HEALTH AND SAFETY
U.S. Should Cut the Salt
On average, Americans consume much more sodium each day than is recommended by nutrition experts. Studies indicate excess sodium intake can lead to high blood pressure, heart attacks, strokes, kidney disease, and other debilitating and deadly conditions.
The vast majority of this excess sodium comes from prepared meals and processed foods. New federal standards should be developed for the amount of salt that food manufacturers, restaurants, and food service companies can add to their products, says Strategies to Reduce Sodium Intake in the United States. Regulatory action is necessary because four decades of public education campaigns about the dangers of excessive salt and voluntary efforts by the food industry to cut sodium have generally failed to make a dent in Americans' sodium intake.
To make the change more palatable for consumers, the report says that FDA should gradually reduce the allowed maximum amount of salt that can be added to foods and beverages through a series of incremental reductions. FDA will need time to gather and assess data to determine what limits to set and what the incremental decreases should be. In the meantime, the food industry should pursue voluntary sodium reduction efforts, which could provide information that helps FDA shape the process for implementing the standards.
The Institute of Medicine study was funded by the Centers for Disease Control and Prevention; U.S. Food and Drug Administration; National Heart, Lung, and Blood Institute; and Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services. .
The Evidence on Calcium and Vitamin D
Just how much calcium and vitamin D is needed daily for good health has been a subject of debate in recent years. Vitamin D in particular has raised concerns because of recent studies suggesting that many Americans are deficient in the nutrient. Some researchers have also associated vitamin D with other benefits such as decreased risk for cancer and heart disease.
After reviewing numerous published studies and hearing testimony from scientists and stakeholders, the committee that wrote the report Dietary Reference Intakes for Calcium and Vitamin D concluded that abundant evidence confirms the roles of these nutrients in promoting skeletal growth and healthy bones. However, studies and reports of other possible health effects of vitamin D have yielded conflicting and mixed results and do not offer the evidence needed to confirm that vitamin D imparts other health benefits.
The committee did not find widespread deficiency of vitamin D. Most people up to age 70 need no more than 600 international units (IUs) per day; those over 70 may need up to 800 IUs. The report notes that some North Americans may not be consuming sufficient amounts of calcium. The amount needed varies with age, with most adults requiring between 1,000 and 1,200 milligrams of calcium per day. However, getting too much calcium from dietary supplements has been associated with kidney stones, while excessive vitamin D can damage the kidneys and heart.
This Institute of Medicine study was funded by the U.S. departments of Health and Human Services, Agriculture, and Defense, and Health Canada.
Nurses for the 21st Century
The Patient Protection and Affordable Care Act enacted in 2010 will usher in the most sweeping changes to U.S. medical system in decades. Carrying out these reforms will require major transformation within the health care system, especially for the nation's 3 million nurses, the largest segment of health care work force and the one that spends the greatest amount of time delivering patient care.
The Future of Nursing: Leading Change, Advancing Health says that nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care. To ensure nurses are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor's degree to 80 percent by 2020, and double the number who pursue doctorates. And regulatory and institutional obstacles -- including limits on nurses' scope of practice -- should be removed so that the health system can reap the full benefit of nurses' training, skills, and knowledge in patient care.
Public and private organizations should provide resources to help nurses with associate degrees and diplomas pursue a Bachelor of Science in Nursing within five years of graduation and to help nursing schools ensure that at least 10 percent of their baccalaureate graduates enter a master's or doctoral program within five years, the report says. Lack of academic progression has prevented more nurses from working in faculty and advanced practice roles at a time when there is a significant shortage in both areas.
This Institute of Medicine study was funded by the Robert Wood Johnson Foundation.
Better Oversight for U.S. Food
The Food and Drug Administration is responsible for ensuring the safety of approximately 80 percent of the nation's food supply. In recent years, several outbreaks of foodborne illness in products ranging from peanut butter to spinach have spiked concerns over the adequacy of food monitoring.
Enhancing Food Safety: The Role of the Food and Drug Administration says that FDA should take a risk-based approach to food safety problems. Data and expertise can be used to pinpoint where along the production, distribution, and handling chains there is the greatest potential for contamination and other problems. The agency could then direct resources to those high-risk areas and increase the likelihood of catching problems before they turn into widespread outbreaks.
FDA's abilities to oversee food safety are hampered by impediments to the efficient use of its limited resources and a piecemeal approach to gathering and using information on risks, the report says. A risk-based approach would give FDA's food safety officials the strategic vision needed to evaluate and plan for food safety issues. Congress should also consider amending legislation to explicitly provide the authority FDA needs to fulfill its food safety responsibilities.
Since the report was released, food safety laws were overhauled to emphasize a preventive approach to contamination and give FDA the power to recall food.
This Institute of Medicine study was funded by FDA.
Readjustment Needs of Veterans
Today's armed forces are deployed multiple times to dangerous war zones, exposing them to numerous stressors that can lead to post-traumatic stress disorder, depression, and a number of other psychiatric disorders. In addition, many veterans suffer from brain injuries and the long-lasting pathological conditions associated with such injuries.
Returning Home From Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families says that providing mental health services should be a critical priority. The departments of Defense and Veterans Affairs need to ensure there are enough providers available and in locations where they are most needed, and policies need to encourage service members to seek treatment.
Traumatic brain injury (TBI) has become known as the signature injury for these veterans. The VA has established a comprehensive system for treating brain injuries initially, but the effects of TBI can persist for many decades. The department should sponsor research to identify protocols for long-term management of TBI and multiple traumas.
The report notes that requests for care and compensation by veterans of previous wars did not peak until decades after their service ended. To ensure that the nation is equipped, the VA should expand its annual long-term forecasts of costs associated with health and disability benefits. DOD and VA are enacting the report's recommendations.
