I want to focus on two areas of research with profound, paradigm-shifting implications for us all….as scientists, ethicists, health care and public health professionals, and members of the human community. The first is the ACES, the Adverse Childhood Experiences Study. As I’ll talk about briefly, we have very, very solid evidence that certain adverse experiences during early childhood are strong predictors of learning disabilities, some mental illness, and numerous other chronic illnesses during later childhood and throughout adult life. Many of the correlated conditions don’t appear until decades after the childhood traumas -- in other words, the horse has long ago left the barn. So I’ll speak more about that first. But my great passion, recent, life-changing new information for me, is even more involved with DOHaD, a very rapidly emerging field of research, and I’ll want to spend evenn more time on that today.So get ready, because here we go upstream, to learn about causes, and more causes, and to reflect together, I hope, about the implications.
The ACES was started at Kaiser Permanente in the 1990s though a suggestive predecessor study was conducted earlier in the Kaiser system. Dr. Vincent Felitti looked at 18,00 adults in ACES, asking them to answer a very simple survey – 10 simple questions – about their early childhoods. He was then able to demonstrate a significant correlation between early childhood trauma experiences and severe obesity, heart disease, depression and other psychiatric disorders, diabetes and many other ailments later in life. According to the Oregon Public Health Division, 16% of adult Oregonians had an ACE score of 4 or higher…16% (you get one point for every answer “yes” in the questionnaire). Compared to people with ACE scores of 0, those with an ACE score or 4 or higher are now known to be twice as likely to smoke, 7 times more likely to have alcoholism, 10 times more likely to inject street drugs, and 12 times more likely to commit suicide. But that’s not all – you see other chronic diseases in this very dramatic bar graph (above)
And more illnesses and disabilities continue to be associated with ACES scores…COPD, GI disorders, GU disorders, STIs, sexual dysfunction, and pre-term delivery….
The original ACES work has its own CDC website now, has been internationally received, validated and applied, and the data from the original as well as newer cohorts are behind very robustly studied to see if there are even more chronic health and social conditions that appear after, and correlate with, adverse childhood experiences. I urge you to research ACES for yourself if it’s new to you – the CDC website is a fine place to start. This slide shows a headline from the online newspaper The Huffington Post, which ran a good series of 3 articles for the general public last fall about ACES. But while it’s true that ACES may be the largest public health study you never heard of, I would argue that this is even more true of DOHaD research – it’s just that DOHaD work hasn’t come as closely under the umbrella of public health OR social science research yet….so it’s even less widely known.
So let’s go to DOHaD. If there’s one thing I hope you’ll take away from this morning plenary, it’s that the Developmental Origins of Health and Disease – and more broadly, the field and discoveries of epigenetics that are a part of DOHaD, are standing on its head our former knowledge of genetics, nature and nurture. As I said, paradigm-shifting, and with profound implications for healthcare, public health, the law, social policy and ethics.
Tina Castañares, MD Partnering Together for Community Health Going Upstream ACES, DOHad and Epigenetics Community health workers Priester Conference April 2013 in Corvallis, Oregon
In the wise words of Dr. Don Berwick… Founder, Institute for Healthcare ImprovementPresident Obama’s original director of Medicare and Medicaid (CMS)
“The best hospital bed is empty. The best CT scanis the one we don’t need. The best doctor’s visitis the one we don’t need.”
% Oregon Population Defined as Obese We know we’re (BMI > 30) 30 in trouble% of Population 20 10 0 1989 1996 2003 2007 Trends in Diabetes in USA Year Measured Data from NHANES, CDC 2009 With thanks to Kent Thornburg, PhD, OHSU
MovingUpstream of the Rapids Moving Upstream of the Rapids
Overall, “upstream” population health work: •Promotes wellness, prevents disease and improves health status •Avoids “blame games” about individual responsibility for health •Reduces demand for health care (overall spending, workforce, infrastructure) •Raises all boats at once: truly equitable because population- and community-wide
Population-based Health is… …more than twice as responsiblehistorically for health improvementthan medical, nursing, oral health and mental health services combined.
The poor and minorities experience serioushealth disparities
….because of risk factors such as: •barriers to physical activity in schools, workplaces, neighborhoods •food subsidies making fast and processed foods cheaper •environmental contaminants •targeted tobacco & alcohol advertising •lack of access to fresh foods •crowding and substandard housing •many other well-documented social factors
Achieving social equity• …is the only real answer to preventable health disparities.• …is a goal we have an ethical responsibility to work toward … as citizens, voters, leaders and members of the human commons.
So now, more upstream still….TO THE HEADWATERS
Early childhood, neonatal, fetal, embryonic…. transgenerational !ACES DOHaD researchAdverse Childhood Developmental OriginsExperiences Study of Health and Disease
“The Adverse Childhood Experiences Study -- The Largest Public HealthStudy You Never Heard Of” Huffington Post October 2012 3 parts
So now, more upstream still….The Developmental Origins of Health and Disease (DOHaD)
Low Birth Weight (LBW)• US babies more likely to be LBW than in almost every other developed country. 2• LBW = 2nd leading cause of infant mortality in the US (after birth defects).• Surviving infants at risk for serious medical conditions and learning disorders. 3
Unacceptable disparities•LBW climbing for minority mothers•African-Americans: 2 X likelier than whites, Hispanics for LBW babies•Problem is not “in the genes” …and not always linked to current income
How can this be? Epigenetics is the key.• Our GENES themselves aren’t all that different.• People with identical genes turn out differently, get different diseases, etc.• “Behavioral genetics” has long sought explanations.• Epigenetics brings biological evidence.
What does epigenetics tell us?• Gene REGULATION and EXPRESSION are mostly in charge.• Gene regulation is subject to many influences.• “Social” influences not so very separate from “biological” influences• Amazing: some gene regulation and expression can be inherited…. So this is trans- generational.
Two key epigenetic factors I want to share today :• Maternal and placental nutrition• Maternal and fetal chronic stress (sustained elevated levels of stress hormones ) (A proven, very important third factor is maternal exposure to toxins. Another involves paternal health and age. Doubtless, more will emerge.)
Poor nutrition or sustained stress hormones:• Developing embryo / fetus biochemistry responds by -- making sub-standard vital organs (mostly smaller ones) -- bigger placenta, lower birthweight
Risk of chronic disease ispredicted epigenetically,right from grandmother’s preconception health, through grandchild’s early life.So EARLY prevention andcorrections are imperative.
Epigenetic risk factors are preventable and even reversible.• The earlier, the better• First 1000 days post-conception• Pre-conception too Interventions must improve maternal (community !!!!) nutritional status, and prevent or reverse chronic stress.
This is good news, not bad news… and not “biological determinism”• new scientific evidence to guide social policy, strategies, and investments !• hope for better health for our society – a reversal of the last 100 years of downward health trends!
Why should we do these things? The future of human health is at stake.
I am passionate about Community Health Workers• Peer-to-peer• Culturally competent: understanding from within the culture or subculture• Natural leadership Community-building. Community asset forever.• Special learning and teaching tools/pedagogy (popular education, motivational interviewing)• knowledge not restricted; infinite• role carefully defined, supported: a prestigious and valued position stable staff
CHWs (health promoters) with whom I’ve been privileged to work .
Imagine that we live in a region….…which is the best place in the world for every baby to be born…which is the best place in the world for every child to grow up
Thank you, Extension! You do so much for our communities….and for population health, way upstream! I welcome your feedback. firstname.lastname@example.org