
B. Agree, but keep taking the same number of pills?
C. Try to discuss another option with your doctor?

Monica Peek, MD, assistant professor of internal medicine at the University of Chicago, believes the best answer for long-term health and happiness is C. But she knows that low-income African Americans with diabetes will often, for a variety of reasons, agree with the doctor and then ignore the advice. Peek has spent hours leading classes with patients from this vulnerable group. They role-play talking to their doctor, critique each other as they practice, and give a debriefing on whether they could ever truly feel comfortable taking an active approach with a physician.

The classes are part of a new program to chip away at the disparities in diabetes among low-income African Americans. The gap is huge. The prevalence of diabetes on the South Side is 19.3 percent, compared with an average prevalence in Chicago of about 7 percent. African American neighborhoods in Chicago have five times the rate of diabetes-related leg amputations as primarily white neighborhoods do.

Three years ago, about 40 people at the University of Chicago Medical Center with expertise in nutrition, cultural tailoring, communication, quality improvement, and even community organizing launched an effort to close this gap. They were prepared to tackle multiple factors that exacerbate diabetes outcomes on the South Side. Among them are unhealthy eating habits, limited safe places to exercise, food insecurity and less access to health care.

Their first move was to get out of the hospital.

The group created teams at six community health clinics to focus on improving diabetes care. They led patients on field trips to local grocery stores to practice making smart food choices. The physicians were constantly on the radio, at health fairs, in churches and high school gymnasiums, educating South Siders about diabetes. Still, the Medical Center team ran into challenges from all sides.

“The economic factors of people choosing between food and medications don’t account for all of the disparities,” Peek said. “There is racial and cultural baggage that creeps into clinical encounters between doctors and poor African American patients.” As an example of this long history of bias, Peek cites a famous 1999 study from Georgetown University in which cardiologists were found to offer better care to men over women who complained of heart problems, and to white patients over black patients.

“People who have had bad interactions with the health care system may delay treatment until their condition is dire,” Peek said. Some say they are afraid of being experimented on, that they don’t trust doctors to do right by them, or that they dislike the perceived power imbalance of being in a doctor’s office.

Peek said she was surprised to learn how some low-income African Americans view the doctor-patient relationship. A woman told her that she gets agitated when she goes to a doctor’s office and hears, “What brings you here today?” — she thinks the doctor is saying, “Why are you sitting in front of me when I’m so busy?” read more

As another year comes to a close we’d like to look back at the fascinating research breakthroughs and inspiring patient stories from 2011. ScienceLife ran 168 posts this year, and while we wish we could highlight all of them, here are a handful of our favorites from each month.

January

Patrick Wilson found out that the H1N1 virus could end up helping us fight all types of flu. Stephen Pruett-Jones studied how some male birds mimic the sounds of predators to pick up the ladies (with an audio clip). We interviewed David Gozal about his study on the link between childhood obesity and lack of sleep, and took a look at NCAA regulations mandating sickle cell testing for athletes.

February

Harold Pollack gave a lecture on why violent crime in urban, minority communities should be considered a public health epidemic. Siri Atma Greeley studied the actual medical benefit of widespread genetic testing. Stacy Lindau wanted to know why so few women get help for sexual problems after surviving cancer. We talked to Bana Jabri about the causes of celiac disease, and Sliman Bensmaïa showed us how the brain processes the basic elements of touch very much like it handles visual information.

March

Sola Olopade educated women in Nigeria about using clean-burning stoves to prevent indoor pollution. Stefano Allesina and Jonathan Levine looked at how rock-paper-scissors helps explain evolution. Joshua Miller went to Yellowstone Park to see what stories the ghostly bones of animals can tell, and Scott Eggener questioned the wisdom of indiscriminate prostate cancer screening.

Photo by Gerald Waddell

Andrea King studied the wide range of responses to drinking alcohol, and why it can be fun for some people and a bummer for others. Cheryl Reed took a ride in a helicopter with our UCAN nurses. Kamal Sharma looked at the genes that control animals’ gait, and Ningqi Hou studied how urban environments can dictate how much exercise people get.

May

Daniel McGehee looked at the long-term effects of nicotine on the brain. Habibul Ahsan went to Bangladesh to study the health impacts of accidental exposure to arsenic in drinking water. The brain’s overlooked supporting cells got their due at a conference on neuroscience, and we remembered a landmark discovery about a once popular drug taken during pregnancy that we now know can cause cancer.

June

As we headed into summer, Diana Lauderdale used Google to track MRSA. We learned about an extraordinary transplant where a man received a new heart, liver AND kidney. Daniel Geynisman gave us the rundown on whether or not cell phones are killing us (they’re not, as long as you don’t use them in the car), and some UChicago undergrads studied what happens to gorillas on the birth control pill.

July

We spoke to Donald Jensen and Andrew Aronsohn about the new outlook for patients with hepatitis C. Igor Schneider made a time machine to find the genetic switch for limb development. Farr Curlin led a study about the benefits of addressing spiritual needs alongside medical care, and Adam Cifu looked at the phenomenon of scientific study reversals.

August

Stefano Allesina dug into the long, shady history of nepotism in academia in Italy. John Schneider talked about his work addressing sexual health and stigma in India. Michael Becker discovered a new treatment for the Royal Disease, and we had the rare chance to name check a Spiderman villain in a post.

