NIA Deputy Director Speaks with ASN Kidney News

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KN:

You have been in your post at NIA for 5 years. How have the institute’s priorities changed over those years?

Bernard:

In the almost 5 years that I have been deputy director of NIA, and the more than 25 years that I have followed NIA research, I have been impressed that aging research has gone beyond the “bean counting” stage, that is, qualitative descriptions of aging-related phenomena, as it was characterized in the past, to in-depth exploration of the mechanisms underlying aging and disease. This includes the mechanisms that lead to aging, cognitive health and decline, behavior and social interactions, and the maintenance of health and development of disease. Additionally, there is very thoughtful exploration of means to intervene to maintain and enhance health, both physical and cognitive, with aging.

KN:

As a geriatrician and clinician, you have had experience diagnosing and treating hypertension, diabetes, and other conditions common among older adults. What advances do you deem noteworthy since the early days of your career and how can NIA speed further development in these areas?

Bernard:

As a board-certified geriatrician I have relied upon information from NIA and NIH to guide my care of patients and teaching of students, residents, and fellows. Noteworthy findings during that time related to the impact of lifestyle modification, including exercise and diet, to limit the likelihood of the development of diabetes mellitus and to delay the development of frailty. For example, were it not for the partnering of NIA with NIDDK for the Diabetes Prevention Program (DPP), we might not have known that people who were 60 years and older only responded to lifestyle modification for the prevention of diabetes, whereas the younger participants responded to lifestyle modification and metformin.

Other NIA research has shown that exercise is useful even in the very elderly in nursing homes. It was a great patient motivator when I counseled them to modify their habits to benefit their medical conditions. NIA is making every effort to further develop areas relevant to enhancing health and quality of life. I have been particularly impressed with the efforts to leverage NIA resources by collaborative initiatives with other Institutes and Centers (ICs) within NIH, such as the support of the DPP, and in public-private partnerships such as the Alzheimer’s Disease Neuroimaging Initiative.

KN:

As the elderly population in the United States continues to grow, so will the importance of prevention initiatives to contain escalating health care costs. How does NIA balance its research portfolio between prevention and treatment, and what research opportunities are on the horizon for strengthening health literacy and wellness programs for this population?

Bernard:

NIA has a number of means of obtaining input from the scientific community to help balance its research portfolio between prevention and treatment. There is of course the core of the research enterprise—peer-reviewed, investigator-initiated projects—which make up the vast majority of the research funded by our institute. Peer reviewers are asked to rank research proposals based not only on the science, but also on innovation, as well as importance to public health. Additionally, our National Advisory Council provides a second level of review of all grants considered for funding, and provides guidance regarding priorities for research.

As we consider the development of special initiatives to encourage research in developing fields, we start with workshops and other outreach to the scientific community for input regarding appropriate priorities. These always provide a lively exchange of ideas and insights. Finally, we have periodic reviews of the research portfolios of each of our four extramural funding divisions by our National Advisory Council, seeking advice regarding the current direction of specific research areas and how they can be enhanced in the future. By these means we attempt to maintain a balanced approach to the many opportunities in aging research.

KN:

Elderly patients often experience more than one chronic condition at a time. Older kidney patients may have heart disease, hypertension, or diabetes. How does NIA work with other institutes and centers to maximize efficiencies in the research of co-morbid conditions?

Bernard:

NIA is particularly interested in studies of the impact of multiple chronic conditions (MCCs), given their high prevalence among the elderly. To this end, we collaborate extensively with other NIH institutes to evaluate the impact of various chronic conditions in this population. For example, we are working with the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases in the Systolic Blood Pressure Intervention Trial (SPRINT), which examines the impact of blood pressure reduction in people with hypertension and chronic renal insufficiency. I have mentioned our joint initiatives in diabetes. We have also assembled a group of experts to develop universal outcomes for assessment of individuals with MCCs, as reported last year in the Journal of the American Geriatrics Society.(1). We are also working with the trans-DHHS (Department of Health and Human Services) working group on MCCs, and with the Centers for Medicare & Medicaid Services and the National Quality Forum to consider how MCC outcomes might become quality measures.

KN:

How does NIA plan to ensure that the educational continuum for medical students, residents, and fellows prepares the next generation of physicians to provide the best possible care for the growing elderly population?

Bernard:

We are very concerned about the pipeline of future scientists and clinicians specializing in the care and treatment of older people. In research, we support traditional F, T, and K training and career development awards. We also have the Paul B. Beeson award that provides additional support to clinicians to assure protected time to conduct research. This K08 and K23 opportunity is provided as a request for application (RFA) each year, in collaboration with the National Institute of Neurological Disorders and Stroke, the American Federation for Aging Research, the John A. Hartford Foundation, and others. Recent review of the Beeson program found a high success rate in obtaining subsequent R01 research project grant funding. We have been very pleased that several Beeson Scholars have focused on issues related to chronic kidney disease.

