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"Las causas de las causas"

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Presentación realizada el 01 de marzo del 2013 en el IV Congreso de Educación Médica de Zaragoza.
http://www.congresoeducacionmedica.es/

Published in: Health & Medicine
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"Las causas de las causas"

  1. 1. Las causas de las causas Rafa Cofiño Servicio de Evaluación de la Salud y Programas Observatorio de Salud en Asturias Dirección General de Salud Pública Consejería de Sanidad
  2. 2. de la información a la acción
  3. 3. • ¿Qué es la salud?¿Qué factores influyen en la salud?• ¿Cómo podemos mejorar la salud de las poblaciones?
  4. 4. “el progreso de la medicina debiera eventualmenteprolongar la vida humana, pero la mejoría de lascondiciones sociales podría obtener este resultado conmayor éxito y rapidez”Rudolf Virchow 1821-1902 http://saludcomunitaria.wordpress.com
  5. 5. Fotografía Ana Guti
  6. 6. Fotografía Ana Guti
  7. 7. De todas las personas nacidas en mi año:28% han fallecido
  8. 8. 6% 8% 33% 42% 21% 6%De todas las personas nacidas en mi año:28% han fallecido
  9. 9. Preventable deaths: world mapperThese conditions caused 32% of all deaths worldwide in 2002, an average of 2968 deaths per million people.Territories are sized in proportion to the absolute number of people who died from most preventable (communicableinfections, maternal, perinatal and nutritional conditions) in one year.
  10. 10. Deaths of Women from Pregnancy: World Mapper In 2002 Maternal conditions caused 1.9% of all female deaths (table 3) and 3.2% of all deaths among all adults between ages 15 and 59 years Global Burden of Disease estimated in 2002 Maternal conditions caused 3.3% of all years living with a disability, 6.4% of all female disability (table 6). GBD also estimated it to cause 4.7% of all Female and 3.1% of all Very poor territory burden of disease (Disability Adjusted Lost Years, table 7). Maternal conditions caused 0.9% of all deaths worldwide in 2002, an average of 82 deaths per million people per year. Territories are sized in proportion to the absolute number of people who died from maternal conditions in one year.
  11. 11. Enfermedad CardiovascularModificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  12. 12. Tensión Arterial Indice de Masa Corporal Diabetes Enfermedad Dislipemias Cardiovascular Respuesta al stress Otras...Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  13. 13. Stress y factores psicosocialesActividad físicaAlteración del sueñoAlimentación Tensión ArterialTabaco Indice de Masa Corporal Diabetes Enfermedad Dislipemias Cardiovascular Respuesta al stress Otras... Conductas (dieta, actividad física, tabaco...) Stress y factores psicosociales Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  14. 14. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa CorporalEntorno libre de humos Diabetes Enfermedad Dislipemias CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras... Conductas (dieta, actividad física, tabaco...) Stress y factores psicosociales Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  15. 15. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa CorporalEntorno libre de humos Diabetes Enfermedad Dislipemias CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras...Educación Clase Social Conductas (dieta, actividad física, tabaco...) Normas/ Oportunidades Ingresos sociales Stress y factores psicosociales Género Redes sociales: apoyo y cohesión Entorno socioeconómico Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  16. 16. Problemas de vivienda Problemas nutricionales Salarios insuficientes Problemas educativos BajaEnfermedad producción Disminuye inversión Aumento de en promoción de la salud asistencia sanitaria y salud públicaCiclo económico de la enfermedad de Horwitz
  17. 17. Dahlgren y Whitehead
  18. 18. H WEI GHT? ES H EALT MUC H DOHOW
  19. 19. Booske BC, Athens JK, Kindig D, Park H, Remington P. Different perspectives for assingning weights toDeterminants of Health. Country Health Rankings. Working Paper [Internet]. 2010 Feb; Available from:http://goo.gl/OQCqn
  20. 20. Socioeconómicos 40% Conductas saludables 40% Entorno ambiental 10% Calidad sistema sanitario 10%Booske BC, Athens JK, Kindig D, Park H, Remington P. Different perspectives for assingning weights toDeterminants of Health. Country Health Rankings. Working Paper [Internet]. 2010 Feb; Available from:http://goo.gl/OQCqn
  21. 21. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  22. 22. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  23. 23. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  24. 24. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  25. 25. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  26. 26. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  27. 27. Marco conceptual de los determinantes de las desigualdades sociales en salud.Comisión para reducir las Desigualdades en Salud en España, 2010.