September

Martha McClintock and Suzanne Conzen studied the connection between social isolation, stress and breast cancer. Gallego Romero traveled to India to search for the origins of lactose intolerance. Stephanie Dulawa developed a mouse model for OCD, and Paul Vezina looked at a different kind of obsession, compulsive gambling.

October

Arshiya Baig started a pilot project to help people learn about life with diabetes through pictures. Manyuan Long found that some of the youngest genes are in the brain. Jens Ludwig and Stacy Lindau published a landmark study about the connection between neighborhood poverty and health, and Issam Awad studied a rare brain disease that soon could be treated with a drug instead of surgery.

November

Cathy Pfister and Tim Wootton figured out how to use seashells to track climate change over the years. Lianne Kurina found a link between loneliness and sleep quality. Shantanu Nundy, Monica Peek and Marshall Chin developed a program to send text message reminders to people with diabetes, and Pan Chen looked at the links between childhood abuse and aggressive behavior in adults.

December

Inbal Ben-Ami Bartal, Jean Decety and Peggy Mason discovered that rats can show empathy for their fellow rats in distress. Maciej Lesniak performed a scary but amazing brain surgery on a patient who was awake. Cathryn Nagler searched for the source of food allergies within our bodies, while Stafano Guandalini uncovered the challenges in educating doctors about one of those allergies, celiac disease.

Whew. Hope you were able to click through at least a few of those. We look forward to another great year of research in 2012. We’re taking a break next week, but we’ll be back on January 5. Happy holidays!

Texting has grown from technological fad to a primary route of communication popular around the world. With cell phones in the pockets of people of all incomes and ages, the quick, no-frills conversations enabled by texting have made almost everyone more proficient with their thumbs. Due to such impressive ubiquity, people in health care are starting to ask whether text-messaging can be harnessed as a cheap and user-friendly tool for communicating with patients outside of the clinic - particularly hard-to-reach patients in urban and low income areas.

“People are ignoring that unlike every other technology, mobile phones reverse the digital divide,” said Shantanu Nundy, clinical instructor of medicine at the University of Chicago Medical Center. “More low income patients are using phones for text messaging and internet than other groups. So shouldn’t we then be developing technology for this type of population?”

Nundy and Jonathan Dick, a Pritzker graduate now in residency at Columbia University Medical Center, arrived independently at this same idea after separate trips overseas, where they saw clinics in Uganda and India using text messages as part of their operation. With texts, physicians could follow up with patients with chronic diseases, making sure they were taking medications and doing the types of self-examinations necessary to manage diabetes or HIV - tasks that are just as challenging at home as they are abroad. In some areas of Chicago the diabetes rate is as high as 25 percent, and African-American populations have much higher rates of diabetes complications such as blindness and amputation.

“It seemed to me that we had a lot of the same problems on the South Side of Chicago, so why not try it there?,” Dick said.

To test this premise, Nundy and Dick joined efforts with Medical Center faculty Monica Peek and Marshall Chin, who recently received grants from the Alliance to Reduce Disparities in Diabetes and the National Institutes of Health to look for new ways to improve outcomes in South Side neighborhoods. For a pilot study published last month in the Journal of Diabetes, Science, and Technology, the team recruited 18 African-American diabetes patients to try out a new automated text-messaging communication system that they programmed.

The study participants were not your typical teenage texters, instead reflecting an age range (38-72) more commonly afflicted with diabetes.

“If this is going to work, we needed to look at middle aged people and people in their 60s and 70s. I’m less interested in having this as a hip thing for teenagers with diabetes,” said Peek, assistant professor of medicine. “It needs to be able to work in people I see in clinic. A 55-year-old black woman with diabetes, if it works for her, I’m interested.”

Each participant was asked at the beginning of the study what kinds of text message they would like to receive, with candidates including reminders to take diabetes medications, check blood sugar, or conduct self-examinations to detect potential complications. Participants could also customize when they received the message, and how often they came in over the one-month pilot.

Some were purely notifications (i.e. “Please take your medications now.”) while others required a text response (”How many times did you check your feet this week?”). In one early sign that the messages were reaching their targets, participants often texted back whether a response was required or not, sending an “OK” or a “Thank you” message to what they knew was an automated system. The study reports, “Many participants found that they began anticipating the text messages and readying themselves to answer the questions in an affirmative way, such as preparing the insulin syringe ahead of the expected message.” That enthusiasm was reflected in surveys of the patients after the study period ended, where all but one participant said they were very satisfied with the text reminders.

“In the context of a population that typically has very few interactions with the health care system and may have experiences that are negative or bad or fearful, it was very fulfilling for them to have positive reinforcing messages where they really felt cared for by the system in a way they hadn’t in the past,” Peek said.

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By Matt Wood

Celiac disease is an inherited autoimmune disorder that affects the digestive process of the small intestine. When a person who has celiac disease consumes gluten, a protein found in wheat, rye and barley, the individual’s immune system responds by attacking the small intestine and inhibiting the absorption of important nutrients into the body. At least 1% of Americans, or nearly 3 million people, have celiac, but 97% of them are undiagnosed.

