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Chapter 2: Methods in Chronic
Disease Epidemiology
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Saudi Electronic niversity PHC 331: Chronic Disease Epidemiology and Prevention 1

Definition of Epidemiology
• The science of public health
• Greek ep/(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.”

Definition of Epidemiology, contd.
• 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

The Chronic Disease Continuum
• 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
Developmental,
social, environmental,
genetic determinants
Descriptive Epidemiology, Analytic Epidemiology, Intervention/Evaluative Research
Adapted from
Remington et al.
(2010)
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The Chronic Disease Continuum, contd.
• 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 detrimental effects of the disease
• Both of these factors are used to describe the natural
history of a given disease
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Descriptive Epidemiology
• 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.

The Burden of Disease
• 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
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■ Calculating Rates
• 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

Comparing Rates
• 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

Difference between rat ratio and rate difference
Mortality Rate
Disease Smokers (a) Nonsmokers (b) Ratio (a/b) Difference(a-b)
Lung cancer 131 11 11.9 120
Coronary heart
disease
275 153 1.8 122
PHC 331: Chronic Disease Epidemiology and Prevention 10

■ Study Designs
• 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

Study Designs in Chronic Disease Epidemiology
Experimental Studies
1- RCT :-Randomized controlled trials (RCTs) are considered the most
scientifically rigorous type of epidemiological study. In an RCT, subjects are randomly assigned
to either receive or not receive a preventive or therapeutic procedure, such as a clinical smoking
cessation intervention or a new drug. The disease course or mortality patterns are then
observed over time to assess the effectiveness of the preventive or therapeutic procedure
(Remington et al, 2010)
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Advantages of RCT
• Comparison groups vary in their appropriateness for disease intervention
studies. Least convincing are comparisons with national data or populations in
other studies. Subjects assigned to prevention or non-prevention
• Disease and death-rates monitored and observed over time
• Often impractical/impossible
• Need comparison groups for analysis

■ Study Designs, contd.
• 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
Adapted from Remington et al. (2010)

■ Observational Studies
• 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
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■ Strengths/Limitations of Study Designs
Study Type Strengths Limitations
Experimental studies
Randomized clinical trial *Controls randomly assigned *High cost
*Impractical long-term
*Impractical exposures
Randomized community trial *Population-wide scope
*Multicomponent effectiveness
*Very expensive
*Small number of study groups
Quasi-experimental study *Real-world policy/program intervention
*Multiple comparison groups
*Potential bias
*Lack of control - confounders
Observational studies
Prospective cohort *Measure risk before disease occurs
*Multiple outcomes
*Yields incidence rates/relative risks
*Expensive
*Large number of subjects required
*Lengthy follow-ups
*Hard to control exposure factors
Case-control *Rare diseases
inexpensive
*Quick results
*Possible risk-factor bias
*Possible bias in control group selection
*Identified might not represent population

■ Assessing Valid Study Results
• 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

Confounding
• “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

Selection/Information Bias
• 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

Prevention through Intervention
• 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

Single vs. Series
• 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

Systematic Reviews, Meta-analysis, Expert Panels
• Systematic reviews
• Researchers consolidate information using comprehensive
methods to assess relevant science behind a single health
issue
• Increasingly, meta-analysis is used in these systematic
reviews
• Meta-analysis
• Identify relevant studies, inclusion/exclusion criteria, data
abstraction, heterogeneity across statistical analysis

Risk Assessment/Expert panels
• 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:
• Hazard identification, risk characterization, exposure
assessment and risk estimation
• Expert panels used to assess validity of
epidemiological studies through peer review

■ Key Concepts
• Incidence rate - New events in a specified
period I persons exposed to risk within period
• Relative risk - Risk of death or disease in
population exposed to risk I risk of death or
diseased in unexposed population
• Population attributable risk - Rate of disease
in population attributed to risk factor I total
rate of disease
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Chapter 3: Intervention
Methods for Chronic Disease
Control

Behavioral Determinants
• 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

B Healthcare Determinants
• 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

Environmental Determinants
• 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

Social Determinants
• 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

Levels of Intervention
• Victim-blaming fails to account environmental and social -
ecological approach acknowledges that we live in a world full of
interactions
• Intrapersonal factors
• Interpersonal factors
• Organizational factors
• Community factors
• Policy factors

H Health Belief Model
• 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
• Content of Health Belief Model:-
• Perceived Suscessiability
• Perceived severity
• Perceived benefits
• Perceived barrier
• Cuss to action
• self- efficacy
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Perceived susceptibility - This refers to a person's subjective perception ofthe risk of acquiring an illness or disease.
There is wide variation in a person's feelings ofpersonal vulnerability to an illness or disease.
Perceived severity - This refers to a person's feelings on the seriousness ofcontracting an illness or disease (or leaving
the illness or disease untreated). There is wide variation in a person's feelings of severity, and often a person
considers the medical consequences (e.g., death, disability) and social consequences (e.g., family life, social
relationships) when evaluating the severity.
Perceived benefits - This refers to a person's perception ofthe effectiveness ofvarious actions available to reduce the
threat ofillness or disease (or to cure illness or disease). The course of action a person takes in preventing (or
curing) illness or disease relies on consideration and evaluation ofboth perceived susceptibility and perceived
benefit, such that the person would accept the recommended health action if it was perceived as beneficial.

