AJPH EDITORIALS
Nursing School. When I started to work as a nurse and realized there was an opportunity to participate in the research that 2 generations of nurses who came before me have contributed to, I was thrilled! I remain a proud participant and a vocal supporter of NHS 3 today. I enjoy feeling that I am a part of something bigger than myself, and potentially contributing information that could inform - transform our understanding about health and disease in the future. —Michelle, Ambler, PA
FOLLOWED ME AS MY CAREER UNFOLDED It was clear in my graduate epidemiology courses that women were under-represented in research and much of what we were learning about chronic disease and drug effectiveness was studied using male subjects and findings assumed to apply to women. I had been steeped in the history of professional nursing’s engagement with the Suffragette
Movement. Lavinia Dock, who was jailed a number of times for picketing with the National Women’s Party, joined my list of nursing leaders with whom I would love to dialogue if that “time machine” ever came to fruition. I admired our early nursing leaders and vowed to emulate the courage, commitment and engagement of our early nursing leaders. As a graduate student, I read Ashley’s book, Hospitals, Paternalism, and the Role of the Nurse. This book really solidified my perspective that in addition to nurses being strong advocates for their patients/clients, they also needed to be a strong voice for the field of nursing. So along comes this opportunity to participate in a longitudinal study that would collect data from nurses who were primarily women. It also made sense to me that such a cohort would be able to more precisely report data and to sustain interest in participation so the likelihood of robust data seemed golden! Those NHS envelopes of a characteristic size followed me around the country as my career unfolded. In some ways I miss the symbolism of those envelopes now that data reporting is
electronic. —Pam, West Lafayette, IN
A ROBUST SAMPLE OF COMPLIANT SUBJECTS I was pleased to join the NHS I in 1976, the original sample, and have faithfully answered every questionnaire and offered nail, hair clippings and blood samples. I assume my name was found in Registered Nurse listings for Connecticut. This study is the first and maybe the only, one that focuses mostly on women’s health issues with a robust sample of compliant subjects! I see my own contribution as important for that reason, now 40 years and counting! —Ruth, Cheshire, CT
THE SURVEY IS A PUBLIC HEALTH SERVICE I am in Nurses’ Health Study II. I feel as though I have
A Public Health of Consequence: Review of the September 2016 Issue of AJPH In this issue, we celebrate two interconnected themes: an editorial by Barbara Rimer1 and a host of articles produced from the rich Nurses’ Health Study data sets.
STUDENTS First, we start by endorsing Rimer’s call for the way forward to ensure that we focus on the public health research of consequence: the proper education of
September 2016, Vol 106, No. 9
AJPH
our students.1 Rimer urges us to talk the talk and walk the walk as we, the current public health researchers and educators, are the role models and the conduit of knowledge for our students. She focuses on nine elements that we can practice daily as we engage with our students, and here, we highlight a few. She advocates helping students focus on achieving positive impact for the greatest health threats, altering the morbidity and mortality
trajectories, and being able to articulate the costs on both sides of the ledger. To do that, we must be prepared to provide our students with the corresponding
“grown-up” with the NHS, as my 91 year old mother, also a nurse is in the original 1976 cohort. She would tell me about this “big nurses study from Harvard” that she was participating in, the questions that she answered, and the samples that she sent - I remember being particularly surprised by the toenail clippings. When I received the request to participate in NHS II, I willingly agreed and have sent hair and urine samples myself. I continue to believe it is a privilege and a responsibility to add to the body of knowledge to promote women’s health. I have appreciated the newsletters that are sent with the study findings and completing my NHS survey has become a summer ritual while sitting in the hammock in my backyard. My sons are also in the GUTS study and I have tried to instill in them that accurately completing the survey is a public service. —Ruth, Villanova, PA
Alfredo Morabia, MD, PhD
necessary research skills and tools, and stress the importance of quality measurement to demonstrate change. She stresses that our students need big data tools, data visualization methods, and great communication skills. Finally, among other elements, she also acknowledges that our students need to understand the state of the art in the selected topic area: What does the evidence
ABOUT THE AUTHORS Sandro Galea is Dean and Professor, School of Public Health, Boston University, Boston, MA. Roger Vaughan is an AJPH editor, and is also the Vice Dean and Professor of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY. Correspondence should be sent to Roger Vaughan, Vice Dean and Professor of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted June 22, 2016. doi: 10.2105/AJPH.2016.303346
Galea and Vaughan
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AJPH EDITORIALS
tell us? Where are the gaps? What new data do we need? How strong is the case for causation? She calls for students to be aware of and use extant data sources to help identify the known, as well as articulate the gaps, which leads us to second interconnected theme, the Nurses’ Health Studies (NHS).