The University of Chicago Celiac Disease Center is an international center of excellence providing comprehensive patient and professional education, expert diagnosis and treatment for both children and adults, groundbreaking bench and clinical research, and active leadership in advocacy efforts. Their goal is finding a cure for celiac disease by 2026. We spoke to Dr. Stefano Guandalini, medical director of the Celiac Disease Center, about this unique, comprehensive research and treatment approach. We also discussed the link between celiac and diabetes, and asked pediatric dietitian Lara Field from Comer Children’s Hospital how people with both diseases manage their diets. Lara also discussed how children with celiac disease can learn to go gluten-free.

Loneliness has had a tough run of late, with a growing body of research blaming it for everything from high blood pressure to heart disease to depression and cognitive decline. The research group of John Cacioppo, director of the Center for Cognitive and Social Neuroscience at the University of Chicago, has been among the leaders in leveling these medical charges against loneliness. But one missing piece of the puzzle remains - what biological mechanism connects a person’s feelings of inadequate social contact with the negative health outcomes? A new collaboration with epidemiologists and geneticists at the Medical Center suggest that the missing link might be in the bedroom.

For decades, professor of human genetics Carole Ober has studied a unique society called the Hutterites [pdf]. A religious group that originated in the 16th century, the Hutterites have formed several communal farms in the United States where some 150 people live and work together. The stability and isolation of the Hutterites make them a perfect population for studying the interplay between genes, environment, and disease - the mission of Ober’s research. Those qualities also made them the perfect group of people for a team lead by Lianne Kurina, assistant professor of epidemiology in the University of Chicago Department of Health Studies, to test the link between loneliness and sleep quality.

The new study, which appears in the journal Sleep, is not the first to examine this connection. A 2002 study led by Cacioppo used the most accessible pool of subjects on a college campus - college students - and found that those who scored higher on a psychological loneliness test displayed reduced sleep “efficiency” with no change in sleep duration. In other words, the loneliest subjects slept just as long as their socially satisfied peers, but suffered more “microawakenings” and lower sleep quality.

Because college students reflect only a narrow band of society, it was important to replicate the result in an entirely different population. Enter the Hutterites, who were also tested using a loneliness scale and asked to wear wristband sleep monitors to track their activity during sleep. Because of their communal lifestyle, even the loneliest Hutterites were less lonely than the general population. But the same correlation was detected between loneliness and sleep quality - for each point increase on the loneliness scale used to test the subjects’ social feelings, the researchers observed an 8 percent increase in sleep fragmentation. Furthermore, the lonelier Hutterites did not themselves report poor sleep or daytime sleepiness, indicating that the effects are mostly subconscious.

“Loneliness has been associated with adverse effects on health,” Kurina said in a press release. “We wanted to explore one potential pathway for this, the theory that sleep - a key behavior to staying healthy - could be compromised by feelings of loneliness. What we found was that loneliness does not appear to change the total amount of sleep in individuals, but awakens them more times during the night.”

The evidence is still not strong enough to conclusively place sleep deficits as the intermediary between loneliness and poor health. As the paper admits, the opposite relationship could be true: sleep fragmentation could increase feelings of social disconnection. But a flood of recent evidence, much of it from the University of Chicago Sleep, Metabolism, and Health Center, suggests that the third of each day we spend sleeping can dramatically affect several different aspects of our health, including diabetes, obesity, dieting success, and testosterone levels. Certainly, the newly replicated connection between a lonely heart and restless nights offers an intriguing theory for future study.

But why would feelings of social inadequacy disrupt a person’s time in bed?

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By John Easton

Location, location, location. The three most important words in real estate turn out to be significant for health as well.

In today’s issue of the New England Journal of Medicine, a research team based at the University of Chicago show that low-income women with children who moved from high-poverty to lower-poverty neighborhoods experienced notable long-term reductions in diabetes and extreme obesity.

The research was the first to employ a randomized experimental design on a large scale to learn about the connections between neighborhood poverty and health.

For the study, Jens Ludwig and Stacy Lindau from the University of Chicago, and a team of scholars from around the country, studied 4,498 poor women and children, who from 1994 to 1998, enrolled in a residential mobility program called Moving to Opportunity.

The U.S. Department of Housing and Urban Development (HUD) operated MTO in five United States cities - Baltimore, Boston, Chicago, Los Angeles and New York.

MTO was based on the Chicago Gautreaux program, established in the late 1970s as part of a court-imposed public housing desegregation remedy. It was designed to study the effect of neighborhoods on employment, income and education in families with children living in cities with a 40% or greater poverty rate. It wasn’t originally focused on health, but Ludwig and his team were curious about how poverty in the U.S. correlated with health issues such as obesity and diabetes and they persuaded HUD to add the public health research component.

Moving to Opportunity enrolled low-income families with children living in distressed public housing. Families volunteered for the experiment, and based on the results of a random lottery, were offered the chance to use a housing voucher subsidy to move into a lower-poverty community. Other families were randomly assigned to a control group that received no special assistance under the program.

According to HUD: The four Chicago census tracts targeted for MTO had an average poverty rate of 67 percent and contained six public and assisted housing developments, which housed a total of 2,197 households. The average income among residents of the six targeted projects was $7,114, and over 75 percent of residents received some form of public assistance. Virtually all of these households were African American (99.4) and 70 percent were female-headed.