  28. 28. !"#$%&(%()*+,*#-*(%()."#"+%#%/)) ."+$#01.2+)(*)&"3),%.$"#*3)(*)#*34")%#$" %" &,-./01"213"40"!#$" !" &()*" +"" ++" +++" van Rossum et al. (2000). Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study. Journal of epidemiology and community health, 54(3), 178–84. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1731642&tool=pmcentrez&rendertype=abstract Marmot, M. The Status Syndrome.Holt and company,. New York, 2004.
  29. 29. !"#$%&(%()*+,*#-*(%()."#"+%#%/)) ."+$#01.2+)(*)&"3),%.$"#*3)(*)#*34") &"%#$" %" -./01(2"324"5(1("!#$" !" ()*+" ,"" ,," ,,," van Rossum et al. (2000). Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study. Journal of epidemiology and community health, 54(3), 178–84. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1731642&tool=pmcentrez&rendertype=abstract Marmot, M. The Status Syndrome.Holt and company,. New York, 2004.
  30. 30. !"#$%&(%()*+,*#-*(%()."#"+%#%/)) ."+$#01.2+)(*)&"3),%.$"#*3)(*)#*34") &"%#$" %" -./01(2"324"5(1(" -./01(2"324"617024"(5"4*5/82"!#$" !" ()*+" ,"" ,," ,,," van Rossum et al. (2000). Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study. Journal of epidemiology and community health, 54(3), 178–84. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1731642&tool=pmcentrez&rendertype=abstract Marmot, M. The Status Syndrome.Holt and company,. New York, 2004.
  31. 31. !"#$%&(%()*+,*#-*(%()."#"+%#%/)) ."+$#01.2+)(*)&"3),%.$"#*3)(*)#*34") &"%#$" %" -./01(2"324"5(1(" -./01(2"324"617024"(5"4*5/82"!#$" !" ()*+" ,"" ,," ,,," van Rossum et al. (2000). Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study. Journal of epidemiology and community health, 54(3), 178–84. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1731642&tool=pmcentrez&rendertype=abstract Marmot, M. The Status Syndrome.Holt and company,. New York, 2004.
  32. 32. !"#$%&(%()*+,*#-*(%()."#"+%#%/)) ."+$#01.2+)(*)&"3),%.$"#*3)(*)#*34") &"%#$" %" -./01(2"324"5(1(" -./01(2"324"617024"(5"4*5/82"!#$" !" ()*+" ,"" ,," ,,," van Rossum et al. (2000). Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study. Journal of epidemiology and community health, 54(3), 178–84. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1731642&tool=pmcentrez&rendertype=abstract Marmot, M. The Status Syndrome.Holt and company,. New York, 2004.
  33. 33. !"#$%&(%()*+,*#-*(%()."#"+%#%/)) ."+$#01.2+)(*)&"3),%.$"#*3)(*)#*34") &"%#$" %" -./01(2"324"5(1(" -./01(2"324"617024"(5"4*5/82"!#$" !" ()*+" ,"" ,," ,,," van Rossum et al. (2000). Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study. Journal of epidemiology and community health, 54(3), 178–84. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1731642&tool=pmcentrez&rendertype=abstract Marmot, M. The Status Syndrome.Holt and company,. New York, 2004.
  34. 34. “Un fumador que está en una categoría profesionalbaja tiene más riesgo de enfermedad coronaria que un fumador que está en un nivel superior...” Michael Marmot. The Status Syndrome.
  35. 35. “Un no fumador que está en una categoría profesional baja tiene un riesgo mayor deenfermedad coronaria que un no fumador que tiene un nivel superior....” Michael Marmot. The Status Syndrome.
  36. 36. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa CorporalEntorno libre de humos Diabetes Enfermedad Dislipemias CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras...Educación Clase Social Conductas (dieta, actividad física, tabaco...) Normas/ Oportunidades Ingresos sociales Stress y factores psicosociales Redes sociales: apoyo y cohesión Entorno socioeconómico Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  37. 37. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa Corporal ContextoEntorno libre de humos Conductas Diabetes Dislipemias Enfermedad CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras...Educación Clase Social Conductas (dieta, actividad física, tabaco...) Normas/ Oportunidades Ingresos sociales Stress y factores psicosociales Redes sociales: apoyo y cohesión Entorno socioeconómico Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  38. 38. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa Corporal ContextoEntorno libre de humos Conductas Diabetes Dislipemias Enfermedad CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras...Educación Clase Social Conductas (dieta, actividad física, tabaco...) Normas/ Oportunidades Ingresos sociales Stress y factores psicosociales Redes sociales: apoyo y cohesión Entorno socioeconómico Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  39. 39. “En lo que concierne a nuestra salud es másimportante el código postal que el códigogenético”Robert Wood Johson Foundation
  40. 40. Observatorio de desigualdades. Obesidad 1987-2006. Género y clase social.
