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A woman in a white coat talks to a blonde woman.

Stemming the tide of cancer, one patient at a time

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Stemming the tide of cancer, one patient at a time - North Carolina Health News

An Outer Banks doctor takes a hands-on approach to help patients reduce their cancer risk.

By Liora Engel-Smith

Carolyn Nicholson has been on the diet treadmill for much of her life. The so-called “ketogenic” diet, one low in carbs and high in fat and protein, was the latest diet the 64-year-old was on.

Nicholson, who lives on the Outer Banks’ Roanoke Island, said that approach served her well for a time, she lost weight and kept it off. But the high-fat diet made her cholesterol levels climb, first a little, then enough for her doctor to recommend cholesterol medication.

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Nicholson was hesitant — she didn’t want a prescription. There had to be another way, she thought. That’s when Nicholson met Christina Bowen, a family doctor who specializes in lifestyle medicine. A relatively new specialty that emerged in recent decades, lifestyle medicine doctors help patients get a handle on healthy behaviors, from getting enough sleep to reducing stress, developing an exercise routine and eating more fruits and vegetables.

Doctors and public health practitioners know that health behaviors are an important component of health. A 2007 paper in the influential New England Journal of Medicine ranks health behaviors as far more important than access to medical care when it comes to mortality and morbidity. Behavior even trumps genetics and social characteristics in its degree of influence over health outcomes.

Focusing on that behavior component, Bowen said, can have powerful results, not only in preventing and reversing diabetes and heart disease but also in preventing cancer in high-risk patients. These diseases have a couple of things in common: They disproportionately affect rural populations, and lifestyle modifications can reduce the risk of getting them.

“We know that cancer prevention is not something that people talk about from a lifestyle modification perspective,” Bowen said.

But the link between obesity and a higher cancer risk is well-established for breast, ovarian and colorectal cancers, to name a few.

And Bowen’s Outer Banks Hospital Center for Healthy Living is in the middle of an area of the state where some of these cancers strike all too frequently.

A cancer hot zone

Eastern North Carolina has some of the highest cancer rates in North Carolina, and residents from several area counties, including Washington, Halifax and Pasquotank, are among the top 10 counties with the highest cancer deaths in the state. The picture isn’t much better when it comes to breast cancer. Several eastern North Carolina counties, including Martin, Vance and Nash have higher breast cancer death rates than other North Carolina counties.

A map of cancer incidence rates by county in 2017
Source: NCDHHS.

That’s why Bowen set her sights on working with breast cancer survivors, through an initiative that refers oncology patients to her center after an evaluation of their risk. These high-risk patients — more than 60 to date — arrive at Bowen’s practice through a referral from Charles Shelton after a genetic screening and an initial evaluation for cancer risk, with the goal of preventing a second cancer.

Two doctors in white coats stand in a hallway of a center where they address cancer risk with lifestyle change
Doctors Christina Bowen and Charles Shelton. Photo credit: Vidant Health

“We don’t tell you what you need to change,” said Shelton. “We tell you, ‘Look, here are 10 things you do that we know are bad, you could pick any one of those and make a difference.’”

Bowen then meets with the patients and helps them set goals that would reduce their risk — including incorporating more plant products into their diets, increasing exercise, losing weight and quitting smoking.

Bowen sees relationships with patients as one of collaboration, mentoring and support. The lifestyle physician provides resources and encouragement as patients take steps to change their lifestyles.

Bowen uses the same approach with the breast cancer cohort as she does with other patients, including Nicholson, the 64-year-old who had high cholesterol. Bowen helped Nicholson move from her high-protein diet to a plant-based way of eating — concentrating on whole foods, fruits and vegetables and minimizing animal products. Nicholson was apprehensive about that overhaul at first.

“I was kind of scared about it,” Nicholson said. “This is totally different. Am I going to be able to do it?”

‘Change their lives for the better’ 

Health behaviors are notoriously difficult to influence in a clinical setting. Medical providers spend an average of 15 minutes or less with their patients. Providers may spend as little as five minutes to one minute per topic, hardly enough time to talk about lifestyle choices, beyond the basics.

But Shelton and Bowen’s approach relies on in-depth conversations with patients. And it seems to be working. The two recently published a paper in the journal Oncology Issues that shows all patients in the cancer cohort met one health goal that lowered their risk of a second cancer. Most patients — 80 percent — met all of their health goals.

“We partner with our patients, it’s not a hierarchy,” Bowen said of the reasons for the program’s success. “I’m here to help them change their lives for the better.”

A physician sits behind a desk talking to an older woman
Dr. Christina Bowen of Outer Banks Hospital. Photo credit: Vidant Health

Bowen and Shelton are looking to expand the program to other areas of eastern North Carolina, and to other types of chronic diseases.

“Our goal is to really pilot this locally and then magnify [this approach] to the rest of North Carolina,” Shelton said.

One habit at a time

Nicholson, the patient from Roanoke Island, may have not been confident in her ability to change her diet at first, but she’s made progress in the three months she’s worked with Bowen.

Nicholson added more salads to her meals. She’s tried new plant-based recipes Bowen shared with her. Gradually, Nicholson amassed a collection of cookbooks and go-to recipes. She’s learned to substitute high-fat dairy sauces with cream sauces made of cashews, for instance.

