SlideShare a Scribd company logo

semo2035

•
•
M
memomemo87

k

Business
1 of 227
Download to read offline
1 Chapter 2: Methods in Chronic Disease Epidemiology
2 • The science of public health • Greek epi (upon),demos (people), logos (study) • Now includes injury, disability, risk factors, quality of life, and, traditionally disease • Center for Disease Control (CDC) defines epidemiology as “the study of the distribution and determinants of health-related states in specified populations, and the application of this study to the control of health problems . ” ‫علم‬ ‫الصحة‬ ‫العامة‬ ‫برنامج‬ ‫التحصٌن‬ ‫الموسع‬ ‫الٌونانٌة‬ ( ‫على‬ ) ، ‫والعروض‬ ( ‫الناس‬ ) ، ‫والشعارات‬ ( ‫دراسة‬ ) ‫ٌشمل‬ ‫اآلن‬ ‫اإلصابة‬ ‫والعجز‬ ‫وعوامل‬ ‫الخطر‬ ‫ونوعٌة‬ ‫الحٌاة‬ ، ‫والمرض‬ ‫تملٌدٌا‬ ‫ؾ‬ ّ‫ٌعر‬ ‫مركز‬ ‫السٌطرة‬ ‫على‬ ‫األمراض‬ ( CDC ) ‫علم‬ ‫األوبئة‬ ‫بأنه‬ " ‫دراسة‬ ‫توزٌع‬ ‫ومحددات‬ ‫الحاالت‬ ‫المتعلمة‬ ‫بالصحة‬ ً‫ف‬ ‫مجموعات‬ ‫سكانٌة‬ ‫محددة‬ ، ‫وتطبٌك‬ ‫هذه‬ ‫الدراسة‬ ‫للتحكم‬ ً‫ف‬ ‫المشاكل‬ ‫الصحٌة‬ ." Definition of Epidemiology
3 • Based on the CDC’s definition, a breakdown of the terms: • Study – quantitative, statistic- and research-based • Distribution – characterized through people and how health events happen in populations • Determinants – causes, factors, implemented in analytical epidemiology • Health-related states – not just diseases, a spectrum of ailments • Populations – groups of people, not just individuals • Control – implement decision-making processes to prevent health issues : - - - - - - Definition of Epidemiology,contd.
4 • Diseases of known microorganisms (AIDS, flu, etc.) focus the study of epidemiologists • Likewise, injuries are acute, with often immediate health consequences (car accidents, falling, etc(. • However, many chronic diseases originate early in life through unhealthy behaviors, which, in turn, increase the risk in later life to develop these diseases • This (detailed below) is called the chronic disease continuum ( ) ( .) ( ) The Chronic Disease Continuum Descriptive Epidemiology, Analytic Epidemiology, Intervention/Evaluative Research Developmental, social, environmental, genetic determinants Healthrisk behaviorsand other factors Chronic conditions Chronicdiseases Adapted from Remington et al. ( 2010 )
5 • An important question is at what point are epidemiologist trying to “control” a chronic disease? At which stage of the continuum? • Controlling has become not only achieving lower mortality rates, but also lowering detrimentaleffectsof the disease • Both of these factors are used to describe the natural history of a given disease ‫السؤال‬ ‫المهم‬ ً‫ف‬ ‫أي‬ ‫نمطة‬ ‫ٌحاول‬ ‫علم‬ ‫األوبئة‬ " ‫السٌطرة‬ " ‫على‬ ‫مرض‬ ‫مزمن‬ ‫؟‬ ً‫ف‬ ‫أي‬ ‫مرحلة‬ ‫من‬ ‫التواصل‬ ‫؟‬ ‫أصبحت‬ ‫السٌطرة‬ ‫لٌس‬ ‫فمط‬ ‫انخفاض‬ ‫معدالت‬ ‫الوفٌات‬ ، ‫ولكن‬ ‫أٌضا‬ ‫خفض‬ ‫اآلثار‬ ‫الضارة‬ ‫للمرض‬ ‫ٌتم‬ ‫استخدام‬ ‫كال‬ ‫هذٌن‬ ‫العاملٌن‬ ‫لوصؾ‬ ‫التارٌخ‬ ً‫الطبٌع‬ ‫لمرض‬ ‫معٌن‬ The Chronic Disease Continuum, contd.
6 • Uses readily available data to examine a disease and who it affects in populations by time, place, or person. • Assesses burden, at risk groups, trends • Public tends to focus on incurable diseases or environmental diseases, instead of chronic diseases that fall on the continuum. ‫ٌستخدم‬ ‫البٌانات‬ ‫المتاحة‬ ‫بسهولة‬ ‫لفحص‬ ‫المرض‬ ‫ومن‬ ‫ٌؤثر‬ ً‫ف‬ ‫السكان‬ ‫حسب‬ ‫الولت‬ ‫أو‬ ‫المكان‬ ‫أو‬ ‫الشخص‬ ‫ٌمٌم‬ ‫العبء‬ ، ً‫ف‬ ‫مجموعات‬ ‫الخطر‬ ، ‫االتجاهات‬ ‫ٌمٌل‬ ‫العامة‬ ‫إلى‬ ‫التركٌز‬ ‫على‬ ‫األمراض‬ ‫المستعصٌة‬ ‫أو‬ ‫األمراض‬ ‫البٌئٌة‬ ، ‫ا‬‫ال‬‫بد‬ ‫من‬ ‫األمراض‬ ‫المزمنة‬ ً‫الت‬ ‫تمع‬ ‫على‬ ‫السلسلة‬ ‫المستمرة‬ . Descriptive Epidemiology
7 • Frequently, the count of affected individuals is seen as the fundamental measure • Implemented when analyzing the need for healthcare to aide in lessening the burden • Count is a simple way to present this burden to the general public, but it is dependent on the population size. • Other measures can be used by epidemiologists to highlight different elements of the disease ً‫ف‬ ‫كثٌر‬ ‫من‬ ‫األحٌان‬ ، ‫ٌنظر‬ ‫إلى‬ ‫عدد‬ ‫األفراد‬ ‫المتضررٌن‬ ‫على‬ ‫أنه‬ ‫اإلجراء‬ ً‫األساس‬ ‫نفذت‬ ‫عند‬ ‫تحلٌل‬ ‫الحاجة‬ ‫إلى‬ ‫الرعاٌة‬ ‫الصحٌة‬ ‫للمساعدة‬ ً‫ف‬ ‫تخفٌؾ‬ ‫العبء‬ ‫العد‬ ‫هو‬ ‫طرٌمة‬ ‫بسٌطة‬ ‫لعرض‬ ‫هذا‬ ‫العبء‬ ‫على‬ ‫عامة‬ ‫الناس‬ ، ‫لكنه‬ ‫ٌعتمد‬ ‫على‬ ‫حجم‬ ‫السكان‬ ‫ٌمكن‬ ‫استخدام‬ ‫التدابٌر‬ ‫األخرى‬ ‫من‬ ‫لبل‬ ًٌ‫أخصائ‬ ‫الوبائٌات‬ ‫إلبراز‬ ‫عناصر‬ ‫مختلفة‬ ‫من‬ ‫المرض‬ The Burden of Disease
8 • Rates are used to compare populations – incidence and prevalence • Incidence rate – new cases over period ÷ person-years • Person-years = persons × period monitored • Cumulative incidence – probability of developing a disease, ranging from 0 to 1 • Prevalence – another proportion, this one measured at a point in time instead of a period • Less valuable than incidence in identifying causes - - ÷ = × - 0 1 - Calculating Rates
9 • Compared using risk ratios/relative risks • Rate ratio – incidence rate of one group compared to another • Rate difference – subtracting the rates from one another • Calculates how much risk is different given certain variables in the study • Rates also used to aim program targeting goals • At-risk subgroups are found within populations • Can assist healthcare professionals in joint interventions / - - ComparingRates
10 • Randomized controlled trials (RCTs) – the most thorough and scientific study • Subjects assigned to prevention or non-prevention • Disease and death-rates monitored and observed over time • Often impractical/impossible • Need comparison groups for analysis • Comparisons between (least effective) national data and (most effective) concurrent collection vary in appropriateness ‫التجارب‬ ‫المعشاة‬ ‫ذات‬ ‫الشواهد‬ ( RCTs ) - ‫الدراسة‬ ‫األكثر‬ ‫شمولٌة‬ ‫وعلمٌة‬ ‫الموضوعات‬ ‫المخصصة‬ ‫للولاٌة‬ ‫أو‬ ‫عدم‬ ‫المنع‬ ‫رصد‬ ‫ومعدالت‬ ‫الوفاة‬ ‫والموت‬ ‫ورصد‬ ‫مع‬ ‫مرور‬ ‫الولت‬ ‫اا‬‫ب‬‫ؼال‬ ‫ؼٌر‬ ً‫عمل‬ / ‫مستحٌل‬ ‫تحتاج‬ ‫مجموعات‬ ‫الممارنة‬ ‫للتحلٌل‬ ‫تختلؾ‬ ‫الممارنات‬ ‫بٌن‬ ‫البٌانات‬ ‫الوطنٌة‬ ( ‫األلل‬ ‫فاعلٌة‬ ) ‫ومجموعة‬ ( ‫األكثر‬ ‫فاعلٌة‬ ) ‫المتزامنة‬ ً‫ف‬ ‫مدى‬ ‫مالءمتها‬ Study Designs
11 • Historical or retroactive studies can also be a viable option, if the correct records are available • Downsides include that no incidence rates or cumulative incidence can be gathered • Upsides include that, in certain cases, information was found that affected risks which could be modified and benefit a population in the future Study Designs, contd. Adapted from Remington et al. ( 2010 )
12 • Since RCTs can be unethical, epidemiologists need to observe without intervention • Based on doctor recommendations • Prospective cohort – exposures not randomly assigned, but first identified • Active and intense measurements can be made - Observational Studies
13 Strengths/Limitations of Study Designs Study Type Strengths Limitations Experimental studies Randomizedclinicaltrial * Controls randomly assigned * Highcost * Impracticallong-term * Impracticalexposures Randomizedcommunitytrial * Population-wide scope * Multicomponent effectiveness * Veryexpensive * Small number of studygroups Quasi-experimentalstudy * Real-worldpolicy/programintervention * Multiplecomparison groups * Potential bias * Lackof control – confounders Observational studies Prospectivecohort * Measure riskbeforediseaseoccurs * Multipleoutcomes * Yieldsincidencerates/relativerisks * Expensive * Largenumber of subjects required * Lengthy follow-ups * Hard tocontrol exposure factors Case-control * Rare diseases * Inexpensive * Quickresults * Possiblerisk-factorbias * Possiblebias incontrol group selection * Identifiedmightnot representpopulation Adapted from Remington et al. ( 2010 ) “Information bias”
14 • Most chronic disease studies are from observational studying • Therefore, errors are present in a number of different ways: • Measurement, selection of subjects, bias, etc. • Experts are needed to quantify uncertainty in research methods and decide quality studies • Confounding and bias are important types of error in epidemiological studies ‫معظم‬ ‫دراسات‬ ‫األمراض‬ ‫المزمنة‬ ً‫ه‬ ‫من‬ ‫دراسة‬ ‫المالحظة‬ ‫لذلن‬ ، ‫توجد‬ ‫أخطاء‬ ً‫ف‬ ‫عدد‬ ‫من‬ ‫الطرق‬ ‫المختلفة‬ : ‫المٌاس‬ ، ‫واختٌار‬ ‫الموضوعات‬ ، ‫والتحٌز‬ ، ‫وما‬ ‫إلى‬ ‫ذلن‬ . ‫هنان‬ ‫حاجة‬ ‫لخبراء‬ ‫لمٌاس‬ ‫عدم‬ ‫الٌمٌن‬ ً‫ف‬ ‫أسالٌب‬ ‫البحث‬ ‫وتمرر‬ ‫دراسات‬ ‫الجودة‬ ‫التحٌز‬ ‫ّز‬ٌ‫والتح‬ ‫هما‬ ‫نوعان‬ ‫مهمان‬ ‫من‬ ‫الخطأ‬ ً‫ف‬ ‫الدراسات‬ ‫الوبائٌة‬ Assessing Valid Study Results
15 • “The influence of an exposure of interest is mixed with the effect of another” (Remington et al. 2010 ( • In RCT, confounders can be equally distributed among each study group • In observational studies, confounders have to be measured and adjusted • As long as confounders are measurable and adjusted, then no need for concern • However, some confounders are difficult to measure or unknown " " RCT Confounding
16 • Faulty sampling methods or refusal to participate leads to samples with higher or lower measurement risk • Poorly arranged control groups are major threats to accuracy • Phone samples introduce bias when families without landlines are not taken into account • Classification errors also present a potential bias • Also known as information bias Selection/Information Bias Selection Bias Arises when the relation between exposure and disease is different for those who participate and those who theoretically would be eligible for study but do not participate. InformationBias Can be introduced as a resultof measurement error in assessment of both exposureand disease Exp. 1- Recall bias
17 • Attributable Risk • How much burden is lessened is exposure is eliminated • Relative risk - 1 ÷ relative risk • Population Attributable Risk • How common the exposure is • Rate (total pop.) - rate (unexposed) ÷ rate (total pop). • Also Pe (relative risk - 1) ÷ 1 + Pe (relative risk - 1 ) • Where Pe proportion of population exposure Prevention through Intervention
18 • Often, critical analyses will lead to “important” or “groundbreaking” new information, but this must be taken lightly • One study is never sufficient to answer all or even one question about a chronic disease. • Validity must be measured through repetition and variety or intervention ‫اا‬‫ب‬‫ؼال‬ ‫ما‬ ‫تؤدي‬ ‫التحلٌالت‬ ‫النمدٌة‬ ‫إلى‬ ‫معلومات‬ ‫جدٌدة‬ " ‫مهمة‬ " ‫أو‬ " ‫ؼٌر‬ ‫مسبولة‬ " ، ‫ولكن‬ ‫ٌجب‬ ‫االستخفاؾ‬ ‫بها‬ ‫دراسة‬ ‫واحدة‬ ‫لٌست‬ ‫كافٌة‬ ‫لإلجابة‬ ‫على‬ ‫كل‬ ‫أو‬ ‫حتى‬ ‫سؤال‬ ‫واحد‬ ‫عن‬ ‫مرض‬ ‫مزمن‬ . ‫ٌجب‬ ‫أن‬ ‫تماس‬ ‫الصالحٌة‬ ‫من‬ ‫خالل‬ ‫التكرار‬ ‫والتنوع‬ ‫أو‬ ‫التدخل‬ Single vs. Series
19 • Systematic reviews • Researchersconsolidate information usingcomprehensivemethods to assess relevantsciencebehinda singlehealthissue • Increasingly,meta-analysisis used in thesesystematicreviews • Meta-analysis • Identifyrelevantstudies,inclusion/exclusioncriteria,data abstraction,heterogeneityacross statisticalanalysis / SystematicReviews, Meta-analysis, Expert Panels
20 • An approach to looking at risks posed by adverse exposures like pollutants • A “bridge” between the scientific community and those who create policies and protocol • Four steps to proper risk assessment: 1. Hazard identification, 2. Risk characterization , 3. Exposure assessment and 4. Risk estimation • Expert panels used to assess validity of epidemiological studies through peer review ‫نهج‬ ‫للنظر‬ ً‫ف‬ ‫المخاطر‬ ‫الناجمة‬ ‫عن‬ ‫التعرضات‬ ‫الضارة‬ ‫مثل‬ ‫الملوثات‬ " ‫جسر‬ " ‫بٌن‬ ‫المجتمع‬ ً‫العلم‬ ‫وأولئن‬ ‫الذٌن‬ ‫ٌضعون‬ ‫السٌاسات‬ ‫والبروتوكول‬ ‫أربع‬ ‫خطوات‬ ‫لتمٌٌم‬ ‫المخاطر‬ ‫الصحٌحة‬ : ‫تحدٌد‬ ‫المخاطر‬ ، ‫توصٌؾ‬ ‫المخاطر‬ ، ‫تمٌٌم‬ ‫التعرض‬ ‫وتمدٌر‬ ‫المخاطر‬ ‫لوحات‬ ‫الخبراء‬ ‫المستخدمة‬ ‫لتمٌٌم‬ ‫صحة‬ ‫الدراسات‬ ‫الوبائٌة‬ ‫من‬ ‫خالل‬ ‫مراجعة‬ ‫األلران‬ Risk Assessment/Expert panels Hi Rc Ea Re
21 • Incidence rate – New events in a specified period / persons exposed to risk within period • Relative risk – Risk of death or disease in population exposed to risk / risk of death or diseased in unexposed population • Population attributable risk – Rate of disease in population attributed to risk factor / total rate of disease ‫معدل‬ ‫الولوع‬ - ‫أحداث‬ ‫جدٌدة‬ ً‫ف‬ ‫فترة‬ ‫محددة‬ / ‫األشخاص‬ ‫المعرضٌن‬ ‫للخطر‬ ‫خالل‬ ‫فترة‬ ‫الخطر‬ ً‫النسب‬ - ‫خطر‬ ‫الوفاة‬ ‫أو‬ ‫المرض‬ ‫بٌن‬ ‫السكان‬ ‫المعرضٌن‬ ‫لخطر‬ / ‫خطر‬ ‫الوفاة‬ ‫أو‬ ‫المرض‬ ً‫ف‬ ‫السكان‬ ‫ؼٌر‬ ‫المعرضٌن‬ ‫الخطر‬ ‫المنسوب‬ ‫للسكان‬ - ‫معدل‬ ‫المرض‬ ً‫ف‬ ‫السكان‬ ‫المنسوبة‬ ‫إلى‬ ‫عامل‬ ‫االختطار‬ / ‫المعدل‬ ً‫الكل‬ ‫لألمراض‬ Key Concepts
22 Chapter 3: Intervention Methods for Chronic Disease Control
23 • Behavior changes in individuals can often prevent many chronic diseases • CDC estimates that 80% of heart disease, type II diabetes and 40% of cancer would be eliminated if poor diet, inactivity and smoking were also eliminated • Obesity is now seen more frequently among both adults and children ‫ٌمكن‬ ‫لتؽٌٌرات‬ ‫سلون‬ ‫األفراد‬ ً‫ف‬ ‫كثٌر‬ ‫من‬ ‫األحٌان‬ ‫منع‬ ‫العدٌد‬ ‫من‬ ‫األمراض‬ ‫المزمنة‬ ‫تمدر‬ ‫مراكز‬ ‫مكافحة‬ ‫األمراض‬ ‫والولاٌة‬ ‫منها‬ ‫أن‬ 80 ٪ ‫من‬ ‫أمراض‬ ‫الملب‬ ‫والسكري‬ ‫من‬ ‫النوع‬ ً‫الثان‬ ‫و‬ 40 ٪ ‫من‬ ‫السرطان‬ ‫سوؾ‬ ‫ٌتم‬ ‫المضاء‬ ‫علٌها‬ ‫إذا‬ ‫تم‬ ‫التخلص‬ ‫من‬ ‫الحمٌة‬ ‫الؽذائٌة‬ ‫السٌئة‬ ‫وعدم‬ ‫النشاط‬ ‫والتدخٌن‬ . ‫وٌنظر‬ ‫اآلن‬ ‫السمنة‬ ‫بشكل‬ ‫أكثر‬ ‫تواترا‬ ‫بٌن‬ ‫البالؽٌن‬ ‫واألطفال‬ ‫على‬ ‫حد‬ ‫سواء‬ Behavioral Determinants
24 • The high cost of treating chronic diseases is another reason they are increasing • Secondary prevention can find many diseases earlier when they are cheaper to treat and more beneficial to lifestyle change, and also lead to fewer visits in later years (which will lower health costs) • Lack of incentives for prevention services in US healthcare system ‫التكلفة‬ ‫العالٌة‬ ‫لعالج‬ ‫األمراض‬ ‫المزمنة‬ ً‫ه‬ ‫سبب‬ ‫آخر‬ ‫لزٌادة‬ ‫عددها‬ ‫ٌمكن‬ ‫للولاٌة‬ ‫الثانوٌة‬ ‫أن‬ ‫تجد‬ ‫العدٌد‬ ‫من‬ ‫األمراض‬ ً‫ف‬ ‫ولت‬ ‫مبكر‬ ‫عندما‬ ‫تكون‬ ‫أرخص‬ ً‫ف‬ ‫المعالجة‬ ‫وأكثر‬ ‫فائدة‬ ‫لتؽٌٌر‬ ‫نمط‬ ‫الحٌاة‬ ، ‫وتؤدي‬ ‫اا‬‫ض‬ٌ‫أ‬ ‫إلى‬ ‫عدد‬ ‫ألل‬ ‫من‬ ‫الزٌارات‬ ً‫ف‬ ‫السنوات‬ ‫الالحمة‬ ( ‫مما‬ ‫ٌملل‬ ‫من‬ ‫التكالٌؾ‬ ‫الصحٌة‬ ) ‫نمص‬ ‫الحوافز‬ ‫لخدمات‬ ‫الولاٌة‬ ً‫ف‬ ‫نظام‬ ‫الرعاٌة‬ ‫الصحٌة‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ Healthcare Determinants
25 • Features like sidewalks, parks, bike trails, community pools all encourage healthier choices • Households with multiple televisions and computers also promote a less-active culture which affects the amount of exercise being done • Nutritional choices also under consideration in built environments – menus, work cafeterias, highlight lower costs for less nutritional foods. ‫ع‬ّ‫تشج‬ ‫المٌزات‬ ‫مثل‬ ‫األرصفة‬ ‫والحدائك‬ ‫ومسارات‬ ‫الدراجات‬ ‫والمسابح‬ ‫الجماعٌة‬ ‫على‬ ‫خٌارات‬ ‫صحٌة‬ ‫كما‬ ‫أن‬ ‫األسر‬ ً‫الت‬ ‫لدٌها‬ ‫أجهزة‬ ‫تلفزٌون‬ ‫وأجهزة‬ ‫كمبٌوتر‬ ‫متعددة‬ ‫تعمل‬ ‫على‬ ‫التروٌج‬ ‫لثمافة‬ ‫ألل‬ ‫ا‬‫ا‬‫نشاط‬ ‫تؤثر‬ ‫على‬ ‫كمٌة‬ ‫التمارٌن‬ ً‫الت‬ ‫ٌتم‬ ‫إجراؤها‬ ‫الخٌارات‬ ‫الؽذائٌة‬ ‫لٌد‬ ‫النظر‬ ‫أٌضا‬ ً‫ف‬ ‫البٌئات‬ ‫المبنٌة‬ - ‫لوائم‬ ‫الطعام‬ ، ً‫مماه‬ ‫العمل‬ ، ‫تسلٌط‬ ‫الضوء‬ ‫على‬ ‫تكالٌؾ‬ ‫ألل‬ ‫ألؼذٌة‬ ‫ؼذائٌة‬ ‫ألل‬ Environmental Determinants
26 • Population health is emerging as just as important as individual health • Policymakers are quick to blame individual choices for chronic illness, when, in reality, there are an amplitude of environmental, cultural and economic factors at play • Social determinants are often a large result of health disparities ‫الصحة‬ ‫السكانٌة‬ ‫تظهر‬ ‫بأهمٌة‬ ‫الصحة‬ ‫الفردٌة‬ ‫ٌسارع‬ ‫صناع‬ ‫المرار‬ ً‫السٌاس‬ ‫إلى‬ ‫إلماء‬ ‫اللوم‬ ‫على‬ ‫الخٌارات‬ ‫الفردٌة‬ ‫للمرض‬ ‫المزمن‬ ، ‫عندما‬ ‫ٌكون‬ ‫هنان‬ ً‫ف‬ ‫الوالع‬ ‫عدد‬ ‫كبٌر‬ ‫من‬ ‫العوامل‬ ‫البٌئٌة‬ ‫والثمافٌة‬ ‫وااللتصادٌة‬ ‫أثناء‬ ‫اللعب‬ . ‫وؼالبا‬ ‫ما‬ ‫تكون‬ ‫المحددات‬ ‫االجتماعٌة‬ ‫نتٌجة‬ ‫كبٌرة‬ ‫للفوارق‬ ‫الصحٌة‬ SocialDeterminants
27 • Victim-blaming fails to account environmental and social – ecological approach acknowledges that we live in a world full of interactions • It takes into account the following elements that influence health behavior: 1. Intrapersonal factors 2. Interpersonal factors 3. Organizational factors 4. Community factors 5. Policy factors Levels of Intervention
28 • Early attempt to use theory to study preventive behaviors • If subject perceives moderate severity and susceptibility, then choose preventative action • Often criticized and used to explain how people rarely adopt preventative behaviors ‫محاولة‬ ‫مبكرة‬ ‫الستخدام‬ ‫النظرٌة‬ ‫لدراسة‬ ‫السلوكٌات‬ ‫الولائٌة‬ ‫إذا‬ ‫كان‬ ‫الموضوع‬ ‫ٌدرن‬ ‫خطورة‬ ‫وشدة‬ ‫متوسطة‬ ، ‫فاختر‬ ‫اإلجراء‬ ً‫الولائ‬ ‫ا‬‫ا‬‫كثٌر‬ ‫ما‬ ‫ٌتم‬ ‫نمده‬ ‫واستخدامه‬ ‫لشرح‬ ‫كٌؾ‬ ‫ا‬‫ا‬‫نادر‬ ‫ما‬ ‫ٌتبنى‬ ‫الناس‬ ‫سلوكٌات‬ ‫ولائٌة‬ 1-Health Belief Model
29 • Also known as Stages of Change Model • Not everyone at the same stage to drastically change health behavior, so each plan fits to different characteristics • Series of stages, from pre-contemplation (no change) to termination (problem no longer acceptable) or relapse (retroactively choosing less healthy behavior) ‫عرؾ‬ٌُ ‫ا‬‫ا‬‫ض‬ٌ‫أ‬ ‫باسم‬ ‫نماذج‬ ‫مراحل‬ ‫التؽٌٌر‬ ‫لٌس‬ ‫كل‬ ‫شخص‬ ً‫ف‬ ‫نفس‬ ‫المرحلة‬ ‫لتؽٌٌر‬ ‫السلون‬ ً‫الصح‬ ‫بشكل‬ ‫جذري‬ ، ‫لذلن‬ ‫كل‬ ‫خطة‬ ‫تناسب‬ ‫خصائص‬ ‫مختلفة‬ ‫سلسلة‬ ‫من‬ ‫المراحل‬ ، ‫من‬ ‫مرحلة‬ ‫ما‬ ‫لبل‬ ‫التأمل‬ ( ‫بدون‬ ‫تؽٌٌر‬ ) ‫إلى‬ ‫اإلنهاء‬ ( ‫المشكلة‬ ‫لم‬ ‫تعد‬ ‫ممبولة‬ ) ‫أو‬ ‫االنتكاس‬ ( ‫اختٌار‬ ‫سلون‬ ‫ألل‬ ‫صحٌة‬ ‫بأثر‬ ً‫رجع‬ ) 2-Transtheoretical Model
30 • Individuals are fueled by behavioral intentions • An attitude of a positive behavior is ―is the sum of all the positive feelings…or negative feelings…about performing the behavior‖ )Remington et al. 2010 .) • Places normative beliefs on people’s perceptions and readiness to change ‫ٌتم‬ ‫تؽذٌة‬ ‫األفراد‬ ‫عن‬ ‫طرٌك‬ ‫النواٌا‬ ‫السلوكٌة‬ ‫المولؾ‬ ‫من‬ ‫السلون‬ ً‫اإلٌجاب‬ ‫هو‬ " ‫هو‬ ‫مجموع‬ ‫كل‬ ‫المشاعر‬ ‫اإلٌجابٌة‬ ... ‫أو‬ ‫المشاعر‬ ‫السلبٌة‬ ... ‫حول‬ ‫أداء‬ ‫السلون‬ " ‫ٌضع‬ ‫المعتمدات‬ ‫المعٌارٌة‬ ‫حول‬ ‫تصورات‬ ‫الناس‬ ‫واستعدادهم‬ ‫للتؽٌٌر‬ 3-Theory of Planned Behavior
31 • Expectancy is important when considering control – where, who, what is/are responsible? • If there is belief that a plan of action will result in an outcome, a person is more likely to pursue that option • Control moves from internal (self) to external (higher powers, luck, fate, etc(. • Those who lean toward external control are more likely reached through policy changes ‫التولع‬ ‫مهم‬ ‫عند‬ ‫التفكٌر‬ ً‫ف‬ ‫السٌطرة‬ - ‫أٌن‬ ، ‫من‬ ، ‫ما‬ ‫هو‬ / ‫المسؤول‬ ‫؟‬ ‫إذا‬ ‫كان‬ ‫هنان‬ ‫اعتماد‬ ‫بأن‬ ‫خطة‬ ‫العمل‬ ‫ستؤدي‬ ‫إلى‬ ‫نتٌجة‬ ، ‫فمن‬ ‫المرجح‬ ‫أن‬ ‫ٌتابع‬ ‫هذا‬ ‫الشخص‬ ‫هذا‬ ‫الخٌار‬ ‫ٌتحكم‬ ‫التحكم‬ ‫من‬ ً‫داخل‬ ( ً‫ذات‬ ) ‫إلى‬ ً‫خارج‬ ( ‫لوى‬ ‫أعلى‬ ، ‫حظ‬ ، ‫مصٌر‬ ، ‫إلخ‬ ). ‫من‬ ‫المرجح‬ ‫أن‬ ‫ٌتم‬ ‫الوصول‬ ‫إلى‬ ‫أولئن‬ ‫الذٌن‬ ‫ٌمٌلون‬ ‫نحو‬ ‫السٌطرة‬ ‫الخارجٌة‬ ‫من‬ ‫خالل‬ ‫تؽٌٌرات‬ ‫السٌاسة‬ 4-Health Locus of Control
32 • Addresses dynamic of society that influence health and methods for behavioral change • Triadic, dynamic, reciprocal models • Emphasis placed on highlighting capability and self-confidence • Self-efficacy through mastery of task • Applicable to wide variety of populations ‫ٌعالج‬ ‫دٌنامٌكٌة‬ ‫المجتمع‬ ً‫الت‬ ‫تؤثر‬ ‫على‬ ‫الصحة‬ ‫وأسالٌب‬ ‫تؽٌٌر‬ ‫السلون‬ ‫نماذج‬ ‫ثالثٌة‬ ، ‫دٌنامٌكٌة‬ ، ‫متبادلة‬ ‫التركٌز‬ ‫على‬ ‫إبراز‬ ‫المدرات‬ ‫والثمة‬ ‫بالنفس‬ ‫الكفاءة‬ ‫الذاتٌة‬ ‫من‬ ‫خالل‬ ‫التمكن‬ ‫من‬ ‫المهمة‬ ‫تنطبك‬ ‫على‬ ‫مجموعة‬ ‫واسعة‬ ‫من‬ ‫السكان‬ 1- SocialCognitive Theory
33 • Monopolizes on existing string of social network (family) to implement support • Family trained to assist in weight loss program, for example • ―Family Matters‖ program to prevent youth smoking and alcoholism ‫ٌحتكر‬ ‫على‬ ‫السلسلة‬ ‫الحالٌة‬ ‫من‬ ‫الشبكة‬ ‫االجتماعٌة‬ ( ‫األسرة‬ ) ‫لتنفٌذ‬ ‫الدعم‬ ‫األسرة‬ ‫المدربة‬ ‫للمساعدة‬ ً‫ف‬ ‫برنامج‬ ‫إنماص‬ ‫الوزن‬ ، ‫على‬ ‫سبٌل‬ ‫المثال‬ ‫برنامج‬ " ‫مسائل‬ ‫األسرة‬ " ‫لمنع‬ ‫تدخٌن‬ ‫الشباب‬ ‫وإدمان‬ ‫الكحول‬ 2-Family-Based Interventions
34 • Mentor programs, buddy systems, self-help groups • Creating a new social network with the sole purpose of intervening • Especially important in adolescent interventions ‫برامج‬ ‫التوجٌه‬ ، ‫أنظمة‬ ‫األصدلاء‬ ، ‫مجموعات‬ ‫المساعدة‬ ‫الذاتٌة‬ ‫إنشاء‬ ‫شبكة‬ ‫اجتماعٌة‬ ‫جدٌدة‬ ‫لؽرض‬ ‫وحٌد‬ ‫للتدخل‬ ‫أهمٌة‬ ‫خاصة‬ ً‫ف‬ ‫تدخالت‬ ‫المراهمٌن‬ 3- Friends and SocialNetworks
35 • Social support ‫دعم‬ ً‫اجتماع‬ 1. Emotional support 2. Instrumental support 3. Informational support 4. Appraisal support • Either strengthening existing networks or creating new ones to assist in the problem-solving process ‫إما‬ ‫تعزٌز‬ ‫الشبكات‬ ‫المائمة‬ ‫أو‬ ‫إنشاء‬ ‫شبكات‬ ‫جدٌدة‬ ‫للمساعدة‬ ً‫ف‬ ‫عملٌة‬ ‫حل‬ ‫المشكالت‬ 4- SocialSupportand Social Networks
36 • A member of a social network who gains trust and respect through his or her abilities to offer support and guidance • These strategies are seen frequently in urban and rural settings • Natural helpers are either found in a community organically, or is given specialized training (this is known as a lay health advisor) ‫عضو‬ ً‫ف‬ ‫شبكة‬ ‫اجتماعٌة‬ ‫كسب‬ ‫الثمة‬ ‫واالحترام‬ ‫من‬ ‫خالل‬ ‫لدراته‬ ‫لتمدٌم‬ ‫الدعم‬ ‫واإلرشاد‬ ‫وٌنظر‬ ‫إلى‬ ‫هذه‬ ‫االستراتٌجٌات‬ ً‫ف‬ ‫كثٌر‬ ‫من‬ ‫األحٌان‬ ً‫ف‬ ‫المناطك‬ ‫الحضرٌة‬ ‫والرٌفٌة‬ ‫ٌتم‬ ‫العثور‬ ‫على‬ ‫المساعدٌن‬ ‫الطبٌعٌٌن‬ ً‫ف‬ ‫مجتمع‬ ‫ما‬ ‫اا‬ٌ‫عضو‬ ، ‫أو‬ ‫ٌتم‬ ‫تمدٌم‬ ‫تدرٌب‬ ‫متخصص‬ ‫له‬ ( ‫ُعرؾ‬ٌ ‫هذا‬ ‫بالمستشار‬ ً‫الصح‬ ‫العادي‬ ) 5-Natural Helpers
37 • Effective in providing screening / follow-ups • However, often underutilized in primary prevention (see Slide 3 ( • Brief interventions are low cost alternative to high cost visits • Short, private, non-confrontational, 5-60 minute meeting with counseling and informative education • Can be leveraged depending on a person’s aptitude and readiness for change / ( 3 ) 1- Health Care System and Clinical Services
38 • Youth are a spirited, receptive audience for prevention messages • Establishing healthier habits at an earlier age is essential in stopping or slowing chronic illness ‫الشباب‬ ‫هم‬ ‫جمهور‬ ‫مفعم‬ ‫بالحٌوٌة‬ ‫ومتفهم‬ ‫لرسائل‬ ‫الولاٌة‬ ‫إن‬ ‫إرساء‬ ‫عادات‬ ‫صحٌة‬ ً‫ف‬ ‫سن‬ ‫مبكرة‬ ‫أمر‬ ‫ضروري‬ ‫لولؾ‬ ‫أو‬ ‫إبطاء‬ ‫المرض‬ ‫المزمن‬ 2- Schools
39 • US adult population spends half or more of the day at work, so it becomes a useful tool in dispensing knowledge about prevention education. • Leaders are understanding that chronic diseases are costing more and more (employee absence, insurance costs, etc.) and are mediating this through health knowledge at the workplace. Results: 1. Improved productivity 2. Reduced absences 3. Reduced health risks/health care costs 4. Improved company image ( ) . : / 3- Work Sites
40 • Selected based on priorities of population in question • Priority population partners – participatory, collaborative, local, empowering, research and action blend • Community coalitions • Media advocacy – seen today in suicide prevention, and lead poisoning, to name a few - - Examplesof Community-Level Health PlanningApproaches
41 1. Process planning ‫عملٌة‬ ‫التخطٌط‬ 2. Plan with people ‫خطط‬ ‫مع‬ ‫الناس‬ 3. Plan with data ‫خطة‬ ‫مع‬ ‫البٌانات‬ 4. Institutionalization ‫إضفاء‬ ‫الطابع‬ ً‫المؤسس‬ 5. Priorities‫أولوٌات‬ 6. Short- and long-term outcomes ‫نتائج‬ ‫لصٌرة‬ ‫وطوٌلة‬ ‫األجل‬ 7. Evaluation‫تمٌٌم‬ Community-Level Health Planning
42 1. Mobilizing the community ‫تعبئة‬ ‫المجتمع‬ 2. Developing a community profile ‫تطوٌر‬ ‫ملؾ‬ ‫تعرٌؾ‬ ‫المجتمع‬ 3. Selection behavior/audiences ‫سلون‬ ‫االختٌار‬ / ‫الجماهٌر‬ 4. Formative research ‫البحث‬ ً‫التكوٌن‬ 5. Strategy development ‫تطوٌر‬ ‫اإلستراتٌجٌة‬ 6. Program development ‫تطوٌر‬ ‫البرنامج‬ 7. Program implementation ‫تنفٌذ‬ ‫البرنامج‬ 8. Tracking‫تتبع‬ Community-Based Prevention Marketing
43 Chapter 4: Chronic Disease Surveillance
44 Conceptual Model of Health Surveillance Define the Problem Program Process Evaluate the Effect Find Programs that Work Information Dissemination Data Collection Data Analysis Data Interpretation Epidemiologic Process Adapted from Remington et al. ( 2010 )
