Commentary: The message is rarely simple: the J-curve and beyond
| Autor: | B Rockhill |
|---|---|
| Rok vydání: | 2004 |
| Předmět: |
medicine.medical_specialty
education.field_of_study Epidemiology business.industry Health Status Population General Medicine Population health Moderation Risk Assessment Surgery Primary Prevention Incentive Harm Risk Factors medicine Humans J curve Positive economics business education Health Education Disease burden Preventive healthcare |
| Zdroj: | International journal of epidemiology. 34(1) |
| ISSN: | 0300-5771 |
| Popis: | In their article in this issue of the International Journal of Epidemiology, Adams and White1 take on the important topic of population-based prevention strategies. Their central thesis is that when the relation between exposure and average risk of an outcome is J-shaped, a population-based prevention strategy has the obvious potential to harm a group of individuals by pushing them into a higher risk level through a reduction in exposure. In their paper, the authors focus mainly on the outcome of all-cause morbidity/mortality. In their first paragraph, the authors invoke the name and work of Geoffrey Rose, and note that his reasoning has been so persuasive that the population approach has been described2 as one of the ‘absolute truths’ of preventive medicine. In this era of market individualism3 and consumer-driven medicine, I believe this description of Rose’s impact is, unfortunately, highly debatable in the US, but this is not the central point here. More relevant to Adams and White’s work, I would suggest that whenever one hears the language of ‘absolute truth,’ it is usually necessary to return to the original texts themselves, to see what was actually argued and advocated. In his book The Strategy of Preventive Medicine4 Rose concluded (p. 14) that preventive medicine must embrace both the ‘high-risk’ and population strategy of prevention, but, of the two, the power to bring about sustained reductions in disease burden resided with the population strategy. Rose was not one-sided in his thinking, and in fact laid out four schematic models of exposure–disease associations, with the last one being the J-shaped model that Adams and White focus on. He noted4 that this model was different from the others, and that it demonstrated graphically the oft-expressed wisdom that moderation, rather than extremism, promotes health (pp. 17–18). Adams and White1 make their point well about the potential dangers involved in shifting the entire population downward in exposure level when the relation between exposure and outcome is J-shaped rather than monotonically positive. I will focus the rest of this commentary on some subtle questions and concerns. These subtleties revolve around the relation between the individual and the population level of inference. First, empirical exposure–outcome curves as described and analysed by epidemiologists are based on averages-average exposure levels, and, more importantly, average risks of the outcome at the different exposure levels. When applying average-level data to individuals, paradoxes and conundrums can arise. Some individuals will always be put at higher risk as a result of mass intervention, even when the curve relating average exposure to average outcome risk is monotonically |
| Databáze: | OpenAIRE |
| Externí odkaz: |
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