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The Population Health Research Institute (PHRI) is Canada’s premiere global health research institute and a world leader in large clinical trials and population studies. Through international collaboration and innovation, PHRI explores CVD, diabetes, kidney and lung diseases, brain health, cancer and more.

Originally formed with a focus on cardiovascular disease (CVD) and diabetes, PHRI’s research areas have broadened to include population genomics, perioperative medicine, stroke, thrombosis, CV surgery, renal, obesity, childhood obesity, bone and trauma and implementation science.

Over the years, the PHRI has developed unparalleled expertise in epidemiology, population health and clinical trials. Examining biological and genetic determinants of health, as well as social, environmental and policy factors, the research focuses on the prevention of cardiovascular disease, diabetes and other common conditions. PHRI’s capacity to conduct several international studies concurrently, with tens of thousands of participants in each, is a capability very few organizations in the world can match. To date, PHRI studies have enrolled almost 1,500,000 participants worldwide in 102 countries.

A core strength of the PHRI is the multidisciplinary team of world-class scientists and research support teams. The environment promotes collaboration and a multifaceted approach which allows researchers to capitalize on the wealth of collective knowledge as they each bring areas of expertise to a single study.

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• v.93(3); Mar 2003

What Is Population Health?

David kindig.

David Kindig is with the Department of Population Health Sciences, University of Wisconsin—Madison School of Medicine, Madison. Greg Stoddart is with the Department of Clinical Epidemiology and Biostatistics, McMaster University Health Science Centre, Hamilton, Ontario.

Greg Stoddart

Population health is a relatively new term that has not yet been precisely defined. Is it a concept of health or a field of study of health determinants?

We propose that the definition be “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,” and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.

We present a rationale for this definition and note its differentiation from public health, health promotion, and social epidemiology. We invite critiques and discussion that may lead to some consensus on this emerging concept.

ALTHOUGH THE TERM “population health” has been much more commonly used in Canada than in the United States, a precise definition has not been agreed upon even in Canada, where the concept it denotes has gained some prominence. Probably the most influential contribution to the development of the population health approach is Evans, Barer, and Marmor’s Why Are Some People Healthy and Others Not? The Determinants of Health of Populations , 1 which grew out of the work of the Population Health Program of the Canadian Institute for Advanced Research. No concise definition of the term appears in this volume, although its authors state the concept’s “linking thread [to be] the common focus on trying to understand the determinants of health of populations.” 1(p29)

The idea that population health is a field of study or a research approach focused on determinants seems to have evolved from this work. Early discussions at the Canadian Institute for Advanced Research also considered the definition and measurement of health and the processes of health policymaking, but the dominant emphasis evolved to the determinants themselves, particularly the nonmedical determinants. John Frank, the scientific director of the recently created Canadian Institute of Population and Public Health, has similarly called population health “a newer research strategy for understanding the health of populations.” 2 T. K. Young’s recent book Population Health also tends in this direction; he states that in Canada and the United Kingdom in the 1990s, the term has taken on the connotation of a “conceptual framework for thinking about why some populations are healthier than others as well as the policy development, research agenda, and resource allocation that flow from this framework.” 3(p4)

However, Young also indicates that in the past, the term has been used as a “less cumbersome substitute for the health of populations,” which is of course its literal meaning. Evans and Stoddart, while supporting an emphasis on “understanding of the determinants of population health,” have also stated, however, that “different concepts [of health] are neither right or wrong, they simply have different purposes and applications. . . . [W]hatever the level of definition of health being employed, however, it is important to distinguish this from the question of the determinants of that definition of health.” 1(p28) The Health Promotion and Programs Branch of Health Canada has recently stated that “the overall goal of a population health approach is to maintain and improve the health of the entire population and to reduce inequalities in health between population groups.” 4(p1) They indicate that one guiding principle of a population health approach is “an increased focus on health outcomes (as opposed to inputs, processes, and products) and on determining the degree of change that can actually be attributed to our work.” (p11)

Dunn and Hayes, quoting the definition of the Canadian Federal/Provincial/Territorial Advisory Committee on Population Health, write that “population health refers to the health of a population as measured by health status indicators and as influenced by social, economic, and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services. As an approach, population health focuses on interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well being of those populations.” 5(p57) Kindig has suggested a similarly broad definition: population health is “the aggregate health outcome of health adjusted life expectancy (quantity and quality) of a group of individuals, in an economic framework that balances the relative marginal returns from the multiple determinants of health.” 6(p47) This definition proposes a specific unit of measure of population health and also includes consideration of the relative cost-effectiveness of resource allocation to multiple determinants.