45 • Council of State and Territorial Epidemiologists modifies this list each year • Includes primarily infectious diseases, but also contains some noncommunicable diseases, as well • In 1996, CSTE included smoking, the first behavior on the list • 2004list contains 92 disease systems • Chronic Disease Indicators website includes definitions and data of each in the United States 1996 2004 92 1- Notifiable Disease Systems
46 • Collected information from birth and death • An initial cornerstone of surveillance since the mid-19th century and perhaps earlier • Death certificates are used to list immediate causes of death and a string of events that caused death (underlying cause( • Limitation – incomplete certificate, lack of clinical history ‫المعلومات‬ ً‫الت‬ ‫تم‬ ‫جمعها‬ ‫من‬ ‫الوالدة‬ ‫والوفاة‬ ‫حجر‬ ‫الزاوٌة‬ ً‫األول‬ ‫للمرالبة‬ ‫منذ‬ ‫منتصؾ‬ ‫المرن‬ ‫التاسع‬ ‫عشر‬ ‫وربما‬ ‫لبل‬ ‫ذلن‬ ‫ستخدم‬ُ‫ت‬ ‫شهادات‬ ‫الوفاة‬ ‫لسرد‬ ‫األسباب‬ ‫المباشرة‬ ‫للوفاة‬ ‫وسلسلة‬ ‫من‬ ‫األحداث‬ ً‫الت‬ ‫تسبب‬ ‫الوفاة‬ ( ‫السبب‬ ً‫األساس‬ ) ‫الحد‬ - ‫شهادة‬ ‫ؼٌر‬ ‫كاملة‬ ، ‫ونمص‬ ‫التارٌخ‬ ‫السرٌري‬ 2-Vital Statistics
47 • One symptom or a string of symptoms, disease, disability, etc. • Effectiveness yet to be proven by research • Could potentially identify outbreaks or bioterrorism ‫أحد‬ ‫األعراض‬ ‫أو‬ ‫سلسلة‬ ‫من‬ ‫األعراض‬ ، ‫المرض‬ ، ‫اإلعالة‬ ، ‫إلخ‬ . ‫فعالٌة‬ ‫لم‬ ‫تثبت‬ ‫بعد‬ ‫من‬ ‫خالل‬ ‫البحث‬ ‫ٌمكن‬ ‫أن‬ ‫تحدد‬ ‫حاالت‬ ً‫تفش‬ ‫أو‬ ‫اإلرهاب‬ ً‫البٌولوج‬ 3-Sentinel Surveillance
48 • Used in monitoring trends • Usually mandated in state laws • Most common disease registries – cancer  They are 1. Hospital-based registries 2. population-based registries ‫تستخدم‬ ً‫ف‬ ‫مرالبة‬ ‫االتجاهات‬ ‫عادة‬ ‫ما‬ ‫ٌفوض‬ ً‫ف‬ ‫لوانٌن‬ ‫الوالٌة‬ ‫سجالت‬ ‫األمراض‬ ‫األكثر‬ ‫شٌوعا‬ - ‫السرطان‬ ‫السجالت‬ ‫المستندة‬ ‫إلى‬ ‫المستشفٌات‬ ‫أو‬ ‫السكان‬ 4- Chronic Disease Registries
49 • Implemented when collecting information from self-reported health practices (general pop). • CDC established a phone-based surveillance system of questionnaires • Some surveys go beyond questionnaires and access physical exams and samples • Collected at mobile examination centers ( ) ( CDC ) 5- Health Surveys
50 • Primarily hospital discharge data • Used to locate hospitalization patterns of chronic diseases • Limitations – incomplete records, unreliable imputation of data, missing variables, measurement errors, only focus on hospital setting, not outpatient care ‫بٌانات‬ ‫تفرٌػ‬ ‫المستشفى‬ ً‫ف‬ ‫الممام‬ ‫األول‬ ‫تستخدم‬ ‫لتحدٌد‬ ‫مولع‬ ‫أنماط‬ ‫االستشفاء‬ ‫من‬ ‫األمراض‬ ‫المزمنة‬ ‫المٌود‬ - ‫السجالت‬ ‫ؼٌر‬ ‫المكتملة‬ ، ‫استبعاد‬ ‫البٌانات‬ ‫ؼٌر‬ ‫المضمونة‬ ، ‫المتؽٌرات‬ ‫المفمودة‬ ، ‫أخطاء‬ ‫المٌاس‬ ، ‫التركٌز‬ ‫فمط‬ ‫على‬ ‫إعداد‬ ‫المستشفى‬ ، ‫ولٌس‬ ‫رعاٌة‬ ‫المرضى‬ ‫الخارجٌٌن‬ 6-Administrative Data Collection Systems
51 • Each 10 years, the United States government censuses the entire population – collects detailed information on individual and household • Limitations – census does not include everyone; inevitably some are missed • Minority racial/ethnic groups • Geographic areas 10 - - / 7- Census Data
52 • Charts the variety of a disease given their personal attributions • Race, age, gender, etc. • Realizing differences in these factors helps design effective and group-specific prevention or control programs ‫ٌرسم‬ ‫مجموعة‬ ‫متنوعة‬ ‫من‬ ‫المرض‬ ‫نظرا‬ ‫لخصوصٌاتهم‬ ‫الشخصٌة‬ ‫العرق‬ ، ‫العمر‬ ، ‫الجنس‬ ، ‫إلخ‬ . ‫إدران‬ ‫االختالفات‬ ً‫ف‬ ‫هذه‬ ‫العوامل‬ ‫ٌساعد‬ ‫على‬ ‫تصمٌم‬ ‫برامج‬ ‫للولاٌة‬ ‫أو‬ ‫السٌطرة‬ ‫فعالة‬ ‫ومحددة‬ 1- Person Analyses
53 • Charts a disease that occurs in one geographic region against another region • Typically found in situations when a city or county is compared to state or country • Needs to understand and interpret age structure between areas by age-standardization • Cluster analysis – in acute geographic areas – monitored to avoid health risks specific to a very small area (neighborhoods, communities, suburbs, etc). ‫ٌرسم‬ ‫المرض‬ ‫الذي‬ ‫ٌحدث‬ ً‫ف‬ ‫منطمة‬ ‫جؽرافٌة‬ ‫واحدة‬ ‫ضد‬ ‫منطمة‬ ‫أخرى‬ ‫توجد‬ ‫عادة‬ ً‫ف‬ ‫الحاالت‬ ً‫الت‬ ‫تتم‬ ‫فٌها‬ ‫ممارنة‬ ‫مدٌنة‬ ‫أو‬ ‫مماطعة‬ ‫بالدولة‬ ‫أو‬ ‫الدولة‬ ‫ٌحتاج‬ ‫إلى‬ ‫فهم‬ ‫وتفسٌر‬ ‫الهٌكل‬ ‫العمري‬ ‫بٌن‬ ‫المناطك‬ ‫حسب‬ ‫توحٌد‬ ‫العمر‬ ‫رصد‬ ‫الكتلة‬ - ً‫ف‬ ‫المناطك‬ ‫الجؽرافٌة‬ ‫الحادة‬ - ‫رصد‬ ‫لتجنب‬ ‫المخاطر‬ ‫الصحٌة‬ ‫المحددة‬ ‫لمنطمة‬ ‫صؽٌرة‬ ‫جدا‬ ( ‫األحٌاء‬ ‫والمجتمعات‬ ‫المحلٌة‬ ً‫والضواح‬ ، ‫وما‬ ‫إلى‬ ‫ذلن‬ ) 2- Place Analyses
54 • Charts trends that appear over time • Used to detect outbreaks, transmission patterns, intervention strategies • Temporal trends, regional analysis • Interventions based on variables specific to a certain time in a certain era ‫مؤشرات‬ ‫المخططات‬ ً‫الت‬ ‫تظهر‬ ‫مع‬ ‫مرور‬ ‫الولت‬ ‫ٌستخدم‬ ‫للكشؾ‬ ‫عن‬ ‫الفاشٌات‬ ‫وأنماط‬ ‫االنتمال‬ ‫واستراتٌجٌات‬ ‫التدخل‬ ‫االتجاهات‬ ‫الزمنٌة‬ ، ‫التحلٌل‬ ً‫اإلللٌم‬ ‫التدخالت‬ ‫على‬ ‫أساس‬ ‫المتؽٌرات‬ ‫المحددة‬ ‫لفترة‬ ‫معٌنة‬ ً‫ف‬ ‫عصر‬ ‫معٌن‬ 3-Time Analyses
55 • Data dissemination is the final step in disease monitoring • Often composed in documents with technical language, with little linkage to public health promotion • Epidemiologists asked to disseminate the information collected into health department reports • Five steps in data analysis: 1. Establish the message، 2. set an objective، 3. define the audience ، 4. select the channel ، 5. evaluate the impact : Data Dissemination
56 • Arguably the most important element of data presentations • The role of the epidemiologist is to convey a clear message, one that is worthwhile and somewhat easy to understand • ―Less is more‖ approach • Main points must be easy to understand ‫ٌمكن‬ ‫المول‬ ‫إن‬ ‫العنصر‬ ‫األكثر‬ ‫أهمٌة‬ ً‫ف‬ ‫تمدٌم‬ ‫البٌانات‬ ‫إن‬ ‫دور‬ ‫عالم‬ ‫األوبئة‬ ‫هو‬ ‫نمل‬ ‫رسالة‬ ‫واضحة‬ ، ‫مهمة‬ ‫جدٌرة‬ ‫باالهتمام‬ ‫وسهلة‬ ‫الفهم‬ ‫إلى‬ ‫حد‬ ‫ما‬ ‫نهج‬ " ‫ألل‬ ‫هو‬ ‫أكثر‬ " ‫النماط‬ ‫الرئٌسٌة‬ ‫ٌجب‬ ‫أن‬ ‫تكون‬ ‫سهلة‬ ‫الفهم‬ Message
57 • Goal of epidemiologist is to establish an objective for a piece of writing • Goals vary – sometimes there is no goal, simply that there is something to be reported, other times objective is for general public education • Sometimes the ideal objective is public action - Objective
58 • Target audience varies, but has traditionally been both local health departments and health care providers • These agencies are charged with implementing any strategies for managing disease control • Today, a broader spectrum of target audience exists – from policymakers and legislators, or to the general public, advocacy agencies to promote their efforts ‫الجمهور‬ ‫المستهدؾ‬ ‫ٌختلؾ‬ ، ‫ولكن‬ ‫كان‬ ‫تملٌدٌا‬ ‫كل‬ ‫من‬ ‫اإلدارات‬ ‫الصحٌة‬ ‫المحلٌة‬ ً‫وممدم‬ ‫الرعاٌة‬ ‫الصحٌة‬ ‫هذه‬ ‫الوكاالت‬ ‫مكلفة‬ ‫بتنفٌذ‬ ‫أي‬ ‫استراتٌجٌات‬ ‫إلدارة‬ ‫مكافحة‬ ‫المرض‬ ‫الٌوم‬ ، ‫هنان‬ ‫مجموعة‬ ‫واسعة‬ ‫من‬ ‫الجمهور‬ ‫المستهدؾ‬ - ‫من‬ ‫صناع‬ ‫السٌاسات‬ ‫والمشرعٌن‬ ، ‫أو‬ ‫من‬ ‫عامة‬ ‫الجمهور‬ ، ‫وكاالت‬ ‫الدعوة‬ ‫لتعزٌز‬ ‫جهودها‬ . Audience
59 • The method or medium that an epidemiologist “channels” his or her work • Journals, paper/electronic mail, radio/television, blogs, print/digital media, etc. • Frequently mailed to healthcare facilities • Sometimes a press release is required • Selective channeling aides research in reaching target audience ‫الطرٌمة‬ ‫أو‬ ‫الوسط‬ ‫الذي‬ " ‫م‬ّ‫ٌمن‬ " ً‫اختصاص‬ ‫األوبئة‬ ‫عمله‬ ‫أو‬ ‫عملها‬ ‫دورٌات‬ ، ‫ورلٌة‬ / ‫برٌد‬ ً‫إلكترون‬ ، ‫ورادٌو‬ / ‫تلفزٌون‬ ، ‫ومدونات‬ ، ‫ووسائط‬ ‫مطبوعة‬ / ‫وسائط‬ ‫رلمٌة‬ ، ‫إلخ‬ . ‫إرسالها‬ ‫بشكل‬ ‫متكرر‬ ‫إلى‬ ‫مرافك‬ ‫الرعاٌة‬ ‫الصحٌة‬ ً‫ف‬ ‫بعض‬ ‫األحٌان‬ ‫نشرة‬ ‫صحفٌة‬ ‫مطلوبة‬ ‫بحوث‬ ‫توجٌهٌة‬ ‫انتمائٌة‬ ً‫ف‬ ‫الوصول‬ ‫إلى‬ ‫الجمهور‬ ‫المستهدؾ‬ Channel
60 • Final step is evaluating how the information was distributed using the previous four methods • This can be measured in various ways – number of items distributed, where and how, readership, coverage, hits on a webpage, web searches • The success of the previous methods outline the impact that a particular public health campaign may have ‫الخطوة‬ ‫النهائٌة‬ ً‫ه‬ ‫تمٌٌم‬ ‫كٌفٌة‬ ‫توزٌع‬ ‫المعلومات‬ ‫باستخدام‬ ‫الطرق‬ ‫األربع‬ ‫السابمة‬ ‫ٌمكن‬ ‫لٌاس‬ ‫ذلن‬ ‫بطرق‬ ‫مختلفة‬ - ‫عدد‬ ‫العناصر‬ ‫الموزعة‬ ، ‫وأٌن‬ ‫وكٌؾ‬ ، ‫والمراء‬ ، ‫والتؽطٌة‬ ، ‫والنتائج‬ ‫على‬ ‫صفحة‬ ‫الوٌب‬ ، ‫وبحث‬ ‫الوٌب‬ ‫ٌوضح‬ ‫نجاح‬ ‫األسالٌب‬ ‫السابمة‬ ‫التأثٌر‬ ‫الذي‬ ‫لد‬ ‫تحدثه‬ ‫حملة‬ ‫صحة‬ ‫عامة‬ ‫معٌنة‬ Impact
61 Chapter 5: Tobacco Use
62 • Smoking harms every organ of the body, with diseases including – 1. Cardiovascular diseases 2. Cancers – lip, mouth, esophagus, lung, kidney, etc. 3. Respiratory problems 4. Reproductive disorders 5. SIDS ―Sudden infant death syndrome‖ ،cataracts, slow wound healing 6. Low bone density - - . Significance
63 • Smoking a major risk factor in developing congenital heart disease • Ability of blood to delivery oxygen is reduced • Secondhand smoking causes prothrombotic effects and endothelial cell dysfunctions ‫التدخٌن‬ ‫عامل‬ ‫خطر‬ ً‫رئٌس‬ ً‫ف‬ ‫تطوٌر‬ ‫أمراض‬ ‫الملب‬ ‫الخلمٌة‬ ‫ٌتم‬ ‫تملٌل‬ ‫لدرة‬ ‫الدم‬ ‫لتسلٌم‬ ‫األكسجٌن‬ ‫التدخٌن‬ ً‫السلب‬ ‫ٌسبب‬ ‫آثارا‬ ‫خارجٌة‬ ‫وخالٌا‬ ‫خلوٌة‬ ‫بطانٌة‬ Cardiovascular Disease
64 • “Mainstreamtobacco smoke (MS) contains nearly 5,000 chemicals…and more than 60 known carcinogens” (Remington et al. 2010 ( • These carcinogens have been linked to tobacco-related cancers • Nitrosamines/polyaromatic hydrocarbons – lung cancer • N-nitrosodimethylmine – kidney tumors • Nitrosamine NNK – pancreatic cancer • Benzene, polonium-210, lead-210 – myeloid leukemia " ( MS ) 5000 ... 60 " / - N-nitrosodimethylmine - Nitrosamine NNK - 210 210 - Cancer
65 • When you smoke, additional biological processes like inflammation, degradation of structural proteins and oxidant stress are developed, which can cause alveolar injury 1. Results in COPD ―Chronic obstructive pulmonary disease‖ 2. Hypoxemia 3. Decline in pulmonary function 4. Reduction of tracheal mucus velocity Chronic Lung/Other Respiratory Disease
66 • Nicotine distribution absorbs rapidly to the brain in both oral and inhalation of tobacco – around ten seconds upon initial use • Crosses blood-brain barrier and binds to receptors in brain, which releases neurotransmitters • Effects dependent on rate of use, tolerance • Withdrawal symptoms include irritability, frustration, increased appetite, weight gain, and generally occur within one day and maintain for ten days, though cravings for regular smokers last for years ‫ٌمتص‬ ‫توزٌع‬ ‫النٌكوتٌن‬ ‫بسرعة‬ ‫إلى‬ ‫الدماغ‬ ‫سواء‬ ‫عن‬ ‫طرٌك‬ ‫الفم‬ ‫واستنشاق‬ ‫التبػ‬ - ً‫حوال‬ ‫عشر‬ ‫ثوان‬ ‫عند‬ ‫االستخدام‬ ً‫األول‬ ‫ٌعبر‬ ‫حاجز‬ ‫الدم‬ ً‫ف‬ ‫الدماغ‬ ‫وٌربط‬ ‫بالمستمبالت‬ ً‫ف‬ ‫الدماغ‬ ، ً‫الت‬ ‫تطلك‬ ‫الموصالت‬ ‫العصبٌة‬ ‫آثار‬ ‫تعتمد‬ ‫على‬ ‫معدل‬ ‫االستخدام‬ ‫والتسامح‬ ‫تشمل‬ ‫أعراض‬ ‫االنسحاب‬ ‫التهٌج‬ ، ‫واإلحباط‬ ، ‫وزٌادة‬ ‫الشهٌة‬ ، ‫وزٌادة‬ ‫الوزن‬ ، ‫وعادة‬ ‫ما‬ ‫تحدث‬ ً‫ف‬ ‫ؼضون‬ ‫ٌوم‬ ‫واحد‬ ‫والحفاظ‬ ‫على‬ ‫عشرة‬ ‫أٌام‬ ، ‫على‬ ‫الرؼم‬ ‫من‬ ‫الرؼبة‬ ‫الشدٌدة‬ ‫للمدخنٌن‬ ‫العادٌٌن‬ ‫تستمر‬ ‫لسنوات‬ Nicotine Dependence
67 • In the United States, estimated 43 million smokers • Higher for men (22%) than women ( 17% ) • 10 % - Asians; 13% - Hispanics; 20% - African Americans; 21% - Caucasians; 36% - Native Americans and Alaska Natives (Remington et al. 2010 ) • A 2005 study found that 51% of men and 50% of women were smokers at one time but had quit • Estimated 4,000 young people smoke their first cigarette each year ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ، ‫ٌمدر‬ ‫عدد‬ ‫المدخنٌن‬ ‫بنحو‬ 43 ‫ملٌون‬ ‫شخص‬ ‫أعلى‬ ‫للرجال‬ ( 22 ٪ ) ‫من‬ ‫النساء‬ ( 17 ٪ ) 10 ٪ - ‫اآلسٌوٌٌن‬ . 13 ٪ - ‫من‬ ‫اصل‬ ً‫اسبان‬ 20 ٪ - ‫األمرٌكٌون‬ ‫من‬ ‫أصل‬ ً‫أفرٌم‬ 21 ٪ - ‫المولازٌٌن‬ . 36 ٪ - ‫األمرٌكٌون‬ ‫األصلٌون‬ ً‫وأهال‬ ‫أالسكا‬ ( Remington et al. 2010 ) ‫وجدت‬ ‫دراسة‬ ‫أجرٌت‬ ‫عام‬ 2005 ‫أن‬ 51 ٪ ‫من‬ ‫الرجال‬ ‫و‬ 50 ٪ ‫من‬ ‫النساء‬ ‫كانوا‬ ‫مدخنٌن‬ ً‫ف‬ ‫ولت‬ ‫واحد‬ ‫ولكنهم‬ ‫تركوا‬ ‫التدخٌن‬ ‫ّر‬‫د‬‫ٌم‬ ‫عدد‬ 4000 ‫شاب‬ ‫ٌدخنون‬ ‫سٌجارتهم‬ ‫األولى‬ ‫كل‬ ‫عام‬ High-Risk Groups
68 • Peak cigarette sales in the United States in 1963 – steadily declining since • Over time, the gap between men (historically higher rates) and women (lower) has been narrowing, but the declination rate is lowering at a comparable rate • From 2002, more former smokers than current smokers ‫ذروة‬ ‫مبٌعات‬ ‫السجائر‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ً‫ف‬ ‫عام‬ 1963 - ‫انخفاض‬ ‫مستمر‬ ‫منذ‬ ‫ذلن‬ ‫الحٌن‬ ‫بمرور‬ ‫الولت‬ ، ‫تضٌك‬ ‫الفجوة‬ ‫بٌن‬ ‫الرجال‬ ( ‫معدالت‬ ‫أعلى‬ ‫ا‬‫ا‬‫خ‬ٌ‫تار‬ ) ‫والنساء‬ ( ‫ألل‬ ) ، ‫ولكن‬ ‫معدل‬ ‫االنخفاض‬ ‫ٌنخفض‬ ‫بمعدل‬ ‫مماثل‬ ‫من‬ ‫عام‬ 2002 ، ‫عدد‬ ‫المدخنٌن‬ ‫السابمٌن‬ ‫أكثر‬ ‫من‬ ‫المدخنٌن‬ ‫الحالٌٌن‬ Time Trends
69 • Societal and individual factors – exposure in popular films, perception of safeness among certain brand • Advertising and promotion – media sponsorship, high budget spend on advertisement from tobacco companies • “Safer” tobacco – low-tar branding • Access – vending machines and some sales counters selling to minors ‫العوامل‬ ‫االجتماعٌة‬ ‫والفردٌة‬ - ‫التعرض‬ ً‫ف‬ ‫األفالم‬ ‫الشعبٌة‬ ، ‫وتصور‬ ‫السالمة‬ ‫بٌن‬ ‫ماركة‬ ‫معٌنة‬ ‫اإلعالن‬ - ‫رعاٌة‬ ‫وسائل‬ ‫اإلعالم‬ ، ‫إنفاق‬ ‫مٌزانٌة‬ ‫عالٌة‬ ‫على‬ ‫اإلعالن‬ ‫من‬ ‫شركات‬ ‫التبػ‬ ‫التبػ‬ " ‫األكثر‬ ‫ا‬‫ا‬‫ن‬‫أما‬ " - ‫العالمة‬ ‫التجارٌة‬ ‫منخفضة‬ ‫المطران‬ ‫الوصول‬ - ‫آالت‬ ‫البٌع‬ ‫وبعض‬ ‫عدادات‬ ‫المبٌعات‬ ً‫الت‬ ‫تبٌع‬ ‫للماصرٌن‬ Modifiable Risk Factors
70 • Social norms – societal, local, familial, peer communities all affecting smoking; when access to tobacco exists in these communities, it becomes easier to acquire • Individual psychosocial factors – weaker attachment to parents, stronger attachment to peers, rebelliousness and risk-taking • Continued tobacco use – the role of genetics in treatment response; the effect of advertising and “safer” products ‫المعاٌٌر‬ ‫االجتماعٌة‬ - ‫مجتمعات‬ ‫مجتمعٌة‬ ‫ومحلٌة‬ ‫وعائلٌة‬ ‫وألران‬ ‫تؤثر‬ ‫على‬ ‫التدخٌن‬ ‫عندما‬ ‫ٌكون‬ ‫الوصول‬ ‫إلى‬ ‫التبػ‬ ‫اا‬‫د‬‫موجو‬ ً‫ف‬ ‫هذه‬ ‫المجتمعات‬ ، ‫ٌصبح‬ ‫من‬ ‫األسهل‬ ‫الحصول‬ ‫علٌه‬ ‫عوامل‬ ‫نفسٌة‬ ‫اجتماعٌة‬ - ‫تعلك‬ ‫أضعؾ‬ ‫بالوالدٌن‬ ، ‫ارتباط‬ ‫ألوى‬ ‫باأللران‬ ، ‫التمرد‬ ‫وأخذ‬ ‫المخاطر‬ ‫استمرار‬ ‫استخدام‬ ‫التبػ‬ - ‫دور‬ ‫علم‬ ‫الوراثة‬ ً‫ف‬ ‫االستجابة‬ ‫العالجٌة‬ ‫؛‬ ‫تأثٌر‬ ‫اإلعالن‬ ‫ومنتجات‬ " ‫أكثر‬ ‫ا‬‫ا‬‫ن‬‫أما‬ ‖ Modifiable Risk Factors, contd.
71 • Inadequate understanding – underestimation of smoking-related deaths; assumption that young people will stop before potentially harmful side effects occur • Adults not aware of hazards, which can be attributed to underrepresentation of anti- smoking literature and media • Lower price – the lower the price, the more cigarettes and tobacco are consumed ‫الفهم‬ ‫ؼٌر‬ ً‫الكاف‬ - ‫التملٌل‬ ‫من‬ ‫الوفٌات‬ ‫المرتبطة‬ ‫بالتدخٌن‬ ‫؛‬ ‫االفتراض‬ ‫أن‬ ‫الشباب‬ ‫سوؾ‬ ‫تتولؾ‬ ‫لبل‬ ‫أن‬ ‫تحدث‬ ‫آثار‬ ‫جانبٌة‬ ‫ضارة‬ ‫المحتملة‬ ‫الكبار‬ ‫ؼٌر‬ ‫مدركٌن‬ ‫لألخطار‬ ، ً‫الت‬ ‫ٌمكن‬ ‫أن‬ ‫عزى‬ُ‫ت‬ ‫إلى‬ ‫نمص‬ ‫تمثٌل‬ ‫األدب‬ ‫ووسائل‬ ‫اإلعالم‬ ‫المناهضة‬ ‫للتدخٌن‬ ‫انخفاض‬ ‫األسعار‬ - ‫كلما‬ ‫انخفض‬ ‫السعر‬ ، ‫تم‬ ‫استهالن‬ ‫المزٌد‬ ‫من‬ ‫السجائر‬ ‫والتبػ‬ Modifiable Risk Factors, contd.
72 • Several recent studies have suggested the influence that risk factors play when defining tobacco use • One study postulated that 33% of experimentation with tobacco among youth attributed to advertisements‫؛‬ • Two others speculate that cinema/Hollywood glorification of tobacco leads to higher risks‫؛‬ • A third looks at youth with nonsmoking parents smoking as a direct result of movies and popular culture 33 / . Population-AttributableRisk
73 • Price • Increasing the price of tobacco can help stymy sales, especially among youth • Sales would have to increase across all types of tobacco to be effective • Pointed at youth prevent Counter marketing campaigns • ion, but need to be sustained to be effective • Challenge social norms about tobacco use, educate youth on prevention • Advertising bans • Mixed evidence on effectiveness • When a ban is in place, tobacco companies shift to other forms of delivery – electronic, billboards, points of sale - Prevention and Control
74 • Minors’ access restrictions • More stringent interventions are needed to lower youth accessibility of tobacco • School-based tobacco prevention programs • Effective when taught alongside community interventions • Emphasize tobacco-free campuses, negative health effects • Eliminating secondhand smoke • Eliminating smoking indoors helps, but cannot prevent complete exposure • Also helps reduce cigarette consumption in general Prevention and Control,contd.
75 • Best practice in the medical field – ask about past history with tobacco use • Should be acquired during every visit and thoroughly documented in a medical record • Those who smoke should be screened so effective treatment can be given as needed • Cotinine can be measured in blood, saliva, urine – though acquiring these levels not particularly routine in medical care, except in the case of pregnant women’s tobacco intake ‫أفضل‬ ‫الممارسات‬ ً‫ف‬ ‫المجال‬ ً‫الطب‬ - ‫اسأل‬ ‫عن‬ ‫التارٌخ‬ ً‫الماض‬ ‫مع‬ ‫استخدام‬ ‫التبػ‬ ً‫ٌنبؽ‬ ‫الحصول‬ ‫علٌها‬ ‫خالل‬ ‫كل‬ ‫زٌارة‬ ‫وموثمة‬ ‫بدلة‬ ً‫ف‬ ‫السجل‬ ً‫الطب‬ ‫ٌجب‬ ‫فحص‬ ‫أولئن‬ ‫الذٌن‬ ‫ٌدخنون‬ ‫حتى‬ ‫ٌمكن‬ ‫إعطاء‬ ‫العالج‬ ‫الفعال‬ ‫حسب‬ ‫الحاجة‬ ‫ٌمكن‬ ‫لٌاس‬ ‫الكوتٌنٌن‬ ‫بالدم‬ ‫واللعاب‬ ‫والبول‬ - ‫على‬ ‫الرؼم‬ ‫من‬ ‫أن‬ ‫اكتساب‬ ‫هذه‬ ‫المستوٌات‬ ‫لٌس‬ ‫ا‬‫ا‬‫ن‬ٌ‫روت‬ ً‫ف‬ ‫الرعاٌة‬ ‫الطبٌة‬ ، ‫باستثناء‬ ‫حالة‬ ‫تناول‬ ‫النساء‬ ‫الحوامل‬ ‫للتبػ‬ . Screening and Treatment
76 • Comprehensive tobacco prevention and control programs: • Estimated that prevention programs have added 21 years to the life expectancy between 1964 and 1992 for 1.6 million Americans • California spearheaded the prevention programs, and has lower cases of lung cancer, lowest per capita consumption, and low youth smoking rate than the rest of the United States • Tobacco excise taxes • Increased taxation on cigarettes, though remedied by tobacco companies by coupons and other discounting strategies : 21 1964 1992 1.6 . List of Evidence-Based Interventions
77 • Countermarketing campaigns ‫حمالت‬ ‫مكافحة‬ ‫التسوٌق‬ • Smoke-free policies ‫سٌاسات‬ ‫خالٌة‬ ‫من‬ ‫التدخٌن‬ • Public and private insurance coverage ‫التغطٌة‬ ‫التأمٌنٌة‬ ‫العامة‬ ‫والخاصة‬ • Minors’ access restrictions ‫قٌود‬ ‫الوصول‬ ‫إلى‬ ‫القصر‬ • Telephone cessation quitlines ‫جلسات‬ ‫التوقف‬ ‫عن‬ ‫طرٌق‬ ‫الهاتف‬ • Usually not enough funding to sustain • Product changes ‫تغٌٌرات‬ ‫المنتج‬ List of Evidence-Based Interventions, contd.
78 • Key issues for continued research: • Promised public health interventions • Evaluating state prevention and control programs • Industry practice monitoring and counteraction • Translating the decline in youth and adult dependence • Disparate population interventions • Health impacts of changing products • Most cost-effective interventions locally and internationally : Future Research and Demonstration
79 Chapter 6: Diet and Nutrition
80 Consequences and Causes of Poor Nutrition Chart Causes * Social and cultural factors * Poor social/family support * School lunch policies * Lack of education about diet * Food industry marketing (esp. to children) * Eating out * Watch television At-risk Populations * Infants/elderly * Poor * Undereducated * Urbanpopulations * Racial/ethnic minorities * Familywithboth parents working outside the home Consequences * Obesity * CHD * Diabetes * Selected cancers * Dental caries * High blood pressure * Psychological effect Poor Diet/Nutrition: * High in total calories, saturated fat, animal meat, sugar, salt, and alcohol * Low in fruit,vegetables, whole grains, fiber, unsaturated oils Adaptedfrom Remington et al. ( 2010 )
81 • Cardiovascular disease and cancer, followed closely by Type II diabetes, are the three main causes of mortality in the world, and are chiefly caused by an imbalance of nutrition • High blood pressure/cholesterol • Inversely, micronutrient deficiencies account for 15% of childhood diseases ‫أمراض‬ ‫الملب‬ ‫واألوعٌة‬ ‫الدموٌة‬ ‫والسرطان‬ ، ‫ٌتبعها‬ ‫النوع‬ ً‫الثان‬ ‫من‬ ‫مرض‬ ‫السكري‬ ، ً‫ه‬ ‫األسباب‬ ‫الرئٌسٌة‬ ‫الثالثة‬ ‫للوفٌات‬ ً‫ف‬ ‫العالم‬ ، ‫وٌعود‬ ‫سببها‬ ‫بشكل‬ ً‫رئٌس‬ ‫إلى‬ ‫خلل‬ ً‫ف‬ ‫التؽذٌة‬ ‫ارتفاع‬ ‫ضؽط‬ ‫الدم‬ / ‫الكولٌسترول‬ ‫على‬ ‫النمٌض‬ ‫من‬ ‫ذلن‬ ، ‫تمثل‬ ‫النمص‬ ً‫ف‬ ‫المؽذٌات‬ ‫الدلٌمة‬ 15 ٪ ‫من‬ ‫أمراض‬ ‫الطفولة‬ Significance
82 • Lowers chronic disease risk • High levels of dietary fiber, vitamin C, E, folic acid, etc . • Antioxidants and beta-carotenes • Reduction of serum cholesterol • Manages body weight through high contents of water, fiber, low fat content ‫ٌخفض‬ ‫خطر‬ ‫األمراض‬ ‫المزمنة‬ ‫مستوٌات‬ ‫عالٌة‬ ‫من‬ ‫األلٌاؾ‬ ‫الؽذائٌة‬ ، ‫وفٌتامٌن‬ C ،E ، ‫حمض‬ ‫الفولٌن‬ ، ‫إلخ‬ . ‫مضادات‬ ‫األكسدة‬ ‫وبٌتا‬ ‫الكاروتٌنات‬ ‫خفض‬ ‫الكولسترول‬ ً‫ف‬ ‫الدم‬ ‫ٌدٌر‬ ‫وزن‬ ‫الجسم‬ ‫من‬ ‫خالل‬ ‫محتوٌات‬ ‫عالٌة‬ ‫من‬ ‫الماء‬ ‫واأللٌاؾ‬ ‫ومحتوى‬ ‫للٌل‬ ‫الدهون‬ Pathophysiology– Fruits and Vegetables
83 • Studies show that an increase in dietary fiber result in a lower chance of CHD/certain cancers • Increases stool bulk, increases food’s entry and exit times, lowers risk for carcinogens in the body • Soluble fiber can lower cholesterol • Binds bile acids and prevents reabsorption • High fiber, research shows, has an inverse relationship with insulin levels ‫تشٌر‬ ‫الدراسات‬ ‫إلى‬ ‫أن‬ ‫زٌادة‬ ً‫ف‬ ‫األلٌاؾ‬ ‫الؽذائٌة‬ ‫ٌؤدي‬ ‫إلى‬ ‫فرصة‬ ‫ألل‬ ‫من‬ ‫أمراض‬ ‫الشراٌٌن‬ ‫التاجٌة‬ / ‫بعض‬ ‫أنواع‬ ‫السرطان‬ ‫ٌزٌد‬ ‫الجزء‬ ‫األكبر‬ ‫من‬ ‫البراز‬ ، ‫وٌزٌد‬ ‫من‬ ‫أولات‬ ‫دخول‬ ‫وخروج‬ ‫الطعام‬ ، ‫وٌملل‬ ‫من‬ ‫خطر‬ ‫التعرض‬ ‫للسرطان‬ ً‫ف‬ ‫الجسم‬ ‫األلٌاؾ‬ ‫المابلة‬ ‫للذوبان‬ ‫ٌمكن‬ ‫أن‬ ‫تخفض‬ ‫نسبة‬ ‫الكولٌسترول‬ ‫ٌربط‬ ‫األحماض‬ ‫الصفراوٌة‬ ‫وٌمنع‬ ‫إعادة‬ ‫االمتصاص‬ ‫أظهرت‬ ‫األبحاث‬ ‫أن‬ ‫األلٌاؾ‬ ‫المرتفعة‬ ‫لها‬ ‫عاللة‬ ‫عكسٌة‬ ‫مع‬ ‫مستوٌات‬ ‫األنسولٌن‬ Pathophysiology– Dietary Fiber
84 • Different kinds of fat • Trans fat and saturated fats – adverse toward health • Omega-3 fatty acids and monounsaturated fats – benefit health • Reduction of saturated fat by intake by small increments lowers heart attack risk rates by 25% • Hypothesis is that omega-3 fatty acids alter the immune system’s response to cancer • Red meat – both positive and negative effects • + — high in iron, vitaminsA, B12, protein • - — risk of colorectal cancer, formation of mutagenic free radicals in stomach - 3 - 25 3 - + - A B 12 - Pathophysiology– Dietary Fat and Red Meat
85 • Low fat milk intake shown to lower risk of osteoporosis, CVD, colon cancer • Contains fatty acids • Calcium content lowers lipid collection and higher lipid excretion rates • 2 % and whole milk are high in saturated fat and calories ‫أظهر‬ ‫تناول‬ ‫الحلٌب‬ ‫منخفض‬ ‫الدهون‬ ‫انخفاض‬ ‫مخاطر‬ ‫اإلصابة‬ ‫بهشاشة‬ ‫العظام‬ ، ‫األمراض‬ ‫الملبٌة‬ ‫الوعائٌة‬ ‫وسرطان‬ ‫المولون‬ ‫ٌحتوي‬ ‫على‬ ‫األحماض‬ ‫الدهنٌة‬ ‫ٌملل‬ ‫محتوى‬ ‫الكالسٌوم‬ ‫من‬ ‫جمع‬ ‫الدهون‬ ‫وارتفاع‬ ‫معدالت‬ ‫إفراز‬ ‫الدهون‬ 2 ٪ ‫والحلٌب‬ ‫كامل‬ ‫الدسم‬ ‫عالٌة‬ ‫السعرات‬ ‫الحرارٌة‬ ‫والدهون‬ ‫المشبعة‬ Pathophysiology– Dairy Products and Milk
86 • Caloric sweeteners – “all caloric carbohydrate sweeteners, such as table sugar, honey, and high fructose corn syrup, and excludes naturally occurring sugars and artificial sweeteners‖ (Remington et al. 2010 ( • Consumption of beverages with caloric sweeteners increases risk of obesity and cavities • Increased consumption over the last 30 years has shown spiked levels of excessive consumption ‫محلٌات‬ ‫السعرات‬ ‫الحرارٌة‬ - " ‫جمٌع‬ ‫المحلٌات‬ ‫الكربوهٌدرات‬ ‫الحرارٌة‬ ، ‫مثل‬ ‫سكر‬ ‫المائدة‬ ‫والعسل‬ ‫وشراب‬ ‫الذرة‬ ً‫عال‬ ‫الفركتوز‬ ، ً‫وتستثن‬ ‫السكرٌات‬ ‫الطبٌعٌة‬ ‫والمحلٌات‬ ‫االصطناعٌة‬ " ‫استهالن‬ ‫المشروبات‬ ‫مع‬ ‫المحلٌات‬ ‫السعرات‬ ‫الحرارٌة‬ ‫ٌزٌد‬ ‫من‬ ‫خطر‬ ‫السمنة‬ ‫وتسوس‬ ‫األسنان‬ ‫أظهرت‬ ‫زٌادة‬ ‫االستهالن‬ ‫على‬ ‫مدى‬ ‫السنوات‬ ‫الثالثٌن‬ ‫الماضٌة‬ ‫مستوٌات‬ ‫مرتفعة‬ ‫من‬ ‫االستهالن‬ ‫المفرط‬ Pathophysiology– Sugar-Sweetened Beverages