The results soon followed. Nicholson’s cholesterol dropped to normal levels. Her energy levels also increased. Bowen’s greatest power is her enthusiasm and her ability to help people unstick old habits, Nicholson said.

“We can get stuck in our routine and our lifestyle, and we just need someone that knows a lot and is encouraging,” she said.

With her new way of eating firmly established, Nicholson now has a new goal. As Bowen put it to Nicholson in one meeting, the next new habit is “exercise, exercise, exercise.”

shows a county map of north carolina with darker counties being places with higher rates of COVID-19. The darkest counties right now are all rural.

Coronavirus Today – Oct. 21 – Paused in Phase 3; Counties asked to toughen COVID restrictions; Promising treatment underperforms; Veterans’ home outbreaks

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Coronavirus Today – Oct. 21 – Paused in Phase 3; Counties asked to toughen COVID restrictions; Promising treatment underperforms; Veterans’ home outbreaks - North Carolina Health News

Thirty-six NC counties with high COVID-19 transmission asked to consider restriction measures beyond state requirements.

By Anne Blythe, Hannah Critchfield and Thomas Goldsmith

On a day that North Carolina’s COVID-19 death toll topped the 4,000 mark and the number of people hospitalized with illness related to the novel coronavirus is the second highest in the pandemic, Gov. Roy Cooper hit the pause on any further reopening.

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North Carolina public health officials reported that 4,032 people have died from illness related to COVID-19 and that 1,219 people are in the hospital because of the virus.

The number of cases in this state also passed the quarter-million mark with 250,592 lab-confirmed cases of the virus leading to even more cases of pandemic fatigue.

“As this pandemic continues, I know that it’s tiring and difficult to keep up our guard, especially when we’re gathered with people we love,” Cooper said Wednesday during a briefing with reporters. “But it’s necessary. No one wants to spread COVID-19 accidentally to friends or family. So we must keep prevention at the forefront. Wearing a mask shows that you care about people. It’s more for them than for you. Wearing a mask is an easy way to protect our communities and to look out for each other. Confronting the virus head on and doing our part as individuals is good for our health and it’s good for our economy.”

Despite the pleas throughout the pandemic for mask use, some in North Carolina continue to ignore them, frustrating those who embrace the idea as a necessary measure to slow the spread of COVID-19 and live with the virus more safely as the pandemic continues.

 

Seeking help from high-transmission counties 

On Tuesday, in an effort to reverse disease trends that have been getting worse, the state Department of Health and Human Services and the state Department of Public Safety sent a letter to county managers and chairs of their elected boards asking for help in counties that have:

  • Had 300 or more new cases over the past 14 days;
  • Been identified by the White House COVID-19 Task Force as a county of concern;
  • A rate of cases that is greater than 50 per 10,000 people; or
  • One of the three most populous in the state.

Letters went to Alamance, Avery, Burke, Caldwell, Caswell, Catawba, Chowan, Cleveland, Craven, Cumberland, Davidson, Duplin, Edgecombe, Gaston, Graham, Greene, Guilford, Hoke, Hyde, Johnston, Lincoln, Mecklenburg, Moore, Nash, New Hanover, Onslow, Pitt, Randolph, Robeson, Rockingham, Rowan, Scotland, Union, Wake, Watauga and Wayne counties.

Mandy Cohen, the DHHS secretary, discussed this possible approach a week ago during a briefing with reporters in which she was asked about New York Gov. Andrew Cuomo’s decision to close down schools, restaurants, synagogues and churches in some New York City neighborhoods where COVID-19 cases were on a rapid rise.

The letter suggests that some counties might want to adopt ordinances of their own that are stricter than the statewide thresholds set in Cooper’s executive orders.

Under those orders, criminal citations may be issued to people not following the rules. County ordinances can impose civil penalties, such as fines that won’t result in criminal records, for people who blatantly violate measures intended to protect the public’s health.

Early in the pandemic, some counties and cities set curfews and ordered face coverings in public before statewide measures were in place.

Cooper and Cohen have suggested such actions to help tamp down hotspots where health care systems are beginning to feel strained.

Dan Forest, the Republican lieutenant governor running against Cooper, a Democrat seeking re-election, quickly criticized the request to the 36 counties in a post to Twitter.

The memo in the tweet begins: “Is Gov. Cooper Trying to Continue His Shutdown of NC by Passing the Buck on His Responsibility?”

“To put it bluntly: Governor Cooper is attempting to use local governments to punish individuals doing what they can to survive,” the memo states. “He has repeatedly said he has full authority over his COVID shutdown, which means he also gets 100 percent of the responsibility. Passing the buck to local businesses and municipalities is the antithesis of leadership.”

Forest, who has held rallies indoors and outdoors with attendees not wearing masks or social distancing, has said he would rescind the mask order if elected.

Cooper was asked about Forest’s response during the briefing with reporters.

“What we’re doing now in working with local governments to slow the spread of the virus is no different from how we started this thing back in March and April and June,” Cooper said. “We set a floor with statewide restrictions, but at that time we also encouraged local governments, that if they were seeing more viral spread in their community, and it worked better in their community, they could use restrictions that were greater than the state floor. And a number of our cities across the state did that and it helped us to slow the spread of the virus.”

Who will enforce the orders?

There have been times during the pandemic that local law enforcement officers in some counties have refused to or been reluctant to enforce the restrictions in Cooper’s statewide executive orders.

