Arch Manious, PhD, Community Health & Family Medicine specialist at the University of Florida talks about how people in poverty experience higher rates of inflammation, which can lead to an early death.
Interview conducted by Ivanhoe Broadcast News in 2024.
What is chronic inflammation and how widespread is it?
Mainous: So I think the first thing is we talk about inflammation a lot. And so there are anti-inflammatory diets, there are things that we think about. How do we control inflammation? So there’s really two things to be aware of. There’s acute inflammation. And inflammation is actually good. It’s a response by the body. So that’s why when you have a fever, that’s an example of inflammation. When we think about it though, it’s not acute and it becomes chronic, then that’s when we start to have some problems. So we have a study and we took it across the entire United States about 34% of people aged 20 and older actually have chronic inflammation. So chronic inflammation, we see it in a couple of ways. We see it with things like rheumatoid arthritis, autoimmune diseases. But where we really get concerned now is that there’s a lot of other people who are getting inflammatory responses because of their diet, because of lack of exercise, because of obesity, because of cigarette smoking, even psychological stress. And those have been linked to the development of strokes, heart attacks, cancer, and a variety of things.
So, inflammation, in general is it always caused by lifestyle?
Mainous: No, not at all. Acute inflammation is, a lot of times, caused by infections. So you would see inflammation show up as a sore throat. That would be an example where you might have a fever. Where we’re looking at some of these other things. Like I said, it really falls into two groups. One group would be autoimmune diseases, again like rheumatoid arthritis. But what we find is that there’s a whole lot more people out there who have things like lifestyle, environmental toxins, things like that, that are leading to people having inflammation. And so when people start talking about an anti-inflammatory diet, they’re really hitting back on that. So then they are really about somebody who has rheumatoid arthritis.
Is this the first time that you’ve been able to put together that the inflammation caused by the lifestyle, caused by poverty that can cause a high risk of mortality?
Mainous: So what our study did was, there has been a few studies that look at the amount of inflammation that would be among people who are very poor, who are below poverty. What we did was, we looked at it from the perspective of saying, maybe there’s a double whammy. We know that poverty links to premature mortality, and we know that inflammation links to premature mortality. But the reason why this is particularly important is that no one knows whether or not they have inflammation. No one tested unless you have a thing like an autoimmune disease or whether or not you have an acute inflammatory thing that would come from an infection. So no one gets tested. So no one would know. I wouldn’t know what my level of CRP is right now. You wouldn’t either. And so what we find is that we want to say, since people don’t know this but it is modifiable, what happens when you have two modifiable risk factors? Is there a double whammy if you have inflammation and you are below the poverty level? And so that’s really where this study adds something brand new.
Is this a screening test that should be done for everybody across the board?
Mainous: Well, it’s a very interesting question that you ask there because I think that it probably should be. So here’s the thing, I did a little search earlier today on PubMed and if you use the term chronic inflammation, you find 170,000 articles. So there’s a lot of evidence out there. This isn’t all brand new, that chronic inflammation is related to all these diseases. However, it is not either a screening target or treatment target. So even though we know a lot of things cause inflammation and we know that inflammation is related to development of a lot of diseases, we really just let it go. And so it isn’t that the evidence isn’t there, but I think that we probably should start redefining how we would do disease prevention. And disease prevention, in my opinion, probably should focus on inflammation. It’s not for a lack of evidence that it’s out there it’s that, we just haven’t focused on that.
Isn’t this how medicine is changing in this current day where we’re getting to the root of the cause instead of just treating the symptoms and after-effect?
Mainous: Well, actually I think the inflammation part is a very interesting potential pathway. Because what we do is we look at things usually just say, well, what’s the root cause so let’s go back and let’s fix what’s going on if these people were no longer obese or if they didn’t have hypertension. But the interesting thing about inflammation is that you have a bunch of things – cigarette smoking, psychological stress, things like that all relate to inflammation. And so they feed into this one part along the pathway and then all these diseases pull off of that same pathway. So, think of it like this – there might be a lot of things that caused the fire, and fire can do a lot of things. But if you stop the fire, could you actually stop all the bad outcomes? And so it’s not getting at the complete root cause it’s getting at the middle where rather than saying, well, if somebody stops smoking now they’re going to be fixed. What we’re saying is that it’s terrible if they smoke, let’s get them to stop. But at the same time, we are not as interested in what causes the inflammation if we can stop the inflammation.
How do you stop the inflammation?
Mainous: So you can stop the inflammation in a couple of ways. One way is diet. You’re probably familiar with people talking about antioxidants and oxidative stress, and that if you eat blueberries or you eat certain types of fish, so you have things like that. You have exercise, you have stopping smoking, you have other lifestyle things. You also have some drugs that are out there that might work. So one of the problems that we have with drugs is that we don’t really want to put people on some of these drugs long-term. There could be a lot of downsides. If you put somebody on steroids or non-steroidal anti-inflammatory like ibuprofen for example for a long time. Another thing that’s happened just recently is there is a drug called colchocine and colchocine was used to treat gout. It shows that it has anti inflammatory effects. And just a couple of months ago, the FDA made that the first drug that had ever been approved to basically treat this inflammatory pathway to stop heart disease. So the idea was there had been some trials that said that if you gave people colchocine, it would decrease, and they had high inflammation and you decrease that, that they would actually have a decreased risk of having a heart attack afterwards. I’m not promoting colchocine, I’m just saying that there are ways that people could do it. Some are relatively low risk diet and exercise. Some are probably a little higher risk, like putting people on medication. But there are a variety of ways to do it.