We also recently developed the Grants for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSSTAR) program. This R03 is designed for medical and surgical specialists who are new to aging research. The award is contingent on the applicant demonstrating protected time and resources for career development from another source. The ASN Foundation for Kidney Research and the Alliance for Academic Internal Medicine (AAIM) offer junior development grants in geriatric nephrology (http://www.asn-online.org/foundation/career-development.aspx) as a source of support. Other sources can include the applicant’s institution or affiliated Veterans Administration hospital; a Clinical and Translational Science Award; NIH K12 or R25 program; specialty societies, such as the Association of Specialty Professors or the American Geriatrics Society; Older Americans Independence Center Research Career Development Core; or other government, public, or private sources. The goal of the program is to assist new faculty members in gathering the data needed to successfully compete for a K award. Both the GEMSSTAR and Beeson RFAs are issued in the late spring of each year.

Our Medical Student Training in Aging Research (MSTAR) program encourages medical students, particularly those interested in research, to consider a career in academic geriatrics. NIA partners with the American Federation for Aging Research and several foundations to offer 8- to 12-week MSTAR Program scholarships to first- and second-year medical students, providing hands-on and didactic research training in aging and geriatrics. We also fund training programs that reserve slots for medical students or physicians interested in basic, clinical, and translational geriatric research.

Information about all of NIA’s training and career development awards can be found at http://www.nia.nih.gov/research/dea/research-training-and-career-award-support.

We hope that these initiatives will help with the admittedly leaky pipeline of future aging researchers. There are also a number of initiatives to better prepare clinicians for the demands of our progressively aging society, led by the Health Resources Services Administration (HRSA) and enhanced by enabling legislation and funding as a result of the Affordable Care Act. Review of the HRSA website should be helpful in getting a full sense of the scope of those activities.

KN:

One of NIA’s initiatives is “Minority Aging and Health Disparities.” Studies have shown that African Americans have a disproportionate share of kidney disease compared to Caucasians. What is the institute doing to address health disparities in general, and disparities in kidney disease in particular?

Bernard:

In approaching health disparities, NIA looks at both diversifying the research workforce and exploring health disparities that may exist, in an effort to narrow gaps. NIA’s National Advisory Council recently conducted a review of our health disparities research and minority aging researcher training. We were found to have a strong program for the development of researchers—ranging from the annual Summer Institute on Aging Research to the GEMSSTAR and Beeson programs described earlier. We also have programs to encourage undergraduates interested in aging research through our NIA MSTEM Advancing Diversity in Aging Research through Undergraduate Education program. These grants are made to institutions that propose creative and innovative research education programs to diversify the workforce in aging. And our Aging Research Dissertation Awards to Increase Diversity offer dissertation support to eligible doctoral students through awards to their institutions.

Additionally, we have an Office of Special Populations in the Office of the NIA Director that is responsible for further enhancing our health disparities research portfolio. NIA’s innovative Research Centers on Minority Aging Research (RCMARS) continue to provide leadership in disparities research. We also have a number of specific initiatives looking at health care systems and disparities in care within those systems. A number of clinical studies with oversampling of underrepresented minority groups have allowed us to examine differences in Alzheimer’s disease presentation and osteoporosis by race/ethnicity. The advent of the new trans-NIH health disparities strategic plan, due to be unveiled this fall, will also intensify our efforts in this area. However, our overall efforts related to health disparities have not specifically focused on disparities in kidney disease.

KN:

What do you consider the greatest opportunities for researchers in aging over the next decade?

Bernard:

Researchers in aging have the distinct advantage of the demographic imperative. As more and more of our population turns 65 and older with aging of the baby boomer generation, there will be increased demands for better understanding of the aging process and development of interventions to prevent diseases and disability associated with growing older. That is already being seen in the demands for an invigorated effort in Alzheimer’s disease. In 2011, President Obama signed into law the National Alzheimer’s Project Act (http://aspe.hhs.gov/daltcp/napa/ ). This calls for a national plan for the approach to Alzheimer’s disease, and NIA/NIH leads the research component of that plan. Aging research itself is entering a new era. There is growing interest among most of the NIH ICs in the basic biology underlying aging and age-related disease, as demonstrated by the development of the trans-NIH Geroscience Interest Group, supported by 20 of the 27 ICs. (http://sigs.nih.gov/geroscience/Pages/default.aspx ). The time is right for focus on aging research, and scientists in the field are likely to find support for their interests owing to these converging forces.

KN:

The scientific community is concerned not only about the mandatory automatic spending cuts to NIH that went into effect March 1, but also about the shrinking federal dollars for medical research overall. How will NIA minimize the impact of the cuts and allocate its budget to maximize the scientific impact?

Bernard:

The NIA will move forward with a balanced program funding a spectrum of basic, translational, clinical, and social and behavioral research as best we can. Certainly, we know that cuts and ongoing budget constraints will reduce our ability to capitalize on many scientific opportunities presented to us, as the percentage of investigator-initiated proposals we are able to fund remains quite low. This means that many highly meritorious proposals, which have the promise of moving research on aging and age-related diseases forward in important ways, simply cannot be funded.

Each of the NIH ICs has been given the authority to decide how the sequestration cuts will be made. Different ICs have different priorities and conditions that factor into their decisions. In NIA’s case, we will look at both competing and non-competing grants and strike a balance between funding new studies and maintaining important research projects to which we have already committed.

Reference

1. Working Group on Health Outcomes for Older Persons with Multiple Chronic Conditions. University health outcomes measures for older persons with multiple chronic conditions. J Am Geriatr Soc 2012; 60(12); 2333–2341.

July 2013 (Vol. 5, Number 7)