THE NURSES’ HEALTH STUDY Often mentioned in the same breath as the Framingham Heart Study, the NHS began following the first cohort of nurses in 1976 to help understand the risk factors for major chronic diseases in women, and is now in its third wave (including men and women), having enrolled more than 275 000 participants. The NHS has supported hundreds of high quality publications, most famously perhaps for examining the relationship between long term oral contraceptive use (including postmenopausal hormone replacement therapy) and disease, but dozens more linking behaviors (particularly dietary behaviors) and disease, and on the relationship between social factors and mental health. We highlight three such publications in this issue. Trudel-Fitzgerald et al.2 tackle the cumulative evidence from NHS publications examining the determinants of psychiatric conditions and other psychosocial risk factors for health. For depression, there was clear evidence that high caffeine intake was protective against a 10-year risk of depression, as was higher levels of exercise. This indicated that the modal first onset of depression was among adolescents and young adults. They also note that
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depression was significantly associated with onset of type 2 diabetes, and with higher fatal coronary heart disease risk. The breadth of measures in the NHS allows for some perhaps unconventional hypothesis tests, such as the finding that 15-year exposure to higher air pollution levels was associated with a 9% to 15% increase in the odds of reporting symptoms of anxiety, while those reporting higher levels of gender nonconforming behaviors during childhood led to a 20% to 40% higher risk of posttraumatic stress disorder. Rice et al.3 return to perhaps the motivating research question for NHS; that of the link between oral contraceptive use and breast cancer risk. In their review of NHS publications, they revisit the modifiable risk factors for breast cancer including oral contraceptive use, postmenopausal hormone therapy, weight and weight gain, physical activity, diet, aspirin use, and shift work. The analysis of current oral contraceptive use and breast cancer revealed the complexity and nuance of many risk factors and disease relationships. Rice et al.3 replicated their previous work of observed increased relative risk of cancer (risk ratio = 1.33), but with the low prevalence of breast cancer among younger women, the population attributable risk for current users was only 1.8%, indicating the risk of breast cancer associated with oral contraceptive use had to be balanced with its protective effects for other cancers such as endometrial and ovarian. Finally, Hruby et al.4 review the body of work from NHS publications to reveal the risk factors and consequences of obesity, and focus on the four main classes of risk factors: diet, exercise, the built environment, and genetics. The NHS
prospective data sets allowed for the usual story of “eat less, exercise more” to be interrogated. The long-held belief that dietary fat was the main cause of obesity was challenged by these analyses, where increasing consumption of monounsaturated or polyunsaturated fats was not associated with weight gain whereas increasing consumption of animal fat, saturated fat, and trans fat were positively associated with weight gain. There was also more bad news for sugarsweetened beverages, although their findings revealed more complexity on the alcohol intake-weight gain relationship, observing a U-shaped function where moderate drinkers experienced less weight gain than either nondrinkers or heavy drinkers. Hruby et al.4 explore the complex genetic and gene–lifestyle interactions, revealing the synergistic effects of genes, environment, and behavior.
Sandro Galea, MD, DrPH Roger Vaughan, DrPH, MS CONTRIBUTORS Both authors contributed equally to this editorial.
REFERENCES 1. Rimer BK. Preparing students to engage in public health research of consequence. Am J Public Health. 2016;106(9): 1546–1547. 2. Trudel-Fitzgerald C, Chen Y, Singh A, Okereke OI, Kubzansky LD. Psychiatric, psychological, and social determinants of health in the Nurses’ Health Study cohorts. Am J Public Health. 2016; 106(9): 1644–1649. 3. Rice MS, Eliassen AH, Hankinson SE, Lenart EB, Willett WC, Tamimi RM. Breast cancer research in the Nurses’ Health Studies: exposures across the life course. Am J Public Health. 2016; 106(9): 1592–1598. 4. Hruby A, Manson JE, Qi L, et al. Determinants and consequences of obesity. Am J Public Health. 2016; 106(9): 1656–1662.
STUDENTS AND THE NURSES’ HEALTH STUDY Coming full circle, the plethora of research findings from the NHS allow Rimer’s words to ring true: that research findings from rich data sets such as the NHS help students identify topics that matter, explore what is known, evaluate the evidence, and identify the gaps that they want to fill. We need to continue to ensure that we heed Rimer’s call so that if we are encouraging them to do work of consequence, that we arm them with the correct tools to do so.