The NEJM study collected information during 2008-10 on families who had enrolled in the program 10 to 15 years before. The research team directly measured the heights and weights of MTO participants, and it also collected blood samples to test for diabetes.

At the time of follow-up, 17 percent of the women in the study’s control group were morbidly obese (body mass index at or above 40), and 20 percent had diabetes. However, in the group of women who were offered housing vouchers to move to lower-poverty neighborhoods, the rates of morbid obesity and diabetes were both about one fifth lower than in the control group.

“The initial aim of the study was to help families be safer, but it turns out there’s an effect on these really important health outcomes that’s in the ballpark of lifestyle and medical interventions,” Ludwig said. “That’s pretty striking,”

“This is one of the first studies to show that where you live - the circumstances of your neighborhood, the social characteristics of the people around you - all these things may play a role in your own health,” said Harlan Krumholz, a cardiologist at the Yale School of Medicine who was not involved in the study, during an interview with the Los Angeles Times. “Your health is not just what happens to you, but is influenced by all of those around you and the environment. … Some environments are toxic to health.”

“Giving a low-income woman the opportunity to move with her children to a less impoverished neighborhood appears to lower her risk of … two of the biggest health problems facing our country,” said Lindau, associate professor in obstetrics and gynecology, and an expert in urban health.

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Almost everyone has experienced the boredom of sitting through someone’s vacation photos, forcing a wan smile as a friend hands you picture after picture of beaches, museums, and old buildings. But if you’ve been to the same destination as your friend, there’s an allure to seeing how their experience of a particular place compares to your own. Discussing a gelato stand you both visited outside the Uffizi gallery in Florence or debating the merits of ocean-side vs. sound-side in the Outer Banks can bring a friendship closer. But can that communal photo-sharing power be captured and channeled into improving people’s health?

That concept is a novel component of assistant professor of medicine Arshiya Baig’s pilot project to improve diabetes outcomes in the Chicago Latino community, Picture Good Health/Imagínate una Buena Salud. Designed in cooperation with churches in the predominantly Mexican neighborhood of Little Village, Baig’s program offers focus group classes with Latinos diagnosed with diabetes, seeking to improve their diet, exercise, and disease control. At each of the eight weekly sessions, participants go through education, counseling, and activities to help manage their diabetes. But each meeting begins with a novel concept, called “photovoice,” that puts the storytelling potential of photography to use as a stimulant of healthy discussion.

“We thought we would do something fun, so we are giving disposable cameras to everyone in the intervention group, and they get to take photos of their life with diabetes,” Baig said. “Then each class starts off with a conversation around those photos. People can share stories, they can problem solve, and our class leader is trained to facilitate a conversation. It’s probably the most innovative part of the study.”

The concept of photovoice was not created by Baig, but it is typically used by researchers for different purposes. Typically, the idea of giving subjects cameras and asking them to document their situation is used as a “needs assessment” to help design an intervention. For example, one project asked teenagers in an urban area to photograph negative elements in their daily life and community. Researchers or policy makers could then look at those photos to find places where an intervention could make the largest impact, such as cleaning up abandoned buildings or providing more supervision during walks to school.

However, in Picture Good Health, the photovoice method is the intervention. Participants are told only to document things in their life that are relevant to living with diabetes. After the photos are developed, they can choose which ones to share with the group during the first half-hour of each week’s session. The photographer explains what the photo means to him or her, and then the group discusses from there.

Second-year Pritzker medical student Matthew Stutz joined Baig’s project this summer to start analyzing the photovoice component of the focus groups. He found that the participant’s photos covered a wide range of topics, from the obvious (food, diabetes medications) to more general influences such as their home, workplace, neighborhood, and family. A photo of loaves of white and wheat bread might kick off a group discussion of health grocery choices, or a picture of an ashtray could trigger participants to talk about the methods they have used to try and quit smoking. One man shared a picture of a park and said it reminded him of his deceased daughter, inspiring the other participants to talk about family members they had lost - a topic that wouldn’t typically be on the agenda for a diabetes intervention.

“I think of photovoice as an easy mechanism for someone to convey emotions, experiences, losses, gains, without having to verbalize it,” Stutz said. “By having a prop or a mechanism to share, I feel we can gain a lot more ground and depth and conversation.”

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The future of genetic medicine comes in many flavors, from the discovery of the rare mutations responsible for uncommon diseases to the cataloging of variants that may be responsible for common diseases such as high blood pressure and diabetes. A segment from last night’s ABC 7 Chicago news focused on both aspects of this potential, jumping from a young man in Utah with Miller Syndrome to the 1200 Patient Project of the Medical Center’s Mark Ratain and Peter O’Donnell. Results from the project, currently underway, could help physicians customize medical treatments for individual patients, maximizing effectiveness while reducing side effects. As the segment says, if we really are heading toward a future where every patient has their genetic code read as routinely as they receive a doctor’s check-up, such research will be essential for unleashing the power of genetic medicine.