Recently, even in the United States, the term is being more widely used, but often without clarification of its meaning and definition. While this development might be seen as a useful movement in a new and positive direction, increased use without precision of meaning could threaten to render the term more confusing than helpful, as may already be the case with “community health” or “quality of medical care.” For this reason, we propose a definition that may have a more precise meaning for policymakers and academics alike; our purpose is to stimulate active critiques and debate that may lead to further clarification and uniformity of use.

DEFINITION AND CONCEPT

As indicated above, the primary tension or confusion at present seems to be between defining population health as a field of study of health determinants or as a concept of health. The Group Health Community Foundation has recently stated that “some observers see population health as a new term that highlights the influential role of social and economic forces in combination with biological and environmental factors, that shape the health of entire populations . . . others interpret population health primarily as a goal—a goal of achieving measurable improvements in the health of a defined population.” 7(p7)

We think that there are 3 general possibilities: population health (a) is only concerned with the independent variables (the multiple determinants), (b) is only concerned with the dependent variables (health outcomes), or (c) is concerned with both the definition and measurement of health outcomes and the roles of determinants. While none of the three is normatively correct or incorrect, we believe that the latter is more appropriate, primarily because the concept and measurement of health and health outcomes focuses attention and research effort on the impact of each determinant and their interactions on some appropriate outcome. It also allows one to consider health inequality and inequity and the distribution of health across subpopulations, as well as the ethical and value considerations underpinning these issues. 8

While the original Evans and Stoddart “field model” did not discuss a population health concept in these terms, the idea is implicit in the evolution of the dependent variable from “health care” to “health and function” to “well being.” 1(pp33–53) The Institute of Medicine has given serious attention to measuring population health, thereby encouraging some kind of summary measure that includes mortality and health-related quality of life. 9

Given these considerations, we propose that population health as a concept of health be defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” These populations are often geographic regions, such as nations or communities, but they can also be other groups, such as employees, ethnic groups, disabled persons, or prisoners. Such populations are of relevance to policymakers. In addition, many determinants of health, such as medical care systems, the social environment, and the physical environment, have their biological impact on individuals in part at a population level.

Defining population health this way requires some measure(s) of health outcomes of populations, including their distribution throughout the population. We chose the broader term “health outcomes” rather than the more narrow term “health status”; we believe the latter refers to health at a point in time rather than over a period of years. We do not believe that there is any one definitive measure, but we argue that the development and validation of such measures for different purposes is a critical task for the field of population health research.

Our definition does imply the necessity of one or more broad summary measures capable of being a dependent variable for the spectrum of all determinants (generally including length of life and health-related quality and function of those life years), along with a family of other submeasures for different policy and research purposes. For example, the Health Utilities Index is being used in the Canadian National Population Health Survey, 10 Years of Healthy Life have been used in Healthy People 2000, 11 and the EuroQuol has been recently added to the Medical Expenditure Panel Survey. 12

We support the idea that a hallmark of the field of population health is significant attention to the multiple determinants of such health outcomes, however measured. These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and of the physical environment (urban design, clean air and water), genetics, and individual behavior. We note with caution that such a list of categories can lead to a view that they operate independently; population health research is fundamentally concerned about the interactions between them, and we prefer to refer to “patterns” of determinants.

