CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 1 • Winter 2002

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CDC’s Research Agenda Strives to Build Foundation for Public Health Action

“Our commitment to translation research grows out of our responsibility to develop and implement effective public health programs,” said NCCDPHP Director James S. Marks, MD, MPH. “The needs of public health programs require an emphasis on applied research with practical implications.” 

By using research to establish effective programs, CDC can enhance people’s health-related quality of life, protect new mothers and babies, and reduce the rates of heart disease, stroke, cancer, diabetes, and other debilitating chronic diseases. The center’s chronic disease research agenda, which will guide funding decisions for the next 3–5 years, is based on two priorities: (1) focusing on diseases and conditions that most affect people’s health, longevity, and quality of life; and (2) eliminating health disparities among racial and ethnic populations. The center emphasizes research that is participatory, includes social and ecological determinants of health, and cuts across risk and disease categories. 

When conducting its research, CDC sometimes partners with other organizations to share resources and expertise. CDC is also in a unique position to coordinate and catalyze chronic disease research because of its direct connections with the public health community and populations at risk for disease, injury, and disability. 

Landmark Study Shows Diet and Exercise Can Prevent Diabetes
One partnership that resulted in a major research finding is the Diabetes Prevention Program (DPP) study, which proved that a healthy diet and exercise can actually prevent or delay diabetes. Although smaller studies in China and Finland had reported that a healthy diet and exercise can delay development of type 2 diabetes in people at risk, the DPP trial was the first to find that diabetes can be prevented or delayed in a diverse U.S. population of overweight people with impaired glucose tolerance (IGT), a condition that often precedes diabetes. 

The study was sponsored by the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases. Several other federal, private, and nonprofit organizations were involved, including the Indian Health Service, the American Diabetes Association, and many pharmaceutical companies and other corporations. 

The 27-center clinical trial was designed to determine whether a healthy diet and regular exercise could help at least 10 million Americans at high risk for type 2 diabetes sharply lower their chances of getting the disease. The study, in which 3,234 people with IGT participated, compared the effects of a healthy diet and regular exercise with the effects of treatment with the drug metformin. The trial actually ended a year early because the data clearly demonstrated that the lifestyle changes were more effective than metformin. 

The DPP study came at a critical time. During the past 30 years, the prevalence of type 2 diabetes has tripled, largely because of the dramatic upsurge in obesity. The study also helped increase knowledge about disproportionately high rates of type 2 diabetes among certain minority groups, including African Americans, Hispanics, Asians and Pacific Islanders, and American Indians and Alaska Natives. Forty-five percent of the study’s participants were from these populations. 

In view of the rapidly rising rates of obesity and diabetes in America, this good news couldn’t come at a better time,” said Tommy G. Thompson, Secretary of the U.S. Department of Health and Human Services, at a press conference announcing the findings. “So many of our health problems can be avoided through diet, exercise, and making sure we take care of ourselves. By promoting healthy lifestyles, we can improve the quality of life for all Americans and reduce health care costs dramatically.” 

The DPP study also demonstrates CDC’s commitment to achieving its research priorities by addressing health disparities among racial and ethnic populations, examining established and emerging risk factors, and looking for ways that people can manage their own health. 

“This study addresses several of NCCDPHP’s research priorities,” said Michael M. Engelgau, MD, MS, a CDC epidemiologist in the Division of Diabetes Translation. “Preventing disease and reducing its burden on society clearly are high on the list of goals for both the center and CDC as a whole.” 

For more information on this project, see http://www.cdc.gov/diabetes/news/docs/dpp.htm.

 
Helping Other Countries Identify and Eliminate Micronutrient Deficiencies 
Another important research project that examined how diet affects health is CDC’s International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program. Deficiencies of micronutrients such as iron, iodine, vitamin A, and folic acid affect the health and well-being of nearly 2 billion people in the world, primarily in developing countries. These deficiencies hinder the mental and physical development of children, cause poor pregnancy outcomes, diminish the work capacity of adults, and raise the rates of illness and premature death in many populations. 