When the media hypes the healthy effects of drinking red wine in moderation, they’re talking about resveratrol, the chemical responsible for wine’s benefits. Scientists have long tested whether isolating that chemical can turn it into a super-pill for good health and long life without the alcoholic “side effects” of its normal route, with mixed results. But a new study featured in the New York Times this morning finds an intriguing benefit of a resveratrol derivative called SRT-1720. Obese mice given the experimental drug lived 30 percent longer - as long as control mice - rather than expiring earlier from obesity-related diseases such as fatty liver and diabetes. As the article states, such a drug may represent “more a moral hazard than an incentive to good health,” seen by some as a way of avoiding the consequences of excess. But with trials of the drug in humans still in their earlier stages, the ethical discussions will have to wait on the science.

Since our piece remembering famed bio-statistician Paul Meier ran last week, two more fine obituaries of the UChicago professor emeritus have appeared. Read the Chicago Tribune take to learn what instrument Meier learned to play at the Old Town School of Folk Music, and the New York Times version for the context of how Meier changed randomization in clinical trials forever.

Living shoulder to shoulder (or even closer, on the subway) in an urban environment feels like a particularly modern phenomenon. But as friend of the blog Tim de Chant explains in his guest blog at Scientific American, human societies have concentrated themselves since even the prehistoric hunter-gatherer days. For more of Tim’s great writing on the science of population density, visit his Per Square Mile blog.

Stress can have all sorts of negative effects on your health, but what about the stress of your spouse or partner? Not Exactly Rocket Science looks at a study in finches that suggests a high-strung life mate could actually shorten your life.

The latest cult favorite in the sphere of human genetics is the microbiome, the genes of the bacterial species that live inside and upon the human body. Because bacterial cells outnumber human cells in an adult by approximately ten to one, and tens of thousands of different species make up the human ecosystem, studying this world will be even more of a challenge than the Human Genome Project, which only had to concern itself with a single species: us. But as the microbiome is increasingly discovered to play a role in obesity, diabetes, infant diseases, and hospital-acquired infections, the number of researchers pondering a bacterial angle for their own disease of interest is exploding.

So the microbiome was the ideal topic for the first lecture of the Institute for Translational Medicine seminar series on Advanced Tools, a monthly meeting designed for University of Chicago researchers to share methodological know-how. Leading the discussion was a veteran of the young microbiome scene - Eugene Chang, professor of medicine and an expert on gastroenterology. For several years, Chang has applied the tools of microbiology to the bacterial populations of the human gut, looking for mechanisms involved in digestive diseases. As the techniques for studying the microbiome have evolved, Chang said he has seen the pros and cons of the field’s growth.

“This is an area that is really hot,” Chang said. “It isn’t coincidental that this interest has coincided with emerging technologies, because the emerging technologies over the last decade have allowed us to look at the microbiome in many different ways….but this is a field where you can be easily consumed by the technology.”

Those techniques have changed alongside the trends of the broader field of microbiology, Chang said. Scientists interested in bacteria were once limited to studying what they could both find and grow in a lab dish, which left the vast majority of species unexplored. But new genetic techniques have brought those hidden worlds into the light, allowing scientists to take a more complete census of the bacteria present in a given sample from the Earth’s environment, or the special environments within the human body. With this added power has come a whole new menu of choices for scientists, from low-cost methods (i.e. T-RFLP) that can take a surface-level snapshot of the most common members of a microbial community to deeper sequencing that can identify rare microbes that may turn out to be relevant to disease (i.e. pyrosequencing).

“We have a number of techniques that have advantages and limitations,” Chang said. “What you use is dependent on what your question is and how deep you need to go.”

In Chang’s laboratory, the questions relate to the origins of inflammatory bowel diseases such as ulcerative colitis. A recent study looked at the microbial diversity within the colon, comparing the bacterial populations present in the mucosa of the proximal colon (near the small intestine) to the distal colon (near the anus). A T-RFLP analysis, which looks at fragments of ribosomal DNA in the mucosal samples, found that the microbes present in the two regions were distinct, with higher “richness” (the number of species present) observed in the proximal versus distal colon.

But to determine the role of the microbes in disease, just taking a census isn’t enough. The newest wave of microbiome research is focused on function, using techniques that find out what those billions of bacteria are actually doing inside our bodies or out in the world. With metagenomics, scientists can analyze all the genes from a given sample of soil, skin, or mucus, then group those genes by their functional role (metabolism, transport, etc.) using a technique developed by Argonne called MG-RAST. Many groups, including Chang’s team, are also interested in measuring host-microbe relationships - how the bacterial population affects the biology of their home organism.

“Sure we can say who’s there, but how do we actually know what’s important?,” Chang said.

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Countless campaigns have been launched to steer schoolchildren toward healthy habits, and yet rates of childhood obesity and diabetes continue to soar. Celebrity endorsements, catchy catchphrases, and food pyramid redesigns have struggled to combat the allure of fast food and television in the battle for child health in the United States. But with childhood obesity rates tripling in the last 30 years and type 2 diabetes showing up earlier in life, there’s an urgent need for more effective programs to promote nutrition and exercise in kids. One strategy is to create more relevant programs, locally focused and tailored to the culture of the children the program is trying to help.