In June, the sheriff in Alamance County, one of the counties that received this week’s letter, refused to enforce Phase 2 restrictions when ACE Speedway held events with crowds larger than what was allowed under the statewide order.

The Halifax County sheriff said in June that his deputies would not enforce the face mask order, but reversed course this month, WRAL’s Lena Tillett recently reported, after six deputies in the department fell ill with COVID.

“A lot has happened since June,” Halifax Sheriff Wes Tripp told WRAL. “It is not a hoax.”

“More and more law enforcement across the state are beginning to recognize that it is important for them to play a role in enforcement, even if it is an informal one going and talking to people and being leaders in the community,” Cooper said, citing Tripp’s change of direction.

Health departments have enforcement power, too

Additionally, local health departments and DHHS have authority under public health laws to enforce safety precautions and make sure the state is “sending the signal that is serious and that we have to slow the spread of the virus,” Cooper said.

“I’m feeling more confident that we can enforce what we have to be able to drive down our numbers,” Cooper said. “It really takes people working together, but I think more people are recognizing that it’s important for us to do that.”

Cooper’s order puts much of the onus on retail establishments to make sure people in the restaurants, grocery stores or other shops are following the mask requirements and other social distancing measures put forth.

“Our health departments and our department of Health and Human Services also have the authority under the abatement provisions. … That already has been used in some circumstances and we anticipate that is going to be used more in the coming days, particularly working with local health department,” Cooper said.

The state health department used that process in June to halt ACE Speedway gathering held in defiance of statewide orders.

In her metrics and trends presentation on Wednesday, Cohen noted a bit of good news in that the number of people showing up in emergency departments over the past week with COVID-19 symptoms had started to decline.

But the number of cases is much higher than she or the governor would like to see and the rate of people showing up for COVID-19 tests and testing positive has crept up beyond the 5-percent mark.

Contact tracing is not working as well as Cohen would like to see either. Some people do not pick up their phones. Others are not forthcoming with information about who they have been around when reached by a tracer.

With a united front, this, too, shall pass

“This has been a really hard year. I understand how much everyone wants to be with family and friends without having to worry about a virus,” Cohen said. “We miss the people we love and the places that bring us joy or provide comfort. I haven’t seen my parents in person and I miss seeing them play with my girls. And I’m sad that I’ve never met my new baby niece.”

Over the past two weeks, public health officials have seen an increase in COVID-19 clusters in social gatherings, events such as informal get-togethers, family gatherings and parties.

Additionally there have been more cases in clusters from religious gatherings. The state recently posted new guidance for private social gatherings that includes mask wearing when with anybody not from your own household and setting up tables and chairs outside well distanced.

“Look, we’re doing everything we can to slow the spread of this virus,” Cohen continued. “The simple fact is we can’t do it on our own. Ignoring the virus does not make it go away, just the opposite.”

Cohen assured people that there will be a day when the virus is not at the forefront, but there is much work to be done in the months ahead.

“As hard as this is, it will end,” Cohen said. “We will get through this. Let’s do it by looking out for one another.”

Studies cast doubts over once-hailed COVID-19 treatment

Three new studies of a previously promising therapy for patients with COVID-19 have once again complicated the coronavirus treatment narrative.

Tocilizumab, an antibody drug commonly used to treat inflammatory arthritis, was hailed as a possible treatment for COVID-19 pneumonia early on in the pandemic. Observational studies, first in China and then elsewhere, initially suggested the immunosuppressive drug could alleviate the hyperinflammation that often accompanies severe illness from the virus, leading to a “mortality benefit” — a difference in death between treated and untreated patients.

“As a result of those studies, tocilizumab use became fairly widespread in the United States and other sites,” said Jonathan Parr, a professor of infectious diseases at the University of North Carolina School of Medicine and author of a JAMA article on the impact of the new studies. “We at UNC initially used tocilizumab for a small number of patients, but then significantly scaled back our use when we realized that we weren’t seeing the same types of clinical courses that had been described in the original study.”

Those early observations were limited to a small number of patients; guidelines from organizations such as the National Institutes of Health now recommend against prescribing tocilizumab except in clinical trials.

Three articles on more comprehensive studies, all released yesterday, present mixed results about the drug.

One, a large observational study of tocilizumab in COVID-19 involving about 4,000 people, found that individuals treated with the drug were less likely to die than those who were not (a mortality rate of 28 percent vs. 37 percent).

But the other two, which were randomized studies — considered the gold standard for trials assessing the efficacy of a treatment — found no difference in mortality between COVID-19 patients treated with the drug and those that were not.

“Whenever we are forced to make hard decisions about whether to use an off-label treatment, or an unproven treatment, we always need to give priority to the randomized trial results,” said Parr.

Based on the available evidence, Parr said he doesn’t plan to use tocilizumab for COVID-19 pneumonia in his clinical practice.

“Unless new results come out from randomized trials that tell a different story,” he said. “Which is possible.”

More studies of the impact of the drug in treating COVID-19 infection are slated to be released in the coming weeks and months.

“But until we have those results, it’s difficult to say,” Parr added. “For me personally, it’s hard to justify the use of an expensive, unproven treatment option when the randomized trial data that we have now doesn’t support its use.” – Hannah Critchfield

Two new COVID outbreaks in privately managed state veterans nursing homes

North Carolina health officials are reporting nine new cases of COVID-19 in the state veterans nursing homes privately managed by Georgia-based PruittHealth.