AJPH
September 2016, Vol 106, No. 9
Nursing School. When I started to work as a nurse and realized there was an opportunity to participate in the research that 2 generations of nurses who came before me have contributed to, I was thrilled! I remain a proud participant and a vocal supporter of NHS 3 today. I enjoy feeling that I am a part of something bigger than myself, and potentially contributing information that could inform - transform our understanding about health and disease in the future. —Michelle, Ambler, PA
FOLLOWED ME AS MY CAREER UNFOLDED It was clear in my graduate epidemiology courses that women were under-represented in research and much of what we were learning about chronic disease and drug effectiveness was studied using male subjects and findings assumed to apply to women. I had been steeped in the history of professional nursing’s engagement with the Suffragette
Movement. Lavinia Dock, who was jailed a number of times for picketing with the National Women’s Party, joined my list of nursing leaders with whom I would love to dialogue if that “time machine” ever came to fruition. I admired our early nursing leaders and vowed to emulate the courage, commitment and engagement of our early nursing leaders. As a graduate student, I read Ashley’s book, Hospitals, Paternalism, and the Role of the Nurse. This book really solidified my perspective that in addition to nurses being strong advocates for their patients/clients, they also needed to be a strong voice for the field of nursing. So along comes this opportunity to participate in a longitudinal study that would collect data from nurses who were primarily women. It also made sense to me that such a cohort would be able to more precisely report data and to sustain interest in participation so the likelihood of robust data seemed golden! Those NHS envelopes of a characteristic size followed me around the country as my career unfolded. In some ways I miss the symbolism of those envelopes now that data reporting is
electronic. —Pam, West Lafayette, IN
A ROBUST SAMPLE OF COMPLIANT SUBJECTS I was pleased to join the NHS I in 1976, the original sample, and have faithfully answered every questionnaire and offered nail, hair clippings and blood samples. I assume my name was found in Registered Nurse listings for Connecticut. This study is the first and maybe the only, one that focuses mostly on women’s health issues with a robust sample of compliant subjects! I see my own contribution as important for that reason, now 40 years and counting! —Ruth, Cheshire, CT
THE SURVEY IS A PUBLIC HEALTH SERVICE I am in Nurses’ Health Study II. I feel as though I have
A Public Health of Consequence: Review of the September 2016 Issue of AJPH In this issue, we celebrate two interconnected themes: an editorial by Barbara Rimer1 and a host of articles produced from the rich Nurses’ Health Study data sets.
STUDENTS First, we start by endorsing Rimer’s call for the way forward to ensure that we focus on the public health research of consequence: the proper education of
September 2016, Vol 106, No. 9
AJPH
our students.1 Rimer urges us to talk the talk and walk the walk as we, the current public health researchers and educators, are the role models and the conduit of knowledge for our students. She focuses on nine elements that we can practice daily as we engage with our students, and here, we highlight a few. She advocates helping students focus on achieving positive impact for the greatest health threats, altering the morbidity and mortality
trajectories, and being able to articulate the costs on both sides of the ledger. To do that, we must be prepared to provide our students with the corresponding
“grown-up” with the NHS, as my 91 year old mother, also a nurse is in the original 1976 cohort. She would tell me about this “big nurses study from Harvard” that she was participating in, the questions that she answered, and the samples that she sent - I remember being particularly surprised by the toenail clippings. When I received the request to participate in NHS II, I willingly agreed and have sent hair and urine samples myself. I continue to believe it is a privilege and a responsibility to add to the body of knowledge to promote women’s health. I have appreciated the newsletters that are sent with the study findings and completing my NHS survey has become a summer ritual while sitting in the hammock in my backyard. My sons are also in the GUTS study and I have tried to instill in them that accurately completing the survey is a public service. —Ruth, Villanova, PA
Alfredo Morabia, MD, PhD
necessary research skills and tools, and stress the importance of quality measurement to demonstrate change. She stresses that our students need big data tools, data visualization methods, and great communication skills. Finally, among other elements, she also acknowledges that our students need to understand the state of the art in the selected topic area: What does the evidence
ABOUT THE AUTHORS Sandro Galea is Dean and Professor, School of Public Health, Boston University, Boston, MA. Roger Vaughan is an AJPH editor, and is also the Vice Dean and Professor of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY. Correspondence should be sent to Roger Vaughan, Vice Dean and Professor of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted June 22, 2016. doi: 10.2105/AJPH.2016.303346
Galea and Vaughan
Editorial
1531
AJPH EDITORIALS
tell us? Where are the gaps? What new data do we need? How strong is the case for causation? She calls for students to be aware of and use extant data sources to help identify the known, as well as articulate the gaps, which leads us to second interconnected theme, the Nurses’ Health Studies (NHS).