  41. 41. Observatorio de desigualdades. Obesidad 1987-2006. Género y clase social.
  42. 42. Observatorio de desigualdades. Obesidad 1987-2006. Género y clase social.
  43. 43. Observatorio de desigualdades. Obesidad 1987-2006. Género y clase social.
  44. 44. !"#$%&()*+("+#&,*+-./"(01#+2#1#.34#")+.5++ 6,(078+98(2,#"+("+)8#+:;<=+9.8.,)+ #!!" +!" *!" )!"!"#$%&#()*+,)-+-.+*/$+01,)- (!" !" &!" %!" $!" #!" !" $$" $*" %&" &!" &$" &(" $" *" (!" (&" )!" )(" *$" **" +&" #!!" #!(" ##$" ##*" !"#$%& ,-."/0,-."121" ,-."/03456"121" 3456"/0,-."121" 3456"/03456"121" Feinstein L. Inequality in early cognitive development of British Children in the 1970 Cohort. Economica (2003) 70, 73-97
  45. 45. !"#$%&()*+("+#&,*+-./"(01#+2#1#.34#")+.5++ 6,(078+98(2,#"+("+)8#+:;<=+9.8.,)+ #!!" +!" *!" )!">1#,&/#+3.7(0."+("+2(7),(?%0."+ (!" !" &!" %!" $!" #!" !" $$" $*" %&" &!" &$" &(" $" *" (!" (&" )!" )(" *$" **" +&" #!!" #!(" ##$" ##*" 4.")87+ ,-."/0,-."121" ,-."/03456"121" 3456"/0,-."121" 3456"/03456"121" Feinstein L. Inequality in early cognitive development of British Children in the 1970 Cohort. Economica (2003) 70, 73-97
  46. 46. !"#$%&()*+("+#&,*+-./"(01#+2#1#.34#")+.5++ 6,(078+98(2,#"+("+)8#+:;<=+9.8.,)+ #!!" +!" *!" )!">1#,&/#+3.7(0."+("+2(7),(?%0."+ (!" !" &!" %!" $!" #!" !" $$" $*" %&" &!" &$" &(" $" *" (!" (&" )!" )(" *$" **" +&" #!!" #!(" ##$" ##*" 4.")87+ ,-."/0,-."121" ,-."/03456"121" 3456"/0,-."121" 3456"/03456"121" Feinstein L. Inequality in early cognitive development of British Children in the 1970 Cohort. Economica (2003) 70, 73-97
  47. 47. !"#$%&()*+("+#&,*+-./"(01#+2#1#.34#")+.5++ 6,(078+98(2,#"+("+)8#+:;<=+9.8.,)+ #!!" +!" *!" )!">1#,&/#+3.7(0."+("+2(7),(?%0."+ (!" !" &!" %!" $!" #!" !" $$" $*" %&" &!" &$" &(" $" *" (!" (&" )!" )(" *$" **" +&" #!!" #!(" ##$" ##*" 4.")87+ ,-."/0,-."121" ,-."/03456"121" 3456"/0,-."121" 3456"/03456"121" Feinstein L. Inequality in early cognitive development of British Children in the 1970 Cohort. Economica (2003) 70, 73-97
  48. 48. Nunca han recibido exposición al humo del tabaco. Margolles M, Donate I. Encuesta de Salud Infantil Asturias 2009 Asturias 67,450 60 70 80 Valores (0-100)
  49. 49. Nunca han recibido exposición al humo del tabaco. Margolles M, Donate I. Encuesta de Salud Infantil Asturias 2009 Niñas Niños 67,3 67,6 Asturias 67,450 60 70 80 Valores (0-100)
  50. 50. Nunca han recibido exposición al humo del tabaco. Margolles M, Donate I. Encuesta de Salud Infantil Asturias 2009 Cuencas Zona rural mineras 62 70 Niñas Niños 67,3 67,6 Asturias 67,450 60 70 80 Valores (0-100)
  51. 51. Nunca han recibido exposición al humo del tabaco. Margolles M, Donate I. Encuesta de Salud Infantil Asturias 2009 Estud. Estud. primarios Universitarios 57 80 Cuencas Zona rural mineras 62 70 Niñas Niños 67,3 67,6 Asturias 67,450 60 70 80 Valores (0-100)
  52. 52. Nunca han recibido exposición al humo del tabaco. Margolles M, Donate I. Encuesta de Salud Infantil Asturias 2009 Clase social V Clase social I 60 80 Estud. Estud. primarios Universitarios 57 80 Cuencas Zona rural mineras 62 70 Niñas Niños 67,3 67,6 Asturias 67,450 60 70 80 Valores (0-100)
  53. 53. Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med7(7): e1000316.doi:10.1371/journal.pmed.1000316
  54. 54. Tras la revisión de 148 estudios en elmetanálisis la OR de 1,5 señala que laspersonas con redes sociales más fuertestienen un 50% más de probabilidad desupervivencia que aquellos con redessociales más débiles Estos resultados señalan que la influencia de las relaciones sociales con el riesgo de muerte son comparables con factores bien establecidos de mortalidad tales como el consumo de tabaco y alcohol y que superan la influencia de otros factores de riesgo como la inactividad física y la obesidad. Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316.doi:10.1371/journal.pmed.1000316