Effective and low-cost interventions such as food fortification, vitamin supplementation, and dietary improvements have virtually eliminated most micronutrient deficiencies in developed countries. For example, the World Bank estimates that it costs only about 10 cents per person per year to eliminate iodine deficiency through iodization of salt and 20 cents per person per year to prevent iron deficiency through flour fortification. Although the effects of micronutrient deficiencies are well known, the effectiveness of national prevention programs is not. Few national public health agencies are capable of assessing the extent of micronutrient deficiencies in their populations or of monitoring the adequacy and impact of their intervention strategies. In 2000, CDC led development of the IMMPaCt Program to strengthen the epidemiologic and laboratory capacity of countries to conduct these activities. 

“CDC’s expertise in designing rapid field surveys and public health surveillance methods, as well as its laboratory excellence, makes it uniquely suited to help other countries develop and sustain the infrastructure needed to prevent and control micronutrient deficiencies,” said Ibrahim Parvanta, MS, Director of the IMMPaCt Program. 

Through collaborations with the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United States Agency for International Development (USAID), CDC provides funding and technical assistance to selected countries to conduct sound nutrition surveys and establish sustainable nutrition surveillance systems. For example, personnel from the IMMPaCt Program and UNICEF helped public health authorities in Malawi conduct a national survey of iron, iodine, and vitamin A deficiency. In Nicaragua, USAID and IMMPaCt staff members are helping plan and implement a national surveillance system to monitor programs that fortify sugar with vitamin A and flour with iron. 

Through the IMMPaCt Program, CDC is developing innovative data collection strategies that strengthen the quality of studies needed to improve health. This program also helps public health officials develop and evaluate the effectiveness of (1) interventions to eliminate health disparities; (2) policy and environmental interventions to promote health; and (3) population-based policies and programs at local, national, and international levels. 

Examining Arthritis Risk Factors 

The JCOP was initiated on the basis of information from the National Health Interview Survey (conducted by CDC’s National Center for Health Statistics) that indicated that although whites and African Americans have a similar prevalence of self-reported arthritis, African Americans report a 50% greater activity limitation because of arthritis. Although the JCOP is intended as a long-term follow-up study, initial analyses have already indicated that the rate of osteoarthritis among African Americans is higher than previously thought and that being overweight is an important risk factor. 

“The results of this study will allow us to better understand hip and knee osteoarthritis and what modifiable factors can help reduce their racially disparate impacts,” said Charles Helmick, MD, CDC medical epidemiologist. 

In this regard, Helmick pointed out, the JCOP addresses another CDC research priority—examining emerging risk factors and investigating their potential for public health interventions. 

School Study Seeks to Promote Effective Interventions 
Two other important goals of CDC’s research agenda for chronic disease are to develop effective communication strategies to promote health and to examine approaches for effectively translating successful community interventions into widespread practice. Both goals are supported by the national School Health Policies and Programs Study (SHPPS), conducted periodically since 1994 to assess school health policies and programs at the state, district, school, and classroom levels. This information can then be used to implement and support programs that promote healthy behaviors at earlier ages. 

Less than 1 in 10 elementary, middle/ junior, and senior high schools require students to participate in daily physical education.

The most recent survey, SHPPS 2000, examined policies and programs at state, district, school, and classroom levels for elementary, middle/junior, and senior high schools. Researchers then assessed the extent to which policies and programs that promote the health of school-aged children are in place in schools nationwide. The results, which were published in the Journal of School Health 2001;71(7), indicated that approximately 80% of states and districts required schools to teach some health education. Although this percentage increased during elementary school—from 33% in kindergarten to 44% in grade 5—it decreased from 27% in grade 6 to 2% in grade 12. In addition, only 8% of elementary schools and 6% of middle/junior and senior high schools required daily physical education or its equivalent for all grades; only about half of schools had the recommended nurse-to-student ratio; and most schools had vending machines or school stores that sold foods high in fat and sugar. 

“We hope that health and education officials and school health professionals will use SHPPS 2000 as a road map to understanding the nature of school health programs nationwide,” said Dr. Marks. “The success of this assessment will really be determined by how much it stimulates improvement in school health policies and programs around the country.” 

Throughout these projects and the dozens of others conducted each year, CDC researchers always keep one goal in mind—to use the information they gather to improve public health. The knowledge gained can then be used to implement, evaluate, or improve programs; issue new recommendations to the public and to public health practioners; and help national, state, and local decision makers allocate funding and other resources where they are most urgently needed.

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