Population health researchers tend to use a set of methods and approaches that have the following important characteristics: examination of systematic differences in outcomes across populations, complexity of interactions among determinants, biological pathways linking determinants to population health outcomes, and the influence of different determinants over time and throughout the life cycle. 13– 15

In our view, a population health perspective also requires attention to the resource allocation issues involved in linking determinants to outcomes. Part of the study of population health involves the estimation of the cross-sectoral cost-effectiveness of different types and combinations of investments for producing health. 16 Because improvement in population health requires the attention and actions of multiple actors (legislators, managers, providers, and individuals), the field of population health needs to pay careful attention to the knowledge transfer and academic-practice partnerships that are required for positive change to occur. 17, 18 Figure 1 ▶ shows how we view the field of population health. The field investigates each of the components shown in the figure, but particularly their interactions.

A schematic definition of the field of population health.

We expect and welcome critiques of the definition presented here. As noted above, one critique will be that the tasks of defining and measuring concepts of health are large enough to constitute a subject of their own, rather than being combined with the study of determinants of health. We have already given our rationale for including them in population health as a field of study, but we would add that the need for accountability argues strongly for the inclusion of outcome and distributional considerations if a population health approach is to be useful in guiding policymaking regarding resource allocation across determinants and sectors. Without such a framework, advocacy and financial incentives for individual determinants can proceed independently of their impact, as some would argue is now the case for some medical care expenditures in the United States.

A second critique is that such a definition and concept is so broad that it includes everything and is therefore not useful to guide either research or policy. We understand this concern but do not agree with it. We believe that a guiding synthesis is essential for considering both the relative impacts of the pattern of determinants and their interactions. Integration of knowledge about health and its multiple determinants seldom occurs. Policy managers typically have responsibility for a single sector; advocacy groups typically have an interest in only one disease or determinant. No one in the public or private sectors currently has responsibility for overall health improvement. We suggest that the importance of a population health perspective is that it forces review of health outcomes in a population across determinants. For population health research, specific investigations into a single determinant, outcome measure, or policy intervention are relevant, and may even be critical in some cases, but they must be recognized as only a part and not the whole.

Those in public health or health promotion may legitimately feel that population health is simply a renaming of what has been their work or legacy. Hamilton and Bhatti have attempted to show the complementarity and overlap between population health and health promotion, 19 building on the Canadian Achieving Health for All Framework for Health Promotion 20 and the World Health Organization Ottawa Charter on Health Promotion. 21 Frank has indicated that historic concepts of public health were similarly broad, until the biomedical paradigm became dominant. Those who define public health as the “health of the public” would not disagree with the definition of population health proposed here; in the words of Frank, the “shift in thinking entailed in population health should be a small one for public health workers . . . in fact it is not so much a shift as a return to our historical roots encompassing all the primary determinants of health in human populations.” 22(p163)

However, much of public health activity, in the United States at least, does not have such a broad mandate even in the “assurance” functions, since major determinants such as medical care, education, and income remain outside of public health authority and responsibility, and current resources do not even allow adequate attention to traditional and emerging public health functions. Similarly, we believe that the emerging prominence of social epidemiology is a very important development for population health but does not have the breadth, or imply all of the multiple interactions and pathways, of the definition proposed here for population health.

We believe that the time has come for a clarification of the meaning and scope of the term “population health.” We have offered a clarification of the term that combines the definition and measurement of health outcomes and their distribution, the patterns of determinants that influence such outcomes, and the policies that influence the optimal balance of determinants. We welcome discussion and debate regarding these suggestions as a way of moving toward some consensus on this important and emergent concept.

Acknowledgments

D. Kindig was funded in part by the Robert Wood Johnson Health and Society Scholars Planning Grant to the Department of Population Health Sciences at the University of Wisconsin Madison School of Medicine.

We acknowledge the helpful comments of John Mullahy, Stephanie Robert, Donn D’Alessio, John Lavis, and many members of the Robert Wood Johnson Foundation Health and Society Scholars Planning Group.

Both authors contributed equally to the planning and writing of this article.

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• UH Population Health

UH Population Health to Host Scholars Focused on Obesity Health Disparities

Federal Grant Supporting Ongoing Training for Emerging Researchers

April 29, 2024

By Mike Emery

University of Houston Population Health (UHPH) has focused programming and research on cardiovascular health including obesity. Soon, it will begin a new phase in its efforts to facilitate the development of scientific investigations addressing this worldwide epidemic.  