87 • U.S. men – higher intake of red meat, dairy • U.S. women – higher intake of fruits, vegetables, salts, cholesterol • Greater importance on eating healthily - - High-Risk Populations– Sex
88 • Young and old are susceptible to poor nutrition • Young – targeted by food industry to eat energy-dense foods; poor diet habits developed in youth tend to carry into adulthood • Old – lower metabolism and physical activity, changes in taste and smell; 80% of elderly need improvements ‫الصؽار‬ ‫والكبار‬ ‫عرضة‬ ‫لسوء‬ ‫التؽذٌة‬ ‫الشباب‬ - ‫الذٌن‬ ‫تستهدفهم‬ ‫صناعة‬ ‫األؼذٌة‬ ‫لتناول‬ ‫األطعمة‬ ‫الؽنٌة‬ ‫بالطالة‬ ‫؛‬ ‫العادات‬ ‫الؽذائٌة‬ ‫السٌئة‬ ً‫الت‬ ‫تطورت‬ ً‫ف‬ ‫الشباب‬ ‫تمٌل‬ ‫إلى‬ ‫تحملها‬ ‫إلى‬ ‫مرحلة‬ ‫البلوغ‬ ‫العمر‬ - ‫انخفاض‬ ‫األٌض‬ ‫والنشاط‬ ً‫البدن‬ ، ‫والتؽٌرات‬ ً‫ف‬ ‫الذوق‬ ‫والرائحة‬ ‫؛‬ 80 ٪ ‫من‬ ‫كبار‬ ‫السن‬ ‫بحاجة‬ ‫إلى‬ ‫تحسٌنات‬ High-Risk Populations– Age and Life Course
89 • African Americans and Caucasians increased total energy-dense foods from 1971 and 2002 • Racially diverse populations, on average in the United States, have lower access to fresh fruits and vegetables • Sociocultural and behavioral factors influence the dietary variety of the three major racial groups in the United States • African American, Caucasian (white), and Mexican American 1971 2002 ( ) High-Risk Populations– Race and Ethnicity
90 • As wealth decreases, direct relationship between the ability to acquire healthy foods • Similarly, energy-dense foods are more likely to be consumed by those with lower income • This is partly due to the inaccessibility, such as the high price and the lack of larger stores that support a variety of nutritional fruits and vegetables in urban/low- income areas / . High-Risk Populations– Income
91 • Income and education have a corollary relationship, so both affect chronic disease outcome at similar rates • Higher consumption of fruits/vegetables has been linked to higher education, and those with the most education are more likely to spend more per capita on these foods ‫الدخل‬ ‫والتعلٌم‬ ‫له‬ ‫عاللة‬ ‫طبٌعٌة‬ ، ‫لذلن‬ ‫كل‬ ‫من‬ ‫ٌؤثر‬ ‫على‬ ‫نتائج‬ ‫األمراض‬ ‫المزمنة‬ ‫بمعدالت‬ ‫مماثلة‬ ‫وارتبط‬ ‫ارتفاع‬ ‫استهالن‬ ‫الفاكهة‬ / ‫الخضار‬ ‫بالتعلٌم‬ ً‫العال‬ ، ‫ومن‬ ‫المرجح‬ ‫أن‬ ‫ٌنفك‬ ‫أكثر‬ ‫هؤالء‬ ‫الذٌن‬ ‫ٌنفمون‬ ‫أكثر‬ ‫على‬ ‫التعلٌم‬ ‫نصٌب‬ ‫الفرد‬ ‫من‬ ‫هذه‬ ‫األؼذٌة‬ . High-Risk Populations– Education
92 • Geographic distribution • Developed countries have higher diets with animal products and saturated fats • Fish consumed more frequently in coastal regions • Industrial development and immigration • As a country shifts from underdeveloped to developed, chronic disease patterns can occur in as little as one generation • Time trends • Larger portion sizes appeared over time • Higher kcal consumption for both men (+196kcal) and women (+283 kcal) +( 196 kcal ) +( 283 ) High-Risk Populations– Other
93 • Individual preference • Appearance, taste, texture • Community and family • Environments that support positive food choices make it easier to follow a healthy diet • Lowest cost foods – least nutritious • Fast-food density has been shown to be connected to poor nutrition • Parental modeling affects familial diet among adolescents • Families with both parents working outside the home have increased chances of seeking nutrition in energy-dense, unhealthy foods - Barriers to Healthy Eating
94 • Dietary Guidelines created by the US Department of Health and Human Service • Areas of consideration include adequate nutrients within calorie needs, weight management, physical activity, fats, carbohydrates, sodium and potassium, alcoholic beverages, food safety • Emphasizes a balanced diet • From ―Basic Seven‖ to ―MyPlate‖ " Basic Seven " " MyPlate" Primary Prevention Policy Anearlynutritional guidedevelopedinthe 1940s by the U.S.Department of Agriculture, CCBY 2.0, viaWikimedia Commons
95 Primary Prevention Policy, contd. The current nutritional policy,MyPlate,developedin 2011.Image by OpenStax College, CCBY 3.0,via WikimediaCommons Food Pyramidnutritional policy,developedin1992 by the USDA. Image by the USDA College, Public Domain, viaWikimediaCommons
96 • Various nutritional analyses that make up the National Nutrition Monitoring System survey. • Food disappearance programs chart the available consumable foods . Food disappearance data provide information about quantities of foods and nutrients in retail food distribution each year. • Food questionnaires used by epidemiologists to chart frequency of intake and a list of consumed foods • Effective because participants are likely to remember recent food choices, as opposed to long-term dietary analyses Surveillance
97 • Origins in the 1980s – It’s a healthy nutrition promotion started with National Cancer Institute /Kellogg's Campaign • National Fruit and Vegetable Program • 1 % or Less Campaign" The 1% or Less Campaign sought to shift consumption from whole milk, 2% milk, or high-fat milk products to 1%, skim milk, or low-fat milk products” • Site-based interventions 1. Workplace 2. Schools 3. Faith-based 1980 s - / Kelloggs 1 Large-Scale Initiatives “examples of publid health interventions”
98 • Population-specific initiatives • Community approaches in urban areas • Federal safety net • School lunch programs • Supplemental Nutrition Assistance Program (formerly Food Stamps) • Eliminating racial disparities • Heart to Heart Program ( ) Large-Scale Initiatives, contd.
99 • Policy approaches 1. Agricultural policies – which crops are produced 2. Nutrition right-to-know – advocacy groups attempt to make nutritional assessments in restaurants more accessible 3. School wellness policies – improved physical activity programs and healthy food options in vending machines 4. Advertising to children - - - Large-Scale Initiatives, contd.
10 0 Chapter 7: Physical Activity
10 1 1. Affects physiological, psychological, societal of health 2. Reduces chance of premature death, developing CHD/diabetes/colon cancer 3. Promotes healthy bones and joints • Less falls and functional dependency in older adults / / Consequences
10 2 Consequences, contd. Causes * Psychosocial (motivation * Self-efficacy * Social/cultural factors * Physical environment * Perceptions of competence in sports * Enjoyment At-risk Populations * Older adults * Adolescents * Women * Those with low incomes * Overweight adults * Those with conditions that limit movement * Injured or disabled individuals Consequences * Obesity * CHD * Diabetes * Colon cancer * High blood pressure * Falls/osteoporosis * Psychological effects Physical Inactivity Adaptedfrom Remington et al. ( 2010 )
10 3 • Physical activity“PA” – movement produced by skeletomuscular system that burns energy • Occupational and nonoccupational (leisure, family, transportation, household, other activities) • Contrasted with exercise • Exercise • Repetitive movement used to maintain physical fitness • Physical fitness • Achievable attributes related to physical activity • Cardiorespiratory, muscular, metabolic, morphological, motor • Frequency – number of times PA is performed • Duration – minutes/hours PA is performed ‫النشاط‬ ً‫البدن‬ - ‫الحركة‬ ً‫الت‬ ‫ٌنتجها‬ ‫النظام‬ ً‫العضل‬ ً‫العظم‬ ‫الذي‬ ‫ٌحرق‬ ‫الطالة‬ ‫المهنٌة‬ ‫وؼٌر‬ ‫المهنٌة‬ ‫ٌتنالض‬ ‫مع‬ ‫ممارسة‬ ‫الرٌاضة‬ ‫ممارسه‬ ‫الرٌاضه‬ ‫حركة‬ ‫متكررة‬ ‫تستخدم‬ ‫للحفاظ‬ ‫على‬ ‫اللٌالة‬ ‫البدنٌة‬ ‫اللٌالة‬ ‫البدنٌة‬ ‫السمات‬ ‫المابلة‬ ‫للتحمٌك‬ ‫المتعلمة‬ ‫بالنشاط‬ ً‫البدن‬ ‫تنفسٌة‬ ‫للبٌة‬ ، ‫عضلٌة‬ ، ‫أٌضٌة‬ ، ‫مورفولوجٌة‬ ، ‫حركٌة‬ ‫التردد‬ - ‫عدد‬ ‫المرات‬ ً‫الت‬ ‫ٌتم‬ ‫فٌها‬ ‫إجراء‬ PA ‫المدة‬ - ‫دلٌمة‬ / ‫ساعة‬ ‫ٌتم‬ ‫تنفٌذ‬ PA Pathophysiology
10 4 • Intensity‫الشدة‬ • METs : The activitymetaboliccost dividedby the resting metabolicrate • MET-minutes METmultiplied by minutes “ TheadtivityMETlevel ×minutes of partidipation” • Kcal – MET-minutes times body weight “Met-minutes ×(body weight inkilograms/60kg(” • Light intensity – PA < 3 METs • Moderate intensity PA between3 to 6 METs • Vigorous intensity – PA > 6 METs • Activity dose ‫جرعة‬ ‫نشاط‬ • Leisure – free choice periods of PA ‫حرٌة‬ ‫اختٌار‬ ‫الفترات‬ • Occupation PA – done during paid employment ‫المٌام‬ ‫به‬ ‫أثناء‬ ‫العمل‬ ‫المأجور‬ Pathophysiology,contd.
10 5 • Transportation PA – done while traveling to a destination • Household PA – done during the maintenance of the home • Family PA – done when performing the care of others • PA affects all body systems that deal with the production of energy • Lower risk of CHD PA - PA - PA - PA Pathophysiology,contd.
10 6 • Needs constant updating to chart meaningful activity patterns • Two primary population-based surveys used to measure physical activity: 1. National Health Interview Survey • Household survey • Frequency, self-assessed intensity, duration 2. Behavioral Risk Factor Surveillance System • Phone-based survey • Type, frequency, duration : Distribution
10 7 • Surveillance estimations of PA were created to unify results across the board: • Recommended PA – moderate-intensity workouts, 30 minutes/day, 5 days/week; vigorous-intensity workouts, 20 minutes/day, 3 days/week • Insufficient PA – more than 10 minutes spent doingmoderate- to vigorous-intensityworkouts,but infrequentlevels • Inactivity – Less than 10 minutes/week spent doing moderate- to vigorous- intensity workouts P A: P A - 30 / 5 / . 20 / 3 / P A - 10 - - 10 / Distribution,contd.
10 8 • Physical inactivity increases with age and is more common among women and ethnic minorities • Highest among men between 18-24 years old • Among adolescents, two guidelines for physical activity: • Daily physical movement in lifestyle, and • Three+ sessions of vigorous physical activity per week 18 24 : + High-Risk Groups
109 • Highest prevalence of activity was in urban centers, and the lowest in rural areas • Built environments may play a part in how much physical activity a population performs • Land use patterns, transportation systems, sidewalk development, trail systems, etc . . Geographic Distribution
110 • Though promoted thoroughly, proportion of adults who regularly exercise hasn’t undergone major growth over the years • Adolescents have the same trend over time Time Trends
111 • Personal, psychological, and confidence levels all attribute to a person’s choice to have a physically active lifestyle. • Barriers include ―lack of time, motivation, social support, facilities, and knowledge of ways to become more physically active‖ )Remington et al. 2010 ) • Health conditions also contribute to physical inactivity, and the positive response felt by not being inactive may worsen the health condition. ‫إن‬ ‫المستوٌات‬ ‫الشخصٌة‬ ‫والنفسٌة‬ ‫والثمة‬ ‫تعود‬ ‫جمٌعها‬ ‫إلى‬ ‫اختٌار‬ ‫الشخص‬ ‫لنمط‬ ‫حٌاة‬ ‫نشط‬ ‫اا‬ٌ‫جسد‬ ‫تشمل‬ ‫الحواجز‬ " ‫للة‬ ‫الولت‬ ، ‫والحافز‬ ، ‫والدعم‬ ً‫االجتماع‬ ، ‫والمرافك‬ ، ‫والمعرفة‬ ‫بطرق‬ ‫لتصبح‬ ‫أكثر‬ ‫ا‬‫ا‬‫ط‬‫نشا‬ ‫اا‬ٌ‫بدن‬ " ‫تساهم‬ ‫الظروؾ‬ ‫الصحٌة‬ ‫اا‬‫ض‬ٌ‫أ‬ ً‫ف‬ ‫عدم‬ ‫النشاط‬ ً‫البدن‬ ، ‫ولد‬ ‫تؤدي‬ ‫االستجابة‬ ‫اإلٌجابٌة‬ ً‫الت‬ ‫ٌشعر‬ ‫بها‬ ‫عدم‬ ‫النشاط‬ ‫إلى‬ ‫تدهور‬ ‫الحالة‬ ‫الصحٌة‬ Modifiable Risk Factors
112 • In the United States, national health objectives are developed to set guidelines for activity objectives 1. Healthy People 2010 2. US Preventative Services Task Force 3. The Guide to Clinical Preventive Services • Goals include to establish recommendations for population health, increase overall physical activity in a variety of strata, reduce leisure time that lacks physical activity, etc . ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ، ‫ٌتم‬ ‫تطوٌر‬ ‫األهداؾ‬ ‫الصحٌة‬ ‫الوطنٌة‬ ‫لوضع‬ ‫مبادئ‬ ‫توجٌهٌة‬ ‫ألهداؾ‬ ‫النشاط‬ ‫الناس‬ ‫األصحاء‬ 2010 ‫فرلة‬ ‫العمل‬ ‫المعنٌة‬ ‫بالخدمات‬ ‫الولائٌة‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ‫دلٌل‬ ‫الخدمات‬ ‫الولائٌة‬ ‫السرٌرٌة‬ ‫وتشمل‬ ‫األهداؾ‬ ‫وضع‬ ‫توصٌات‬ ‫لصحة‬ ‫السكان‬ ، ‫وزٌادة‬ ‫النشاط‬ ً‫البدن‬ ‫العام‬ ً‫ف‬ ‫مجموعة‬ ‫متنوعة‬ ‫من‬ ‫الطبمات‬ ، ‫والحد‬ ‫من‬ ‫ولت‬ ‫الفراغ‬ ‫الذي‬ ‫ٌفتمر‬ ‫إلى‬ ‫النشاط‬ ً‫البدن‬ ، ‫إلخ‬ . Prevention
113 • Policy changes frequently begin as grassroots programs • Recently, however, many coordinated efforts between school systems, public health offices, and these grassroots programs have been implemented. • Examples of policy efforts include ease of access to bicyclists and walkers, requiring physical education in school, activity programs through local recreation departments. • Environmental factors include the inclusion of safe stairwells in lobbies, providing an alternative to elevators ‫تؽٌٌرات‬ ‫السٌاسة‬ ‫تبدأ‬ ‫بشكل‬ ‫متكرر‬ ‫كبرامج‬ ‫شعبٌة‬ ‫ومع‬ ‫ذلن‬ ، ‫تم‬ ً‫ف‬ ‫اآلونة‬ ‫األخٌرة‬ ‫تنفٌذ‬ ‫العدٌد‬ ‫من‬ ‫الجهود‬ ‫المنسمة‬ ‫بٌن‬ ‫النظم‬ ‫المدرسٌة‬ ‫ومكاتب‬ ‫الصحة‬ ‫العامة‬ ‫وهذه‬ ‫البرامج‬ ‫على‬ ‫مستوى‬ ‫الماعدة‬ ‫ومن‬ ‫أمثلة‬ ‫الجهود‬ ‫المبذولة‬ ً‫ف‬ ‫مجال‬ ‫السٌاسة‬ ‫العامة‬ ‫سهولة‬ ‫الوصول‬ ‫إلى‬ ً‫راكب‬ ‫الدراجات‬ ‫النارٌة‬ ‫والمشاة‬ ، ‫األمر‬ ‫الذي‬ ‫ٌتطلب‬ ‫التعلٌم‬ ً‫البدن‬ ً‫ف‬ ‫المدرسة‬ ، ‫وبرامج‬ ‫األنشطة‬ ‫من‬ ‫خالل‬ ‫ألسام‬ ‫الترفٌه‬ ‫المحلٌة‬ . ‫وتشمل‬ ‫العوامل‬ ‫البٌئٌة‬ ‫إدراج‬ ‫ساللم‬ ‫آمنة‬ ً‫ف‬ ‫ردهات‬ ، ‫وتوفٌر‬ ‫بدٌل‬ ‫للمصاعد‬ Environmental and Policy Factors
114 • Transtheoretical Model • Precontemplation, contemplation, action, maintenance, relapse • Project Active – an individual-based project • Home exercise vs. traditional exercise (health club/gym) • Home exercise group aimed for thirty minutes of moderate activity per day, unique to the user’s lifestyle, whereas tracitional group took exerdise programs offered by the health club • By the end of the study, smaller decline in home exercise group - ( / ) Public Health Interventions
115 • Work sites, schools, assisted living facilities – all are options for intervention-based programs • Transdisciplinary partnerships are very effective ways of promotion • Example – teams fromthe Department of Transportation, state education systems, nonprofit organizations, and healthcare facilities worked together to form the National Safe Routes to School Task Force • National Coalition for Promoting Physical Activity (NCPPA) • Presicent’s Coundil on Physidal Fitness anc Sports (PCPFS) • State Governor’s Coundil on Physidal Fitness • State Health Department Physical Activity Initiatives and Campaigns - : Public Health Interventions, contd.
116 • More work done with questionnaire development and surveys • Quantification of popular trends in physical activities • A difficulty to overcome in the research is inaccuracy due to self-analysis ‫تم‬ ‫إنجاز‬ ‫المزٌد‬ ‫من‬ ‫العمل‬ ‫من‬ ‫خالل‬ ‫تطوٌر‬ ‫االستبٌانات‬ ‫والدراسات‬ ‫االستمصائٌة‬ ‫المٌاس‬ ً‫الكم‬ ‫لالتجاهات‬ ‫الشعبٌة‬ ً‫ف‬ ‫األنشطة‬ ‫البدنٌة‬ ‫صعوبة‬ ً‫ف‬ ‫التؽلب‬ ‫على‬ ‫هذا‬ ‫البحث‬ ً‫ه‬ ‫عدم‬ ‫الدلة‬ ‫بسبب‬ ‫التحلٌل‬ ً‫الذات‬ Measurement of Physical Activity – Future Research
117 • Relatively recent adoption of guidelines for school programs that promote physical activity established a framework for analysis • Additional studies needed to strengthen findings, especially in young women, and the balance between adequate nutrition and activity levels ‫أدى‬ ‫االعتماد‬ ‫الحدٌث‬ ‫ا‬‫ا‬ٌ‫نسب‬ ‫للمبادئ‬ ‫التوجٌهٌة‬ ‫للبرامج‬ ‫المدرسٌة‬ ً‫الت‬ ‫تعزز‬ ‫النشاط‬ ً‫البدن‬ ‫إلى‬ ‫وضع‬ ‫إطار‬ ‫للتحلٌل‬ ‫هنان‬ ‫حاجة‬ ‫لدراسات‬ ‫إضافٌة‬ ‫لتعزٌز‬ ‫النتائج‬ ، ‫ال‬ ‫سٌما‬ ً‫ف‬ ‫الشابات‬ ، ‫والتوازن‬ ‫بٌن‬ ‫التؽذٌة‬ ‫الكافٌة‬ ‫ومستوٌات‬ ‫النشاط‬ Adolescent Physical Activity – Future Research
118 • Continued efforts required to effect policy changes designed to promote activity in communities 1. Working with neighborhood coalitions 2. Writing to local papers 3. Lobbying for changes made by city planners 4. Forming position statements for agencies • Funding is required to research effectiveness of already established programs, especially those in disadvantaged communities ‫استمرار‬ ‫الجهود‬ ‫المطلوبة‬ ‫إلحداث‬ ‫تؽٌٌرات‬ ً‫ف‬ ‫السٌاسات‬ ‫تهدؾ‬ ‫إلى‬ ‫تعزٌز‬ ‫النشاط‬ ً‫ف‬ ‫المجتمعات‬ ‫العمل‬ ‫مع‬ ‫تحالفات‬ ‫الجوار‬ ‫الكتابة‬ ً‫ف‬ ‫الصحؾ‬ ‫المحلٌة‬ ‫الضؽط‬ ‫من‬ ‫أجل‬ ‫التؽٌٌرات‬ ً‫الت‬ ‫لام‬ ‫بها‬ ‫مخططو‬ ‫المدن‬ ‫تشكٌل‬ ‫بٌانات‬ ‫المولؾ‬ ‫للوكاالت‬ ‫التموٌل‬ ‫مطلوب‬ ‫للبحث‬ ً‫ف‬ ‫فعالٌة‬ ‫البرامج‬ ‫المنشأة‬ ‫بالفعل‬ ، ‫خاصة‬ ‫تلن‬ ‫الموجودة‬ ً‫ف‬ ‫المجتمعات‬ ‫المحرومة‬ Environmental and Policy Changes – Future Research
119 • Baby boomer generation in need of study to understand efficacy and effectiveness of policies centered around the elderly ‫جٌل‬ ‫جٌل‬ ‫العامل‬ ً‫ف‬ ‫حاجة‬ ‫إلى‬ ‫دراسة‬ ‫لفهم‬ ‫فعالٌة‬ ‫وفعالٌة‬ ‫السٌاسات‬ ً‫الت‬ ‫تركز‬ ‫على‬ ‫كبار‬ ‫السن‬ Older Adults – Future Research
12 0 Chapter 10: Diabetes
12 1 • One of the ten major causes of death in the United States since the 1930s • Responsible for hundreds of thousands of deaths each year • Underreported because diabetes leads to the cause of death but doesn’t cause death itself ‫أحد‬ ‫األسباب‬ ‫الرئٌسٌة‬ ‫العشرة‬ ‫للوفاة‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ‫منذ‬ ‫الثالثٌنٌات‬ ‫مسؤولة‬ ‫عن‬ ‫مئات‬ ‫اآلالف‬ ‫من‬ ‫الوفٌات‬ ‫كل‬ ‫عام‬ ‫ال‬ ‫ٌتم‬ ‫اإلبالغ‬ ‫عنه‬ ‫ألن‬ ‫مرض‬ ‫السكري‬ ‫ٌؤدي‬ ‫إلى‬ ‫سبب‬ ‫الوفاة‬ ‫ولكنه‬ ‫ال‬ ‫ٌسبب‬ ‫الموت‬ ‫نفسه‬ Significance By Blausen.com Staff. "Blausen gallery 2014". WikiversityJournal of Medicine. (Ownwork) CC BY3.0,via Wikimedia Commons
12 2 • Diabetes leads to various life-threatening complications: • CVD • Blindness • Kidney failure • Injury, infection, amputation of limbs • Depression • Diabetes carries a huge economic impact • Partly due to long-term complications and prescription costs : Significance, contd.
12 3 • In general, Type II diabetics are unable to utilize insulin in the liver/muscle despite regular insulin production in these places • As disease progresses, pancreas fails to increase insulin secretion • Prediabetics: • Impaired glucose tolerance (IGT) • Impaired fasting glucose (IFG) • Two classifications of diabetes complications • Microvascular • Macrovascular / : ( IGT) ( IFG) Pathophysiology
12 4 • Relies on health survey data for monitoring • No distinction between Types I and II • Type II accounts for the majority of all diabetes cases, estimated at around 90%-95% • Type II usually found in older adults, whereas Type I is associated with minors and adolescents ‫ٌعتمد‬ ‫على‬ ‫بٌانات‬ ‫المسح‬ ً‫الصح‬ ‫للرصد‬ ‫ال‬ ‫ٌوجد‬ ‫تمٌٌز‬ ‫بٌن‬ ‫النوعٌن‬ ‫األول‬ ً‫والثان‬ ‫النوع‬ ً‫الثان‬ ‫ٌمثل‬ ‫ؼالبٌة‬ ‫حاالت‬ ‫مرض‬ ‫السكري‬ ، ً‫والت‬ ‫تمدر‬ ً‫بحوال‬ 90 ٪ - 95 ٪ ‫النوع‬ ً‫الثان‬ ‫عادة‬ ‫ما‬ ‫ٌوجد‬ ً‫ف‬ ‫كبار‬ ‫السن‬ ، ‫بٌنما‬ ‫ٌرتبط‬ ‫النوع‬ ‫األول‬ ‫بالماصرٌن‬ ‫والمراهمٌن‬ Descriptive Epidemiology
12 5 • Not an equal distribution • The elderly, racial minorities, lower socioeconomic status, family history • Increased exposure to a variety of health complications, all of which increase substantially with age • Tend to be higher in minority populations in the United States • Native Americans/Alaska Natives two to three times higher than other US adults / High-Risk Groups
12 6 • Those with lower socioeconomic status, i.e. those with lower education and income, have an increased risk, as well • Common factors include less access to care, less opportunities for education about diabetes, high stress levels • Family history of diabetes strongly affects risk factor • 2.4times greater odds of acquiring Type II when there is a moderate familial risk • 5.8times greater when there is a high familial risk 2.4 5.8 High-Risk Groups, contd.
12 7 • In the United States, clear geographic regions show patterns in developing diabetes • South/Southeastern at high risk, due to ethic makeup and obesity • Where there are higher levels of obesity there are higher levels of diabetes • Susceptibility to Type I diabetes shows a similarity across the different regions of the world ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ، ‫تظهر‬ ‫المناطك‬ ‫الجؽرافٌة‬ ‫الواضحة‬ ‫ا‬‫ا‬‫ط‬‫أنما‬ ً‫ف‬ ‫تطوٌر‬ ‫مرض‬ ‫السكري‬ ‫الجنوب‬ / ‫الجنوب‬ ً‫الشرل‬ ً‫ف‬ ‫خطر‬ ‫كبٌر‬ ، ‫بسبب‬ ‫التركٌب‬ ً‫األخالل‬ ‫والسمنة‬ ‫حٌث‬ ‫توجد‬ ‫مستوٌات‬ ‫أعلى‬ ‫من‬ ‫السمنة‬ ‫هنان‬ ‫مستوٌات‬ ‫أعلى‬ ‫من‬ ‫مرض‬ ‫السكري‬ ‫الحساسٌة‬ ‫تجاه‬ ‫النوع‬ ‫األول‬ ‫من‬ ‫السكري‬ ‫تظهر‬ ‫ا‬‫ا‬‫ه‬‫تشاب‬ ً‫ف‬ ‫مختلؾ‬ ‫مناطك‬ ‫العالم‬ Geographic Distribution
12 8 • Over time, diabetes has been one of the only CVD risk that has increased • Due to age, ethnic diversity, obesity problem • Increasing in all demographics over time • This is true for both Types I and II • However, due to timely response, medications and therapies, there hasn’t been an increase in diabetes-related complications over time ‫مع‬ ‫مرور‬ ‫الولت‬ ، ‫كان‬ ‫السكري‬ ‫اا‬‫د‬‫واح‬ ‫من‬ ‫مخاطر‬ ‫األمراض‬ ‫الملبٌة‬ ‫الوعائٌة‬ ‫الوحٌدة‬ ً‫الت‬ ‫ازدادت‬ ‫بسبب‬ ‫السن‬ ‫والتنوع‬ ً‫العرل‬ ‫ومشكلة‬ ‫السمنة‬ ‫زٌادة‬ ً‫ف‬ ‫جمٌع‬ ‫الدٌموؼرافٌات‬ ‫مع‬ ‫مرور‬ ‫الولت‬ ‫وٌنطبك‬ ‫ذلن‬ ‫على‬ ‫كال‬ ‫النوعٌن‬ ‫األول‬ ً‫والثان‬ ‫ومع‬ ‫ذلن‬ ، ‫بسبب‬ ‫االستجابة‬ ً‫ف‬ ‫الولت‬ ‫المناسب‬ ، ‫واألدوٌة‬ ‫والعالجات‬ ، ‫لم‬ ‫تكن‬ ‫هنان‬ ‫زٌادة‬ ً‫ف‬ ‫المضاعفات‬ ‫المرتبطة‬ ‫بداء‬ ‫السكري‬ ‫على‬ ‫مر‬ ‫الزمن‬ Time Trends
129 • Very few modifiable risks for Type I diabetes • However, research has shown that there is some correlation between environmental factors • Nutrition and viruses may come into play • Type I patients were 43% more likely to have breastfed for less than 3 months and 63% more likely to consume cow’s milk before age three • Enteroviruses • Stress, higher maternal age at birth, birth order, birth weight, overnutrition are other possible risks ‫للٌل‬ ‫جدا‬ ‫من‬ ‫المخاطر‬ ‫المابلة‬ ‫للتعدٌل‬ ‫لمرض‬ ‫السكري‬ ‫من‬ ‫النوع‬ ‫األول‬ ‫ومع‬ ‫ذلن‬ ، ‫فمد‬ ‫أظهرت‬ ‫األبحاث‬ ‫أن‬ ‫هنان‬ ‫بعض‬ ‫االرتباط‬ ‫بٌن‬ ‫العوامل‬ ‫البٌئٌة‬ ‫التؽذٌة‬ ‫والفٌروسات‬ ‫لد‬ ‫تلعب‬ ‫دورا‬ ‫كان‬ ‫المرضى‬ ‫من‬ ‫النوع‬ ‫األول‬ ‫أكثر‬ ‫عرضة‬ ‫بنسبة‬ 43 ٪ ‫للرضاعة‬ ‫الطبٌعٌة‬ ‫لمدة‬ ‫ألل‬ ‫من‬ 3 ‫أشهر‬ ‫و‬ 63 ٪ ‫أكثر‬ ‫عرضة‬ ‫الستهالن‬ ‫حلٌب‬ ‫البمر‬ ‫لبل‬ ‫سن‬ ‫الثالثة‬ ‫الفٌروسات‬ ‫المعوٌة‬ ‫اإلجهاد‬ ، ‫ارتفاع‬ ‫سن‬ ‫األم‬ ‫عند‬ ‫الوالدة‬ ، ‫ترتٌب‬ ‫الوالدة‬ ، ‫وزن‬ ‫الوالدة‬ ، ‫التؽذٌة‬ ً‫ه‬ ‫مخاطر‬ ‫محتملة‬ ‫أخرى‬ Modifiable Risk Factors– Type I
130 • Obesity – 80% of patients obese at diagnosis • Distribution of fat also plays a role • Those with a higher hip-to-waist ratio are more susceptible • Dietary elements • Whole grains, coffee, magnesium, peanut butter/nuts, low-fat dairy products, moderate alcohol consumption all been shown to reduce risk • High saturated fat diets and increase red meat consumption have been linked to an increased risk of Type II - 80 / Modifiable Risk Factors– Type II
131 • Lack of physical activity • Almost a linear relationship between frequency/intensity to diminished risks of Type II Diabetes • Smoking • Increased risk factor • Factors that reduce chance of developing Type II: • Relatively low BMI, high fiber diet, high polyunsaturated fat diet, 30 minutes of moderate exercise a day, smoke-free, less than half a serving of alcohol per day / : 30 Modifiable Risk Factors– Type II, contd.
132 • Often external factors that are intrinsic to developing Type II often increase the risk of complications • Risks can be reduced by working with health care professionals to manage macro- and microvascular complications ‫اا‬‫ب‬‫ؼال‬ ‫ما‬ ‫تؤدي‬ ‫العوامل‬ ‫الخارجٌة‬ ً‫الت‬ ‫تؤثر‬ ‫اا‬ٌ‫جوهر‬ ً‫ف‬ ‫تطوٌر‬ ‫النمط‬ ً‫الثان‬ ‫إلى‬ ‫زٌادة‬ ‫خطر‬ ‫حدوث‬ ‫مضاعفات‬ ‫ٌمكن‬ ‫تملٌل‬ ‫المخاطر‬ ‫من‬ ‫خالل‬ ‫العمل‬ ‫مع‬ ‫المتخصصٌن‬ ً‫ف‬ ‫الرعاٌة‬ ‫الصحٌة‬ ‫إلدارة‬ ‫المضاعفات‬ ‫الكلٌة‬ ‫واألوعٌة‬ ‫الدموٌة‬ ‫الدلٌمة‬ Complications
133 Causes, Consequences, Risk PopulationsChart Causes * Obesity * Physicalinactivity * Poor diet * Smoking At-risk Populations * Elderly * Poor * Less educated * Minorities * Persons witha familyhistory of diabetes Consequences * Coronaryheart disease * Stroke * Peripheral vascular disease * End-stage renal disease * Blindness * Lower leg amputations * Disability * Depression * Poor pregnancy outcomes * Premature mortality Type 2 Diabetes Adaptedfrom Remington et al. ( 2010 )
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035
semo2035