That approach inspired not one but two child diabetes prevention programs created by Medical Center researchers and tested with our neighbors on Chicago’s South Side. The two programs - called Reach-Out and Power-Up - are siblings, with similar designs, goals, and measures, but in slightly different populations and venues. The pilot studies, both published in recent months, demonstrate the challenges faced by researchers in creating effective, reproducible programs with a local focus…and also offer hope that a successful intervention is possible.

Before the programs could be designed, the first step was to listen. The research team, led by Deborah Burnet, professor of medicine and pediatrics, organized focus groups with overweight children and their parents to learn about their specific obstacles to improving health and gather ideas about the types of physical activity and classes that would appeal to them. For example, the African-American children said they would like to try martial arts and yoga, so instructors for those activities were recruited. The conversations laid the groundwork for programs that would take the unique circumstances of families on the South Side of Chicago into account.

“Nutrition and exercise are both behaviors we do in a social context; in a place, in a neighborhood, in the context of certain social mores and expectations and cultural factors,” Burnet said. “Food, especially - who cooks, where we learn how to cook, how do our tastes get shaped in what we like to eat - those occur in social and cultural contexts.”

While both programs were designed to improve the health and behavior of children, the targets were both the kids and their parents. In Reach-Out, families gathered at a local YMCA for 14 weeks, splitting into separate parent and child groups for the first part of each session and then reconvening for a combined activity. Sessions included grocery store tours, exercise training, cooking classes, and even a family basketball game. Scavenger hunts, relay races, and Family Feud-style review quizzes were used to keep the kids and their parents engaged. But addressing the family’s cooking and eating habits could also be a sensitive topic.

“Feeding is all bound up with caring and love, so it’s very complicated - if you tell grandma she’s not cooking for her grandchildren right, her feelings get hurt,” Burnet said. “So how do you do that in a constructive way so that grandma is valued, but also moves in this healthy direction?”

At the end of the Reach-Out pilot study, published in the Journal of the National Medical Association, the program earned glowing reviews from participants, who said that it helped reduce food intake, steered them toward new fruits and vegetables, and encouraged increased physical activity. However, the clinical improvements were modest, including slight dips in BMI z-score (which scales the measure to child age) and glucose-to-insulin ratio. The incremental changes might mean that very heavy kids need more help to get back to healthy habits, Burnet said: “Kids who are this big probably need a more intensive treatment and intervention than a weekly community-based program.”

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By Dianna Douglas

More research practically begging people to get a good night’s sleep has come out of the sleep labs at the University of Chicago. Eve Van Cauter and Rachel Leproult have discovered that a week of inadequate sleep means less testosterone in young men.

A lot less.

In the study, ten healthy young men gave blood samples after a week of sleeping just five hours a night. By the end of the week, they had 15 percent less testosterone than normal. “This is not an insignificant amount, since it is about the amount that occurs with normal aging by 10 to 15 years,” Van Cauter said. As a man ages, testosterone production decreases by 1 to 2 percent a year.

The lack of testosterone affected not only the reproductive function of these young men, but their happiness as well. Testosterone is a vital hormone for a man’s physical and mental health, and is released into the body during sleep.

“Low testosterone levels are associated with reduced well being and vigor,” Van Cauter said, explaining why the young men said they felt grumpy and lethargic, and their mood worsened as the study progressed.

Low testosterone is associated with low energy, reduced libido, and poor concentration. Consumer Reports Health found in a recent survey that feeling too tired is the reason men cite most often for a low sex drive.

This isn’t just a lab exercise - sleep loss is endemic in modern society. At least 15 percent of the adults in the US get less than 5 hours of sleep a night. Shift workers are especially at risk for lost sleep. The average American got nine hours of sleep in 1910 and got seven in 1975. The cumulative effects of short sleep are still being discovered, and they’re all bad. People who don’t get enough sleep are fatter, more likely to have diabetes, have all sorts of learning and cognitive problems, and die earlier. Van Cauter says that a nation that doesn’t sleep enough has an epidemic of obesity and diabetes.

“As research progresses, low sleep duration and poor sleep quality are increasingly recognized as endocrine disruptors,” Van Cauter said. Mess with the delivery of hormones throughout the body, and people become hungrier and sadder. Their blood pressure goes up and their insulin production goes haywire.

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In the 2000s, a new kind of genetic experiment was born: the genome-wide association study, or GWAS. If geneticists could recruit enough people with a particular disease and compare them to an equal number of disease-free controls, they believed GWAS would point the way to common gene variants associated with disease risk and novel biological pathways. One of the strengths of GWAS was that it was hypothesis-free, an unbiased comparison that could reveal surprising risk-associated genes that had not occurred to scientists in the past. More than 1,000 GWAS studies have been conducted to date, on diseases ranging from diabetes to Parkinson’s disease to Crohn’s disease to various types of cancer.

While these studies have identified thousands of gene variants (called single nucleotide polymorphisms, or SNPs) associated with disease risk, they can still only explain a small fraction of the heritability of disease. Some scientists have thus moved on from GWAS to the next wave of genetic studies, including whole-genome sequencing to look for rare variants and gene-environment interaction studies. But some geneticists think the field may be moving too quickly onto the next big thing, and that there remains value in the volumes of GWAS data collected over the last decade. A second generation of GWAS is taking place, where the data from the first round is approached in new ways to find previously hidden gems of information.