A recent grant from the National Heart, Lung, and Blood Institute (one of the National Institutes of Health), will provide UHPH with resources to further train and mentor new generations of obesity researchers.  

This is the third time that Bettina Beech, UH Chief Population Health Officer and UHPH founder and colleagues have been awarded this grant, which supports Obesity Health Disparities Programs for Inclusion and Diversity Among Individuals Engaged in Health-Related Research (OHD PRIDE). Through OHD PRIDE, UH Population Health will work with early career investigators from around the nation to help them develop and share their research.

 “UH Population Health will contribute to the next generation of scientists who are focusing their energies on health issues such as obesity,” said Marino Bruce, director of UH Population Health Collaboratories and OHD PRIDE Multiple Investigator. “We’re helping them launch their careers as early faculty members and assisting them to develop research studies designed to reverse disturbing global trends in obesity.”

Beech, Bruce and Roland J. Thorpe Jr. at Johns Hopkins Bloomberg School of Public Health are multiple principal investigators of OHD PRIDE. Rosenda Murillo, Associate Professor in the UH College of Education along with a national team of mentors and program faculty will work with early career scholars as OHD PRIDE Fellows. OHD PRIDE mentors and program faculty are scientists from leading research universities who have distinguished careers in obesity-related cardiovascular research. This group will deliver presentations on the latest developments in obesity science and provide feedback to Fellows about their research ideas in group and individual settings.  OHD PRIDE mentors and program faculty  will work with Fellows to produce competitive research grants and high impact peer-reviewed publications; the primary elements of an independent research career.

UHPH will welcome the next cohort of OHD PRIDE Fellows during a 10-day summer institute this June. Additional follow-up meetings will be scheduled both virtually and on campus through 2025. OHD PRIDE will mentor and train four cohorts of Fellows over the next five years.

“Fellows will not only master the nuts and bolts of manuscript and grant writing; they also will learn the nuances of biomedical, behavioral and social science research,” Bruce said. “They need to understand that revisions and rewrites are common, and research writing is a marathon … not a sprint.”

Beyond developing fellows’ writing and research skills, OHD PRIDE aims to continue making contributions the research literature and bringing awareness to the health risks associated with obesity in the U.S. and around the world.

“Obesity has been an international epidemic for two decades … going on three,” Bruce said. “It is one of the major risk factors for hypertension, diabetes, chronic kidney disease, heart disease and some forms of cancer. This has affected marginalized populations more than others.”

According to data from the Centers for Disease Control (CDC), adult obesity is most prevalent among Black and Hispanic adult populations. Bruce added that social and economic factors also affect obesity rates. Living in areas that are not conducive to walking or basic exercise contributes to obesity as do communities without access to fresh, healthy food options.

 “There is not a ‘one size fits all’ solution for obesity,” Bruce said. “That’s why we need a diverse biomedical research workforce to collaborate, produce, and disseminate research on this weight related outcomes.”

While obesity has long contributed to several cardiovascular diseases and cancers, new developments related to the disease are affecting communities. Bruce cites the rise in weight loss drugs as offering scientists new opportunities to conduct obesity prevention and intervention studies. The jury is still out on medications such as Ozempic, he said.

“We simply don’t know what the long-term effects of these drugs are,” Bruce said. “Initiatives like OHD PRIDE can help the next generation of scientists produce research about accelerated weight gain and weight loss ensure that is accessible to and understood by the general public.”

OHD PRIDE perfectly complements the mission of UH Population Health. Since its introduction at the University, UHPH has addressed quality of life and has launched academic health programs. In doing so, Beech, Bruce and others within UHPH examine the myriad factors affecting health—physical, social, environmental, economic, spiritual and more.

“There is so much to understand with regard to health, nutrition and obesity,” Bruce said. “We are looking forward to continuing to work with early career researchers who are ready to explore these areas, establish careers as successful independent investigators, and share their discoveries with the world.”

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Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by excessive anxiety and worry about a variety of events or activities (e.g., work or school performance) that occurs more days than not, for at least 6 months. People with generalized anxiety disorder find it difficult to control their worry, which may cause impairment in social, occupational, or other areas of functioning.

