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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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minimal intervention. A combination intervention seems
to increase an individual’s chance of quitting by about
10% to 25%.
18
Mobile phone–based text message interventions have
been shown to reduce smoking rates at 6 months. It
should be noted that most of these studies were conducted
in high-income countries, and so their generalizability to
low-income countries is unclear.
19
Programs that utilize incentives appear to increase rates
of smoking cessation, while the incentives are in place.
Programs that require participants to make a deposit have
higher rates of smoking cessation, although they also
have lower rates of enrollment.
20
Mass media campaigns can be an effective way to
promote smoking cessation among the general public.
Campaigns that contain information about the negative
health effects of smoking seem to be most effective at
increasing knowledge, have higher perceived
effectiveness ratings, and are most likely to result in
quitting behavior.
21
Obesity
Obesity is associated with an increased MS risk, and that risk
is modulated by the level of obesity. There is an increased
odds of MS with increasing levels of obesity.
22–24
It is believed
that the association between obesity and MS may be stronger
among females, as obesity is associated with a significantly
increased risk of MS or clinically isolated syndrome in girls
but not in boys. 23 The relationship between obesity and MS is
particularly important given the childhood obesity epidemic.
Thus, initiatives to decrease obesity, such as the following,
may also have a positive impact on MS outcomes:
Behavioral weight management programs that combine
both diet and physical activity seem to be more effective
in the long term than programs focusing on diet or
physical activity alone.
25
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Programs that aim to prevent childhood obesity are
particularly effective if targeting children ages 6 to
12 years. 26 There is moderately strong evidence that
school-based interventions are effective for preventing
childhood obesity. 27 Programs and policies that may be
helpful to reduce childhood obesity include a school
curriculum that provides education about healthy eating,
physical activity, and body image; increased opportunities
for physical activity throughout the school week; more
nutrition food in schools; support for teachers and staff to
implement health promotion activities; and a home
environment that encourages increased activity, more
nutritious meals, and less screen time. 26 Community
health workers in the home, clinic, school, or community
setting may also help improve body mass index among
children.
28
Modifying the built environment may also positively
influence health. Environmental factors that had a greater
effect include bans or restriction on unhealthy foods,
mandates offering healthier foods, altering rules for food
purchased using low-income food vouchers, and
improvements to active transportation infrastructure.
29
Diet
Diet has a significant impact on body weight, cholesterol
levels, and other vascular risk factors that affect MS risk and
disease course. These include effects mediated by dietary
metabolites derived directly from food, dietary induction of
metabolite production by gut microbiota, and diet-mediated
changes in gut microbial composition. To summarize, some
proinflammatory dietary factors that people with MS may
want to avoid include saturated fatty acids of animal origin,
trans fats, red meat, sweetened drinks, increased dietary salt,
cow milk proteins of the milk fat globule membrane (MGFM
proteins), and salt. 30 A low-calorie diet rich in vegetables,
fruit, legumes, fish, prebiotics, and probiotics is beneficial
because it helps upregulate oxidative metabolism,
downregulate the synthesis of proinflammatory molecules, and
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restore or maintain a healthy symbiotic gut microbiota. 30 The
Mediterranean diet, which is a diet rich in vegetables,
legumes, and fruits; moderate in fish; and low in meat, has
been positively correlated with a reduced risk of acquiring
MS.
31
Given this baseline understanding, we have detailed some of
the dietary factors that affect MS:
High salt: It is well established that a diet high in salt
increases MS risk. This is because salt can encourage
pathogenic T cell responses, which are believed to
promote central nervous system autoimmunity. 32 Clinical
observations have noted that patients with a high sodium
intake tend to present with worse and more frequent
radiological disease activity.
33
Dairy: The Nurses’ Health Study cohorts showed an
increased risk for developing MS among women with
high intake of whole milk during adolescence. 34 Patients
with MS have presented with remarkably heightened T
cell responses to milk antigens.
34
Fats: The results of studies on the relationship between
dietary fat and MS risk are mixed, with one large-scale
study showing that dietary fat intake is not linked to an
increased risk of MS. 35 In two large cohorts of over
90,000 women enrolled in each study, it was shown that
dietary fat intake is not linked to an increased risk of MS.
Theoretically, consumption of fatty foods may lead to
inflammation, which could lead to worsening MS
symptoms.
Saturated fats are found in foods such as whole milk,
butter, cheese, and meat. They are associated with
inflammation and are potentially relevant to MS for
this reason. 34 It is also established that saturated fat
plays a role in increasing low-density lipoprotein
cholesterol, which has been correlated with poor
outcomes in MS. 34 Saturated fats directly affect the
innate immune system through activation of
proinflammatory toll-like receptors.
34
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Trans fats were introduced in the 1960s to replace
animal fat but are not actually healthy, as they still
have deleterious effects on metabolism. 30 Intake is
associated with gut inflammation and upregulation
of proinflammatory cytokines.
Regarding omega 3 fatty acids, a self-reported
survey of people with MS has found that those
consuming fish more frequently and those taking
omega 3 supplements had significantly better quality
of life and less disability.