Recommended

STUDY DESIGN in health and medical research .pptx
STUDY DESIGN in health and medical research .pptxSTUDY DESIGN in health and medical research .pptx
STUDY DESIGN in health and medical research .pptxAbubakar Hammadama
 
slidebank331
slidebank331slidebank331
slidebank331ssuser8fbb87
 
slidebank331slide
slidebank331slideslidebank331slide
slidebank331slidessuser8fbb87
 
semo2037
semo2037semo2037
semo2037memomemo87
 
General epidemiology
General epidemiologyGeneral epidemiology
General epidemiologyDr.Shahzad A. Daula
 
2010-Epidemiology (Dr. Sameem) basics and priciples.ppt
2010-Epidemiology (Dr. Sameem) basics and priciples.ppt2010-Epidemiology (Dr. Sameem) basics and priciples.ppt
2010-Epidemiology (Dr. Sameem) basics and priciples.pptAmirRaziq1
 
slide331slide
slide331slideslide331slide
slide331slidessuser8fbb87
 
Epidemiology
EpidemiologyEpidemiology
Epidemiologymeducationdotnet
 

Recommended

STUDY DESIGN in health and medical research .pptx
STUDY DESIGN in health and medical research .pptxSTUDY DESIGN in health and medical research .pptx
STUDY DESIGN in health and medical research .pptxAbubakar Hammadama
 
slidebank331
slidebank331slidebank331
slidebank331ssuser8fbb87
 
slidebank331slide
slidebank331slideslidebank331slide
slidebank331slidessuser8fbb87
 
semo2037
semo2037semo2037
semo2037memomemo87
 
General epidemiology
General epidemiologyGeneral epidemiology
General epidemiologyDr.Shahzad A. Daula
 
2010-Epidemiology (Dr. Sameem) basics and priciples.ppt
2010-Epidemiology (Dr. Sameem) basics and priciples.ppt2010-Epidemiology (Dr. Sameem) basics and priciples.ppt
2010-Epidemiology (Dr. Sameem) basics and priciples.pptAmirRaziq1
 
slide331slide
slide331slideslide331slide
slide331slidessuser8fbb87
 
Epidemiology
EpidemiologyEpidemiology
Epidemiologymeducationdotnet
 
Epidemiology Concepts
Epidemiology ConceptsEpidemiology Concepts
Epidemiology ConceptsMANULALVS
 
Epidemiology of periodontal diseases
Epidemiology of periodontal diseasesEpidemiology of periodontal diseases
Epidemiology of periodontal diseasesDr. Ayushi Naagar
 
STUDY DESIGNs PRESENTATION BY AFFRAM.pdf
STUDY DESIGNs PRESENTATION BY AFFRAM.pdfSTUDY DESIGNs PRESENTATION BY AFFRAM.pdf
STUDY DESIGNs PRESENTATION BY AFFRAM.pdfAfframHspt
 
Cohort study
Cohort study Cohort study
Cohort study soudfaiza
 
Epidemiology an overview
Epidemiology an overviewEpidemiology an overview
Epidemiology an overviewBhoj Raj Singh
 
Definition, types, tools and uses of.pptx
Definition, types, tools and uses of.pptxDefinition, types, tools and uses of.pptx
Definition, types, tools and uses of.pptxFeniksRetails
 
Epidemiological Studies
Epidemiological StudiesEpidemiological Studies
Epidemiological StudiesINAAMUL HAQ
 
Epidemiological study designs
Epidemiological study designsEpidemiological study designs
Epidemiological study designsjarati
 
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)Dr. Abhishek Ashok Sharma
 
Lecture of epidemiology
Lecture of epidemiologyLecture of epidemiology
Lecture of epidemiologyAmany El-seoud
 
SGUL ArabSoc Semester 2 PPD Revision Lecture
SGUL ArabSoc Semester 2 PPD Revision LectureSGUL ArabSoc Semester 2 PPD Revision Lecture
SGUL ArabSoc Semester 2 PPD Revision LectureSGULArabSoc
 
Crossectional studies 2
Crossectional studies 2Crossectional studies 2
Crossectional studies 2Bruno Mmassy
 
Domestic animal diseases.pptx
Domestic animal diseases.pptxDomestic animal diseases.pptx
Domestic animal diseases.pptxNarayanNeupane3
 
community dentistry lecture 4
community dentistry lecture 4community dentistry lecture 4
community dentistry lecture 4NoorahMurad
 
Lec 3 (2019)
Lec 3 (2019)Lec 3 (2019)
Lec 3 (2019)NoorahMurad
 
Epidemiology an introduction
Epidemiology an introductionEpidemiology an introduction
Epidemiology an introductionBhoj Raj Singh
 
Epidemiology methods, approaches and tools of measurement
Epidemiology methods, approaches and tools of measurement Epidemiology methods, approaches and tools of measurement
Epidemiology methods, approaches and tools of measurement Swapnilsalve1998
 
Epidemiological methods
Epidemiological methodsEpidemiological methods
Epidemiological methodsDr Pralhad Patki
 
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda umfrfouda
 
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdfLECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdfOgunsina1
 
road2041
road2041road2041
road2041memomemo87
 
road2040
road2040road2040
road2040memomemo87
 

More Related Content

Similar to semo2035

Epidemiology Concepts
Epidemiology ConceptsEpidemiology Concepts
Epidemiology ConceptsMANULALVS
 
Epidemiology of periodontal diseases
Epidemiology of periodontal diseasesEpidemiology of periodontal diseases
Epidemiology of periodontal diseasesDr. Ayushi Naagar
 
STUDY DESIGNs PRESENTATION BY AFFRAM.pdf
STUDY DESIGNs PRESENTATION BY AFFRAM.pdfSTUDY DESIGNs PRESENTATION BY AFFRAM.pdf
STUDY DESIGNs PRESENTATION BY AFFRAM.pdfAfframHspt
 
Cohort study
Cohort study Cohort study
Cohort study soudfaiza
 
Epidemiology an overview
Epidemiology an overviewEpidemiology an overview
Epidemiology an overviewBhoj Raj Singh
 
Definition, types, tools and uses of.pptx
Definition, types, tools and uses of.pptxDefinition, types, tools and uses of.pptx
Definition, types, tools and uses of.pptxFeniksRetails
 
Epidemiological Studies
Epidemiological StudiesEpidemiological Studies
Epidemiological StudiesINAAMUL HAQ
 
Epidemiological study designs
Epidemiological study designsEpidemiological study designs
Epidemiological study designsjarati
 
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)Dr. Abhishek Ashok Sharma
 
Lecture of epidemiology
Lecture of epidemiologyLecture of epidemiology
Lecture of epidemiologyAmany El-seoud
 
SGUL ArabSoc Semester 2 PPD Revision Lecture
SGUL ArabSoc Semester 2 PPD Revision LectureSGUL ArabSoc Semester 2 PPD Revision Lecture
SGUL ArabSoc Semester 2 PPD Revision LectureSGULArabSoc
 
Crossectional studies 2
Crossectional studies 2Crossectional studies 2
Crossectional studies 2Bruno Mmassy
 
Domestic animal diseases.pptx
Domestic animal diseases.pptxDomestic animal diseases.pptx
Domestic animal diseases.pptxNarayanNeupane3
 
community dentistry lecture 4
community dentistry lecture 4community dentistry lecture 4
community dentistry lecture 4NoorahMurad
 
Epidemiology an introduction
Epidemiology an introductionEpidemiology an introduction
Epidemiology an introductionBhoj Raj Singh
 
Epidemiology methods, approaches and tools of measurement
Epidemiology methods, approaches and tools of measurement Epidemiology methods, approaches and tools of measurement
Epidemiology methods, approaches and tools of measurement Swapnilsalve1998
 
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda umfrfouda
 
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdfLECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdfOgunsina1
 

Similar to semo2035 (20)

Epidemiology Concepts
Epidemiology ConceptsEpidemiology Concepts
Epidemiology Concepts
 
Epidemiology of periodontal diseases
Epidemiology of periodontal diseasesEpidemiology of periodontal diseases
Epidemiology of periodontal diseases
 
STUDY DESIGNs PRESENTATION BY AFFRAM.pdf
STUDY DESIGNs PRESENTATION BY AFFRAM.pdfSTUDY DESIGNs PRESENTATION BY AFFRAM.pdf
STUDY DESIGNs PRESENTATION BY AFFRAM.pdf
 
Cohort study
Cohort study Cohort study
Cohort study
 
Epidemiology an overview
Epidemiology an overviewEpidemiology an overview
Epidemiology an overview
 
Definition, types, tools and uses of.pptx
Definition, types, tools and uses of.pptxDefinition, types, tools and uses of.pptx
Definition, types, tools and uses of.pptx
 
Epidemiological Studies
Epidemiological StudiesEpidemiological Studies
Epidemiological Studies
 
Epidemiological study designs
Epidemiological study designsEpidemiological study designs
Epidemiological study designs
 
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
Epidemiology of periodontal diseases By Dr. Abhishek Gaur (8741095005)
 
Lecture of epidemiology
Lecture of epidemiologyLecture of epidemiology
Lecture of epidemiology
 
SGUL ArabSoc Semester 2 PPD Revision Lecture
SGUL ArabSoc Semester 2 PPD Revision LectureSGUL ArabSoc Semester 2 PPD Revision Lecture
SGUL ArabSoc Semester 2 PPD Revision Lecture
 
Crossectional studies 2
Crossectional studies 2Crossectional studies 2
Crossectional studies 2
 
Domestic animal diseases.pptx
Domestic animal diseases.pptxDomestic animal diseases.pptx
Domestic animal diseases.pptx
 
community dentistry lecture 4
community dentistry lecture 4community dentistry lecture 4
community dentistry lecture 4
 
Lec 3 (2019)
Lec 3 (2019)Lec 3 (2019)
Lec 3 (2019)
 
Epidemiology an introduction
Epidemiology an introductionEpidemiology an introduction
Epidemiology an introduction
 
Epidemiology methods, approaches and tools of measurement
Epidemiology methods, approaches and tools of measurement Epidemiology methods, approaches and tools of measurement
Epidemiology methods, approaches and tools of measurement
 
Epidemiological methods
Epidemiological methodsEpidemiological methods
Epidemiological methods
 
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
Fundamentals of clinical research and experimental design, Prof. Usama M.Fouda
 
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdfLECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
LECTURE NOTE ON NAEM LECTURER EPIDEMIOLOGY A.pdf
 

More from memomemo87

More from memomemo87 (12)

road2041
road2041road2041
road2041
 
road2040
road2040road2040
road2040
 
road2039
road2039road2039
road2039
 
road2038
road2038road2038
road2038
 
semo2036
semo2036semo2036
semo2036
 
road2037
road2037road2037
road2037
 
road2036
road2036road2036
road2036
 
road2035
road2035road2035
road2035
 
memo2037
memo2037memo2037
memo2037
 
memo2036-1-2
memo2036-1-2memo2036-1-2
memo2036-1-2
 
memo2036
memo2036memo2036
memo2036
 
memo2035
memo2035memo2035
memo2035
 

Recently uploaded

Moradia Isolada com Logradouro; Detached house with patio in Penacova
Moradia Isolada com Logradouro; Detached house with patio in PenacovaMoradia Isolada com Logradouro; Detached house with patio in Penacova
Moradia Isolada com Logradouro; Detached house with patio in Penacovaimostorept
 
Innomantra Viewpoint - Building Moonshots : May-Jun 2024.pdf
Innomantra Viewpoint - Building Moonshots : May-Jun 2024.pdfInnomantra Viewpoint - Building Moonshots : May-Jun 2024.pdf
Innomantra Viewpoint - Building Moonshots : May-Jun 2024.pdfInnomantra
 
Jual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg Pfizer
Jual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg PfizerJual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg Pfizer
Jual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg PfizerPusat Herbal Resmi BPOM
 
Presentation4 (2) survey responses clearly labelled
Presentation4 (2) survey responses clearly labelledPresentation4 (2) survey responses clearly labelled
Presentation4 (2) survey responses clearly labelledCaitlinCummins3
 
Beyond Numbers A Holistic Approach to Forensic Accounting
Beyond Numbers A Holistic Approach to Forensic AccountingBeyond Numbers A Holistic Approach to Forensic Accounting
Beyond Numbers A Holistic Approach to Forensic AccountingYourLegal Accounting
 
Space Tech Expo Exhibitor List 2024 - Exhibitors Data
Space Tech Expo Exhibitor List 2024 - Exhibitors DataSpace Tech Expo Exhibitor List 2024 - Exhibitors Data
Space Tech Expo Exhibitor List 2024 - Exhibitors DataExhibitors Data
 
wagamamaLab presentation @MIT 20240509 IRODORI
wagamamaLab presentation @MIT 20240509 IRODORIwagamamaLab presentation @MIT 20240509 IRODORI
wagamamaLab presentation @MIT 20240509 IRODORIIRODORI inc.
 