Additional information about generalized anxiety disorder can be found on the NIMH Health Topics page on anxiety disorders .

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• An estimated 2.7% of U.S. adults had generalized anxiety disorder in the past year.
• Past year prevalence of generalized anxiety disorder among adults was higher for females (3.4%) than for males (1.9%).
• An estimated 5.7% of U.S. adults experience generalized anxiety disorder at some time in their lives. 2

Generalized Anxiety Disorder with Impairment Among Adults

• Of adults with generalized anxiety disorder in the past year, degree of impairment ranged from mild to serious, as shown in Figure 2. Impairment was determined by scores on the Sheehan Disability Scale. 3
• Impairment was distributed evenly among adults with generalized anxiety disorder. An estimated 32.3% had serious impairment, 44.6% had moderate impairment, and 23.1% had mild impairment.

Prevalence of Generalized Anxiety Disorder Among Adolescents

• An estimated 2.2% of adolescents had generalized anxiety disorder, and an estimated 0.9% had severe impairment. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria were used to determine impairment.
• The prevalence of generalized anxiety disorder among adolescents was higher for females (3.0%) than for males (1.5%).

Data Sources

• Harvard Medical School, 2007. National Comorbidity Survey (NCS). (2017, August 21). Retrieved from https://www.hcp.med.harvard.edu/ncs/index.php   . Data Table 2: 12-month prevalence DSM-IV/WMH-CIDI disorders by sex and cohort.  
• Harvard Medical School, 2007. National Comorbidity Survey (NCS). (2017, August 21). Retrieved from https://www.hcp.med.harvard.edu/ncs/index.php   . Data Table 1: Lifetime prevalence DSM-IV/WMH-CIDI disorders by sex and cohort   .
• Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27. PMID: 15939839 
• Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9. PMID: 20855043 

Statistical Methods and Measurement Caveats

National comorbidity survey replication (ncs-r).

Diagnostic Assessment and Population:

• The NCS-R is a nationally representative, face-to-face, household survey conducted between February 2001 and April 2003 with a response rate of 70.9%. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay-administered diagnostic interview that generates both International Classification of Diseases, 10 th Revision, and DSM-IV diagnoses. The DSM-IV criteria were used here. The Sheehan Disability Scale (SDS) assessed disability in work role performance, household maintenance, social life, and intimate relationships on a 0–10 scale. Participants for the main interview totaled 9,282 English-speaking, non-institutionalized, civilian respondents. Any anxiety disorder was assessed in a subsample of 5,692 adults. The NCS-R was led by Harvard University.
• Unlike the DSM-IV criteria used in the NCS-R and NCS-A, the current DSM-5 no longer places post-traumatic stress disorder or obsessive compulsive disorder in the anxiety disorder category. They are listed in new DSM5 categories.

Survey Non-response:

• In 2001-2002, non-response was 29.1% of primary respondents and 19.6% of secondary respondents.
• Reasons for non-response to interviewing include: refusal to participate (7.3% of primary, 6.3% of secondary); respondent was reluctant- too busy but did not refuse (17.7% of primary, 11.6% of secondary); circumstantial, such as intellectual developmental disability or overseas work assignment (2.0% of primary, 1.7% of secondary); and household units that were never contacted (2.0).
• For more information, see PMID: 15297905  .

National Comorbidity Survey Adolescent Supplement (NCS-A)

• The NCS-A was carried out under a cooperative agreement sponsored by NIMH to meet a request from Congress to provide national data on the prevalence and correlates of mental disorders among U.S. youth. The NCS-A was a nationally representative, face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States. The survey was based on a dual-frame design that included 904 adolescent residents of the households that participated in the adult U.S. National Comorbidity Survey Replication and 9,244 adolescent students selected from a nationally representative sample of 320 schools. The survey was fielded between February 2001 and January 2004. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview.
• The overall adolescent non-response rate was 24.4%. This is made up of non-response rates of 14.1% in the household sample, 18.2% in the un-blinded school sample, and 77.7% in the blinded school sample. Non-response was largely due to refusal (21.3%), which in the household and un-blinded school samples came largely from parents rather than adolescents (72.3% and 81.0%, respectively). The refusals in the blinded school sample, in comparison, came almost entirely (98.1%) from parents failing to return the signed consent postcard.
• For more information, see  PMID: 19507169   and the NIMH NCS-A study page .