The N.C. State Veterans Home in Salisbury, where 15 residents died of the disease earlier this year, has five new cases, according to DHHS. The State Veterans Home in Kinston, with one previous veteran’s COVID-related death in 2020, has four new cases. Both are classified under a definition that defines an outbreak as being two or more cases.

As previously reported in NC Health News, in the four Pruitt-run veterans nursing homes in the state, 36 residents have died during the pandemic. Attempts to reach Pruitt officials for comment Wednesday were unsuccessful.

PruittHealth officials have said they will request an annual renewal this year of their long-term contract to manage the four NC state veterans nursing homes for a 9.25 percent commission. A renewed contract would also put the company in charge of two additional veterans nursing homes in the planning stages.

Gov. Roy Cooper’s administration has said it will reexamine the contract before a planned Dec. 1 contract renewal.  – Thomas Goldsmith

Coronavirus by the numbers

According to NCDHHS data, as of Wednesday afternoon:

  • 4,032 people total in North Carolina have died of coronavirus.
  • 250,592 have been diagnosed with the disease. Of those, 1,219 are in the hospital. The hospitalization figure is a snapshot of people hospitalized with COVID-19 infections on a given day and does not represent all of the North Carolinians who may have been in the hospital throughout the course of the epidemic.
  • 218,541 people who had COVID-19 are presumed to have recovered. This weekly estimate does not denote how many of the diagnosed cases in the state are still infectious. Nor does it reflect the number of so-called “long-haul” survivors of COVID who continue to feel the effects of the disease beyond the defined “recovery” period.
  • To date, 3,668,243 tests have been completed in North Carolina. As of July 7, all labs in the state are required to report both their positive and negative test results to the lab, so that figure includes all of the COVID-19 tests performed in the state.
  • People ages 25-49 make up the largest group of cases (40 percent). While 13 percent of the positive diagnoses were in people ages 65 and older, seniors make up 81 percent of coronavirus deaths in the state.
  • 352 outbreaks are ongoing in group facilities across the state, including nursing homes and correctional and residential care facilities.
  • There are 3,442 ventilators in hospitals across the state and 927 ventilators in use, not just for coronavirus cases but also for patients with other reasons for being in the hospital. As of Tuesday, 308 suspected COVID-19 cases were in intensive care units across the state.
Kendrick Ransome is a farmer in Edgecombe County, which has the highest rates of hunger in the state

Eastern North Carolina communities look to map their way out of hunger

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Eastern North Carolina communities look to map their way out of hunger - North Carolina Health News

Organizations from five counties with high food insecurity rates will participate in creating a map of their food ecosystem. The information they gather will be used to guide food policy decisions in the region.

By Liora Engel-Smith

On his family farm in Edgecombe County, Kendrick Ransome grows good food.

With winter not yet over, Ransome, a fourth-generation farmer, cultivates hardy vegetables on roughly 10 acres: collards, mustard greens, turnips and cabbage. In spring and summer, Ransome branches out to other organic crops such as squash, cucumbers, watermelon and cantaloupe.

Situated in Pinetops, a rural town with two traffic lights and roughly 1,200 people, Ransome’s farm is an island of food in a county where, according to 2017 statistics from Feeding America, nearly one in four people experienced hunger, the highest rate of food insecurity in the state.

Ransome sees some of the challenges people in his community face surrounding access to food. Farmers markets rarely convene in rural communities, he said. And traveling 10 or 20 miles to the nearest city for a market isn’t always possible.

“Some folks in rural communities don’t have transportation to get to a farmers market,” Ransome, 27, said. “Farmers markets might not be open every day [people] have a chance to get out there.”

Related: As the rate of lifestyle diseases rises, one obesity prevention strategy is gaining ground

Ransome has partnered with other businesses to offer pop-up markets in smaller towns around the county, but even when a market is nearby, the price of fresh produce can be a limiting factor, he said.

Growing fruits and vegetables, particularly organic ones, can be expensive, he added, and Ransome has to price his produce to cover those costs.

The challenges Ransome describes — transportation and price barriers — are features of the food ecosystem in his community. And when put together with factors such as unemployment and lack of grocery stores in a neighborhood, these conditions can inhibit people’s access to healthy food and contribute to hunger and lifestyle diseases such as diabetes, obesity and high blood pressure. 

Kendrick Ransome is a farmer in Edgecombe County, which has the highest rates of hunger in the state
Kendrick Ransome is a 4th generation farmer in Edgecombe County. Photo courtesy of Kendrick Ransome.

A new collaboration between the Upper Coastal Plain Council of Governments and community groups in Edgecombe and four neighboring counties wants to  understand the totality of these factors and how they affect people in the region. The collaboration will map out food sources in each community — grocery stores, food growers and corner stores, to name a few — and the relationships among them.

The goal is to use the information to guide policy solutions on issues such as food insecurity and hunger, said Ron Townley, planning and development services program director at the council.

“It’s really hard to create connectivity and build synergies to support local healthy food efforts without understanding more completely what we have, where we have it and how it supports communities that are traditionally underserved and have limited access to resources,” he said.