From your study, could you be very specific on the number that you found?
Mainous: What we found was we broke the U.S. population, and so we looked at people 40 and older because we were looking at mortality. We don’t really look at mortality risk and people who are like 20 years old because not very many of them are going to die in the next 15 years, so we started people 40 and older. What we did was we broke that population into four groups. So one group was the bad group and that would be the people with high inflammation, and they were below the poverty level. Then you had another group that had low information but was poor. Then you had another group that had high inflammation but was above the poverty level, and then you had what would be considered the best group, which would be low inflammation and above the poverty level. What we found was that the two middle groups tended to look the same. There was an increased risk as we would have expected. The people who were poor had an increased risk above the people who were very good. So the people who had inflammation at an increased risk above the people who were very good. But what we found though was that once we looked at that group that had the two bad characteristics versus the good group, we saw an extreme difference. We saw this double whammy in effect. In fact, we saw a risk of mortality over the next 15 years, which actually isn’t that long when you think about it, that was doubled. I think when we looked at cancer, I think it was tripled. And so I think those are some of the very specific things, is that yeah, there was an increased risk if you had inflammation, there was an increased risk if you were poor. But where you really saw the effect was when you had both.
And so you suggest screening for populations, right?
Mainous: Yeah, I would say that right now we have a lot of screening tests that have been advocated by the government through the U.S. Preventive Services Task Force or through the American Heart Association or the American Diabetes Association. There’s a lot of screening tests out there, but nothing really focuses on inflammation even though inflammation cuts across a lot of these diseases and is a modifiable risk factor. So I think that particularly in a vulnerable population like this, I think that it probably would be useful. So when we think about screening tests, sometimes we do screening tests only among certain people. So if we’re going to screen for pre-diabetes, for example, we only take people who are overweight or obese. So we don’t take everybody just like this, we wouldn’t take everybody, but I think that there are people who could probably be helped because of the significant increased risk. The other thing I think it’s important to be aware of is when we’re talking about this split on poverty, and I think this is important is these aren’t poor people and rich people. These are people at or below the poverty level, and the people who are above the poverty level, and the people above the poverty may only make $1,000 more a year. It’s not like comparing people who are billionaires versus people who are in poverty. We specifically went very conservative on this, rather than saying, well, let’s compare billionaires versus people in poverty. No, these are people in poverty and people who aren’t in poverty. A lot of those people wouldn’t be considered rich.
Now, when it comes to product inflation, does it hurt you? Like are a lot of people out there without any signs but they are suffering from chronic inflammation?
Mainous: Absolutely, I would say that on the levels that we looked at, they wouldn’t know it. People wouldn’t pick up on it and people aren’t screening for it. So it would be one of those things where, like I said, I wouldn’t know if I have it. You probably wouldn’t know if you have it. So let me give you another example. So, these are some little technical things, but we looked at levels of inflammation at 0.3 milligrams per deciliter and then we got it up to a little higher level of 1.0 milligrams per deciliter. Well, this is actually important because when people think about elevated inflammation in an infection, they’re looking at 10 milligrams per deciliter. So they’re looking at a level 10 times higher than what we had is the highest level. So people could have inflammation in some infection that could be 50 milligrams per deciliter. We were looking at 0.3 and then just one milligram per deciliter. So we were looking at levels that are actually pretty low. People aren’t going to know it and they’re definitely not going to feel it.
But still, there is such a higher risk of premature mortality, right?
Mainous: Oh absolutely, they’re at higher risk and the value of this study is that this actually is built not off of some unique population. This is built off the U.S. population. So we have representative estimates from 95 million people.
Is screening a simple blood test?
Mainous: Yeah, it would just be a simple blood test. It wouldn’t be very complicated. It wouldn’t be any more complicated than a screening test for high cholesterol or a screening test for high glucose for diabetes.
So the current cost of it is not going to be the actual cost of it because you’re going to save by keeping these people out of the hospital and office medications for life and things like that, right?
Mainous: Yeah, I haven’t seen any cost effectiveness studies on it, but I would say in general, prevention costs on the front end. But it actually saves on the back end. So it costs on the front end. You have to pay for the tests, but if you want to keep people out of the hospital, you want to keep them from having a heart attack or a stroke, then it’s worthwhile. So yes, I haven’t seen actual cost effectiveness on it, but based on what I know about diabetes and some others like that. If you go on you screen, you are typically going to save money on the back end.
Anything we’re missing, anything else you want people to know?
Mainous: I think the main thing for people to understand is that, like I said, about 34% of the adult population in the United States would meet these criteria for 0.3 milligrams per deciliter. That’s a lot of people. I think that when we see this increased mortality risk, when you have both of these things, I think it should be a bit of a wake up call to say, hey, oh yeah, we know that inflammation is bad. We’ve got 170,000 articles on it, but we don’t do anything about it. We don’t look for it and we don’t use it as a treatment target.
END OF INTERVIEW
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