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Thursday, June 6, 2024

NIH launches $30 million pilot to test feasibility of a national primary care research network

Initiative aims to improve health outcomes by integrating research in everyday primary care settings.

CARE for Health infographic

The National Institutes of Health (NIH) is investing approximately $30 million in total over fiscal years 2024 and 2025 to pilot a national primary care research network that integrates clinical research with community-based primary care. The new initiative called Communities Advancing Research Equity for Health – or CARE for Health – seeks to improve access to clinical research to inform medical care, particularly for those in communities historically underrepresented in clinical research or underserved in health care. Informed by the health needs of these communities, CARE for Health will help to grow an evidence base that contributes to improved patient outcomes, provide communities access to the best available scientific research and expand opportunities to participate in clinical trials and studies. NIH Director Monica M. Bertagnolli, M.D., lays out her vision for CARE for Health in a Science Editorial that was published today.

“Despite tremendous scientific progress, the health of important segments of the U.S. population is getting worse, not better,” said Dr. Bertagnolli. “Health is dependent upon many factors.  We recognize that environmental and societal factors are very important, and that each community is unique. Because of this, we must adapt our research to be more inclusive and more responsive to the needs of communities currently underserved in health research. Our vision for CARE for Health is to help primary care providers and their patients contribute to knowledge generation, and to deliver evidence back to them to achieve better care.”

Supported through the NIH Common Fund, CARE for Health will initially leverage existing NIH-funded clinical research networks and community partners to establish the infrastructure that will support research at select primary care sites. Initial awards will fund organizations that serve rural communities and are expected to be made in fall 2024.

“Health research should be accessible to all populations. Clinical trials should reflect the diversity of Americans – because we know that delivers the best results,” said HHS Secretary Xavier Becerra. “We are taking a big step towards ensuring communities that are historically underrepresented in clinical research are fully included and have the same access to the best available results and analysis. There has never been more potential for progress than we have today.”

Participating clinical sites will be able to choose research studies based on health issues affecting and prioritized by their communities. Patients will be able to contribute their data to research in order to generate results that are clinically meaningful to them. Final study findings and aggregate results will be shared with research participants. CARE for Health will expand NIH-funded research studies to increase engagement with people from communities historically underrepresented or underserved in health care and clinical research. This includes people from certain racial and ethnic groups, those who are older, those who live in rural areas and those who have low socioeconomic status or lower educational attainment. Studies will seek to address common health issues, as well as disease prevention.  

“Community-oriented primary care not only provides essential health services, but it also engenders trust among those who lack confidence in recommended medical care or science,” said Dr. Bertagnolli. “In fact, greater availability of primary care services in communities is associated with fewer disparities in health outcomes and lower mortality. We earn people’s trust when they get access to the care they need and when they can see direct benefits from their participation in research.”

As CARE for Health expands, the program will launch new studies across the network and further establish study sites, training capabilities, data management and increased interoperability. By expanding collaborations to integrate research data into clinical practice and clinical data collection into research studies, the network will facilitate the use of innovative practices and trial designs to minimize burden of research on primary care providers and patients.

“The goal is to create a learning health system in which research informs clinical practice and clinical data informs research,” said NIH Deputy Director for Program Coordination, Planning, and Strategic Initiatives Tara A. Schwetz, Ph.D. “As the program grows, sites and their communities will help design new clinical studies reflecting their specific health needs, and results from those studies will inform the care they receive.”

The NIH is hosting a public workshop on Friday, June 7 from 10 a.m. to 12:30 p.m. EDT to share findings from a series of listening sessions on the challenges and opportunities for integrating research into primary care. Learn more about the workshop and register for the event .

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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Hashimoto's Disease

On this page:

What is Hashimoto’s disease?

How common is hashimoto’s disease.