Pitch Deck Teardown: Goodcarbon's $5.5m Seed deck
Pitch Deck Teardown: Goodcarbon's $5.5m Seed deckPitch Deck Teardown: Goodcarbon's $5.5m Seed deck
Pitch Deck Teardown: Goodcarbon's $5.5m Seed deckHajeJanKamps
 
What are the differences between an international company, a global company, ...
What are the differences between an international company, a global company, ...What are the differences between an international company, a global company, ...
What are the differences between an international company, a global company, ...AbhishekSharma823325
 
Shots fired Budget Presentation.pdf12312
Shots fired Budget Presentation.pdf12312Shots fired Budget Presentation.pdf12312
Shots fired Budget Presentation.pdf12312LR1709MUSIC
 
NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...
NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...
NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...Khaled Al Awadi
 
A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...
A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...
A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...prakheeshc
 
如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证
如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证
如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证ogawka
 
#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...
#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...
#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...drm1699
 
MichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdfMichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdfmstarkes24
 
SCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjw
SCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjwSCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjw
SCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjwadimosmejiaslendon
 
Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.
Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.
Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.daisycvs
 
00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر
00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر
00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© رnafizanafzal
 
Navigating Tax Season with Confidence Streamlines CPA Firms
Navigating Tax Season with Confidence Streamlines CPA FirmsNavigating Tax Season with Confidence Streamlines CPA Firms
Navigating Tax Season with Confidence Streamlines CPA FirmsYourLegal Accounting
 

Recently uploaded (20)

Moradia Isolada com Logradouro; Detached house with patio in Penacova
Moradia Isolada com Logradouro; Detached house with patio in PenacovaMoradia Isolada com Logradouro; Detached house with patio in Penacova
Moradia Isolada com Logradouro; Detached house with patio in Penacova
 
Innomantra Viewpoint - Building Moonshots : May-Jun 2024.pdf
Innomantra Viewpoint - Building Moonshots : May-Jun 2024.pdfInnomantra Viewpoint - Building Moonshots : May-Jun 2024.pdf
Innomantra Viewpoint - Building Moonshots : May-Jun 2024.pdf
 
Jual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg Pfizer
Jual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg PfizerJual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg Pfizer
Jual Obat Aborsi Di Sibolga wa 0851/7541/5434 Cytotec Misoprostol 200mcg Pfizer
 
Presentation4 (2) survey responses clearly labelled
Presentation4 (2) survey responses clearly labelledPresentation4 (2) survey responses clearly labelled
Presentation4 (2) survey responses clearly labelled
 
Beyond Numbers A Holistic Approach to Forensic Accounting
Beyond Numbers A Holistic Approach to Forensic AccountingBeyond Numbers A Holistic Approach to Forensic Accounting
Beyond Numbers A Holistic Approach to Forensic Accounting
 
Space Tech Expo Exhibitor List 2024 - Exhibitors Data
Space Tech Expo Exhibitor List 2024 - Exhibitors DataSpace Tech Expo Exhibitor List 2024 - Exhibitors Data
Space Tech Expo Exhibitor List 2024 - Exhibitors Data
 
wagamamaLab presentation @MIT 20240509 IRODORI
wagamamaLab presentation @MIT 20240509 IRODORIwagamamaLab presentation @MIT 20240509 IRODORI
wagamamaLab presentation @MIT 20240509 IRODORI
 
Pitch Deck Teardown: Goodcarbon's $5.5m Seed deck
Pitch Deck Teardown: Goodcarbon's $5.5m Seed deckPitch Deck Teardown: Goodcarbon's $5.5m Seed deck
Pitch Deck Teardown: Goodcarbon's $5.5m Seed deck
 
Obat Aborsi Malang 0851\7696\3835 Jual Obat Cytotec Di Malang
Obat Aborsi Malang 0851\7696\3835 Jual Obat Cytotec Di MalangObat Aborsi Malang 0851\7696\3835 Jual Obat Cytotec Di Malang
Obat Aborsi Malang 0851\7696\3835 Jual Obat Cytotec Di Malang
 
What are the differences between an international company, a global company, ...
What are the differences between an international company, a global company, ...What are the differences between an international company, a global company, ...
What are the differences between an international company, a global company, ...
 
Shots fired Budget Presentation.pdf12312
Shots fired Budget Presentation.pdf12312Shots fired Budget Presentation.pdf12312
Shots fired Budget Presentation.pdf12312
 
NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...
NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...
NewBase 17 May 2024 Energy News issue - 1725 by Khaled Al Awadi_compresse...
 
A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...
A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...
A BUSINESS PROPOSAL FOR SLAUGHTER HOUSE WASTE MANAGEMENT IN MYSORE MUNICIPAL ...
 
如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证
如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证
如何办理(SUT毕业证书）斯威本科技大学毕业证成绩单本科硕士学位证留信学历认证
 
#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...
#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...
#Mtp-Kit Prices » Qatar. Doha (+27737758557) Abortion Pills For Sale In Doha,...
 
MichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdfMichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdf
 
SCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjw
SCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjwSCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjw
SCI9-Q4-MOD8.1.pdfjttstwjwetw55k5wwtwrjw
 
Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.
Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.
Abortion pills in Muscut<Oman(+27737758557) Cytotec available.inn Kuwait City.
 
00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر
00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر
00971508021841 حبوب الإجهاض في دبي | أبوظبي | الشارقة | السطوة |❇ ❈ ((![© ر
 
Navigating Tax Season with Confidence Streamlines CPA Firms
Navigating Tax Season with Confidence Streamlines CPA FirmsNavigating Tax Season with Confidence Streamlines CPA Firms
Navigating Tax Season with Confidence Streamlines CPA Firms
 