THE NURSES’ HEALTH STUDY Often mentioned in the same breath as the Framingham Heart Study, the NHS began following the first cohort of nurses in 1976 to help understand the risk factors for major chronic diseases in women, and is now in its third wave (including men and women), having enrolled more than 275 000 participants. The NHS has supported hundreds of high quality publications, most famously perhaps for examining the relationship between long term oral contraceptive use (including postmenopausal hormone replacement therapy) and disease, but dozens more linking behaviors (particularly dietary behaviors) and disease, and on the relationship between social factors and mental health. We highlight three such publications in this issue. Trudel-Fitzgerald et al.2 tackle the cumulative evidence from NHS publications examining the determinants of psychiatric conditions and other psychosocial risk factors for health. For depression, there was clear evidence that high caffeine intake was protective against a 10-year risk of depression, as was higher levels of exercise. This indicated that the modal first onset of depression was among adolescents and young adults. They also note that
1532
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depression was significantly associated with onset of type 2 diabetes, and with higher fatal coronary heart disease risk. The breadth of measures in the NHS allows for some perhaps unconventional hypothesis tests, such as the finding that 15-year exposure to higher air pollution levels was associated with a 9% to 15% increase in the odds of reporting symptoms of anxiety, while those reporting higher levels of gender nonconforming behaviors during childhood led to a 20% to 40% higher risk of posttraumatic stress disorder. Rice et al.3 return to perhaps the motivating research question for NHS; that of the link between oral contraceptive use and breast cancer risk. In their review of NHS publications, they revisit the modifiable risk factors for breast cancer including oral contraceptive use, postmenopausal hormone therapy, weight and weight gain, physical activity, diet, aspirin use, and shift work. The analysis of current oral contraceptive use and breast cancer revealed the complexity and nuance of many risk factors and disease relationships. Rice et al.3 replicated their previous work of observed increased relative risk of cancer (risk ratio = 1.33), but with the low prevalence of breast cancer among younger women, the population attributable risk for current users was only 1.8%, indicating the risk of breast cancer associated with oral contraceptive use had to be balanced with its protective effects for other cancers such as endometrial and ovarian. Finally, Hruby et al.4 review the body of work from NHS publications to reveal the risk factors and consequences of obesity, and focus on the four main classes of risk factors: diet, exercise, the built environment, and genetics. The NHS
prospective data sets allowed for the usual story of “eat less, exercise more” to be interrogated. The long-held belief that dietary fat was the main cause of obesity was challenged by these analyses, where increasing consumption of monounsaturated or polyunsaturated fats was not associated with weight gain whereas increasing consumption of animal fat, saturated fat, and trans fat were positively associated with weight gain. There was also more bad news for sugarsweetened beverages, although their findings revealed more complexity on the alcohol intake-weight gain relationship, observing a U-shaped function where moderate drinkers experienced less weight gain than either nondrinkers or heavy drinkers. Hruby et al.4 explore the complex genetic and gene–lifestyle interactions, revealing the synergistic effects of genes, environment, and behavior.
Sandro Galea, MD, DrPH Roger Vaughan, DrPH, MS CONTRIBUTORS Both authors contributed equally to this editorial.
REFERENCES 1. Rimer BK. Preparing students to engage in public health research of consequence. Am J Public Health. 2016;106(9): 1546–1547. 2. Trudel-Fitzgerald C, Chen Y, Singh A, Okereke OI, Kubzansky LD. Psychiatric, psychological, and social determinants of health in the Nurses’ Health Study cohorts. Am J Public Health. 2016; 106(9): 1644–1649. 3. Rice MS, Eliassen AH, Hankinson SE, Lenart EB, Willett WC, Tamimi RM. Breast cancer research in the Nurses’ Health Studies: exposures across the life course. Am J Public Health. 2016; 106(9): 1592–1598. 4. Hruby A, Manson JE, Qi L, et al. Determinants and consequences of obesity. Am J Public Health. 2016; 106(9): 1656–1662.
STUDENTS AND THE NURSES’ HEALTH STUDY Coming full circle, the plethora of research findings from the NHS allow Rimer’s words to ring true: that research findings from rich data sets such as the NHS help students identify topics that matter, explore what is known, evaluate the evidence, and identify the gaps that they want to fill. We need to continue to ensure that we heed Rimer’s call so that if we are encouraging them to do work of consequence, that we arm them with the correct tools to do so.
AJPH
September 2016, Vol 106, No. 9