Launched earlier this month with support from The Kate B. Reynolds Charitable Trust, the project also includes Wilson, Nash, Northampton and Halifax counties — all counties, that like Edgecombe, have high rates of food insecurity.

‘It touches everybody’

Helping local people understand the food environment in the region could guide solutions to many economic and health challenges, said Cooper Blackwell, advisory board chair of the Just Foods Collaborative of Nash/Edgecombe Counties, a grassroots food policy organization.

“Ultimately it’s important because every person is affected by food,” he added. “… Everyone has to eat, but not everyone has access to healthy food.”

The project, he said, will help Just Foods identify what’s available to people and what is missing, and will ultimately guide the collaborative’s work on disparities in access to food and resources.

“It touches everybody,” he said.

But change to the conditions that gave rise to hunger and food insecurity isn’t likely to occur immediately, Townley said.

“It’s taken a long time to get the region into this situation,” he said. “We’re not going to fix it overnight.”

As advocates in central North Carolina discovered, mapping community resources and identifying gaps can change the food landscape in a county.

From maps to action

Erin Brighton has been through the process of mapping the resources in Mecklenburg County twice: once in 2010, and again in 2015. And this year, Brighton and other staff at the Charlotte-Mecklenburg Food Policy Council are repeating the process.

Brighton, education director and former executive director of the food policy council, said that the mapping process is labor-intensive and can take months to achieve, but the insights it produces can lead to conversations that can eventually bring about change.

More than 150 organizations in Mecklenburg County used data from the 2010 report in their grant applications for programs to address food insecurity, hunger and related issues, Brighton said.

Members of the food policy council also talk about their findings at Charlotte city council meetings. After learning that some neighborhoods in the city lack easy access to fruits and vegetables, city council worked to change zoning rules to allow mobile farmers markets to set up shop in the city. Since the adoption of the amendment, some neighborhoods where maps identified high rates of food insecurity have gotten a mobile farmers market, increasing their access to fresh fruits and vegetables, Brighton said.

Changing a food system isn’t easy or fast, Brighton said, but it can lead to lasting change.

“I’m really happy that another North Carolina community is trying to do this as well,” she added. “Nothing but good can come out of it. When you get a group of people together to kind of really look at these issues, only positive things can happen.”

Disclosure: The Kate B. Reynolds Trust is an underwriter of North Carolina Health News. The Trust has no input into editorial choices or stories produced by NC Health News.

A group of people is placing a playground equipment on the ground, behind them are trees and an excavator. This is part of their efforts to address obesity.

As the rate of lifestyle diseases rises, one obesity prevention strategy is gaining ground

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As the rate of lifestyle diseases rises, one obesity prevention strategy is gaining ground - North Carolina Health News

A four-county program promoting wellness and preventing obesity through changing people’s surroundings is eyeing expansion to other parts of North Carolina.

By Liora Engel-Smith

School children carrying backpacks walk in line on a highway. There is a house and an empty field in the background ahead of them.
Willis Hare Elementary school student participate in a walk to school celebration in Pendleton. Source: NC State University.

For many years, Clark Memorial Park in Tarboro had been crumbling. The community of roughly 10,000 boasts one of the oldest town commons in the country, yet the recreation area just blocks away from the county manager’s office was far from charming.

Floods from two hurricanes — Floyd in 1999 and Matthew in 2016 — damaged the equipment at the recreation area on the east side of town, and general decay during years of economic hardship in Edgecombe County didn’t help.

Money for the park’s rehabilitation in 2017 came from an unlikely source. A Centers for Disease Control and Prevention grant funded a partnership between North Carolina State University, N.C. State Extension and the community made a $12,000-facelift to the park possible. The Tarboro Department of Parks and Recreation contributed roughly $4,500 in materials and personnel, installing the new playground equipment, swing set, signage and more.

The program, dubbed Health Matters, worked on dozens of similar initiatives across four North Carolina counties, creating environments that promote physical activity, healthy eating and recreation, with the goal of eventually decreasing obesity rates, said co-leader Annie Hardison-Moody, assistant professor and extension specialist at the N.C. State’s Department of Agricultural and Human Sciences.

Three other counties where obesity rates top 40 percent, also participated: Lee, Halifax and Northampton.

The 79 projects the grant funded ran the gamut from creating a utensil and small appliance lending library to promote home cooking and healthy eating to installing bike racks in a community.

Though the grant expired last December, Hardison Moody said, the work — in these counties and beyond — is far from over.

Stringing pearls

Edgecombe County Manager Eric Evans has come to call the Health Matters projects — like the park renovation in Tarboro — pearls. And real change, he added, comes from stringing them together.

“We’ve got a high rate of chronic disease, high obesity rates, all the things you expect in a county in Eastern North Carolina,” he said. “So to have these opportunities (for physical activity) and to see people make use of it is very exciting. … It’s not something that would turn the page for the county overnight, but it’s pointing us in a better direction.”

Evans isn’t far off. Over the past two decades or so, the public health community has established that the causes of obesity are multifaceted and involve, among other things, cues from the environment. So when a nearby park isn’t safe, accessible or inviting to play on, the research says, children and their parents are likely to avoid it. And if no other recreation options are available in an area, families may become more sedentary, putting them at risk for obesity and associated conditions, such as Type 2 diabetes and heart disease.