semo2035

  • 1. 1 Chapter 2: Methods in Chronic Disease Epidemiology
  • 2. 2 • The science of public health • Greek epi (upon),demos (people), logos (study) • Now includes injury, disability, risk factors, quality of life, and, traditionally disease • Center for Disease Control (CDC) defines epidemiology as “the study of the distribution and determinants of health-related states in specified populations, and the application of this study to the control of health problems . ” ‫علم‬ ‫الصحة‬ ‫العامة‬ ‫برنامج‬ ‫التحصٌن‬ ‫الموسع‬ ‫الٌونانٌة‬ ( ‫على‬ ) ، ‫والعروض‬ ( ‫الناس‬ ) ، ‫والشعارات‬ ( ‫دراسة‬ ) ‫ٌشمل‬ ‫اآلن‬ ‫اإلصابة‬ ‫والعجز‬ ‫وعوامل‬ ‫الخطر‬ ‫ونوعٌة‬ ‫الحٌاة‬ ، ‫والمرض‬ ‫تملٌدٌا‬ ‫ؾ‬ ّ‫ٌعر‬ ‫مركز‬ ‫السٌطرة‬ ‫على‬ ‫األمراض‬ ( CDC ) ‫علم‬ ‫األوبئة‬ ‫بأنه‬ " ‫دراسة‬ ‫توزٌع‬ ‫ومحددات‬ ‫الحاالت‬ ‫المتعلمة‬ ‫بالصحة‬ ً‫ف‬ ‫مجموعات‬ ‫سكانٌة‬ ‫محددة‬ ، ‫وتطبٌك‬ ‫هذه‬ ‫الدراسة‬ ‫للتحكم‬ ً‫ف‬ ‫المشاكل‬ ‫الصحٌة‬ ." Definition of Epidemiology
  • 3. 3 • Based on the CDC’s definition, a breakdown of the terms: • Study – quantitative, statistic- and research-based • Distribution – characterized through people and how health events happen in populations • Determinants – causes, factors, implemented in analytical epidemiology • Health-related states – not just diseases, a spectrum of ailments • Populations – groups of people, not just individuals • Control – implement decision-making processes to prevent health issues : - - - - - - Definition of Epidemiology,contd.
  • 4. 4 • Diseases of known microorganisms (AIDS, flu, etc.) focus the study of epidemiologists • Likewise, injuries are acute, with often immediate health consequences (car accidents, falling, etc(. • However, many chronic diseases originate early in life through unhealthy behaviors, which, in turn, increase the risk in later life to develop these diseases • This (detailed below) is called the chronic disease continuum ( ) ( .) ( ) The Chronic Disease Continuum Descriptive Epidemiology, Analytic Epidemiology, Intervention/Evaluative Research Developmental, social, environmental, genetic determinants Healthrisk behaviorsand other factors Chronic conditions Chronicdiseases Adapted from Remington et al. ( 2010 )
  • 5. 5 • An important question is at what point are epidemiologist trying to “control” a chronic disease? At which stage of the continuum? • Controlling has become not only achieving lower mortality rates, but also lowering detrimentaleffectsof the disease • Both of these factors are used to describe the natural history of a given disease ‫السؤال‬ ‫المهم‬ ً‫ف‬ ‫أي‬ ‫نمطة‬ ‫ٌحاول‬ ‫علم‬ ‫األوبئة‬ " ‫السٌطرة‬ " ‫على‬ ‫مرض‬ ‫مزمن‬ ‫؟‬ ً‫ف‬ ‫أي‬ ‫مرحلة‬ ‫من‬ ‫التواصل‬ ‫؟‬ ‫أصبحت‬ ‫السٌطرة‬ ‫لٌس‬ ‫فمط‬ ‫انخفاض‬ ‫معدالت‬ ‫الوفٌات‬ ، ‫ولكن‬ ‫أٌضا‬ ‫خفض‬ ‫اآلثار‬ ‫الضارة‬ ‫للمرض‬ ‫ٌتم‬ ‫استخدام‬ ‫كال‬ ‫هذٌن‬ ‫العاملٌن‬ ‫لوصؾ‬ ‫التارٌخ‬ ً‫الطبٌع‬ ‫لمرض‬ ‫معٌن‬ The Chronic Disease Continuum, contd.
  • 6. 6 • Uses readily available data to examine a disease and who it affects in populations by time, place, or person. • Assesses burden, at risk groups, trends • Public tends to focus on incurable diseases or environmental diseases, instead of chronic diseases that fall on the continuum. ‫ٌستخدم‬ ‫البٌانات‬ ‫المتاحة‬ ‫بسهولة‬ ‫لفحص‬ ‫المرض‬ ‫ومن‬ ‫ٌؤثر‬ ً‫ف‬ ‫السكان‬ ‫حسب‬ ‫الولت‬ ‫أو‬ ‫المكان‬ ‫أو‬ ‫الشخص‬ ‫ٌمٌم‬ ‫العبء‬ ، ً‫ف‬ ‫مجموعات‬ ‫الخطر‬ ، ‫االتجاهات‬ ‫ٌمٌل‬ ‫العامة‬ ‫إلى‬ ‫التركٌز‬ ‫على‬ ‫األمراض‬ ‫المستعصٌة‬ ‫أو‬ ‫األمراض‬ ‫البٌئٌة‬ ، ‫ا‬‫ال‬‫بد‬ ‫من‬ ‫األمراض‬ ‫المزمنة‬ ً‫الت‬ ‫تمع‬ ‫على‬ ‫السلسلة‬ ‫المستمرة‬ . Descriptive Epidemiology
  • 7. 7 • Frequently, the count of affected individuals is seen as the fundamental measure • Implemented when analyzing the need for healthcare to aide in lessening the burden • Count is a simple way to present this burden to the general public, but it is dependent on the population size. • Other measures can be used by epidemiologists to highlight different elements of the disease ً‫ف‬ ‫كثٌر‬ ‫من‬ ‫األحٌان‬ ، ‫ٌنظر‬ ‫إلى‬ ‫عدد‬ ‫األفراد‬ ‫المتضررٌن‬ ‫على‬ ‫أنه‬ ‫اإلجراء‬ ً‫األساس‬ ‫نفذت‬ ‫عند‬ ‫تحلٌل‬ ‫الحاجة‬ ‫إلى‬ ‫الرعاٌة‬ ‫الصحٌة‬ ‫للمساعدة‬ ً‫ف‬ ‫تخفٌؾ‬ ‫العبء‬ ‫العد‬ ‫هو‬ ‫طرٌمة‬ ‫بسٌطة‬ ‫لعرض‬ ‫هذا‬ ‫العبء‬ ‫على‬ ‫عامة‬ ‫الناس‬ ، ‫لكنه‬ ‫ٌعتمد‬ ‫على‬ ‫حجم‬ ‫السكان‬ ‫ٌمكن‬ ‫استخدام‬ ‫التدابٌر‬ ‫األخرى‬ ‫من‬ ‫لبل‬ ًٌ‫أخصائ‬ ‫الوبائٌات‬ ‫إلبراز‬ ‫عناصر‬ ‫مختلفة‬ ‫من‬ ‫المرض‬ The Burden of Disease
  • 8. 8 • Rates are used to compare populations – incidence and prevalence • Incidence rate – new cases over period ÷ person-years • Person-years = persons × period monitored • Cumulative incidence – probability of developing a disease, ranging from 0 to 1 • Prevalence – another proportion, this one measured at a point in time instead of a period • Less valuable than incidence in identifying causes - - ÷ = × - 0 1 - Calculating Rates
  • 9. 9 • Compared using risk ratios/relative risks • Rate ratio – incidence rate of one group compared to another • Rate difference – subtracting the rates from one another • Calculates how much risk is different given certain variables in the study • Rates also used to aim program targeting goals • At-risk subgroups are found within populations • Can assist healthcare professionals in joint interventions / - - ComparingRates
  • 10. 10 • Randomized controlled trials (RCTs) – the most thorough and scientific study • Subjects assigned to prevention or non-prevention • Disease and death-rates monitored and observed over time • Often impractical/impossible • Need comparison groups for analysis • Comparisons between (least effective) national data and (most effective) concurrent collection vary in appropriateness ‫التجارب‬ ‫المعشاة‬ ‫ذات‬ ‫الشواهد‬ ( RCTs ) - ‫الدراسة‬ ‫األكثر‬ ‫شمولٌة‬ ‫وعلمٌة‬ ‫الموضوعات‬ ‫المخصصة‬ ‫للولاٌة‬ ‫أو‬ ‫عدم‬ ‫المنع‬ ‫رصد‬ ‫ومعدالت‬ ‫الوفاة‬ ‫والموت‬ ‫ورصد‬ ‫مع‬ ‫مرور‬ ‫الولت‬ ‫اا‬‫ب‬‫ؼال‬ ‫ؼٌر‬ ً‫عمل‬ / ‫مستحٌل‬ ‫تحتاج‬ ‫مجموعات‬ ‫الممارنة‬ ‫للتحلٌل‬ ‫تختلؾ‬ ‫الممارنات‬ ‫بٌن‬ ‫البٌانات‬ ‫الوطنٌة‬ ( ‫األلل‬ ‫فاعلٌة‬ ) ‫ومجموعة‬ ( ‫األكثر‬ ‫فاعلٌة‬ ) ‫المتزامنة‬ ً‫ف‬ ‫مدى‬ ‫مالءمتها‬ Study Designs
  • 11. 11 • Historical or retroactive studies can also be a viable option, if the correct records are available • Downsides include that no incidence rates or cumulative incidence can be gathered • Upsides include that, in certain cases, information was found that affected risks which could be modified and benefit a population in the future Study Designs, contd. Adapted from Remington et al. ( 2010 )
  • 12. 12 • Since RCTs can be unethical, epidemiologists need to observe without intervention • Based on doctor recommendations • Prospective cohort – exposures not randomly assigned, but first identified • Active and intense measurements can be made - Observational Studies
  • 13. 13 Strengths/Limitations of Study Designs Study Type Strengths Limitations Experimental studies Randomizedclinicaltrial * Controls randomly assigned * Highcost * Impracticallong-term * Impracticalexposures Randomizedcommunitytrial * Population-wide scope * Multicomponent effectiveness * Veryexpensive * Small number of studygroups Quasi-experimentalstudy * Real-worldpolicy/programintervention * Multiplecomparison groups * Potential bias * Lackof control – confounders Observational studies Prospectivecohort * Measure riskbeforediseaseoccurs * Multipleoutcomes * Yieldsincidencerates/relativerisks * Expensive * Largenumber of subjects required * Lengthy follow-ups * Hard tocontrol exposure factors Case-control * Rare diseases * Inexpensive * Quickresults * Possiblerisk-factorbias * Possiblebias incontrol group selection * Identifiedmightnot representpopulation Adapted from Remington et al. ( 2010 ) “Information bias”
  • 14. 14 • Most chronic disease studies are from observational studying • Therefore, errors are present in a number of different ways: • Measurement, selection of subjects, bias, etc. • Experts are needed to quantify uncertainty in research methods and decide quality studies • Confounding and bias are important types of error in epidemiological studies ‫معظم‬ ‫دراسات‬ ‫األمراض‬ ‫المزمنة‬ ً‫ه‬ ‫من‬ ‫دراسة‬ ‫المالحظة‬ ‫لذلن‬ ، ‫توجد‬ ‫أخطاء‬ ً‫ف‬ ‫عدد‬ ‫من‬ ‫الطرق‬ ‫المختلفة‬ : ‫المٌاس‬ ، ‫واختٌار‬ ‫الموضوعات‬ ، ‫والتحٌز‬ ، ‫وما‬ ‫إلى‬ ‫ذلن‬ . ‫هنان‬ ‫حاجة‬ ‫لخبراء‬ ‫لمٌاس‬ ‫عدم‬ ‫الٌمٌن‬ ً‫ف‬ ‫أسالٌب‬ ‫البحث‬ ‫وتمرر‬ ‫دراسات‬ ‫الجودة‬ ‫التحٌز‬ ‫ّز‬ٌ‫والتح‬ ‫هما‬ ‫نوعان‬ ‫مهمان‬ ‫من‬ ‫الخطأ‬ ً‫ف‬ ‫الدراسات‬ ‫الوبائٌة‬ Assessing Valid Study Results
  • 15. 15 • “The influence of an exposure of interest is mixed with the effect of another” (Remington et al. 2010 ( • In RCT, confounders can be equally distributed among each study group • In observational studies, confounders have to be measured and adjusted • As long as confounders are measurable and adjusted, then no need for concern • However, some confounders are difficult to measure or unknown " " RCT Confounding
  • 16. 16 • Faulty sampling methods or refusal to participate leads to samples with higher or lower measurement risk • Poorly arranged control groups are major threats to accuracy • Phone samples introduce bias when families without landlines are not taken into account • Classification errors also present a potential bias • Also known as information bias Selection/Information Bias Selection Bias Arises when the relation between exposure and disease is different for those who participate and those who theoretically would be eligible for study but do not participate. InformationBias Can be introduced as a resultof measurement error in assessment of both exposureand disease Exp. 1- Recall bias
  • 17. 17 • Attributable Risk • How much burden is lessened is exposure is eliminated • Relative risk - 1 ÷ relative risk • Population Attributable Risk • How common the exposure is • Rate (total pop.) - rate (unexposed) ÷ rate (total pop). • Also Pe (relative risk - 1) ÷ 1 + Pe (relative risk - 1 ) • Where Pe proportion of population exposure Prevention through Intervention
  • 18. 18 • Often, critical analyses will lead to “important” or “groundbreaking” new information, but this must be taken lightly • One study is never sufficient to answer all or even one question about a chronic disease. • Validity must be measured through repetition and variety or intervention ‫اا‬‫ب‬‫ؼال‬ ‫ما‬ ‫تؤدي‬ ‫التحلٌالت‬ ‫النمدٌة‬ ‫إلى‬ ‫معلومات‬ ‫جدٌدة‬ " ‫مهمة‬ " ‫أو‬ " ‫ؼٌر‬ ‫مسبولة‬ " ، ‫ولكن‬ ‫ٌجب‬ ‫االستخفاؾ‬ ‫بها‬ ‫دراسة‬ ‫واحدة‬ ‫لٌست‬ ‫كافٌة‬ ‫لإلجابة‬ ‫على‬ ‫كل‬ ‫أو‬ ‫حتى‬ ‫سؤال‬ ‫واحد‬ ‫عن‬ ‫مرض‬ ‫مزمن‬ . ‫ٌجب‬ ‫أن‬ ‫تماس‬ ‫الصالحٌة‬ ‫من‬ ‫خالل‬ ‫التكرار‬ ‫والتنوع‬ ‫أو‬ ‫التدخل‬ Single vs. Series
  • 19. 19 • Systematic reviews • Researchersconsolidate information usingcomprehensivemethods to assess relevantsciencebehinda singlehealthissue • Increasingly,meta-analysisis used in thesesystematicreviews • Meta-analysis • Identifyrelevantstudies,inclusion/exclusioncriteria,data abstraction,heterogeneityacross statisticalanalysis / SystematicReviews, Meta-analysis, Expert Panels
  • 20. 20 • An approach to looking at risks posed by adverse exposures like pollutants • A “bridge” between the scientific community and those who create policies and protocol • Four steps to proper risk assessment: 1. Hazard identification, 2. Risk characterization , 3. Exposure assessment and 4. Risk estimation • Expert panels used to assess validity of epidemiological studies through peer review ‫نهج‬ ‫للنظر‬ ً‫ف‬ ‫المخاطر‬ ‫الناجمة‬ ‫عن‬ ‫التعرضات‬ ‫الضارة‬ ‫مثل‬ ‫الملوثات‬ " ‫جسر‬ " ‫بٌن‬ ‫المجتمع‬ ً‫العلم‬ ‫وأولئن‬ ‫الذٌن‬ ‫ٌضعون‬ ‫السٌاسات‬ ‫والبروتوكول‬ ‫أربع‬ ‫خطوات‬ ‫لتمٌٌم‬ ‫المخاطر‬ ‫الصحٌحة‬ : ‫تحدٌد‬ ‫المخاطر‬ ، ‫توصٌؾ‬ ‫المخاطر‬ ، ‫تمٌٌم‬ ‫التعرض‬ ‫وتمدٌر‬ ‫المخاطر‬ ‫لوحات‬ ‫الخبراء‬ ‫المستخدمة‬ ‫لتمٌٌم‬ ‫صحة‬ ‫الدراسات‬ ‫الوبائٌة‬ ‫من‬ ‫خالل‬ ‫مراجعة‬ ‫األلران‬ Risk Assessment/Expert panels Hi Rc Ea Re
  • 21. 21 • Incidence rate – New events in a specified period / persons exposed to risk within period • Relative risk – Risk of death or disease in population exposed to risk / risk of death or diseased in unexposed population • Population attributable risk – Rate of disease in population attributed to risk factor / total rate of disease ‫معدل‬ ‫الولوع‬ - ‫أحداث‬ ‫جدٌدة‬ ً‫ف‬ ‫فترة‬ ‫محددة‬ / ‫األشخاص‬ ‫المعرضٌن‬ ‫للخطر‬ ‫خالل‬ ‫فترة‬ ‫الخطر‬ ً‫النسب‬ - ‫خطر‬ ‫الوفاة‬ ‫أو‬ ‫المرض‬ ‫بٌن‬ ‫السكان‬ ‫المعرضٌن‬ ‫لخطر‬ / ‫خطر‬ ‫الوفاة‬ ‫أو‬ ‫المرض‬ ً‫ف‬ ‫السكان‬ ‫ؼٌر‬ ‫المعرضٌن‬ ‫الخطر‬ ‫المنسوب‬ ‫للسكان‬ - ‫معدل‬ ‫المرض‬ ً‫ف‬ ‫السكان‬ ‫المنسوبة‬ ‫إلى‬ ‫عامل‬ ‫االختطار‬ / ‫المعدل‬ ً‫الكل‬ ‫لألمراض‬ Key Concepts
  • 22. 22 Chapter 3: Intervention Methods for Chronic Disease Control
  • 23. 23 • Behavior changes in individuals can often prevent many chronic diseases • CDC estimates that 80% of heart disease, type II diabetes and 40% of cancer would be eliminated if poor diet, inactivity and smoking were also eliminated • Obesity is now seen more frequently among both adults and children ‫ٌمكن‬ ‫لتؽٌٌرات‬ ‫سلون‬ ‫األفراد‬ ً‫ف‬ ‫كثٌر‬ ‫من‬ ‫األحٌان‬ ‫منع‬ ‫العدٌد‬ ‫من‬ ‫األمراض‬ ‫المزمنة‬ ‫تمدر‬ ‫مراكز‬ ‫مكافحة‬ ‫األمراض‬ ‫والولاٌة‬ ‫منها‬ ‫أن‬ 80 ٪ ‫من‬ ‫أمراض‬ ‫الملب‬ ‫والسكري‬ ‫من‬ ‫النوع‬ ً‫الثان‬ ‫و‬ 40 ٪ ‫من‬ ‫السرطان‬ ‫سوؾ‬ ‫ٌتم‬ ‫المضاء‬ ‫علٌها‬ ‫إذا‬ ‫تم‬ ‫التخلص‬ ‫من‬ ‫الحمٌة‬ ‫الؽذائٌة‬ ‫السٌئة‬ ‫وعدم‬ ‫النشاط‬ ‫والتدخٌن‬ . ‫وٌنظر‬ ‫اآلن‬ ‫السمنة‬ ‫بشكل‬ ‫أكثر‬ ‫تواترا‬ ‫بٌن‬ ‫البالؽٌن‬ ‫واألطفال‬ ‫على‬ ‫حد‬ ‫سواء‬ Behavioral Determinants
  • 24. 24 • The high cost of treating chronic diseases is another reason they are increasing • Secondary prevention can find many diseases earlier when they are cheaper to treat and more beneficial to lifestyle change, and also lead to fewer visits in later years (which will lower health costs) • Lack of incentives for prevention services in US healthcare system ‫التكلفة‬ ‫العالٌة‬ ‫لعالج‬ ‫األمراض‬ ‫المزمنة‬ ً‫ه‬ ‫سبب‬ ‫آخر‬ ‫لزٌادة‬ ‫عددها‬ ‫ٌمكن‬ ‫للولاٌة‬ ‫الثانوٌة‬ ‫أن‬ ‫تجد‬ ‫العدٌد‬ ‫من‬ ‫األمراض‬ ً‫ف‬ ‫ولت‬ ‫مبكر‬ ‫عندما‬ ‫تكون‬ ‫أرخص‬ ً‫ف‬ ‫المعالجة‬ ‫وأكثر‬ ‫فائدة‬ ‫لتؽٌٌر‬ ‫نمط‬ ‫الحٌاة‬ ، ‫وتؤدي‬ ‫اا‬‫ض‬ٌ‫أ‬ ‫إلى‬ ‫عدد‬ ‫ألل‬ ‫من‬ ‫الزٌارات‬ ً‫ف‬ ‫السنوات‬ ‫الالحمة‬ ( ‫مما‬ ‫ٌملل‬ ‫من‬ ‫التكالٌؾ‬ ‫الصحٌة‬ ) ‫نمص‬ ‫الحوافز‬ ‫لخدمات‬ ‫الولاٌة‬ ً‫ف‬ ‫نظام‬ ‫الرعاٌة‬ ‫الصحٌة‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ Healthcare Determinants
  • 25. 25 • Features like sidewalks, parks, bike trails, community pools all encourage healthier choices • Households with multiple televisions and computers also promote a less-active culture which affects the amount of exercise being done • Nutritional choices also under consideration in built environments – menus, work cafeterias, highlight lower costs for less nutritional foods. ‫ع‬ّ‫تشج‬ ‫المٌزات‬ ‫مثل‬ ‫األرصفة‬ ‫والحدائك‬ ‫ومسارات‬ ‫الدراجات‬ ‫والمسابح‬ ‫الجماعٌة‬ ‫على‬ ‫خٌارات‬ ‫صحٌة‬ ‫كما‬ ‫أن‬ ‫األسر‬ ً‫الت‬ ‫لدٌها‬ ‫أجهزة‬ ‫تلفزٌون‬ ‫وأجهزة‬ ‫كمبٌوتر‬ ‫متعددة‬ ‫تعمل‬ ‫على‬ ‫التروٌج‬ ‫لثمافة‬ ‫ألل‬ ‫ا‬‫ا‬‫نشاط‬ ‫تؤثر‬ ‫على‬ ‫كمٌة‬ ‫التمارٌن‬ ً‫الت‬ ‫ٌتم‬ ‫إجراؤها‬ ‫الخٌارات‬ ‫الؽذائٌة‬ ‫لٌد‬ ‫النظر‬ ‫أٌضا‬ ً‫ف‬ ‫البٌئات‬ ‫المبنٌة‬ - ‫لوائم‬ ‫الطعام‬ ، ً‫مماه‬ ‫العمل‬ ، ‫تسلٌط‬ ‫الضوء‬ ‫على‬ ‫تكالٌؾ‬ ‫ألل‬ ‫ألؼذٌة‬ ‫ؼذائٌة‬ ‫ألل‬ Environmental Determinants
  • 26. 26 • Population health is emerging as just as important as individual health • Policymakers are quick to blame individual choices for chronic illness, when, in reality, there are an amplitude of environmental, cultural and economic factors at play • Social determinants are often a large result of health disparities ‫الصحة‬ ‫السكانٌة‬ ‫تظهر‬ ‫بأهمٌة‬ ‫الصحة‬ ‫الفردٌة‬ ‫ٌسارع‬ ‫صناع‬ ‫المرار‬ ً‫السٌاس‬ ‫إلى‬ ‫إلماء‬ ‫اللوم‬ ‫على‬ ‫الخٌارات‬ ‫الفردٌة‬ ‫للمرض‬ ‫المزمن‬ ، ‫عندما‬ ‫ٌكون‬ ‫هنان‬ ً‫ف‬ ‫الوالع‬ ‫عدد‬ ‫كبٌر‬ ‫من‬ ‫العوامل‬ ‫البٌئٌة‬ ‫والثمافٌة‬ ‫وااللتصادٌة‬ ‫أثناء‬ ‫اللعب‬ . ‫وؼالبا‬ ‫ما‬ ‫تكون‬ ‫المحددات‬ ‫االجتماعٌة‬ ‫نتٌجة‬ ‫كبٌرة‬ ‫للفوارق‬ ‫الصحٌة‬ SocialDeterminants
  • 27. 27 • Victim-blaming fails to account environmental and social – ecological approach acknowledges that we live in a world full of interactions • It takes into account the following elements that influence health behavior: 1. Intrapersonal factors 2. Interpersonal factors 3. Organizational factors 4. Community factors 5. Policy factors Levels of Intervention
  • 28. 28 • Early attempt to use theory to study preventive behaviors • If subject perceives moderate severity and susceptibility, then choose preventative action • Often criticized and used to explain how people rarely adopt preventative behaviors ‫محاولة‬ ‫مبكرة‬ ‫الستخدام‬ ‫النظرٌة‬ ‫لدراسة‬ ‫السلوكٌات‬ ‫الولائٌة‬ ‫إذا‬ ‫كان‬ ‫الموضوع‬ ‫ٌدرن‬ ‫خطورة‬ ‫وشدة‬ ‫متوسطة‬ ، ‫فاختر‬ ‫اإلجراء‬ ً‫الولائ‬ ‫ا‬‫ا‬‫كثٌر‬ ‫ما‬ ‫ٌتم‬ ‫نمده‬ ‫واستخدامه‬ ‫لشرح‬ ‫كٌؾ‬ ‫ا‬‫ا‬‫نادر‬ ‫ما‬ ‫ٌتبنى‬ ‫الناس‬ ‫سلوكٌات‬ ‫ولائٌة‬ 1-Health Belief Model
  • 29. 29 • Also known as Stages of Change Model • Not everyone at the same stage to drastically change health behavior, so each plan fits to different characteristics • Series of stages, from pre-contemplation (no change) to termination (problem no longer acceptable) or relapse (retroactively choosing less healthy behavior) ‫عرؾ‬ٌُ ‫ا‬‫ا‬‫ض‬ٌ‫أ‬ ‫باسم‬ ‫نماذج‬ ‫مراحل‬ ‫التؽٌٌر‬ ‫لٌس‬ ‫كل‬ ‫شخص‬ ً‫ف‬ ‫نفس‬ ‫المرحلة‬ ‫لتؽٌٌر‬ ‫السلون‬ ً‫الصح‬ ‫بشكل‬ ‫جذري‬ ، ‫لذلن‬ ‫كل‬ ‫خطة‬ ‫تناسب‬ ‫خصائص‬ ‫مختلفة‬ ‫سلسلة‬ ‫من‬ ‫المراحل‬ ، ‫من‬ ‫مرحلة‬ ‫ما‬ ‫لبل‬ ‫التأمل‬ ( ‫بدون‬ ‫تؽٌٌر‬ ) ‫إلى‬ ‫اإلنهاء‬ ( ‫المشكلة‬ ‫لم‬ ‫تعد‬ ‫ممبولة‬ ) ‫أو‬ ‫االنتكاس‬ ( ‫اختٌار‬ ‫سلون‬ ‫ألل‬ ‫صحٌة‬ ‫بأثر‬ ً‫رجع‬ ) 2-Transtheoretical Model
  • 30. 30 • Individuals are fueled by behavioral intentions • An attitude of a positive behavior is ―is the sum of all the positive feelings…or negative feelings…about performing the behavior‖ )Remington et al. 2010 .) • Places normative beliefs on people’s perceptions and readiness to change ‫ٌتم‬ ‫تؽذٌة‬ ‫األفراد‬ ‫عن‬ ‫طرٌك‬ ‫النواٌا‬ ‫السلوكٌة‬ ‫المولؾ‬ ‫من‬ ‫السلون‬ ً‫اإلٌجاب‬ ‫هو‬ " ‫هو‬ ‫مجموع‬ ‫كل‬ ‫المشاعر‬ ‫اإلٌجابٌة‬ ... ‫أو‬ ‫المشاعر‬ ‫السلبٌة‬ ... ‫حول‬ ‫أداء‬ ‫السلون‬ " ‫ٌضع‬ ‫المعتمدات‬ ‫المعٌارٌة‬ ‫حول‬ ‫تصورات‬ ‫الناس‬ ‫واستعدادهم‬ ‫للتؽٌٌر‬ 3-Theory of Planned Behavior
  • 31. 31 • Expectancy is important when considering control – where, who, what is/are responsible? • If there is belief that a plan of action will result in an outcome, a person is more likely to pursue that option • Control moves from internal (self) to external (higher powers, luck, fate, etc(. • Those who lean toward external control are more likely reached through policy changes ‫التولع‬ ‫مهم‬ ‫عند‬ ‫التفكٌر‬ ً‫ف‬ ‫السٌطرة‬ - ‫أٌن‬ ، ‫من‬ ، ‫ما‬ ‫هو‬ / ‫المسؤول‬ ‫؟‬ ‫إذا‬ ‫كان‬ ‫هنان‬ ‫اعتماد‬ ‫بأن‬ ‫خطة‬ ‫العمل‬ ‫ستؤدي‬ ‫إلى‬ ‫نتٌجة‬ ، ‫فمن‬ ‫المرجح‬ ‫أن‬ ‫ٌتابع‬ ‫هذا‬ ‫الشخص‬ ‫هذا‬ ‫الخٌار‬ ‫ٌتحكم‬ ‫التحكم‬ ‫من‬ ً‫داخل‬ ( ً‫ذات‬ ) ‫إلى‬ ً‫خارج‬ ( ‫لوى‬ ‫أعلى‬ ، ‫حظ‬ ، ‫مصٌر‬ ، ‫إلخ‬ ). ‫من‬ ‫المرجح‬ ‫أن‬ ‫ٌتم‬ ‫الوصول‬ ‫إلى‬ ‫أولئن‬ ‫الذٌن‬ ‫ٌمٌلون‬ ‫نحو‬ ‫السٌطرة‬ ‫الخارجٌة‬ ‫من‬ ‫خالل‬ ‫تؽٌٌرات‬ ‫السٌاسة‬ 4-Health Locus of Control
  • 32. 32 • Addresses dynamic of society that influence health and methods for behavioral change • Triadic, dynamic, reciprocal models • Emphasis placed on highlighting capability and self-confidence • Self-efficacy through mastery of task • Applicable to wide variety of populations ‫ٌعالج‬ ‫دٌنامٌكٌة‬ ‫المجتمع‬ ً‫الت‬ ‫تؤثر‬ ‫على‬ ‫الصحة‬ ‫وأسالٌب‬ ‫تؽٌٌر‬ ‫السلون‬ ‫نماذج‬ ‫ثالثٌة‬ ، ‫دٌنامٌكٌة‬ ، ‫متبادلة‬ ‫التركٌز‬ ‫على‬ ‫إبراز‬ ‫المدرات‬ ‫والثمة‬ ‫بالنفس‬ ‫الكفاءة‬ ‫الذاتٌة‬ ‫من‬ ‫خالل‬ ‫التمكن‬ ‫من‬ ‫المهمة‬ ‫تنطبك‬ ‫على‬ ‫مجموعة‬ ‫واسعة‬ ‫من‬ ‫السكان‬ 1- SocialCognitive Theory
  • 33. 33 • Monopolizes on existing string of social network (family) to implement support • Family trained to assist in weight loss program, for example • ―Family Matters‖ program to prevent youth smoking and alcoholism ‫ٌحتكر‬ ‫على‬ ‫السلسلة‬ ‫الحالٌة‬ ‫من‬ ‫الشبكة‬ ‫االجتماعٌة‬ ( ‫األسرة‬ ) ‫لتنفٌذ‬ ‫الدعم‬ ‫األسرة‬ ‫المدربة‬ ‫للمساعدة‬ ً‫ف‬ ‫برنامج‬ ‫إنماص‬ ‫الوزن‬ ، ‫على‬ ‫سبٌل‬ ‫المثال‬ ‫برنامج‬ " ‫مسائل‬ ‫األسرة‬ " ‫لمنع‬ ‫تدخٌن‬ ‫الشباب‬ ‫وإدمان‬ ‫الكحول‬ 2-Family-Based Interventions
  • 34. 34 • Mentor programs, buddy systems, self-help groups • Creating a new social network with the sole purpose of intervening • Especially important in adolescent interventions ‫برامج‬ ‫التوجٌه‬ ، ‫أنظمة‬ ‫األصدلاء‬ ، ‫مجموعات‬ ‫المساعدة‬ ‫الذاتٌة‬ ‫إنشاء‬ ‫شبكة‬ ‫اجتماعٌة‬ ‫جدٌدة‬ ‫لؽرض‬ ‫وحٌد‬ ‫للتدخل‬ ‫أهمٌة‬ ‫خاصة‬ ً‫ف‬ ‫تدخالت‬ ‫المراهمٌن‬ 3- Friends and SocialNetworks
  • 35. 35 • Social support ‫دعم‬ ً‫اجتماع‬ 1. Emotional support 2. Instrumental support 3. Informational support 4. Appraisal support • Either strengthening existing networks or creating new ones to assist in the problem-solving process ‫إما‬ ‫تعزٌز‬ ‫الشبكات‬ ‫المائمة‬ ‫أو‬ ‫إنشاء‬ ‫شبكات‬ ‫جدٌدة‬ ‫للمساعدة‬ ً‫ف‬ ‫عملٌة‬ ‫حل‬ ‫المشكالت‬ 4- SocialSupportand Social Networks
  • 36. 36 • A member of a social network who gains trust and respect through his or her abilities to offer support and guidance • These strategies are seen frequently in urban and rural settings • Natural helpers are either found in a community organically, or is given specialized training (this is known as a lay health advisor) ‫عضو‬ ً‫ف‬ ‫شبكة‬ ‫اجتماعٌة‬ ‫كسب‬ ‫الثمة‬ ‫واالحترام‬ ‫من‬ ‫خالل‬ ‫لدراته‬ ‫لتمدٌم‬ ‫الدعم‬ ‫واإلرشاد‬ ‫وٌنظر‬ ‫إلى‬ ‫هذه‬ ‫االستراتٌجٌات‬ ً‫ف‬ ‫كثٌر‬ ‫من‬ ‫األحٌان‬ ً‫ف‬ ‫المناطك‬ ‫الحضرٌة‬ ‫والرٌفٌة‬ ‫ٌتم‬ ‫العثور‬ ‫على‬ ‫المساعدٌن‬ ‫الطبٌعٌٌن‬ ً‫ف‬ ‫مجتمع‬ ‫ما‬ ‫اا‬ٌ‫عضو‬ ، ‫أو‬ ‫ٌتم‬ ‫تمدٌم‬ ‫تدرٌب‬ ‫متخصص‬ ‫له‬ ( ‫ُعرؾ‬ٌ ‫هذا‬ ‫بالمستشار‬ ً‫الصح‬ ‫العادي‬ ) 5-Natural Helpers
  • 37. 37 • Effective in providing screening / follow-ups • However, often underutilized in primary prevention (see Slide 3 ( • Brief interventions are low cost alternative to high cost visits • Short, private, non-confrontational, 5-60 minute meeting with counseling and informative education • Can be leveraged depending on a person’s aptitude and readiness for change / ( 3 ) 1- Health Care System and Clinical Services
  • 38. 38 • Youth are a spirited, receptive audience for prevention messages • Establishing healthier habits at an earlier age is essential in stopping or slowing chronic illness ‫الشباب‬ ‫هم‬ ‫جمهور‬ ‫مفعم‬ ‫بالحٌوٌة‬ ‫ومتفهم‬ ‫لرسائل‬ ‫الولاٌة‬ ‫إن‬ ‫إرساء‬ ‫عادات‬ ‫صحٌة‬ ً‫ف‬ ‫سن‬ ‫مبكرة‬ ‫أمر‬ ‫ضروري‬ ‫لولؾ‬ ‫أو‬ ‫إبطاء‬ ‫المرض‬ ‫المزمن‬ 2- Schools
  • 39. 39 • US adult population spends half or more of the day at work, so it becomes a useful tool in dispensing knowledge about prevention education. • Leaders are understanding that chronic diseases are costing more and more (employee absence, insurance costs, etc.) and are mediating this through health knowledge at the workplace. Results: 1. Improved productivity 2. Reduced absences 3. Reduced health risks/health care costs 4. Improved company image ( ) . : / 3- Work Sites
  • 40. 40 • Selected based on priorities of population in question • Priority population partners – participatory, collaborative, local, empowering, research and action blend • Community coalitions • Media advocacy – seen today in suicide prevention, and lead poisoning, to name a few - - Examplesof Community-Level Health PlanningApproaches
  • 41. 41 1. Process planning ‫عملٌة‬ ‫التخطٌط‬ 2. Plan with people ‫خطط‬ ‫مع‬ ‫الناس‬ 3. Plan with data ‫خطة‬ ‫مع‬ ‫البٌانات‬ 4. Institutionalization ‫إضفاء‬ ‫الطابع‬ ً‫المؤسس‬ 5. Priorities‫أولوٌات‬ 6. Short- and long-term outcomes ‫نتائج‬ ‫لصٌرة‬ ‫وطوٌلة‬ ‫األجل‬ 7. Evaluation‫تمٌٌم‬ Community-Level Health Planning
  • 42. 42 1. Mobilizing the community ‫تعبئة‬ ‫المجتمع‬ 2. Developing a community profile ‫تطوٌر‬ ‫ملؾ‬ ‫تعرٌؾ‬ ‫المجتمع‬ 3. Selection behavior/audiences ‫سلون‬ ‫االختٌار‬ / ‫الجماهٌر‬ 4. Formative research ‫البحث‬ ً‫التكوٌن‬ 5. Strategy development ‫تطوٌر‬ ‫اإلستراتٌجٌة‬ 6. Program development ‫تطوٌر‬ ‫البرنامج‬ 7. Program implementation ‫تنفٌذ‬ ‫البرنامج‬ 8. Tracking‫تتبع‬ Community-Based Prevention Marketing
  • 44. 44 Conceptual Model of Health Surveillance Define the Problem Program Process Evaluate the Effect Find Programs that Work Information Dissemination Data Collection Data Analysis Data Interpretation Epidemiologic Process Adapted from Remington et al. ( 2010 )