  55. 55. Análisis del capital social, de la capacidad “salutogénica”The networks of actors as key items in local development. Contributions from sociology and anthropology of developmentRafael Merinero Rodríguez
  56. 56. ....Comprar el pan, la leche, las galletas del desayuno, el café, el aceite, azúcar, sal,el resto de la comida, algún regalo para los nietos, pagar la luz, el agua, el alquiler,ayudar algo a su hija que no acaba de encontrar trabajo, algo para las navidades,la ropa, las zapatillas, revisar las gafas, arreglar la dentadura, tomar el autobúspara ir a las revisiones en el hospital, aprender a hacer la dieta y caminar algotodos los días, controlar la tensión, cuidar las piernas, una crema para los pies,arreglar las uñas, no conseguir el recambio para las audioprótesis, hacer lalimpieza de la casa, sacar a pasear a su madre por el barrio en la silla de ruedas,manejar este dolor de espalda y los problemas para dormir y descansar por lasnoches y vivir casi sola.Y con 418 euros de pensión mínima de viudedad....http://saludcomunitaria.wordpress.com/2006/12/21/418/
  57. 57. ...Comprar cereales con fibra, leche de soja, verduras, vino, reservar para cenar elviernes, frutas exóticas para el plato que proponía el suplemento del domingo, llevarcinco años sin fumar, haber vuelto a practicar deporte, algo de gimnasio, yoga ynatación, pasar unos días de vacaciones en algún lugar tranquilo, preparar los regalosde navidades, pagar los estudios de mi hijo en el extranjero, comprar varios libros alcabo del mes, pertenecer a distintos colectivos, tener influencia y asumir ciertoprestigio profesional, quitar la sal de las comidas y tener cuidado con el LDL,plantearme las pruebas de cribado que se recomiendan, cuestionarme si todo loanterior realmente tiene un peso importante en mi salud, cambiar las ruedas delcoche, pintar la casa, ir a varios conciertos y no vivir casi solo.Y con 6.180 euros demi puesto de alto cargo directivo...http://saludcomunitaria.wordpress.com/2006/12/21/418/
  58. 58. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa CorporalEntorno libre de humos Diabetes Enfermedad Dislipemias CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras...Educación Clase Social Conductas (dieta, actividad física, tabaco...) Normas/ Oportunidades Ingresos sociales Stress y factores psicosociales Género Redes sociales: apoyo y cohesión Entorno socioeconómico Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  59. 59. Entorno físico Reacción inflamatoria Stress y factores psicosociales Daño endotelialContaminación del aire Alteración frecuencia cardiacaEstética del entorno Actividad físicaDiseño urbanístico Alteración del sueñoRuidoControl publicidad AlimentaciónRegulación de alimentación saludable Tensión Arterial Tabaco Indice de Masa CorporalEntorno libre de humos Diabetes Enfermedad Dislipemias CardiovascularAcceso a espacios de ocio y tiempo libre Respuesta al stress Otras...Educación Clase Social Conductas (dieta, actividad física, tabaco...) Normas/ Oportunidades Ingresos sociales Stress y factores psicosociales Redes sociales: apoyo y cohesión Entorno socioeconómico Modificada de Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003 Dic;80(4):569-589)
  60. 60. “La medicina es una ciencia social y lapolítica no es más que medicina en unaescala más amplia” Rudolf Virchow 1821-1902
  61. 61. Contribución a la estadística de Wislawa Szymborska

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