An African-American Woman and an white man pose near a sign that says
Yvonne Murphy of Edgecombe County Extension and Travis Stigge, the Tarboro Parks and Recreation director pose in front of the newly renovated Clark Memorial Park in east Tarboro. The park renovation was one of 79 projects in four N.C. Counties funded by a CDC grant designed to create healthy environments that promote obesity prevention. Source: courtesy of Annie Hardison-Moody

The opposite is also true, researchers discovered: the right environmental cues — lush, inviting parks, walking tracks and well-maintained sidewalks — can be a powerful ally in mitigating obesity.

Health Matters created or laid the groundwork for many such changes in Edgecombe County, Evans said. It also fostered opportunities for counties to learn from one another. For example, Evans learned of a Halifax County program that gives out small grants to promote recreation and physical activity. Over the last couple of years, Evans said, his county followed suit, creating a similar initiative. Thus far, Edgecombe supported a wide array of activities through grants of up to $2,000 from teaching children to play tennis to creating a music therapy program for seniors.

And Evans wants to expand the government’s role in creating an environment of wellness in Edgecombe. He wants to establish a county parks and recreation department that would coordinate future initiatives. The effort is likely to take time, he said, but he hopes for a department that will be up and running in the next three years.

“That recreation mini-grant is just another one of those pearls,” he added. “It’s small, but we’re stringing together collectively these things and it’s shaping up to be a more organized recreation effort from the county.”

Walking the walk

Health Matters didn’t just put new resources in place, N.C. State’s Hardison-Moody said. It also helped communities identify and make better use of facilities they already had by removing obstacles to access when needed.

“Especially rural counties that don’t have the financial resources that more urban counties have, they do have these incredible assets whether it’s through schools or faith communities or other assets that are local to their communities and by thinking about what they have, they were able to be very creative (with solutions),” Hardison-Moody said.

A man in a bright yellow vest stands on the edge of a highway, inspecting a hole on the ground as cars drive in the background
Seaboard Commissioner George Jerman, Sr., inspects a hole at the edge of Highway 186 during a walk audit to a local park last summer. Courtesy: NC State University.

Sometimes, those barriers can be trash cans, said Extension associate Lauren Morris, who works in Northampton and Halifax County.

Last summer, Morris led a walk to a newly installed local park in Seaboard along with lawmakers, county commissioners, the mayor and community members. It was during that walk they noticed trash cans left out for collectors in the middle of the sidewalk made it difficult to access a street en route to the park.

“(We) found that all the trash cans were right on the sidewalk after it was picked up,” she said. “ … So we had to move all of them (to walk there during trash day).”

One solution the group explored was to ask the contractors who pick the trash to place the empty cans away from the sidewalk, Morris added.

Morris has since taught others to take stock of walkability on their own. Staff has been exploring an option to write a manual that would train other extension agents to audit their own communities in a similar way.

Increasingly, extension staff are looking for ways to share what they’ve learned with others, Hardison-Moody said. These skills may be valuable to many counties in the state, as North Carolina’s adult obesity rates more than doubled in recent decades, surging from 12.3 percent in 1990 to 32.1 percent in 2017.

“There’s so many opportunities that it’s almost like an endless list of things that could be done,” Morris said. “I never thought that being a Health Matters associate that I would be trying to help a community to put a playground. It never even crossed my mind.”

dental hygientists tools laid out on a tray and a hand picking up one of those tools.

Can North Carolina dental hygienists help fill coverage gaps through a public-private partnership program?

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Can North Carolina dental hygienists help fill coverage gaps through a public-private partnership program? - North Carolina Health News

N.C. Dental Board proposes a rule change that could slightly expand the scope of practice for the state’s hygienists.

By Anne Blythe

Hygienists in North Carolina have been lobbying for years to be able to clean teeth, take X-rays, check gum health and apply sealants when a dentist is not on-site with them.

At long last, they seem to be one step closer to being able to do just that in certain schools, elder care facilities and special-needs centers in some parts of the state.

The N.C. Board of Dental Examiners recently endorsed a rule change that could give hygienists a slightly broader scope of practice in one of the most restrictive states in the country.

That proposal must survive a months-long process that calls for review by legislative staff, public comment periods, hearings and a rules commission review before troops of hygienists can fan out to underserved regions of the state.

If all that happens, other counties could build on a public-private partnership experiment started two years ago in Edgecombe and Halifax counties.

‘Innovative idea’

Frank Courts, a dentist in Rocky Mount and chair of the North Carolina Dental Society Council on Prevention and Oral Health, has been involved with the Edgecombe program and the effort to create similar ones elsewhere.

“We were looking for a way to provide direct services without state funding,” Courts said in a recent telephone interview. “It turns out it’s a pretty innovative idea.”

For a little more than two years, dentists in private practice in Edgecombe and Halifax counties have contracted with county health departments to allow their hygienists to work as “public health” providers.

“Most dentists don’t work on Fridays,” Courts said. In the program, the hygienists and dental assistants who would normally be off on those Fridays are free to provide screenings, cleanings and preventive services at high-needs settings such as schools with a high percentage of students from low-income households.


Hygienists in an experimental public-private partner program provide sealants to a child at Coker-Wimberly Elementary School in Edgecombe County. The program is a model that could be expanded to other counties in the coming months. Video courtesy: Frank Courts, a Rocky Mount dentist and chairman of the North Carolina Dental Society Council on Prevention and Oral Health. Used with permission.