  • 45. 45 • Council of State and Territorial Epidemiologists modifies this list each year • Includes primarily infectious diseases, but also contains some noncommunicable diseases, as well • In 1996, CSTE included smoking, the first behavior on the list • 2004list contains 92 disease systems • Chronic Disease Indicators website includes definitions and data of each in the United States 1996 2004 92 1- Notifiable Disease Systems
  • 46. 46 • Collected information from birth and death • An initial cornerstone of surveillance since the mid-19th century and perhaps earlier • Death certificates are used to list immediate causes of death and a string of events that caused death (underlying cause( • Limitation – incomplete certificate, lack of clinical history ‫المعلومات‬ ً‫الت‬ ‫تم‬ ‫جمعها‬ ‫من‬ ‫الوالدة‬ ‫والوفاة‬ ‫حجر‬ ‫الزاوٌة‬ ً‫األول‬ ‫للمرالبة‬ ‫منذ‬ ‫منتصؾ‬ ‫المرن‬ ‫التاسع‬ ‫عشر‬ ‫وربما‬ ‫لبل‬ ‫ذلن‬ ‫ستخدم‬ُ‫ت‬ ‫شهادات‬ ‫الوفاة‬ ‫لسرد‬ ‫األسباب‬ ‫المباشرة‬ ‫للوفاة‬ ‫وسلسلة‬ ‫من‬ ‫األحداث‬ ً‫الت‬ ‫تسبب‬ ‫الوفاة‬ ( ‫السبب‬ ً‫األساس‬ ) ‫الحد‬ - ‫شهادة‬ ‫ؼٌر‬ ‫كاملة‬ ، ‫ونمص‬ ‫التارٌخ‬ ‫السرٌري‬ 2-Vital Statistics
  • 47. 47 • One symptom or a string of symptoms, disease, disability, etc. • Effectiveness yet to be proven by research • Could potentially identify outbreaks or bioterrorism ‫أحد‬ ‫األعراض‬ ‫أو‬ ‫سلسلة‬ ‫من‬ ‫األعراض‬ ، ‫المرض‬ ، ‫اإلعالة‬ ، ‫إلخ‬ . ‫فعالٌة‬ ‫لم‬ ‫تثبت‬ ‫بعد‬ ‫من‬ ‫خالل‬ ‫البحث‬ ‫ٌمكن‬ ‫أن‬ ‫تحدد‬ ‫حاالت‬ ً‫تفش‬ ‫أو‬ ‫اإلرهاب‬ ً‫البٌولوج‬ 3-Sentinel Surveillance
  • 48. 48 • Used in monitoring trends • Usually mandated in state laws • Most common disease registries – cancer  They are 1. Hospital-based registries 2. population-based registries ‫تستخدم‬ ً‫ف‬ ‫مرالبة‬ ‫االتجاهات‬ ‫عادة‬ ‫ما‬ ‫ٌفوض‬ ً‫ف‬ ‫لوانٌن‬ ‫الوالٌة‬ ‫سجالت‬ ‫األمراض‬ ‫األكثر‬ ‫شٌوعا‬ - ‫السرطان‬ ‫السجالت‬ ‫المستندة‬ ‫إلى‬ ‫المستشفٌات‬ ‫أو‬ ‫السكان‬ 4- Chronic Disease Registries
  • 49. 49 • Implemented when collecting information from self-reported health practices (general pop). • CDC established a phone-based surveillance system of questionnaires • Some surveys go beyond questionnaires and access physical exams and samples • Collected at mobile examination centers ( ) ( CDC ) 5- Health Surveys
  • 50. 50 • Primarily hospital discharge data • Used to locate hospitalization patterns of chronic diseases • Limitations – incomplete records, unreliable imputation of data, missing variables, measurement errors, only focus on hospital setting, not outpatient care ‫بٌانات‬ ‫تفرٌػ‬ ‫المستشفى‬ ً‫ف‬ ‫الممام‬ ‫األول‬ ‫تستخدم‬ ‫لتحدٌد‬ ‫مولع‬ ‫أنماط‬ ‫االستشفاء‬ ‫من‬ ‫األمراض‬ ‫المزمنة‬ ‫المٌود‬ - ‫السجالت‬ ‫ؼٌر‬ ‫المكتملة‬ ، ‫استبعاد‬ ‫البٌانات‬ ‫ؼٌر‬ ‫المضمونة‬ ، ‫المتؽٌرات‬ ‫المفمودة‬ ، ‫أخطاء‬ ‫المٌاس‬ ، ‫التركٌز‬ ‫فمط‬ ‫على‬ ‫إعداد‬ ‫المستشفى‬ ، ‫ولٌس‬ ‫رعاٌة‬ ‫المرضى‬ ‫الخارجٌٌن‬ 6-Administrative Data Collection Systems
  • 51. 51 • Each 10 years, the United States government censuses the entire population – collects detailed information on individual and household • Limitations – census does not include everyone; inevitably some are missed • Minority racial/ethnic groups • Geographic areas 10 - - / 7- Census Data
  • 52. 52 • Charts the variety of a disease given their personal attributions • Race, age, gender, etc. • Realizing differences in these factors helps design effective and group-specific prevention or control programs ‫ٌرسم‬ ‫مجموعة‬ ‫متنوعة‬ ‫من‬ ‫المرض‬ ‫نظرا‬ ‫لخصوصٌاتهم‬ ‫الشخصٌة‬ ‫العرق‬ ، ‫العمر‬ ، ‫الجنس‬ ، ‫إلخ‬ . ‫إدران‬ ‫االختالفات‬ ً‫ف‬ ‫هذه‬ ‫العوامل‬ ‫ٌساعد‬ ‫على‬ ‫تصمٌم‬ ‫برامج‬ ‫للولاٌة‬ ‫أو‬ ‫السٌطرة‬ ‫فعالة‬ ‫ومحددة‬ 1- Person Analyses
  • 53. 53 • Charts a disease that occurs in one geographic region against another region • Typically found in situations when a city or county is compared to state or country • Needs to understand and interpret age structure between areas by age-standardization • Cluster analysis – in acute geographic areas – monitored to avoid health risks specific to a very small area (neighborhoods, communities, suburbs, etc). ‫ٌرسم‬ ‫المرض‬ ‫الذي‬ ‫ٌحدث‬ ً‫ف‬ ‫منطمة‬ ‫جؽرافٌة‬ ‫واحدة‬ ‫ضد‬ ‫منطمة‬ ‫أخرى‬ ‫توجد‬ ‫عادة‬ ً‫ف‬ ‫الحاالت‬ ً‫الت‬ ‫تتم‬ ‫فٌها‬ ‫ممارنة‬ ‫مدٌنة‬ ‫أو‬ ‫مماطعة‬ ‫بالدولة‬ ‫أو‬ ‫الدولة‬ ‫ٌحتاج‬ ‫إلى‬ ‫فهم‬ ‫وتفسٌر‬ ‫الهٌكل‬ ‫العمري‬ ‫بٌن‬ ‫المناطك‬ ‫حسب‬ ‫توحٌد‬ ‫العمر‬ ‫رصد‬ ‫الكتلة‬ - ً‫ف‬ ‫المناطك‬ ‫الجؽرافٌة‬ ‫الحادة‬ - ‫رصد‬ ‫لتجنب‬ ‫المخاطر‬ ‫الصحٌة‬ ‫المحددة‬ ‫لمنطمة‬ ‫صؽٌرة‬ ‫جدا‬ ( ‫األحٌاء‬ ‫والمجتمعات‬ ‫المحلٌة‬ ً‫والضواح‬ ، ‫وما‬ ‫إلى‬ ‫ذلن‬ ) 2- Place Analyses
  • 54. 54 • Charts trends that appear over time • Used to detect outbreaks, transmission patterns, intervention strategies • Temporal trends, regional analysis • Interventions based on variables specific to a certain time in a certain era ‫مؤشرات‬ ‫المخططات‬ ً‫الت‬ ‫تظهر‬ ‫مع‬ ‫مرور‬ ‫الولت‬ ‫ٌستخدم‬ ‫للكشؾ‬ ‫عن‬ ‫الفاشٌات‬ ‫وأنماط‬ ‫االنتمال‬ ‫واستراتٌجٌات‬ ‫التدخل‬ ‫االتجاهات‬ ‫الزمنٌة‬ ، ‫التحلٌل‬ ً‫اإلللٌم‬ ‫التدخالت‬ ‫على‬ ‫أساس‬ ‫المتؽٌرات‬ ‫المحددة‬ ‫لفترة‬ ‫معٌنة‬ ً‫ف‬ ‫عصر‬ ‫معٌن‬ 3-Time Analyses
  • 55. 55 • Data dissemination is the final step in disease monitoring • Often composed in documents with technical language, with little linkage to public health promotion • Epidemiologists asked to disseminate the information collected into health department reports • Five steps in data analysis: 1. Establish the message، 2. set an objective، 3. define the audience ، 4. select the channel ، 5. evaluate the impact : Data Dissemination
  • 56. 56 • Arguably the most important element of data presentations • The role of the epidemiologist is to convey a clear message, one that is worthwhile and somewhat easy to understand • ―Less is more‖ approach • Main points must be easy to understand ‫ٌمكن‬ ‫المول‬ ‫إن‬ ‫العنصر‬ ‫األكثر‬ ‫أهمٌة‬ ً‫ف‬ ‫تمدٌم‬ ‫البٌانات‬ ‫إن‬ ‫دور‬ ‫عالم‬ ‫األوبئة‬ ‫هو‬ ‫نمل‬ ‫رسالة‬ ‫واضحة‬ ، ‫مهمة‬ ‫جدٌرة‬ ‫باالهتمام‬ ‫وسهلة‬ ‫الفهم‬ ‫إلى‬ ‫حد‬ ‫ما‬ ‫نهج‬ " ‫ألل‬ ‫هو‬ ‫أكثر‬ " ‫النماط‬ ‫الرئٌسٌة‬ ‫ٌجب‬ ‫أن‬ ‫تكون‬ ‫سهلة‬ ‫الفهم‬ Message
  • 57. 57 • Goal of epidemiologist is to establish an objective for a piece of writing • Goals vary – sometimes there is no goal, simply that there is something to be reported, other times objective is for general public education • Sometimes the ideal objective is public action - Objective
  • 58. 58 • Target audience varies, but has traditionally been both local health departments and health care providers • These agencies are charged with implementing any strategies for managing disease control • Today, a broader spectrum of target audience exists – from policymakers and legislators, or to the general public, advocacy agencies to promote their efforts ‫الجمهور‬ ‫المستهدؾ‬ ‫ٌختلؾ‬ ، ‫ولكن‬ ‫كان‬ ‫تملٌدٌا‬ ‫كل‬ ‫من‬ ‫اإلدارات‬ ‫الصحٌة‬ ‫المحلٌة‬ ً‫وممدم‬ ‫الرعاٌة‬ ‫الصحٌة‬ ‫هذه‬ ‫الوكاالت‬ ‫مكلفة‬ ‫بتنفٌذ‬ ‫أي‬ ‫استراتٌجٌات‬ ‫إلدارة‬ ‫مكافحة‬ ‫المرض‬ ‫الٌوم‬ ، ‫هنان‬ ‫مجموعة‬ ‫واسعة‬ ‫من‬ ‫الجمهور‬ ‫المستهدؾ‬ - ‫من‬ ‫صناع‬ ‫السٌاسات‬ ‫والمشرعٌن‬ ، ‫أو‬ ‫من‬ ‫عامة‬ ‫الجمهور‬ ، ‫وكاالت‬ ‫الدعوة‬ ‫لتعزٌز‬ ‫جهودها‬ . Audience
  • 59. 59 • The method or medium that an epidemiologist “channels” his or her work • Journals, paper/electronic mail, radio/television, blogs, print/digital media, etc. • Frequently mailed to healthcare facilities • Sometimes a press release is required • Selective channeling aides research in reaching target audience ‫الطرٌمة‬ ‫أو‬ ‫الوسط‬ ‫الذي‬ " ‫م‬ّ‫ٌمن‬ " ً‫اختصاص‬ ‫األوبئة‬ ‫عمله‬ ‫أو‬ ‫عملها‬ ‫دورٌات‬ ، ‫ورلٌة‬ / ‫برٌد‬ ً‫إلكترون‬ ، ‫ورادٌو‬ / ‫تلفزٌون‬ ، ‫ومدونات‬ ، ‫ووسائط‬ ‫مطبوعة‬ / ‫وسائط‬ ‫رلمٌة‬ ، ‫إلخ‬ . ‫إرسالها‬ ‫بشكل‬ ‫متكرر‬ ‫إلى‬ ‫مرافك‬ ‫الرعاٌة‬ ‫الصحٌة‬ ً‫ف‬ ‫بعض‬ ‫األحٌان‬ ‫نشرة‬ ‫صحفٌة‬ ‫مطلوبة‬ ‫بحوث‬ ‫توجٌهٌة‬ ‫انتمائٌة‬ ً‫ف‬ ‫الوصول‬ ‫إلى‬ ‫الجمهور‬ ‫المستهدؾ‬ Channel
  • 60. 60 • Final step is evaluating how the information was distributed using the previous four methods • This can be measured in various ways – number of items distributed, where and how, readership, coverage, hits on a webpage, web searches • The success of the previous methods outline the impact that a particular public health campaign may have ‫الخطوة‬ ‫النهائٌة‬ ً‫ه‬ ‫تمٌٌم‬ ‫كٌفٌة‬ ‫توزٌع‬ ‫المعلومات‬ ‫باستخدام‬ ‫الطرق‬ ‫األربع‬ ‫السابمة‬ ‫ٌمكن‬ ‫لٌاس‬ ‫ذلن‬ ‫بطرق‬ ‫مختلفة‬ - ‫عدد‬ ‫العناصر‬ ‫الموزعة‬ ، ‫وأٌن‬ ‫وكٌؾ‬ ، ‫والمراء‬ ، ‫والتؽطٌة‬ ، ‫والنتائج‬ ‫على‬ ‫صفحة‬ ‫الوٌب‬ ، ‫وبحث‬ ‫الوٌب‬ ‫ٌوضح‬ ‫نجاح‬ ‫األسالٌب‬ ‫السابمة‬ ‫التأثٌر‬ ‫الذي‬ ‫لد‬ ‫تحدثه‬ ‫حملة‬ ‫صحة‬ ‫عامة‬ ‫معٌنة‬ Impact
  • 62. 62 • Smoking harms every organ of the body, with diseases including – 1. Cardiovascular diseases 2. Cancers – lip, mouth, esophagus, lung, kidney, etc. 3. Respiratory problems 4. Reproductive disorders 5. SIDS ―Sudden infant death syndrome‖ ،cataracts, slow wound healing 6. Low bone density - - . Significance
  • 63. 63 • Smoking a major risk factor in developing congenital heart disease • Ability of blood to delivery oxygen is reduced • Secondhand smoking causes prothrombotic effects and endothelial cell dysfunctions ‫التدخٌن‬ ‫عامل‬ ‫خطر‬ ً‫رئٌس‬ ً‫ف‬ ‫تطوٌر‬ ‫أمراض‬ ‫الملب‬ ‫الخلمٌة‬ ‫ٌتم‬ ‫تملٌل‬ ‫لدرة‬ ‫الدم‬ ‫لتسلٌم‬ ‫األكسجٌن‬ ‫التدخٌن‬ ً‫السلب‬ ‫ٌسبب‬ ‫آثارا‬ ‫خارجٌة‬ ‫وخالٌا‬ ‫خلوٌة‬ ‫بطانٌة‬ Cardiovascular Disease
  • 64. 64 • “Mainstreamtobacco smoke (MS) contains nearly 5,000 chemicals…and more than 60 known carcinogens” (Remington et al. 2010 ( • These carcinogens have been linked to tobacco-related cancers • Nitrosamines/polyaromatic hydrocarbons – lung cancer • N-nitrosodimethylmine – kidney tumors • Nitrosamine NNK – pancreatic cancer • Benzene, polonium-210, lead-210 – myeloid leukemia " ( MS ) 5000 ... 60 " / - N-nitrosodimethylmine - Nitrosamine NNK - 210 210 - Cancer
  • 65. 65 • When you smoke, additional biological processes like inflammation, degradation of structural proteins and oxidant stress are developed, which can cause alveolar injury 1. Results in COPD ―Chronic obstructive pulmonary disease‖ 2. Hypoxemia 3. Decline in pulmonary function 4. Reduction of tracheal mucus velocity Chronic Lung/Other Respiratory Disease
  • 66. 66 • Nicotine distribution absorbs rapidly to the brain in both oral and inhalation of tobacco – around ten seconds upon initial use • Crosses blood-brain barrier and binds to receptors in brain, which releases neurotransmitters • Effects dependent on rate of use, tolerance • Withdrawal symptoms include irritability, frustration, increased appetite, weight gain, and generally occur within one day and maintain for ten days, though cravings for regular smokers last for years ‫ٌمتص‬ ‫توزٌع‬ ‫النٌكوتٌن‬ ‫بسرعة‬ ‫إلى‬ ‫الدماغ‬ ‫سواء‬ ‫عن‬ ‫طرٌك‬ ‫الفم‬ ‫واستنشاق‬ ‫التبػ‬ - ً‫حوال‬ ‫عشر‬ ‫ثوان‬ ‫عند‬ ‫االستخدام‬ ً‫األول‬ ‫ٌعبر‬ ‫حاجز‬ ‫الدم‬ ً‫ف‬ ‫الدماغ‬ ‫وٌربط‬ ‫بالمستمبالت‬ ً‫ف‬ ‫الدماغ‬ ، ً‫الت‬ ‫تطلك‬ ‫الموصالت‬ ‫العصبٌة‬ ‫آثار‬ ‫تعتمد‬ ‫على‬ ‫معدل‬ ‫االستخدام‬ ‫والتسامح‬ ‫تشمل‬ ‫أعراض‬ ‫االنسحاب‬ ‫التهٌج‬ ، ‫واإلحباط‬ ، ‫وزٌادة‬ ‫الشهٌة‬ ، ‫وزٌادة‬ ‫الوزن‬ ، ‫وعادة‬ ‫ما‬ ‫تحدث‬ ً‫ف‬ ‫ؼضون‬ ‫ٌوم‬ ‫واحد‬ ‫والحفاظ‬ ‫على‬ ‫عشرة‬ ‫أٌام‬ ، ‫على‬ ‫الرؼم‬ ‫من‬ ‫الرؼبة‬ ‫الشدٌدة‬ ‫للمدخنٌن‬ ‫العادٌٌن‬ ‫تستمر‬ ‫لسنوات‬ Nicotine Dependence
  • 67. 67 • In the United States, estimated 43 million smokers • Higher for men (22%) than women ( 17% ) • 10 % - Asians; 13% - Hispanics; 20% - African Americans; 21% - Caucasians; 36% - Native Americans and Alaska Natives (Remington et al. 2010 ) • A 2005 study found that 51% of men and 50% of women were smokers at one time but had quit • Estimated 4,000 young people smoke their first cigarette each year ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ، ‫ٌمدر‬ ‫عدد‬ ‫المدخنٌن‬ ‫بنحو‬ 43 ‫ملٌون‬ ‫شخص‬ ‫أعلى‬ ‫للرجال‬ ( 22 ٪ ) ‫من‬ ‫النساء‬ ( 17 ٪ ) 10 ٪ - ‫اآلسٌوٌٌن‬ . 13 ٪ - ‫من‬ ‫اصل‬ ً‫اسبان‬ 20 ٪ - ‫األمرٌكٌون‬ ‫من‬ ‫أصل‬ ً‫أفرٌم‬ 21 ٪ - ‫المولازٌٌن‬ . 36 ٪ - ‫األمرٌكٌون‬ ‫األصلٌون‬ ً‫وأهال‬ ‫أالسكا‬ ( Remington et al. 2010 ) ‫وجدت‬ ‫دراسة‬ ‫أجرٌت‬ ‫عام‬ 2005 ‫أن‬ 51 ٪ ‫من‬ ‫الرجال‬ ‫و‬ 50 ٪ ‫من‬ ‫النساء‬ ‫كانوا‬ ‫مدخنٌن‬ ً‫ف‬ ‫ولت‬ ‫واحد‬ ‫ولكنهم‬ ‫تركوا‬ ‫التدخٌن‬ ‫ّر‬‫د‬‫ٌم‬ ‫عدد‬ 4000 ‫شاب‬ ‫ٌدخنون‬ ‫سٌجارتهم‬ ‫األولى‬ ‫كل‬ ‫عام‬ High-Risk Groups
  • 68. 68 • Peak cigarette sales in the United States in 1963 – steadily declining since • Over time, the gap between men (historically higher rates) and women (lower) has been narrowing, but the declination rate is lowering at a comparable rate • From 2002, more former smokers than current smokers ‫ذروة‬ ‫مبٌعات‬ ‫السجائر‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ً‫ف‬ ‫عام‬ 1963 - ‫انخفاض‬ ‫مستمر‬ ‫منذ‬ ‫ذلن‬ ‫الحٌن‬ ‫بمرور‬ ‫الولت‬ ، ‫تضٌك‬ ‫الفجوة‬ ‫بٌن‬ ‫الرجال‬ ( ‫معدالت‬ ‫أعلى‬ ‫ا‬‫ا‬‫خ‬ٌ‫تار‬ ) ‫والنساء‬ ( ‫ألل‬ ) ، ‫ولكن‬ ‫معدل‬ ‫االنخفاض‬ ‫ٌنخفض‬ ‫بمعدل‬ ‫مماثل‬ ‫من‬ ‫عام‬ 2002 ، ‫عدد‬ ‫المدخنٌن‬ ‫السابمٌن‬ ‫أكثر‬ ‫من‬ ‫المدخنٌن‬ ‫الحالٌٌن‬ Time Trends
  • 69. 69 • Societal and individual factors – exposure in popular films, perception of safeness among certain brand • Advertising and promotion – media sponsorship, high budget spend on advertisement from tobacco companies • “Safer” tobacco – low-tar branding • Access – vending machines and some sales counters selling to minors ‫العوامل‬ ‫االجتماعٌة‬ ‫والفردٌة‬ - ‫التعرض‬ ً‫ف‬ ‫األفالم‬ ‫الشعبٌة‬ ، ‫وتصور‬ ‫السالمة‬ ‫بٌن‬ ‫ماركة‬ ‫معٌنة‬ ‫اإلعالن‬ - ‫رعاٌة‬ ‫وسائل‬ ‫اإلعالم‬ ، ‫إنفاق‬ ‫مٌزانٌة‬ ‫عالٌة‬ ‫على‬ ‫اإلعالن‬ ‫من‬ ‫شركات‬ ‫التبػ‬ ‫التبػ‬ " ‫األكثر‬ ‫ا‬‫ا‬‫ن‬‫أما‬ " - ‫العالمة‬ ‫التجارٌة‬ ‫منخفضة‬ ‫المطران‬ ‫الوصول‬ - ‫آالت‬ ‫البٌع‬ ‫وبعض‬ ‫عدادات‬ ‫المبٌعات‬ ً‫الت‬ ‫تبٌع‬ ‫للماصرٌن‬ Modifiable Risk Factors
  • 70. 70 • Social norms – societal, local, familial, peer communities all affecting smoking; when access to tobacco exists in these communities, it becomes easier to acquire • Individual psychosocial factors – weaker attachment to parents, stronger attachment to peers, rebelliousness and risk-taking • Continued tobacco use – the role of genetics in treatment response; the effect of advertising and “safer” products ‫المعاٌٌر‬ ‫االجتماعٌة‬ - ‫مجتمعات‬ ‫مجتمعٌة‬ ‫ومحلٌة‬ ‫وعائلٌة‬ ‫وألران‬ ‫تؤثر‬ ‫على‬ ‫التدخٌن‬ ‫عندما‬ ‫ٌكون‬ ‫الوصول‬ ‫إلى‬ ‫التبػ‬ ‫اا‬‫د‬‫موجو‬ ً‫ف‬ ‫هذه‬ ‫المجتمعات‬ ، ‫ٌصبح‬ ‫من‬ ‫األسهل‬ ‫الحصول‬ ‫علٌه‬ ‫عوامل‬ ‫نفسٌة‬ ‫اجتماعٌة‬ - ‫تعلك‬ ‫أضعؾ‬ ‫بالوالدٌن‬ ، ‫ارتباط‬ ‫ألوى‬ ‫باأللران‬ ، ‫التمرد‬ ‫وأخذ‬ ‫المخاطر‬ ‫استمرار‬ ‫استخدام‬ ‫التبػ‬ - ‫دور‬ ‫علم‬ ‫الوراثة‬ ً‫ف‬ ‫االستجابة‬ ‫العالجٌة‬ ‫؛‬ ‫تأثٌر‬ ‫اإلعالن‬ ‫ومنتجات‬ " ‫أكثر‬ ‫ا‬‫ا‬‫ن‬‫أما‬ ‖ Modifiable Risk Factors, contd.
  • 71. 71 • Inadequate understanding – underestimation of smoking-related deaths; assumption that young people will stop before potentially harmful side effects occur • Adults not aware of hazards, which can be attributed to underrepresentation of anti- smoking literature and media • Lower price – the lower the price, the more cigarettes and tobacco are consumed ‫الفهم‬ ‫ؼٌر‬ ً‫الكاف‬ - ‫التملٌل‬ ‫من‬ ‫الوفٌات‬ ‫المرتبطة‬ ‫بالتدخٌن‬ ‫؛‬ ‫االفتراض‬ ‫أن‬ ‫الشباب‬ ‫سوؾ‬ ‫تتولؾ‬ ‫لبل‬ ‫أن‬ ‫تحدث‬ ‫آثار‬ ‫جانبٌة‬ ‫ضارة‬ ‫المحتملة‬ ‫الكبار‬ ‫ؼٌر‬ ‫مدركٌن‬ ‫لألخطار‬ ، ً‫الت‬ ‫ٌمكن‬ ‫أن‬ ‫عزى‬ُ‫ت‬ ‫إلى‬ ‫نمص‬ ‫تمثٌل‬ ‫األدب‬ ‫ووسائل‬ ‫اإلعالم‬ ‫المناهضة‬ ‫للتدخٌن‬ ‫انخفاض‬ ‫األسعار‬ - ‫كلما‬ ‫انخفض‬ ‫السعر‬ ، ‫تم‬ ‫استهالن‬ ‫المزٌد‬ ‫من‬ ‫السجائر‬ ‫والتبػ‬ Modifiable Risk Factors, contd.
  • 72. 72 • Several recent studies have suggested the influence that risk factors play when defining tobacco use • One study postulated that 33% of experimentation with tobacco among youth attributed to advertisements‫؛‬ • Two others speculate that cinema/Hollywood glorification of tobacco leads to higher risks‫؛‬ • A third looks at youth with nonsmoking parents smoking as a direct result of movies and popular culture 33 / . Population-AttributableRisk
  • 73. 73 • Price • Increasing the price of tobacco can help stymy sales, especially among youth • Sales would have to increase across all types of tobacco to be effective • Pointed at youth prevent Counter marketing campaigns • ion, but need to be sustained to be effective • Challenge social norms about tobacco use, educate youth on prevention • Advertising bans • Mixed evidence on effectiveness • When a ban is in place, tobacco companies shift to other forms of delivery – electronic, billboards, points of sale - Prevention and Control
  • 74. 74 • Minors’ access restrictions • More stringent interventions are needed to lower youth accessibility of tobacco • School-based tobacco prevention programs • Effective when taught alongside community interventions • Emphasize tobacco-free campuses, negative health effects • Eliminating secondhand smoke • Eliminating smoking indoors helps, but cannot prevent complete exposure • Also helps reduce cigarette consumption in general Prevention and Control,contd.
  • 75. 75 • Best practice in the medical field – ask about past history with tobacco use • Should be acquired during every visit and thoroughly documented in a medical record • Those who smoke should be screened so effective treatment can be given as needed • Cotinine can be measured in blood, saliva, urine – though acquiring these levels not particularly routine in medical care, except in the case of pregnant women’s tobacco intake ‫أفضل‬ ‫الممارسات‬ ً‫ف‬ ‫المجال‬ ً‫الطب‬ - ‫اسأل‬ ‫عن‬ ‫التارٌخ‬ ً‫الماض‬ ‫مع‬ ‫استخدام‬ ‫التبػ‬ ً‫ٌنبؽ‬ ‫الحصول‬ ‫علٌها‬ ‫خالل‬ ‫كل‬ ‫زٌارة‬ ‫وموثمة‬ ‫بدلة‬ ً‫ف‬ ‫السجل‬ ً‫الطب‬ ‫ٌجب‬ ‫فحص‬ ‫أولئن‬ ‫الذٌن‬ ‫ٌدخنون‬ ‫حتى‬ ‫ٌمكن‬ ‫إعطاء‬ ‫العالج‬ ‫الفعال‬ ‫حسب‬ ‫الحاجة‬ ‫ٌمكن‬ ‫لٌاس‬ ‫الكوتٌنٌن‬ ‫بالدم‬ ‫واللعاب‬ ‫والبول‬ - ‫على‬ ‫الرؼم‬ ‫من‬ ‫أن‬ ‫اكتساب‬ ‫هذه‬ ‫المستوٌات‬ ‫لٌس‬ ‫ا‬‫ا‬‫ن‬ٌ‫روت‬ ً‫ف‬ ‫الرعاٌة‬ ‫الطبٌة‬ ، ‫باستثناء‬ ‫حالة‬ ‫تناول‬ ‫النساء‬ ‫الحوامل‬ ‫للتبػ‬ . Screening and Treatment
  • 76. 76 • Comprehensive tobacco prevention and control programs: • Estimated that prevention programs have added 21 years to the life expectancy between 1964 and 1992 for 1.6 million Americans • California spearheaded the prevention programs, and has lower cases of lung cancer, lowest per capita consumption, and low youth smoking rate than the rest of the United States • Tobacco excise taxes • Increased taxation on cigarettes, though remedied by tobacco companies by coupons and other discounting strategies : 21 1964 1992 1.6 . List of Evidence-Based Interventions
  • 77. 77 • Countermarketing campaigns ‫حمالت‬ ‫مكافحة‬ ‫التسوٌق‬ • Smoke-free policies ‫سٌاسات‬ ‫خالٌة‬ ‫من‬ ‫التدخٌن‬ • Public and private insurance coverage ‫التغطٌة‬ ‫التأمٌنٌة‬ ‫العامة‬ ‫والخاصة‬ • Minors’ access restrictions ‫قٌود‬ ‫الوصول‬ ‫إلى‬ ‫القصر‬ • Telephone cessation quitlines ‫جلسات‬ ‫التوقف‬ ‫عن‬ ‫طرٌق‬ ‫الهاتف‬ • Usually not enough funding to sustain • Product changes ‫تغٌٌرات‬ ‫المنتج‬ List of Evidence-Based Interventions, contd.
  • 78. 78 • Key issues for continued research: • Promised public health interventions • Evaluating state prevention and control programs • Industry practice monitoring and counteraction • Translating the decline in youth and adult dependence • Disparate population interventions • Health impacts of changing products • Most cost-effective interventions locally and internationally : Future Research and Demonstration
  • 79. 79 Chapter 6: Diet and Nutrition
  • 80. 80 Consequences and Causes of Poor Nutrition Chart Causes * Social and cultural factors * Poor social/family support * School lunch policies * Lack of education about diet * Food industry marketing (esp. to children) * Eating out * Watch television At-risk Populations * Infants/elderly * Poor * Undereducated * Urbanpopulations * Racial/ethnic minorities * Familywithboth parents working outside the home Consequences * Obesity * CHD * Diabetes * Selected cancers * Dental caries * High blood pressure * Psychological effect Poor Diet/Nutrition: * High in total calories, saturated fat, animal meat, sugar, salt, and alcohol * Low in fruit,vegetables, whole grains, fiber, unsaturated oils Adaptedfrom Remington et al. ( 2010 )
  • 81. 81 • Cardiovascular disease and cancer, followed closely by Type II diabetes, are the three main causes of mortality in the world, and are chiefly caused by an imbalance of nutrition • High blood pressure/cholesterol • Inversely, micronutrient deficiencies account for 15% of childhood diseases ‫أمراض‬ ‫الملب‬ ‫واألوعٌة‬ ‫الدموٌة‬ ‫والسرطان‬ ، ‫ٌتبعها‬ ‫النوع‬ ً‫الثان‬ ‫من‬ ‫مرض‬ ‫السكري‬ ، ً‫ه‬ ‫األسباب‬ ‫الرئٌسٌة‬ ‫الثالثة‬ ‫للوفٌات‬ ً‫ف‬ ‫العالم‬ ، ‫وٌعود‬ ‫سببها‬ ‫بشكل‬ ً‫رئٌس‬ ‫إلى‬ ‫خلل‬ ً‫ف‬ ‫التؽذٌة‬ ‫ارتفاع‬ ‫ضؽط‬ ‫الدم‬ / ‫الكولٌسترول‬ ‫على‬ ‫النمٌض‬ ‫من‬ ‫ذلن‬ ، ‫تمثل‬ ‫النمص‬ ً‫ف‬ ‫المؽذٌات‬ ‫الدلٌمة‬ 15 ٪ ‫من‬ ‫أمراض‬ ‫الطفولة‬ Significance
  • 82. 82 • Lowers chronic disease risk • High levels of dietary fiber, vitamin C, E, folic acid, etc . • Antioxidants and beta-carotenes • Reduction of serum cholesterol • Manages body weight through high contents of water, fiber, low fat content ‫ٌخفض‬ ‫خطر‬ ‫األمراض‬ ‫المزمنة‬ ‫مستوٌات‬ ‫عالٌة‬ ‫من‬ ‫األلٌاؾ‬ ‫الؽذائٌة‬ ، ‫وفٌتامٌن‬ C ،E ، ‫حمض‬ ‫الفولٌن‬ ، ‫إلخ‬ . ‫مضادات‬ ‫األكسدة‬ ‫وبٌتا‬ ‫الكاروتٌنات‬ ‫خفض‬ ‫الكولسترول‬ ً‫ف‬ ‫الدم‬ ‫ٌدٌر‬ ‫وزن‬ ‫الجسم‬ ‫من‬ ‫خالل‬ ‫محتوٌات‬ ‫عالٌة‬ ‫من‬ ‫الماء‬ ‫واأللٌاؾ‬ ‫ومحتوى‬ ‫للٌل‬ ‫الدهون‬ Pathophysiology– Fruits and Vegetables
  • 83. 83 • Studies show that an increase in dietary fiber result in a lower chance of CHD/certain cancers • Increases stool bulk, increases food’s entry and exit times, lowers risk for carcinogens in the body • Soluble fiber can lower cholesterol • Binds bile acids and prevents reabsorption • High fiber, research shows, has an inverse relationship with insulin levels ‫تشٌر‬ ‫الدراسات‬ ‫إلى‬ ‫أن‬ ‫زٌادة‬ ً‫ف‬ ‫األلٌاؾ‬ ‫الؽذائٌة‬ ‫ٌؤدي‬ ‫إلى‬ ‫فرصة‬ ‫ألل‬ ‫من‬ ‫أمراض‬ ‫الشراٌٌن‬ ‫التاجٌة‬ / ‫بعض‬ ‫أنواع‬ ‫السرطان‬ ‫ٌزٌد‬ ‫الجزء‬ ‫األكبر‬ ‫من‬ ‫البراز‬ ، ‫وٌزٌد‬ ‫من‬ ‫أولات‬ ‫دخول‬ ‫وخروج‬ ‫الطعام‬ ، ‫وٌملل‬ ‫من‬ ‫خطر‬ ‫التعرض‬ ‫للسرطان‬ ً‫ف‬ ‫الجسم‬ ‫األلٌاؾ‬ ‫المابلة‬ ‫للذوبان‬ ‫ٌمكن‬ ‫أن‬ ‫تخفض‬ ‫نسبة‬ ‫الكولٌسترول‬ ‫ٌربط‬ ‫األحماض‬ ‫الصفراوٌة‬ ‫وٌمنع‬ ‫إعادة‬ ‫االمتصاص‬ ‫أظهرت‬ ‫األبحاث‬ ‫أن‬ ‫األلٌاؾ‬ ‫المرتفعة‬ ‫لها‬ ‫عاللة‬ ‫عكسٌة‬ ‫مع‬ ‫مستوٌات‬ ‫األنسولٌن‬ Pathophysiology– Dietary Fiber
  • 84. 84 • Different kinds of fat • Trans fat and saturated fats – adverse toward health • Omega-3 fatty acids and monounsaturated fats – benefit health • Reduction of saturated fat by intake by small increments lowers heart attack risk rates by 25% • Hypothesis is that omega-3 fatty acids alter the immune system’s response to cancer • Red meat – both positive and negative effects • + — high in iron, vitaminsA, B12, protein • - — risk of colorectal cancer, formation of mutagenic free radicals in stomach - 3 - 25 3 - + - A B 12 - Pathophysiology– Dietary Fat and Red Meat
  • 85. 85 • Low fat milk intake shown to lower risk of osteoporosis, CVD, colon cancer • Contains fatty acids • Calcium content lowers lipid collection and higher lipid excretion rates • 2 % and whole milk are high in saturated fat and calories ‫أظهر‬ ‫تناول‬ ‫الحلٌب‬ ‫منخفض‬ ‫الدهون‬ ‫انخفاض‬ ‫مخاطر‬ ‫اإلصابة‬ ‫بهشاشة‬ ‫العظام‬ ، ‫األمراض‬ ‫الملبٌة‬ ‫الوعائٌة‬ ‫وسرطان‬ ‫المولون‬ ‫ٌحتوي‬ ‫على‬ ‫األحماض‬ ‫الدهنٌة‬ ‫ٌملل‬ ‫محتوى‬ ‫الكالسٌوم‬ ‫من‬ ‫جمع‬ ‫الدهون‬ ‫وارتفاع‬ ‫معدالت‬ ‫إفراز‬ ‫الدهون‬ 2 ٪ ‫والحلٌب‬ ‫كامل‬ ‫الدسم‬ ‫عالٌة‬ ‫السعرات‬ ‫الحرارٌة‬ ‫والدهون‬ ‫المشبعة‬ Pathophysiology– Dairy Products and Milk
  • 86. 86 • Caloric sweeteners – “all caloric carbohydrate sweeteners, such as table sugar, honey, and high fructose corn syrup, and excludes naturally occurring sugars and artificial sweeteners‖ (Remington et al. 2010 ( • Consumption of beverages with caloric sweeteners increases risk of obesity and cavities • Increased consumption over the last 30 years has shown spiked levels of excessive consumption ‫محلٌات‬ ‫السعرات‬ ‫الحرارٌة‬ - " ‫جمٌع‬ ‫المحلٌات‬ ‫الكربوهٌدرات‬ ‫الحرارٌة‬ ، ‫مثل‬ ‫سكر‬ ‫المائدة‬ ‫والعسل‬ ‫وشراب‬ ‫الذرة‬ ً‫عال‬ ‫الفركتوز‬ ، ً‫وتستثن‬ ‫السكرٌات‬ ‫الطبٌعٌة‬ ‫والمحلٌات‬ ‫االصطناعٌة‬ " ‫استهالن‬ ‫المشروبات‬ ‫مع‬ ‫المحلٌات‬ ‫السعرات‬ ‫الحرارٌة‬ ‫ٌزٌد‬ ‫من‬ ‫خطر‬ ‫السمنة‬ ‫وتسوس‬ ‫األسنان‬ ‫أظهرت‬ ‫زٌادة‬ ‫االستهالن‬ ‫على‬ ‫مدى‬ ‫السنوات‬ ‫الثالثٌن‬ ‫الماضٌة‬ ‫مستوٌات‬ ‫مرتفعة‬ ‫من‬ ‫االستهالن‬ ‫المفرط‬ Pathophysiology– Sugar-Sweetened Beverages