36
Fruits and vegetables—Gut microbiota are connected to
high-fiber foods. A case control study found protective
role for components in plants (fruits/vegetables and
grains), including vegetable protein, dietary fiber, cereal
fiber, vitamin C, thiamin, riboflavin, calcium, and
potassium. 37 This is a public health interest, as it can
possibly reduce the incidence and decrease the severity of
disease. Among people with MS, healthy consumption of
fruit and vegetables and dietary fat predicted better
quality of life and less likelihood of higher disability
when compared with respondents with a “poor” diet.
38
Exercise
Exercise can prove to be challenging to patients with MS
because of barriers such as pain, frequent medical
appointments, and transportation. 39 However, exercise therapy
may lead to small but important improvements in walking,
balance, cognition, fatigue, depression, and quality of life in
MS.
40–42
Given the lack of effective therapeutic strategies for
managing the long-term disability associated with MS,
exercise training can be an alternative approach.
43
Air Pollution
There is an association between air pollution and autoimmune
diseases, including MS. 44 For example, a cross-sectional study
in the state of Georgia found that the best predictive models of
MS prevalence in the state included PM-10 for females.
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Another study found a clustering of prevalence of MS around
Atlanta, the largest metropolitan statistical area in Georgia,
even after controlling for population distribution, suggesting
that another factor such as pollution may be at play. 45 Another
study in Tehran, Iran, found that there was a significant
difference in exposure to certain air pollutants (PM10, SO2,
NO2, NOx) in those with MS compared with controls. 46 The
potential relationship between MS and air pollution is
important given the urbanization of societies and increased
exposure to pollutants. Decreasing exposure to these pollutants
has important health implications, including for MS.
Health Disparities
MS causes a host of different problems, including physical
disability, fatigue, depression, pain, bladder dysfunction, and
more, and requires extensive services. Effective management
of MS requires coordination between various medical
providers and social services to meet the needs of the patient.
However, many people with MS do not receive the appropriate
treatment for disease management. For example, when asked
about the percentage of qualifying people with MS who
received treatment, the average answer was 64% from
responding members of the European Union, 45% from Brazil,
50% from Russia, 10% to 15% from Turkey, and less than 5%
from India.
47
There is significant variation in delivery of care based on the
resources available locally. Lack of resources is particularly an
issue in developing countries, where there may not be a
magnetic resonance imaging (MRI) scanner, which is needed
for diagnosis; a sufficient number of neurologists; or
rehabilitation centers for people with MS. 47 On the bright side,
there have been increases in these resources over the years.
Between 2008 and 2013, the number of neurologists
worldwide increased by 30%, and more emerging countries
have acquired MRI machines. 48 However, this increase has
not occurred equitably: high-income countries saw an increase
of 4.7 new neurologists per 100,000 people, whereas lowincome countries only saw 0.4 per 100,000. 48 There are also
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areas of the United States where it is more difficult to access
MS care. Compared with individuals with MS living in urban
areas, those living in rural areas are more likely to use a
general practitioner rather than a neurologist as their primary
physician and they have to travel greater distances to access
MS-focused care.
49
Public health efforts to quantify the resources available in a
given region can provide valuable data to motivate
governments to initiate change. For example, in 2008, the
Multiple Sclerosis Atlas, a joint project of the Multiple
Sclerosis International Society and the World Health
Organization, found that Ireland had the lowest number of
neurologists per head in the European Union. This information
was used to advocate for increasing the number of neurologists
in the country, and by 2013, the number of neurologists in the
country had increased from 14 to 34.
48
In addition to difficulties accessing MS-specific care,
disparities also exist in the management of MS comorbidities.
For example:
Mental health conditions are often underdiagnosed and
undertreated among people with MS. This holds
particularly true for those with lower socioeconomic
status: a lower income is associated with increased odds
of depression and increased odds of undiagnosed
depression, and a lower education level is associated with
increased odds of untreated depression.
50
People with MS often have bladder dysfunction that
would benefit from special care, although they do not
always receive the treatment they need. Those without
health insurance have reduced odds of receiving
medications for bladder symptoms.
50
Individuals with MS commonly have a number of risk
factors for osteoporosis, including impaired mobility,
limited weight-bearing activity, and low vitamin D levels,
which places them at increased risk of fractures. One
study of 20 years of a sample of hospital admissions in
the United States found that the prevalence of hip
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fractures among the MS cohort was over two times
greater than in the non-MS cohort and those with MS
tended to be younger at the time of fracture. 51 Another
study found that many people with MS did not take
vitamin D or calcium supplements, which are often
recommended to improve bone health.
52
Cost is another source of health disparity among individuals
with MS. Those living in low-income countries receive less
assistance to fund their MS treatment: 96% of high-income
countries partly or fully fund disease-modifying therapies for
MS, whereas there is no funding in low-income countries.