• Who is more likely to develop Hashimoto’s disease?

What are the complications of Hashimoto’s disease?

What are the symptoms of hashimoto’s disease, what causes hashimoto’s disease, how do doctors diagnose hashimoto’s disease, how do doctors treat hashimoto’s disease, how does eating, diet, and nutrition affect hashimoto’s disease, clinical trials for hashimoto’s disease.

Hashimoto’s disease is an autoimmune disorder  that can cause hypothyroidism , or underactive thyroid. Rarely, the disease can cause hyperthyroidism , or overactive thyroid.

The thyroid is a small, butterfly-shaped gland  in the front of your neck. In people with Hashimoto’s disease

• the immune system  makes antibodies  that attack the thyroid gland
• large numbers of white blood cells, which are part of the immune system, build up in the thyroid
• the thyroid becomes damaged and can’t make enough thyroid hormones

Thyroid hormones control how your body uses energy, so they affect nearly every organ in your body—even the way your heart beats.

Does Hashimoto’s disease have another name?

Hashimoto’s disease is also called Hashimoto’s thyroiditis, chronic lymphocytic thyroiditis, or autoimmune thyroiditis.

The number of people who have Hashimoto’s disease in the United States is unknown. However, the disease is the most common cause of hypothyroidism , which affects about 5 in 100 Americans. 1

Who is more likely to have Hashimoto’s disease?

Hashimoto’s disease is 4 to 10 times more common in women than men. 2 Although the disease may occur in teens or young women, it more often develops in women ages 30 to 50. 3 Your chance of developing Hashimoto’s disease increases if other family members have the disease.

You are more likely to develop Hashimoto’s disease if you have other autoimmune disorders, including 4

• celiac disease , a digestive disorder that damages the small intestine
• lupus , a chronic, or long-term, disorder that can affect many parts of the body
• rheumatoid arthritis , a disorder that affects the joints
• Sjögren’s syndrome , a disease that causes dry eyes and mouth
• type 1 diabetes , a disease that occurs when your blood glucose, also called blood sugar, is too high

Many people with Hashimoto’s disease develop hypothyroidism . Untreated, hypothyroidism can lead to several health problems, including 5

• high cholesterol
• heart disease and heart failure
• high blood pressure
• myxedema , a rare condition in which the body’s functions slow down to the point that it can threaten your life

Left untreated, hypothyroidism can also cause problems during pregnancy .

Many people with Hashimoto’s disease have no symptoms at first. As the disease progresses, you may have one or more of the symptoms of hypothyroidism.

Some common symptoms of hypothyroidism include

• weight gain
• trouble tolerating cold
• joint and muscle pain
• constipation
• dry skin or dry, thinning hair
• heavy or irregular menstrual periods or fertility problems
• slowed heart rate

Hashimoto’s disease causes your thyroid to become damaged. Most people with Hashimoto’s disease develop hypothyroidism. Rarely, early in the course of the disease, thyroid damage may lead to the release of too much thyroid hormone into your blood, causing symptoms of hyperthyroidism. 3

Your thyroid may get larger and cause the front of the neck to look swollen. The enlarged thyroid, called a goiter , may create a feeling of fullness in your throat, though it is usually not painful. After many years, or even decades, damage to the thyroid may cause the gland to shrink and the goiter to disappear.

Researchers don’t know why some people develop Hashimoto’s disease, but a family history of thyroid disease is common. Several factors may play a role, including 2

• viruses , such as hepatitis C

Hypothyroidism can also be caused by

• some medicines used to treat bipolar disorder or other mental health problems
• iodine-containing medicines used to treat abnormal heart rhythm
• exposure to toxins, such as nuclear radiation

Doctors diagnose Hashimoto’s disease based on

• medical history and physical exam . Your doctor will start by taking a medical history and performing a physical exam. In addition to asking about symptoms, the doctor will check your neck for a goiter, which some people with Hashimoto’s disease can develop.
• the thyroid hormones T4 (thyroxine) and T3 (triiodothyronine)
• thyroid-stimulating hormone, or TSH
• thyroid peroxidase antibodies (TPO), a type of thyroid antibody that is present in most people with Hashimoto’s disease

You probably won’t need other tests to confirm you have Hashimoto’s disease. However, if your doctor suspects Hashimoto’s disease but you don’t have antithyroid antibodies in your blood, you may have an ultrasound of your thyroid. The ultrasound images can show the size of your thyroid and other features of Hashimoto’s disease. The ultrasound also can rule out other causes of an enlarged thyroid, such as thyroid nodules—small lumps in the thyroid gland.