They also can paint sealants on children’s teeth, adding the thin coating to help stave off decay.

If there is decay, hygienists cannot drill, but they can apply silver diamine fluoride to fight further deterioration, a treatment option approved almost five years ago by the Food and Drug Administration.

If patients need more care than hygienists and dental assistants can provide in the public settings, the private dentists in the program will welcome them into their offices, offering what they describe as “a dental home” for routine checkups.

The push to expand the program comes as the state wrestles with how to ensure oral health care access in counties and communities described as Health Provider Shortage Areas.

Unmet oral health needs ‘profound’

North Carolina, according to the federal Department of Health and Human Services, had 165 Dental Health Provider Shortage Areas at the end of last year, encompassing more than 2.5 million residents.

About three-quarters of the state’s 100 counties are designated as having a shortage of dental health providers.

In those areas, too, there is an added hurdle for low-income people in need of oral health care.

Many dentists do not take Medicaid patients because of the low reimbursement rates.

The North Carolina Oral Health Collaborative compiled information from the American Dental Association, showing that only 29.7 percent of North Carolina dentists participated in Medicaid as of 2016, compared to the national average of 39 percent.

Many of the students and others cared for through the Edgecombe and Halifax counties public-private partnership are eligible for Medicaid.

Hygienists in North Carolina cannot bill for Medicaid reimbursements, but the dentists they work for can and do so through the model program the Dental Society and North Carolina Dental Board hope to expand.

Courts, who takes Medicaid patients at his private practice, said the reimbursements help him pay the salaries for his staff who have participated in the pilot project.

Zachary Brian, director of the North Carolina Oral Health Collaborative, described the proposed rule change for hygienists as a step in the right direction toward opening access to better dental care for a large swath of the state.

“The unmet oral health needs in our state are profound, however, not insurmountable,” Brian said.

Goal is oral health, ‘not filling a bunch of teeth’

If the legislative staffers do not sign off on the rule change or if it makes it to public hearings but does not receive favorable review there, Brian and others are ready to push for statute changes that could open a broader discussion on whether the state is ready to expand the scope of practice for hygienists.

There long has been friction between dental hygienists fighting to get out from under some of the most restrictive scope of practice laws in the country and dentists unwilling to budge on their push for expansion.

Hygienists, for the most part, are prohibited from looking inside someone’s mouth unless a dentist is on-site with them, and that’s limited to only two hygienists at a time.

Under the proposed rule change, the hygienists in the public-private partnerships could provide screenings and cleanings without a dentist right there. If drilling is not necessary, they could also treat for decay in some instances without a prescreening by a dentist.

The rule-change proposal was put forward after oral health advocates from state offices, private foundations, the state’s two dental schools and the North Carolina Dental Society met in the summer of 2018 and formed the Council on Prevention and Oral Health.

The council evaluates evidence-based data and endeavors to engineer and push for cost-effective solutions for improving oral health care.

Courts, chairman of the council, said the goal of expanding the pilot project in Edgecombe and Halifax counties, which was funded with grants from Blue Cross Blue Shield and the Duke Endowment, is to empower hygienists already trained to do much of the needed work so they can help at state and federally qualified facilities. (Note: Both the BCBSNC Foundation and the Duke Endowment provide grant funding to NC Health News)

The council also is advocating for teledentistry, which uses technology to connect dentists and other clinicians to patients outside their offices, perhaps at schools, nursing homes and other state or federal facilities.

The idea is to get to children and others in underserved areas into a dentist’s or hygienist’s chair before they’ve experienced problems.

Some of that preventive care used to fall to the state’s public health hygienists, a workforce that has been cut by state lawmakers over the past 10 years, to 24 from the 54 in the state Division of Public Health in 2009.

“There’s not enough money in the state budget to fix everybody’s teeth,” Courts said. “The goal of the committee is oral health, not filling a bunch of teeth. Every dollar you invest in preventing disease, you end up saving a lot of money in the long run.”

A county by county map of US colored to show opioid death risk, including access to medication-assisted treatment

Forty-one N.C. counties classified as “high risk” in new opioid study

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Forty-one N.C. counties classified as “high risk” in new opioid study - North Carolina Health News

In a national study, researchers classified 41 North Carolina counties as “opioid high-risk” with few providers of medication-assisted treatment and many opioid-related deaths.

By Yen Duong

While conversations about the national opioid epidemic often focus on hardest-hit states such as Ohio, West Virginia and Kentucky, few people have analyzed county-by-county trends, where those state’s policies can make a difference.

But a new study, published last month in an open-access version of the Journal of the American Medical Association, classified 412 counties as “high-risk” and 1,485 as “not high-risk.” Among those, 41 of North Carolina’s 100 counties qualified as “opioid high-risk” counties.

“That was one of the highest states that we found in terms of the number of counties relative to the total number of counties in the state,” said Rebecca Haffajee, a University of Michigan public health professor who ran the study. “That tells us that North Carolina and these counties in particular need to think about how to get more providers to those areas.”

Counties were deemed high risk if they had higher than the national rate of 12.5 opioid-related deaths per 100,000 people, and lower than the national rate of 9.7 providers of medication-assisted treatment, or MAT, for opioid use disorders.