  • 87. 87 • U.S. men – higher intake of red meat, dairy • U.S. women – higher intake of fruits, vegetables, salts, cholesterol • Greater importance on eating healthily - - High-Risk Populations– Sex
  • 88. 88 • Young and old are susceptible to poor nutrition • Young – targeted by food industry to eat energy-dense foods; poor diet habits developed in youth tend to carry into adulthood • Old – lower metabolism and physical activity, changes in taste and smell; 80% of elderly need improvements ‫الصؽار‬ ‫والكبار‬ ‫عرضة‬ ‫لسوء‬ ‫التؽذٌة‬ ‫الشباب‬ - ‫الذٌن‬ ‫تستهدفهم‬ ‫صناعة‬ ‫األؼذٌة‬ ‫لتناول‬ ‫األطعمة‬ ‫الؽنٌة‬ ‫بالطالة‬ ‫؛‬ ‫العادات‬ ‫الؽذائٌة‬ ‫السٌئة‬ ً‫الت‬ ‫تطورت‬ ً‫ف‬ ‫الشباب‬ ‫تمٌل‬ ‫إلى‬ ‫تحملها‬ ‫إلى‬ ‫مرحلة‬ ‫البلوغ‬ ‫العمر‬ - ‫انخفاض‬ ‫األٌض‬ ‫والنشاط‬ ً‫البدن‬ ، ‫والتؽٌرات‬ ً‫ف‬ ‫الذوق‬ ‫والرائحة‬ ‫؛‬ 80 ٪ ‫من‬ ‫كبار‬ ‫السن‬ ‫بحاجة‬ ‫إلى‬ ‫تحسٌنات‬ High-Risk Populations– Age and Life Course
  • 89. 89 • African Americans and Caucasians increased total energy-dense foods from 1971 and 2002 • Racially diverse populations, on average in the United States, have lower access to fresh fruits and vegetables • Sociocultural and behavioral factors influence the dietary variety of the three major racial groups in the United States • African American, Caucasian (white), and Mexican American 1971 2002 ( ) High-Risk Populations– Race and Ethnicity
  • 90. 90 • As wealth decreases, direct relationship between the ability to acquire healthy foods • Similarly, energy-dense foods are more likely to be consumed by those with lower income • This is partly due to the inaccessibility, such as the high price and the lack of larger stores that support a variety of nutritional fruits and vegetables in urban/low- income areas / . High-Risk Populations– Income
  • 91. 91 • Income and education have a corollary relationship, so both affect chronic disease outcome at similar rates • Higher consumption of fruits/vegetables has been linked to higher education, and those with the most education are more likely to spend more per capita on these foods ‫الدخل‬ ‫والتعلٌم‬ ‫له‬ ‫عاللة‬ ‫طبٌعٌة‬ ، ‫لذلن‬ ‫كل‬ ‫من‬ ‫ٌؤثر‬ ‫على‬ ‫نتائج‬ ‫األمراض‬ ‫المزمنة‬ ‫بمعدالت‬ ‫مماثلة‬ ‫وارتبط‬ ‫ارتفاع‬ ‫استهالن‬ ‫الفاكهة‬ / ‫الخضار‬ ‫بالتعلٌم‬ ً‫العال‬ ، ‫ومن‬ ‫المرجح‬ ‫أن‬ ‫ٌنفك‬ ‫أكثر‬ ‫هؤالء‬ ‫الذٌن‬ ‫ٌنفمون‬ ‫أكثر‬ ‫على‬ ‫التعلٌم‬ ‫نصٌب‬ ‫الفرد‬ ‫من‬ ‫هذه‬ ‫األؼذٌة‬ . High-Risk Populations– Education
  • 92. 92 • Geographic distribution • Developed countries have higher diets with animal products and saturated fats • Fish consumed more frequently in coastal regions • Industrial development and immigration • As a country shifts from underdeveloped to developed, chronic disease patterns can occur in as little as one generation • Time trends • Larger portion sizes appeared over time • Higher kcal consumption for both men (+196kcal) and women (+283 kcal) +( 196 kcal ) +( 283 ) High-Risk Populations– Other
  • 93. 93 • Individual preference • Appearance, taste, texture • Community and family • Environments that support positive food choices make it easier to follow a healthy diet • Lowest cost foods – least nutritious • Fast-food density has been shown to be connected to poor nutrition • Parental modeling affects familial diet among adolescents • Families with both parents working outside the home have increased chances of seeking nutrition in energy-dense, unhealthy foods - Barriers to Healthy Eating
  • 94. 94 • Dietary Guidelines created by the US Department of Health and Human Service • Areas of consideration include adequate nutrients within calorie needs, weight management, physical activity, fats, carbohydrates, sodium and potassium, alcoholic beverages, food safety • Emphasizes a balanced diet • From ―Basic Seven‖ to ―MyPlate‖ " Basic Seven " " MyPlate" Primary Prevention Policy Anearlynutritional guidedevelopedinthe 1940s by the U.S.Department of Agriculture, CCBY 2.0, viaWikimedia Commons
  • 95. 95 Primary Prevention Policy, contd. The current nutritional policy,MyPlate,developedin 2011.Image by OpenStax College, CCBY 3.0,via WikimediaCommons Food Pyramidnutritional policy,developedin1992 by the USDA. Image by the USDA College, Public Domain, viaWikimediaCommons
  • 96. 96 • Various nutritional analyses that make up the National Nutrition Monitoring System survey. • Food disappearance programs chart the available consumable foods . Food disappearance data provide information about quantities of foods and nutrients in retail food distribution each year. • Food questionnaires used by epidemiologists to chart frequency of intake and a list of consumed foods • Effective because participants are likely to remember recent food choices, as opposed to long-term dietary analyses Surveillance
  • 97. 97 • Origins in the 1980s – It’s a healthy nutrition promotion started with National Cancer Institute /Kellogg's Campaign • National Fruit and Vegetable Program • 1 % or Less Campaign" The 1% or Less Campaign sought to shift consumption from whole milk, 2% milk, or high-fat milk products to 1%, skim milk, or low-fat milk products” • Site-based interventions 1. Workplace 2. Schools 3. Faith-based 1980 s - / Kelloggs 1 Large-Scale Initiatives “examples of publid health interventions”
  • 98. 98 • Population-specific initiatives • Community approaches in urban areas • Federal safety net • School lunch programs • Supplemental Nutrition Assistance Program (formerly Food Stamps) • Eliminating racial disparities • Heart to Heart Program ( ) Large-Scale Initiatives, contd.
  • 99. 99 • Policy approaches 1. Agricultural policies – which crops are produced 2. Nutrition right-to-know – advocacy groups attempt to make nutritional assessments in restaurants more accessible 3. School wellness policies – improved physical activity programs and healthy food options in vending machines 4. Advertising to children - - - Large-Scale Initiatives, contd.
  • 101. 10 1 1. Affects physiological, psychological, societal of health 2. Reduces chance of premature death, developing CHD/diabetes/colon cancer 3. Promotes healthy bones and joints • Less falls and functional dependency in older adults / / Consequences
  • 102. 10 2 Consequences, contd. Causes * Psychosocial (motivation * Self-efficacy * Social/cultural factors * Physical environment * Perceptions of competence in sports * Enjoyment At-risk Populations * Older adults * Adolescents * Women * Those with low incomes * Overweight adults * Those with conditions that limit movement * Injured or disabled individuals Consequences * Obesity * CHD * Diabetes * Colon cancer * High blood pressure * Falls/osteoporosis * Psychological effects Physical Inactivity Adaptedfrom Remington et al. ( 2010 )
  • 103. 10 3 • Physical activity“PA” – movement produced by skeletomuscular system that burns energy • Occupational and nonoccupational (leisure, family, transportation, household, other activities) • Contrasted with exercise • Exercise • Repetitive movement used to maintain physical fitness • Physical fitness • Achievable attributes related to physical activity • Cardiorespiratory, muscular, metabolic, morphological, motor • Frequency – number of times PA is performed • Duration – minutes/hours PA is performed ‫النشاط‬ ً‫البدن‬ - ‫الحركة‬ ً‫الت‬ ‫ٌنتجها‬ ‫النظام‬ ً‫العضل‬ ً‫العظم‬ ‫الذي‬ ‫ٌحرق‬ ‫الطالة‬ ‫المهنٌة‬ ‫وؼٌر‬ ‫المهنٌة‬ ‫ٌتنالض‬ ‫مع‬ ‫ممارسة‬ ‫الرٌاضة‬ ‫ممارسه‬ ‫الرٌاضه‬ ‫حركة‬ ‫متكررة‬ ‫تستخدم‬ ‫للحفاظ‬ ‫على‬ ‫اللٌالة‬ ‫البدنٌة‬ ‫اللٌالة‬ ‫البدنٌة‬ ‫السمات‬ ‫المابلة‬ ‫للتحمٌك‬ ‫المتعلمة‬ ‫بالنشاط‬ ً‫البدن‬ ‫تنفسٌة‬ ‫للبٌة‬ ، ‫عضلٌة‬ ، ‫أٌضٌة‬ ، ‫مورفولوجٌة‬ ، ‫حركٌة‬ ‫التردد‬ - ‫عدد‬ ‫المرات‬ ً‫الت‬ ‫ٌتم‬ ‫فٌها‬ ‫إجراء‬ PA ‫المدة‬ - ‫دلٌمة‬ / ‫ساعة‬ ‫ٌتم‬ ‫تنفٌذ‬ PA Pathophysiology
  • 104. 10 4 • Intensity‫الشدة‬ • METs : The activitymetaboliccost dividedby the resting metabolicrate • MET-minutes METmultiplied by minutes “ TheadtivityMETlevel ×minutes of partidipation” • Kcal – MET-minutes times body weight “Met-minutes ×(body weight inkilograms/60kg(” • Light intensity – PA < 3 METs • Moderate intensity PA between3 to 6 METs • Vigorous intensity – PA > 6 METs • Activity dose ‫جرعة‬ ‫نشاط‬ • Leisure – free choice periods of PA ‫حرٌة‬ ‫اختٌار‬ ‫الفترات‬ • Occupation PA – done during paid employment ‫المٌام‬ ‫به‬ ‫أثناء‬ ‫العمل‬ ‫المأجور‬ Pathophysiology,contd.
  • 105. 10 5 • Transportation PA – done while traveling to a destination • Household PA – done during the maintenance of the home • Family PA – done when performing the care of others • PA affects all body systems that deal with the production of energy • Lower risk of CHD PA - PA - PA - PA Pathophysiology,contd.
  • 106. 10 6 • Needs constant updating to chart meaningful activity patterns • Two primary population-based surveys used to measure physical activity: 1. National Health Interview Survey • Household survey • Frequency, self-assessed intensity, duration 2. Behavioral Risk Factor Surveillance System • Phone-based survey • Type, frequency, duration : Distribution
  • 107. 10 7 • Surveillance estimations of PA were created to unify results across the board: • Recommended PA – moderate-intensity workouts, 30 minutes/day, 5 days/week; vigorous-intensity workouts, 20 minutes/day, 3 days/week • Insufficient PA – more than 10 minutes spent doingmoderate- to vigorous-intensityworkouts,but infrequentlevels • Inactivity – Less than 10 minutes/week spent doing moderate- to vigorous- intensity workouts P A: P A - 30 / 5 / . 20 / 3 / P A - 10 - - 10 / Distribution,contd.
  • 108. 10 8 • Physical inactivity increases with age and is more common among women and ethnic minorities • Highest among men between 18-24 years old • Among adolescents, two guidelines for physical activity: • Daily physical movement in lifestyle, and • Three+ sessions of vigorous physical activity per week 18 24 : + High-Risk Groups
  • 109. 109 • Highest prevalence of activity was in urban centers, and the lowest in rural areas • Built environments may play a part in how much physical activity a population performs • Land use patterns, transportation systems, sidewalk development, trail systems, etc . . Geographic Distribution
  • 110. 110 • Though promoted thoroughly, proportion of adults who regularly exercise hasn’t undergone major growth over the years • Adolescents have the same trend over time Time Trends
  • 111. 111 • Personal, psychological, and confidence levels all attribute to a person’s choice to have a physically active lifestyle. • Barriers include ―lack of time, motivation, social support, facilities, and knowledge of ways to become more physically active‖ )Remington et al. 2010 ) • Health conditions also contribute to physical inactivity, and the positive response felt by not being inactive may worsen the health condition. ‫إن‬ ‫المستوٌات‬ ‫الشخصٌة‬ ‫والنفسٌة‬ ‫والثمة‬ ‫تعود‬ ‫جمٌعها‬ ‫إلى‬ ‫اختٌار‬ ‫الشخص‬ ‫لنمط‬ ‫حٌاة‬ ‫نشط‬ ‫اا‬ٌ‫جسد‬ ‫تشمل‬ ‫الحواجز‬ " ‫للة‬ ‫الولت‬ ، ‫والحافز‬ ، ‫والدعم‬ ً‫االجتماع‬ ، ‫والمرافك‬ ، ‫والمعرفة‬ ‫بطرق‬ ‫لتصبح‬ ‫أكثر‬ ‫ا‬‫ا‬‫ط‬‫نشا‬ ‫اا‬ٌ‫بدن‬ " ‫تساهم‬ ‫الظروؾ‬ ‫الصحٌة‬ ‫اا‬‫ض‬ٌ‫أ‬ ً‫ف‬ ‫عدم‬ ‫النشاط‬ ً‫البدن‬ ، ‫ولد‬ ‫تؤدي‬ ‫االستجابة‬ ‫اإلٌجابٌة‬ ً‫الت‬ ‫ٌشعر‬ ‫بها‬ ‫عدم‬ ‫النشاط‬ ‫إلى‬ ‫تدهور‬ ‫الحالة‬ ‫الصحٌة‬ Modifiable Risk Factors
  • 112. 112 • In the United States, national health objectives are developed to set guidelines for activity objectives 1. Healthy People 2010 2. US Preventative Services Task Force 3. The Guide to Clinical Preventive Services • Goals include to establish recommendations for population health, increase overall physical activity in a variety of strata, reduce leisure time that lacks physical activity, etc . ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ، ‫ٌتم‬ ‫تطوٌر‬ ‫األهداؾ‬ ‫الصحٌة‬ ‫الوطنٌة‬ ‫لوضع‬ ‫مبادئ‬ ‫توجٌهٌة‬ ‫ألهداؾ‬ ‫النشاط‬ ‫الناس‬ ‫األصحاء‬ 2010 ‫فرلة‬ ‫العمل‬ ‫المعنٌة‬ ‫بالخدمات‬ ‫الولائٌة‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ‫دلٌل‬ ‫الخدمات‬ ‫الولائٌة‬ ‫السرٌرٌة‬ ‫وتشمل‬ ‫األهداؾ‬ ‫وضع‬ ‫توصٌات‬ ‫لصحة‬ ‫السكان‬ ، ‫وزٌادة‬ ‫النشاط‬ ً‫البدن‬ ‫العام‬ ً‫ف‬ ‫مجموعة‬ ‫متنوعة‬ ‫من‬ ‫الطبمات‬ ، ‫والحد‬ ‫من‬ ‫ولت‬ ‫الفراغ‬ ‫الذي‬ ‫ٌفتمر‬ ‫إلى‬ ‫النشاط‬ ً‫البدن‬ ، ‫إلخ‬ . Prevention
  • 113. 113 • Policy changes frequently begin as grassroots programs • Recently, however, many coordinated efforts between school systems, public health offices, and these grassroots programs have been implemented. • Examples of policy efforts include ease of access to bicyclists and walkers, requiring physical education in school, activity programs through local recreation departments. • Environmental factors include the inclusion of safe stairwells in lobbies, providing an alternative to elevators ‫تؽٌٌرات‬ ‫السٌاسة‬ ‫تبدأ‬ ‫بشكل‬ ‫متكرر‬ ‫كبرامج‬ ‫شعبٌة‬ ‫ومع‬ ‫ذلن‬ ، ‫تم‬ ً‫ف‬ ‫اآلونة‬ ‫األخٌرة‬ ‫تنفٌذ‬ ‫العدٌد‬ ‫من‬ ‫الجهود‬ ‫المنسمة‬ ‫بٌن‬ ‫النظم‬ ‫المدرسٌة‬ ‫ومكاتب‬ ‫الصحة‬ ‫العامة‬ ‫وهذه‬ ‫البرامج‬ ‫على‬ ‫مستوى‬ ‫الماعدة‬ ‫ومن‬ ‫أمثلة‬ ‫الجهود‬ ‫المبذولة‬ ً‫ف‬ ‫مجال‬ ‫السٌاسة‬ ‫العامة‬ ‫سهولة‬ ‫الوصول‬ ‫إلى‬ ً‫راكب‬ ‫الدراجات‬ ‫النارٌة‬ ‫والمشاة‬ ، ‫األمر‬ ‫الذي‬ ‫ٌتطلب‬ ‫التعلٌم‬ ً‫البدن‬ ً‫ف‬ ‫المدرسة‬ ، ‫وبرامج‬ ‫األنشطة‬ ‫من‬ ‫خالل‬ ‫ألسام‬ ‫الترفٌه‬ ‫المحلٌة‬ . ‫وتشمل‬ ‫العوامل‬ ‫البٌئٌة‬ ‫إدراج‬ ‫ساللم‬ ‫آمنة‬ ً‫ف‬ ‫ردهات‬ ، ‫وتوفٌر‬ ‫بدٌل‬ ‫للمصاعد‬ Environmental and Policy Factors
  • 114. 114 • Transtheoretical Model • Precontemplation, contemplation, action, maintenance, relapse • Project Active – an individual-based project • Home exercise vs. traditional exercise (health club/gym) • Home exercise group aimed for thirty minutes of moderate activity per day, unique to the user’s lifestyle, whereas tracitional group took exerdise programs offered by the health club • By the end of the study, smaller decline in home exercise group - ( / ) Public Health Interventions
  • 115. 115 • Work sites, schools, assisted living facilities – all are options for intervention-based programs • Transdisciplinary partnerships are very effective ways of promotion • Example – teams fromthe Department of Transportation, state education systems, nonprofit organizations, and healthcare facilities worked together to form the National Safe Routes to School Task Force • National Coalition for Promoting Physical Activity (NCPPA) • Presicent’s Coundil on Physidal Fitness anc Sports (PCPFS) • State Governor’s Coundil on Physidal Fitness • State Health Department Physical Activity Initiatives and Campaigns - : Public Health Interventions, contd.
  • 116. 116 • More work done with questionnaire development and surveys • Quantification of popular trends in physical activities • A difficulty to overcome in the research is inaccuracy due to self-analysis ‫تم‬ ‫إنجاز‬ ‫المزٌد‬ ‫من‬ ‫العمل‬ ‫من‬ ‫خالل‬ ‫تطوٌر‬ ‫االستبٌانات‬ ‫والدراسات‬ ‫االستمصائٌة‬ ‫المٌاس‬ ً‫الكم‬ ‫لالتجاهات‬ ‫الشعبٌة‬ ً‫ف‬ ‫األنشطة‬ ‫البدنٌة‬ ‫صعوبة‬ ً‫ف‬ ‫التؽلب‬ ‫على‬ ‫هذا‬ ‫البحث‬ ً‫ه‬ ‫عدم‬ ‫الدلة‬ ‫بسبب‬ ‫التحلٌل‬ ً‫الذات‬ Measurement of Physical Activity – Future Research
  • 117. 117 • Relatively recent adoption of guidelines for school programs that promote physical activity established a framework for analysis • Additional studies needed to strengthen findings, especially in young women, and the balance between adequate nutrition and activity levels ‫أدى‬ ‫االعتماد‬ ‫الحدٌث‬ ‫ا‬‫ا‬ٌ‫نسب‬ ‫للمبادئ‬ ‫التوجٌهٌة‬ ‫للبرامج‬ ‫المدرسٌة‬ ً‫الت‬ ‫تعزز‬ ‫النشاط‬ ً‫البدن‬ ‫إلى‬ ‫وضع‬ ‫إطار‬ ‫للتحلٌل‬ ‫هنان‬ ‫حاجة‬ ‫لدراسات‬ ‫إضافٌة‬ ‫لتعزٌز‬ ‫النتائج‬ ، ‫ال‬ ‫سٌما‬ ً‫ف‬ ‫الشابات‬ ، ‫والتوازن‬ ‫بٌن‬ ‫التؽذٌة‬ ‫الكافٌة‬ ‫ومستوٌات‬ ‫النشاط‬ Adolescent Physical Activity – Future Research
  • 118. 118 • Continued efforts required to effect policy changes designed to promote activity in communities 1. Working with neighborhood coalitions 2. Writing to local papers 3. Lobbying for changes made by city planners 4. Forming position statements for agencies • Funding is required to research effectiveness of already established programs, especially those in disadvantaged communities ‫استمرار‬ ‫الجهود‬ ‫المطلوبة‬ ‫إلحداث‬ ‫تؽٌٌرات‬ ً‫ف‬ ‫السٌاسات‬ ‫تهدؾ‬ ‫إلى‬ ‫تعزٌز‬ ‫النشاط‬ ً‫ف‬ ‫المجتمعات‬ ‫العمل‬ ‫مع‬ ‫تحالفات‬ ‫الجوار‬ ‫الكتابة‬ ً‫ف‬ ‫الصحؾ‬ ‫المحلٌة‬ ‫الضؽط‬ ‫من‬ ‫أجل‬ ‫التؽٌٌرات‬ ً‫الت‬ ‫لام‬ ‫بها‬ ‫مخططو‬ ‫المدن‬ ‫تشكٌل‬ ‫بٌانات‬ ‫المولؾ‬ ‫للوكاالت‬ ‫التموٌل‬ ‫مطلوب‬ ‫للبحث‬ ً‫ف‬ ‫فعالٌة‬ ‫البرامج‬ ‫المنشأة‬ ‫بالفعل‬ ، ‫خاصة‬ ‫تلن‬ ‫الموجودة‬ ً‫ف‬ ‫المجتمعات‬ ‫المحرومة‬ Environmental and Policy Changes – Future Research
  • 119. 119 • Baby boomer generation in need of study to understand efficacy and effectiveness of policies centered around the elderly ‫جٌل‬ ‫جٌل‬ ‫العامل‬ ً‫ف‬ ‫حاجة‬ ‫إلى‬ ‫دراسة‬ ‫لفهم‬ ‫فعالٌة‬ ‫وفعالٌة‬ ‫السٌاسات‬ ً‫الت‬ ‫تركز‬ ‫على‬ ‫كبار‬ ‫السن‬ Older Adults – Future Research
  • 121. 12 1 • One of the ten major causes of death in the United States since the 1930s • Responsible for hundreds of thousands of deaths each year • Underreported because diabetes leads to the cause of death but doesn’t cause death itself ‫أحد‬ ‫األسباب‬ ‫الرئٌسٌة‬ ‫العشرة‬ ‫للوفاة‬ ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ‫منذ‬ ‫الثالثٌنٌات‬ ‫مسؤولة‬ ‫عن‬ ‫مئات‬ ‫اآلالف‬ ‫من‬ ‫الوفٌات‬ ‫كل‬ ‫عام‬ ‫ال‬ ‫ٌتم‬ ‫اإلبالغ‬ ‫عنه‬ ‫ألن‬ ‫مرض‬ ‫السكري‬ ‫ٌؤدي‬ ‫إلى‬ ‫سبب‬ ‫الوفاة‬ ‫ولكنه‬ ‫ال‬ ‫ٌسبب‬ ‫الموت‬ ‫نفسه‬ Significance By Blausen.com Staff. "Blausen gallery 2014". WikiversityJournal of Medicine. (Ownwork) CC BY3.0,via Wikimedia Commons
  • 122. 12 2 • Diabetes leads to various life-threatening complications: • CVD • Blindness • Kidney failure • Injury, infection, amputation of limbs • Depression • Diabetes carries a huge economic impact • Partly due to long-term complications and prescription costs : Significance, contd.
  • 123. 12 3 • In general, Type II diabetics are unable to utilize insulin in the liver/muscle despite regular insulin production in these places • As disease progresses, pancreas fails to increase insulin secretion • Prediabetics: • Impaired glucose tolerance (IGT) • Impaired fasting glucose (IFG) • Two classifications of diabetes complications • Microvascular • Macrovascular / : ( IGT) ( IFG) Pathophysiology
  • 124. 12 4 • Relies on health survey data for monitoring • No distinction between Types I and II • Type II accounts for the majority of all diabetes cases, estimated at around 90%-95% • Type II usually found in older adults, whereas Type I is associated with minors and adolescents ‫ٌعتمد‬ ‫على‬ ‫بٌانات‬ ‫المسح‬ ً‫الصح‬ ‫للرصد‬ ‫ال‬ ‫ٌوجد‬ ‫تمٌٌز‬ ‫بٌن‬ ‫النوعٌن‬ ‫األول‬ ً‫والثان‬ ‫النوع‬ ً‫الثان‬ ‫ٌمثل‬ ‫ؼالبٌة‬ ‫حاالت‬ ‫مرض‬ ‫السكري‬ ، ً‫والت‬ ‫تمدر‬ ً‫بحوال‬ 90 ٪ - 95 ٪ ‫النوع‬ ً‫الثان‬ ‫عادة‬ ‫ما‬ ‫ٌوجد‬ ً‫ف‬ ‫كبار‬ ‫السن‬ ، ‫بٌنما‬ ‫ٌرتبط‬ ‫النوع‬ ‫األول‬ ‫بالماصرٌن‬ ‫والمراهمٌن‬ Descriptive Epidemiology
  • 125. 12 5 • Not an equal distribution • The elderly, racial minorities, lower socioeconomic status, family history • Increased exposure to a variety of health complications, all of which increase substantially with age • Tend to be higher in minority populations in the United States • Native Americans/Alaska Natives two to three times higher than other US adults / High-Risk Groups
  • 126. 12 6 • Those with lower socioeconomic status, i.e. those with lower education and income, have an increased risk, as well • Common factors include less access to care, less opportunities for education about diabetes, high stress levels • Family history of diabetes strongly affects risk factor • 2.4times greater odds of acquiring Type II when there is a moderate familial risk • 5.8times greater when there is a high familial risk 2.4 5.8 High-Risk Groups, contd.
  • 127. 12 7 • In the United States, clear geographic regions show patterns in developing diabetes • South/Southeastern at high risk, due to ethic makeup and obesity • Where there are higher levels of obesity there are higher levels of diabetes • Susceptibility to Type I diabetes shows a similarity across the different regions of the world ً‫ف‬ ‫الوالٌات‬ ‫المتحدة‬ ، ‫تظهر‬ ‫المناطك‬ ‫الجؽرافٌة‬ ‫الواضحة‬ ‫ا‬‫ا‬‫ط‬‫أنما‬ ً‫ف‬ ‫تطوٌر‬ ‫مرض‬ ‫السكري‬ ‫الجنوب‬ / ‫الجنوب‬ ً‫الشرل‬ ً‫ف‬ ‫خطر‬ ‫كبٌر‬ ، ‫بسبب‬ ‫التركٌب‬ ً‫األخالل‬ ‫والسمنة‬ ‫حٌث‬ ‫توجد‬ ‫مستوٌات‬ ‫أعلى‬ ‫من‬ ‫السمنة‬ ‫هنان‬ ‫مستوٌات‬ ‫أعلى‬ ‫من‬ ‫مرض‬ ‫السكري‬ ‫الحساسٌة‬ ‫تجاه‬ ‫النوع‬ ‫األول‬ ‫من‬ ‫السكري‬ ‫تظهر‬ ‫ا‬‫ا‬‫ه‬‫تشاب‬ ً‫ف‬ ‫مختلؾ‬ ‫مناطك‬ ‫العالم‬ Geographic Distribution
  • 128. 12 8 • Over time, diabetes has been one of the only CVD risk that has increased • Due to age, ethnic diversity, obesity problem • Increasing in all demographics over time • This is true for both Types I and II • However, due to timely response, medications and therapies, there hasn’t been an increase in diabetes-related complications over time ‫مع‬ ‫مرور‬ ‫الولت‬ ، ‫كان‬ ‫السكري‬ ‫اا‬‫د‬‫واح‬ ‫من‬ ‫مخاطر‬ ‫األمراض‬ ‫الملبٌة‬ ‫الوعائٌة‬ ‫الوحٌدة‬ ً‫الت‬ ‫ازدادت‬ ‫بسبب‬ ‫السن‬ ‫والتنوع‬ ً‫العرل‬ ‫ومشكلة‬ ‫السمنة‬ ‫زٌادة‬ ً‫ف‬ ‫جمٌع‬ ‫الدٌموؼرافٌات‬ ‫مع‬ ‫مرور‬ ‫الولت‬ ‫وٌنطبك‬ ‫ذلن‬ ‫على‬ ‫كال‬ ‫النوعٌن‬ ‫األول‬ ً‫والثان‬ ‫ومع‬ ‫ذلن‬ ، ‫بسبب‬ ‫االستجابة‬ ً‫ف‬ ‫الولت‬ ‫المناسب‬ ، ‫واألدوٌة‬ ‫والعالجات‬ ، ‫لم‬ ‫تكن‬ ‫هنان‬ ‫زٌادة‬ ً‫ف‬ ‫المضاعفات‬ ‫المرتبطة‬ ‫بداء‬ ‫السكري‬ ‫على‬ ‫مر‬ ‫الزمن‬ Time Trends
  • 129. 129 • Very few modifiable risks for Type I diabetes • However, research has shown that there is some correlation between environmental factors • Nutrition and viruses may come into play • Type I patients were 43% more likely to have breastfed for less than 3 months and 63% more likely to consume cow’s milk before age three • Enteroviruses • Stress, higher maternal age at birth, birth order, birth weight, overnutrition are other possible risks ‫للٌل‬ ‫جدا‬ ‫من‬ ‫المخاطر‬ ‫المابلة‬ ‫للتعدٌل‬ ‫لمرض‬ ‫السكري‬ ‫من‬ ‫النوع‬ ‫األول‬ ‫ومع‬ ‫ذلن‬ ، ‫فمد‬ ‫أظهرت‬ ‫األبحاث‬ ‫أن‬ ‫هنان‬ ‫بعض‬ ‫االرتباط‬ ‫بٌن‬ ‫العوامل‬ ‫البٌئٌة‬ ‫التؽذٌة‬ ‫والفٌروسات‬ ‫لد‬ ‫تلعب‬ ‫دورا‬ ‫كان‬ ‫المرضى‬ ‫من‬ ‫النوع‬ ‫األول‬ ‫أكثر‬ ‫عرضة‬ ‫بنسبة‬ 43 ٪ ‫للرضاعة‬ ‫الطبٌعٌة‬ ‫لمدة‬ ‫ألل‬ ‫من‬ 3 ‫أشهر‬ ‫و‬ 63 ٪ ‫أكثر‬ ‫عرضة‬ ‫الستهالن‬ ‫حلٌب‬ ‫البمر‬ ‫لبل‬ ‫سن‬ ‫الثالثة‬ ‫الفٌروسات‬ ‫المعوٌة‬ ‫اإلجهاد‬ ، ‫ارتفاع‬ ‫سن‬ ‫األم‬ ‫عند‬ ‫الوالدة‬ ، ‫ترتٌب‬ ‫الوالدة‬ ، ‫وزن‬ ‫الوالدة‬ ، ‫التؽذٌة‬ ً‫ه‬ ‫مخاطر‬ ‫محتملة‬ ‫أخرى‬ Modifiable Risk Factors– Type I
  • 130. 130 • Obesity – 80% of patients obese at diagnosis • Distribution of fat also plays a role • Those with a higher hip-to-waist ratio are more susceptible • Dietary elements • Whole grains, coffee, magnesium, peanut butter/nuts, low-fat dairy products, moderate alcohol consumption all been shown to reduce risk • High saturated fat diets and increase red meat consumption have been linked to an increased risk of Type II - 80 / Modifiable Risk Factors– Type II
  • 131. 131 • Lack of physical activity • Almost a linear relationship between frequency/intensity to diminished risks of Type II Diabetes • Smoking • Increased risk factor • Factors that reduce chance of developing Type II: • Relatively low BMI, high fiber diet, high polyunsaturated fat diet, 30 minutes of moderate exercise a day, smoke-free, less than half a serving of alcohol per day / : 30 Modifiable Risk Factors– Type II, contd.
  • 132. 132 • Often external factors that are intrinsic to developing Type II often increase the risk of complications • Risks can be reduced by working with health care professionals to manage macro- and microvascular complications ‫اا‬‫ب‬‫ؼال‬ ‫ما‬ ‫تؤدي‬ ‫العوامل‬ ‫الخارجٌة‬ ً‫الت‬ ‫تؤثر‬ ‫اا‬ٌ‫جوهر‬ ً‫ف‬ ‫تطوٌر‬ ‫النمط‬ ً‫الثان‬ ‫إلى‬ ‫زٌادة‬ ‫خطر‬ ‫حدوث‬ ‫مضاعفات‬ ‫ٌمكن‬ ‫تملٌل‬ ‫المخاطر‬ ‫من‬ ‫خالل‬ ‫العمل‬ ‫مع‬ ‫المتخصصٌن‬ ً‫ف‬ ‫الرعاٌة‬ ‫الصحٌة‬ ‫إلدارة‬ ‫المضاعفات‬ ‫الكلٌة‬ ‫واألوعٌة‬ ‫الدموٌة‬ ‫الدلٌمة‬ Complications
  • 133. 133 Causes, Consequences, Risk PopulationsChart Causes * Obesity * Physicalinactivity * Poor diet * Smoking At-risk Populations * Elderly * Poor * Less educated * Minorities * Persons witha familyhistory of diabetes Consequences * Coronaryheart disease * Stroke * Peripheral vascular disease * End-stage renal disease * Blindness * Lower leg amputations * Disability * Depression * Poor pregnancy outcomes * Premature mortality Type 2 Diabetes Adaptedfrom Remington et al. ( 2010 )