48
Even in developed countries, a patient’s insurance influences
the ability to adhere to recommended treatment. Higher out-ofpocket copayments and coinsurance are associated with less
adherence to disease-modifying therapies. 53 Adherence to
therapy affects health outcomes, with increased adherence
being associated with less risk of relapse, fewer emergency
room visits, and fewer inpatient admissions, 54 as well as less
medical costs. 55 Thus, strategies that address cost barriers are
important to promote the health of those with MS and to
reduce cost to the health care system.
Programs that assist patients with managing their therapy may
increase treatment adherence. One study showed that a
specialty care management program, which consisted of
mailed medications, educational materials, and phone calls
from a nurse, was associated with increased adherence to
therapy, as well as fewer MS-related hospitalizations in the
next year and reduced MS-related medical costs.
56
Additionally, there is a need to better understand the impact of
MS on minority populations to deliver better patient-centered
care. A persistent challenge in MS treatment is that long-term
adherence to treatment is low when compared with other
serious, progressive conditions. 57 A more patient-centered
approach, which takes into account a patient’s cultural beliefs,
treatment preferences, and personal values, may help improve
patient experience and quality of life among people with MS.
Although such information is important, the severity of MS
among non-Hispanic African American and Hispanic
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populations remains grossly underresearched in the literature.
58
Thus, it is necessary to study the experience of MS among
minority populations, to address this barrier to providing
patient-centered care.
Socioeconomic Disparities
The age of onset for MS is usually between 20 and 40 years;
therefore, the disease can result in a substantial loss of
productivity for an individual with MS. Many individuals with
MS give up their jobs sooner than they would otherwise, and
individuals often face a decrease in their standard of living.
59
Factors that influence work capacity include:
Symptomatology: In studies, reported reasons for
reducing work hours or becoming unemployed include
fatigue, heat sensitivity, cognitive difficulties, and
emotional distress.
60,61
Social factors: A study of 50 individuals with MS found
that, compared with those who were unemployed, those
who had reduced their work hours had more hours of
education and higher occupational prestige.
61
Caregivers may also face a negative impact on their
professional development because of MS.
59
As a chronic disease that can result in long-term disability, MS
can result in significant cost to the health care system. As the
prevalence of MS increases, the economic burden of the
disease will grow as well. Sources of cost to the economic
system include:
Health care costs
Other financial burdens outside hospital service such as
alternative transportation methods
Disability benefits and collection of social welfare
Unemployment
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Like any chronic disease, MS results in a cost to the economic
system. Nonetheless, cost should not be a barrier for an
individual with MS to access treatments and support services,
as the inability to access necessary care in the present may
result in greater costs in the future. From an economic
perspective, programs that help individuals with MS gain
independence, such as vocational rehabilitation and training
services, and employer education about MS may be beneficial.
Population-Level Awareness
MS is a disease with significant morbidity; in many cases, it
affects individuals when they are young and results in
increasing disability over time. Individuals with MS not only
have to cope with the physical limitations that result from the
disease but also may experience psychosocial distress.
Consequently, support services are an essential resource for
individuals with MS and their families as they navigate the
consequences of illness.
The number of MS organizations worldwide has increased
from 2008 to 2013, but there is still an unmet need in many
parts of the world. Public health efforts to increase the number
of organizations in areas where such groups are lacking are
necessary.
MS groups and organizations are an important source of
support and information about MS, but low-income countries
are unlikely to have any such groups. In 2013, 14% of lowincome countries reported having an MS group or
organization, compared with 91.3% of upper-middle-income
countries. 48 According to the 2013 Multiple Sclerosis Atlas,
MS organizations often play a role in advising governments
and lobbying or campaigning to improve the lives of people
with MS. Thus, in countries lacking these organizations,
governments may not be aware of the needs of people with
MS before creating policy.
According to the Multiple Sclerosis Atlas, MS organizations
are also a frequent source for employment advice, legal
advice, education advice, home visits, support groups,
adaptations, living aids or technical support, and
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transportation. 48 Still, many countries lack some of these
important support services. Of note:
MS support groups were not available in 22% of
responding countries. 48 However, there is evidence that
suggests that identification with a support group is
associated with less depression and anxiety, as well as
increased satisfaction with life. 62 As a public health
initiative, MS support groups can be relatively easy to
organize and provide significant benefit to people’s
quality of life.
48
About 45% of countries surveyed did not have any
transportation support available. 48 Individuals with MS
may have physical disabilities that affect their ability to
access transportation, including public transportation.
However, lack of transportation results in reduced access
to health care and support services and social isolation.
Conducting research identifying barriers to transportation
and implementing strategies to increase access to
transportation is imperative.
Family members of those with MS often assume the role
of the caregiver. The Multiple Sclerosis Atlas notes that
respite care is an important type of support for family
members, but only 39% of responding countries reported
that such a service was provided. 48 Investigation into the
lack of respite service and creation of such programs may
help ease the emotional and physical burden that family
members face.
On the other hand, health professionals in the public sector
were not a common source of MS support or services.
Furthermore, 17% of countries that responded reported that
specific training for health professionals in MS is not
available. This suggests that there is room to increase
professional education, awareness, and advocacy regarding the
multiple dimensions of MS.
Conclusion
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