In two recent studies, assistant professor of health studies Brandon Pierce applied this Reuse/Recycle/Reduce philosophy to GWAS data on pancreatic cancer risk, a disease where genetic and biological explanations are particularly lacking. For both experiments, Pierce bended the “hypothesis-free” rule of GWAS in order to narrow the field of gene variant candidates and allow for a more selective scan of pre-existing data. By reducing the number of candidates from the ~550,000 of a full GWAS, the statistical threshold for confirming a SNP association with risk can be set lower. If the original GWAS experiments were the equivalent of looking for a needle in a haystack, the new techniques are a much less daunting task, he said.

“You conduct fewer tests, so the haystack is smaller,” Pierce said. “In all of the tests you are conducting, you know the SNPs are biologically meaningful, whereas in a typical GWAS, a large percentage of the SNPs may have very little to do with human biology.”

In the first study, published in March in Cancer Causes & Control, Pierce adapted a connection discovered by epidemiology studies to his genetic scan. Patients with type 2 diabetes were measured to have elevated risk for pancreatic cancer - a logical relationship given that diabetes is primarily a disease of the pancreas. Pierce took 37  SNPs associated with type 2 diabetes and tested them in the GWAS data collected by a previous study of pancreatic cancer. None of the SNPs tested showed a strong association with pancreatic cancer, though two new gene variants produced suggestive evidence of an association. The results suggested that the biological link between type 2 diabetes and pancreatic cancer may not be as strong as the epidemiology data indicated.

“We didn’t find any major associations that popped out at us from the diabetes study, so the conclusion was that these established genes for type 2 diabetes don’t seem to have a big effect on pancreatic cancer risk,” Pierce said.

But a second study, published in Cancer Research, would lead Pierce almost full circle. This time around, he ran the pancreatic cancer GWAS data through what he dubbed a “pleiotropy scan,” testing only SNPs previously demonstrated to have a biological effect in humans. For many of the more than half-million SNPs typically tested in a GWAS, scientists have yet to discover a linkage to any disease or biological effect, suggesting that these markers may sit without effect in the long gaps between protein-encoding genes in human DNA. Like the first study, limiting his GWAS tests to only these SNPs (1,087 in this case) allowed Pierce to pick up more subtle associations than in a full-blown GWAS.

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Over the year-long discussion of health disparities in the MacLean Center for Clinical Medical Ethics seminar series, the health gaps presented between American whites and blacks have been predominantly a one-way street. On nearly every health measure - from infant mortality to diabetes to cardiovascular disease - higher rates are observed for African-Americans. But there’s one health gap where the racial positions are surprisingly flipped, said James Jackson of the University of Michigan in his visit to the series in early May. Over the course of a provocative talk, Jackson demonstrated how this strange reverse disparity in mental health could be hiding a model explaining the physical health gaps that continue to resist reduction efforts.

In a 2007 study, a survey project led by Jackson measured the lifetime prevalence of major depressive disorder in African-Americans, Caribbean blacks, and white Americans. An almost complete reversal from the normal health disparity was observed, with roughly 18% of whites diagnosed with major depression at some point in their lives, compared to only 10.4% of African-Americans. The data, though replicated several times, was initially greeted with skepticism by observers who were mostly familiar with biased data based on hospital admissions, Jackson said.

“When people noticed this, they really began to contort  the data,” said Jackson, a psychologist and director of the Institute for Social Research at the U. of M. “The argument was that there must be something wrong with the way it was assessed, because everybody knows that African-Americans have to have higher rates of psychiatric disorders than whites.”

But now that the reverse disparity has been verified in many different populations, Jackson has started to ask why these differences exist. His working theory hinges on two other observations: the delayed appearance of physical health disparities over the course of life, and cultural differences in the way people cope with stress. When well-known health disparities on measures such as diabetes or hypertension are broken down by age, there is not a consistent gap between blacks and whites, but a gap that emerges and rapidly grows in middle age (45-64 years old). Putting aside differences in infant mortality rates, some evidence actually suggests that black children are healthier than white children on many measures, Jackson said.

The growing gap in health measures over the life course is paralleled by another growing gap - in the frequency of poor health behaviors. In white populations, smoking rates peak in young adulthood and then decline, while the rate in black populations accelerates with age. The same pattern holds true for heavy alcohol use and drug use, Jackson said, while frequency of vigorous physical activity declines with age faster for black females than white females. Obesity is more complex - it is the only black-white difference observed early in life, at least for females - but this gap also widens over life course, regardless of socioeconomic status.

The core of Jackson’s theory was to cast those physically unhealthy behaviors not as mere vices, but as methods people use to self-medicate themselves against the stress of daily living.

“If you’re having a bad day…you know it. At the end of the day, your stomach is upset, you have a headache. There are palpable things that are present with regard to the stress reaction to the circumstances,” Jackson said. “But if you are growing a tumor for cancer, you don’t know it, until it reaches a certain stage.”

“If you know you’re having these stress-related kinds of problems, this awareness motivates you to action - you are motivated to do something about the physiological and psychological consequences of stressors in your life. And what do you want to do? People eat comfort food to reduce stress, the activity in the chronic stress response network,” Jackson said. “If I’m stressed, a Twinkie makes me feel better.”