This ongoing IOM study is funded by the U.S. Department of Defense.
Mental Health Services for the Military
Military service can take a toll on the mental health of active-duty and retired service members and their families. Under TRICARE -- the single-payer health care plan for the military -- those seeking services from mental health counselors must be referred by a physician, who must also supervise that care. However, recent analyses suggest that these requirements neither improve quality of care nor add to the protection of beneficiaries.
Provision of Mental Health Counseling Services Under TRICARE says that the U.S. Department of Defense should replace these requirements with a quality monitoring and management system that enables counselors to care for military personnel independently as long as providers have education, licensure, and clinical experience that adequately prepare them to diagnose and treat conditions. The report identifies specific criteria that counselors should meet to practice independently under TRICARE.
Currently, mental health care is provided by an array of practitioners -- including psychiatrists, psychologists, social workers, marriage and family counselors, and psychiatric nurses -- who have varying levels of education and experience. Research indicates that there are deficiencies in their training to serve a military population. A comprehensive quality-management system for these professionals would establish well-defined scopes of practice and promote proven, evidence-based practices for treating conditions and monitoring results, the report says.
The Institute of Medicine study was funded by the U.S. Department of Defense.
Health Problems of Gulf War Veterans
The 1991 Persian Gulf War was a relatively brief military operation for the U.S., with few injuries and deaths. However, soon after returning from duty, many veterans began reporting health problems they believed were associated with their service in the Gulf.
Gulf War and Health, Vol. 8: Update of Health Effects of Serving in the Gulf War is the latest report of an ongoing review of the evidence to determine veterans' long-term health problems and their possible causes. The report says that military service in the war is a cause of post-traumatic stress disorder in some veterans and is also associated with multisymptom illness, some gastrointestinal disorders, substance abuse, particularly alcoholism, and psychiatric problems such as anxiety and depressive disorders.
There is a pressing need to answer lingering questions about why some veterans suffer a range of symptoms whereas others experience specific, isolated health problems. The dearth of data on veterans' pre-deployment and immediate post-deployment health status and lack of measurement and monitoring of the various substances to which veterans may have been exposed make it difficult -- and in many cases impossible -- to reconstruct what happened to service members during their deployments nearly 20 years ago.
The report calls for a substantial commitment to improve the identification and treatment of multisymptom illness in Gulf War veterans, including continued health monitoring and better medical care for those with persistent, unexplained symptoms.
This Institute of Medicine study was funded by the U.S. Department of Veterans Affairs.
Women's Health Comes a Long Way
Inadequate focus on the health issues of women was first comprehensively documented in a 1985 federal report, which led to a transformation in government and public support of women's health research and in related policies and regulations. How much progress has this initiative achieved?
Women's Health Research: Progress, Pitfalls, and Promise says requirements that forced researchers to enroll women in clinical trials spurred many advances, including fewer deaths among women due to cardiovascular disease, breast cancer, and cervical cancer. The effort also yielded some progress in reducing the effects of depression, HIV/AIDS, and osteoporosis on women. However, several health issues important to women have seen little improvement, and overall, fewer gains have been made on chronic and debilitating conditions that cause significant suffering but have lower death rates -- such as autoimmune diseases, unintended pregnancies, and drug and alcohol addiction. The report identifies steps that researchers and the government should take to strengthen research initiatives on women's health and to communicate the findings more effectively.
This Institute of Medicine study was funded by the U.S. Department of Health and Human Services.
Africa and HIV/AIDS Beyond 2020
Recent reports are bringing some good news on the global HIV/AIDS front. In the past 10 years, antiretroviral therapy has become more affordable and is reaching more people who need it, and fewer people are dying from AIDS. But in sub-Saharan Africa, where more than 90 percent of new infections occur, only about half of the Africans who should have received antiretroviral therapy according to current guidelines are being treated.
Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility says that long-term planning must begin now to avert a major catastrophe on the continent in the future. By the end of the next decade, it estimates, the number of HIV/AIDS cases in Africa will grow to over 30 million, far outstripping resources for treatment. While little can be done to reverse the short-term course of the epidemic, prospects for 2020 and beyond can be greatly improved with a renewed emphasis on reducing new infections, promoting more efficient models of care, and encouraging shared responsibility between African nations and the U.S. for treatment and prevention efforts. In the meantime, decision makers in Africa will need to expand local capacities for choosing how to allocate scarce resources ethically.
Funding for this Institute of Medicine study was provided by the Doris Duke Charitable Foundation; Atlantic Philanthropies; (BD) Becton, Dickinson, and Co.; Bill & Melinda Gates Foundation; Carnegie Corporation of New York; Ford Foundation; Institute of International Education; Johnson & Johnson Services; Merck; Pfizer; and the Rockefeller Foundation.
Improving Food Labels
To help them maintain healthier diets and lifestyles, Americans are demanding easily accessible information about the food they purchase. Food manufacturers, government agencies, and others have developed a number of systems to communicate nutritional information prominently on food packaging. However, these rating systems and symbols are unregulated, and the systems' underlying nutritional criteria are raising questions.
Examination of Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report says that the systems would be most useful if they highlighted four nutrients of highest concern -- -- calories, saturated fat, trans fat, and sodium. These food components are routinely overconsumed and associated most strongly with common diet-related health problems such as obesity, heart disease, high blood pressure, type 2 diabetes, and certain kinds of cancer.
Some organizations and nutrition experts have called for nutrition rating systems to also focus on the sugars added to products during manufacturing. The report says highlighting calories per serving in nutrition rating systems would address this issue.
This Institute of Medicine study was funded by the Centers for Disease Control and Prevention and the U.S. Food and Drug Administration. A second report exploring consumer understanding and use of these systems is expected in fall 2011.