North Carolina’s Department of Health and Human Services is spending two-thirds of a recent $12 million federal grant to fight the opioid epidemic on direct treatment for uninsured people with the remaining third spent on “linkages to care” or support for housing, case management, employment and other social factors, said Kody Kinsley, who works in behavioral health for DHHS.

“A lot of other states that have expanded Medicaid are able to use their Medicaid program to pay for treatment, and they can pump almost all of their federal grant money into linkages to care,” Kinsley said. “That’s a big reason why we continue to struggle in this fight.”

What ‘high risk’ means

High-risk counties had a few common characteristics: fewer primary care physicians per 100,000 residents, higher unemployment, a higher proportion of whites, fewer people with a high school education and fewer residents under the age of 25.

Of rural counties in the U.S., 71 percent had no publicly listed providers of any of the three medications, versus 46 percent of all counties with no such providers. But urban areas were also likely to be high risk.

“We were a little surprised by that finding,” Haffajee said. “The reason, we think, is because we use more recent death data … We’re picking up the risks of fentanyl and [other] illicits that other studies haven’t yet, because those hadn’t become super prevalent and saturated urban areas in the earlier years.”


41 of 100 N.C. counties were classified as opioid “high risk” counties in a recent JAMA study, with higher than national rates of opioid overdose deaths and lower than national rates of providers of medication assistant treatment. Map: Yen Duong

Although Henderson County, south of Asheville, has a federally qualified health center that offers methadone, it was classified as high risk. Steven Smith, the health director in Henderson County, thinks that may be because, with more education, more deaths have been identified as opioid-related.

“Henderson County overall is a pretty well-off county in terms of their percentage of primary care physicians and relatively low amount of uninsured,” said Smith, who is also the president of the North Carolina Association of Local Health Directors “We have been focused with community partners for years here, doing a lot of work upstream with prevention and harm reduction.”

Many barriers to MAT

People who want to get medication-assisted therapy face multiple barriers before they can access the three forms of MAT: buprenorphine, methadone and naltrexone. To dole out buprenorphine, the most common MAT, doctors complete an eight-hour training and apply for a federal waiver to prescribe to up to 30 patients. They can apply for a waiver to prescribe up to 100 patients, and after a year they can reapply to prescribe to 275 per year.

Currently, only about 7 percent of the nation’s physicians have taken the extra time and effort to train for prescribing the medications.

Methadone can only be given under a physician’s supervision in opioid treatment programs approved by the federal Substance Abuse and Mental Health Services Administration. There are 76 such approved programs in North Carolina listed on the SAMHSA website.

“It’s still crazy that both buprenorphine and methadone are regulated more strictly than opioid analgesics,” Haffajee said. “Any prescriber can prescribe hydrocodone or oxycodone [opioid painkillers] without any hoops they have to jump through.”

For naltrexone, patients need to be entirely free from opioids for seven to 10 days before starting treatment; otherwise, they’ll have serious side effects. For those with opioid use disorder, that means withdrawing from opioids first, a hurdle that can be insurmountable for many. But naltrexone has no waiver requirements for prescribing and can be useful for some patients.

“What might work for one patient might not work for another,” Haffajee said. “Having the full panoply of options available and you try one and then [if] that doesn’t work as well, you try other is the best course of treatment.”

Because of how costly MAT is, DHHS funds have gone toward treating “ten to twelve thousand people,” which is not enough, Kinsley said.

“The truth is, we’re still scratching the surface. We suspect one in 20 people have a substance use disorder in North Carolina,” Kinsley said. “It’s a long-term treatment. It’s a chronic disease like diabetes; people don’t go to one dialysis visit and they’re done. It’s a lifetime thing. We’re really behind the curve in keeping up with that.”

Ideas to address the whole person

The study argues that increasing access to these medications in high-risk opioid counties could reduce deaths by up to 60 percent. Haffajee said states should encourage doctors to prescribe more buprenorphine, help more doctors get the waiver, and also focus on policies that address the other conditions of high-risk counties—the linkages to care mentioned by Kinsley.

“If you don’t have a high school education, if you don’t have a safe place to live, if you don’t have access to transportation, the least of your problems is getting a provider to give you a medication for your substance use disorder,” Smith said. “You have to start addressing that whole person in a meaningful way to give them even a chance of climbing out of that abyss.”

Right now, federally waivered doctors who prescribe buprenorphine must also register with the state. House Bill 325, which was just signed by Governor Cooper, gets rid of that requirement and gives more support to needle exchange programs and people who test drugs for contaminants.

In addition to that legislative change, DHHS is hoping to change rules to build up “satellite” dosing offices. In that case, patients could go to a usual MAT provider for their first few doses, and then the provider could send out a nurse or doctor out to rural satellite offices near the patient a few times a week, Kinsley said.

“Right now, if you live in Rutherford County, and you’re on medication-assisted treatment, you’re probably driving to Buncombe County two to three times a week to receive your dose,” Kinsley said. “I couldn’t drive 60 miles somewhere three times a week and keep a job and maintain a family and that sort of stuff.”

Smith said that even if lawmakers do not expand Medicaid, “the cost of this crisis does not go away.”

“Communities are paying for it every day, in terms of support services, human services, legal intervention, detention facilities, emergency departments,” Smith said. “We’re all paying for this, one way or another, regardless of whether or not it shows up on the balance sheets at the state.”

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