Self-regulating stress can also go beyond junk food, Jackson said, to severe drug and alcohol use. All of these coping strategies may help dampen the stress response and protect mental health, but only at the cost of exacerbating physical health problems.

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A Magic 8-Ball for Cardiac Arrest

Cardiac arrest is one of the most common ways that people die, and hospitals need to be constantly vigilant about the threat of heart stoppage in their patients. So physicians have long sought to develop a way of predicting who is most at risk for cardiac arrest when checked into the hospital, such that extra care and surveillance can be taken. At the 2011 international meeting of the American Thoracic Society, held this past week in Denver, two Medical Center fellows presented research refining these early warning systems to make them a more effective hospital tool.

In the first study, pulmonary and critical care fellow Gordon E. Carr connected cardiac arrest with another frequent sight on the hospital ward: pneumonia. Carr’s study found that patients admitted with pneumonia are at elevated risk of cardiac arrest over the next three days after admission, and that almost 40 percent of these cardiac arrests occurred while the patient was outside of the intensive care unit. “We found a compelling signal that some patients with pneumonia may develop cardiac arrest outside of the ICU, without apparent shock or respiratory failure,” Carr said in a press release. “If this is true, then we need to improve how we assess risk in pneumonia.”

Adding extra caution about cardiac arrest to the care of patients with pneumonia is a specific way to improve surveillance. But to apply to more patients, a broader scale is needed, one that can be easily assembled from the vital signs that are already routinely measured in the wards. One such scale, called the Modified Early Warning Score or MEWS was tested by pulmonary and critical care fellow Matthew Churpek as a predictor of cardiac arrest, who found it to be better at predicting a cardiac arrest in the next 48 hours than any individual vital sign. But MEWS was designed for general risk of death, not specifically for cardiac arrest, and Churpek suggested a more specialized risk score could be calculated for use by hospitals. The benefits of such a measure, he said in a press release, would be immense.

“Rapid response teams are a complex and resource-intensive intervention, so providing evidence-based criteria for their activation is crucial,” Churpek said. “Our patients will do better if we can detect who is at high risk early enough to intervene and prevent a cardiac arrest.”

Doctors Against Ronald McDonald

Childhood obesity is a growing problem in the United States, and doctors point the finger of blame directly at increased consumption of junk food and fast food. Chains such as McDonalds have made noise about making their food healthier, especially for children, by posting calorie counts on menus and offering snacks such as apples and carrots instead of fries. But according to an open letter signed by over 500 health care professionals and placed in newspapers around the country this week, they have not done enough.

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Kristen Knutson, PhD, recently added to the growing body of research from the University of Chicago on the long-term consequences of skimping on sleep. She found that diabetics who sleep poorly have a harder time controlling their insulin and glucose levels than diabetics who sleep well. The research was published in the journal Diabetes Care. We conducted an extended interview with Kristen Knutson about her research, and below are some of the highlights.

Q: Why study diabetes and chronic sleep problems?

A: Many of our laboratory studies, led by Dr. Eve Van Cauter, have shown that restriction of sleep is associated with alterations in glucose metabolism. Usually, these lab studies are a week. But we wonder about the long-term effects of being a chronic short sleeper.

We think that chronic poor sleep could put people at risk of many health problems, including diabetes.

Q: How did you design your study?

A: We used data from an epidemiologic study called CARDIA (coronary artery risk development in young adults). It started in 1985, and has been going on for more than 20 years.

We gave the participants wrist activity monitors—it’s like a wristwatch that measures the subject’s sleep duration. The participants wore the activity monitors for three nights in a row. A year later, they wore the monitors three more nights. So we had a total of six days of data.

We also asked them about their sleep. Did they wake up frequently during the night, three or more times per week? Did they have trouble falling asleep?

To get the measurements of their fasting blood glucose and fasting blood insulin, we used the data from the CARDIA study, in which the participants gave fasting blood samples. Their fasting blood glucose and insulin give us an estimate of insulin resistance.

Q: Explain your most striking findings, especially with the diabetics who slept poorly.

A: We saw more significant associations between measures of sleep and glucose metabolism markers in the patients with diabetes. In particular, we saw that poor sleep quality was associated with higher fasting glucose and greater estimated insulin resistance. So poor sleep quality meant worse control of their blood glucose levels.

Also, we separated people with and without insomnia. Among the people with type 2 diabetes, those who also had insomnia had worse glucose levels and greater estimated insulin resistance. That suggests that it’s not just sleep duration that’s important, which laboratory studies have shown. But sleep quality is important as well.

The data show that people with diabetes who are poor sleepers will have a more difficult time controlling their glucose levels.

Q: Does this mean that sleeping poorly makes diabetes worse?

A: It could go the other way. It could be that people who are having trouble controlling their glucose will have more complications, more pain, more need to get up in the middle of the night to urinate, and therefore they’re not sleeping as well. What we need to do now is find people with diabetes who aren’t sleeping well, and see if improving their sleep also improves their glucose metabolism.

This study is observational, but suggests that there is a relationship between poor sleep and controlling glucose. We don’t know which factor leads to which outcome. read more