How your doctors treat Hashimoto’s disease usually depends on whether the thyroid is damaged enough to cause hypothyroidism. If you don’t have hypothyroidism, your doctor may choose to simply check your symptoms and thyroid hormone levels regularly.

The medicine levothyroxine , which is identical to the natural thyroid hormone thyroxine (T4), is the recommended way to treat hypothyroidism. Prescribed in pill form for many years, this medicine is now also available as a liquid and in a soft gel capsule. 2 These newer formulas may be helpful to people with digestive problems that affect how the thyroid hormone pill is absorbed.

Some foods and supplements can affect how well your body absorbs levothyroxine. Examples include grapefruit juice, espresso coffee, soy, and multivitamins that contain iron or calcium. 1,6 Taking the medicine on an empty stomach can prevent this from happening. Your doctor may ask you to take the levothyroxine in the morning, 30 to 60 minutes before you eat your first meal.

Your doctor will give you a blood test about 6 to 8 weeks after you begin taking the medicine and adjust your dose if needed. Each time you change your dose, you’ll have another blood test. Once you’ve reached a dose that’s working for you, your doctor will likely repeat the blood test in 6 months and then once a year.

Never stop taking your medicine or take a higher dose without talking with your doctor first. Taking too much thyroid hormone medicine can cause serious problems, such as atrial fibrillation or osteoporosis . 5

Your hypothyroidism can be well-controlled with thyroid hormone medicine, as long as you take the medicine as instructed by your doctor and have regular follow-up blood tests.

The thyroid uses iodine, a mineral in some foods, to make thyroid hormones. However, if you have Hashimoto’s disease or other types of autoimmune thyroid disorders, you may be sensitive to harmful side effects from iodine. Eating foods that have large amounts of iodine—such as kelp, dulse, or other kinds of seaweed, and certain iodine-rich medicines—may cause hypothyroidism or make it worse. Taking iodine supplements can have the same effect.

Talk with members of your health care team about

• what foods and beverages to limit or avoid
• whether you take iodine supplements
• any cough syrups you take that may contain iodine

However, if you are pregnant, you need to take enough iodine because the baby gets iodine from your diet. Too much iodine can cause problems as well, such as a goiter in the baby. If you are pregnant, talk with your doctor about how much iodine you need.

Researchers are looking at other ways in which diet and supplements—such as vitamin D  and selenium —may affect Hashimoto’s disease. 2 However, no specific guidance is currently available. 3

The NIDDK conducts and supports clinical trials in many diseases and conditions, including endocrine diseases. The trials look to find new ways to prevent, detect, or treat disease and improve quality of life.

What are clinical trials for Hashimoto’s disease?

Clinical trials—and other types of clinical studies —are part of medical research and involve people like you. When you volunteer to take part in a clinical study, you help doctors and researchers learn more about Hashimoto’s disease and improve health care for people in the future.

Find out if clinical studies are right for you .

Watch a video of NIDDK Director Dr. Griffin P. Rodgers explaining the importance of participating in clinical trials.

What clinical studies for Hashimoto’s disease are looking for participants?

You can find clinical studies on Hashimoto’s disease at www.ClinicalTrials.gov . In addition to searching for federally funded studies, you can expand or narrow your search to include clinical studies from industry, universities, and individuals; however, the National Institutes of Health does not review these studies and cannot ensure they are safe. Always talk with your health care provider before you participate in a clinical study.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by NIDDK is carefully reviewed by NIDDK scientists and other experts.

The NIDDK would like to thank: Leonard Wartofsky, M.D., M.A.C.P., MedStar Georgetown University Hospital

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