Perceived barriers - This refers to a person's feelings on the obstacles to performing a recommended health
action. There is wide variation in a person's feelings of barriers, or impediments, which lead to a
cost/benefit analysis. The person weighs the effectiveness of the actions against the perceptions that it
may be expensive, dangerous (e.g., side effects), unpleasant (e.g., painful), time-consuming, or
inconvenient.
Cue to action - This is the stimulus needed to trigger the decision-making process to accept a recommended
health action. These cues can be internal (e.g., chest pains, wheezing, etc.) or external (e.g., advice from
others, illness of family member, newspaper article, etc.).
Self-efficacy - This refers to the level of a person's confidence in his or her ability to successfully perform a
behavior. This construct was added to the model most recently in mid-1980. Self-efficacy is a construct in
many behavioral theories as it directly relates to whether a person performs the desired behavior.

H Health Belief Model

Trans theoretical Model
• 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)

Theory of Planned Behavior
• 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

B Health Locus of Control
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
Figure 1: Locus of Control
External
Locus of Control
Outcomes outside your
control - determined by
“fate'' and independent of
your hard work or
decisions
are more likely reached through policy
changes
Internal
Locus of Control
Outcomes within your
control - determined by
your hard work,
attributes or decisions

Social Cognitive Theory
• 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

Family-Based Interventions
• 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

Friends and Social Networks
• Mentor programs, buddy systems, self-help groups
• Creating a new social network with the sole purpose of
intervening
• Especially important in adolescent interventions

Social Support and Social Networks
• Social support
• Emotional support
• Instrumental support
• Informational support
• Appraisal support
• Either strengthening existing networks or creating new ones to
assist in the problem-solving process

■ Natural Helpers
• 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)

B Health Care System and Clinical Services
• 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

Schools
• Youth are a spirited, receptive audience for prevention
messages
• Establishing healthier habits at an earlier age is essential in
stopping or slowing chronic illness

H Work Sites
• 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:
• Improved productivity
• Reduced absences
• Reduced health risks/health care costs
• Improved company image

■Examples of Community-Level Health Planning Approaches
• 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

B Community-Level Health Planning
• Process planning
• Plan with people
• Plan with data
• Institutionalization
• Priorities
• Short- and long-term outcomes
• Evaluation

B Community-Based Prevention Marketing
• Mobilizing the community
• Developing a community profile
• Selection behavior/audiences
• Formative research
• Strategy development
• Program development
• Program implementation
• Tracking

Chapter 4: Chronic Disease
Surveillance

Conceptual Model of Health Surveillance Adapted from Remington et al. (2010)
Define the
Problem
Find
Programs
that Work
Information
Dissemination
Data Collection
Data Analysis
Evaluate
the Effect
Data
Interpretation
Program Process Epidemiologic Process

Notifiable Disease Systems
• 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
• 2004 list contains 92 disease systems
• Chronic Disease Indicators website includes definitions and data of each in the
United States

■ Vital Statistics
• 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

Sentinel Surveillance
• One symptom or a string of symptoms, disease,
disability, etc.
• Effectiveness yet to be proven by research
• Could potentially identify outbreaks or bioterrorism

Chronic Disease Registries
• Used in monitoring trends
• Usually mandated in state laws
• Most common disease registries - cancer
• Hospital-based or population-based registries

■ Health Surveys
• 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

Administrative Data Collection Systems
• 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

■ Census Data
• 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

Person Analyses
• 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

Place Analyses
• 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.)

Time Analyses
• 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

Data Dissemination
• 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:
• Establish the message, set an objective, define the audience, select
the channel, evaluate the impact

■ Message
• 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

■ Objective
• 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

B Audience
• 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

B Channel
• 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

Impact
• 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

Chapter 5: Tobacco Use

Significance
According to WHO,2017: The tobacco epidemic is one of the biggest public health
threats the world has ever faced, killing more than 8 million people a year around the world.
More than 7 million of those deaths are the result of direct tobacco use while around 1.2
million are the result of non-smokers being exposed to second-hand smoke.
• Smoking harms every organ of the body, with diseases including
• Cardiovascular diseases
• Cancers - lip, mouth, esophagus, lung, kidney, etc.
• Respiratory problems
• Reproductive disorders
• SIDS, cataracts, slow wound healing
• Low bone density

Cardiovascular Disease
• 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

■ Cancer
• “Mainstream tobacco 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

■ Chronic Lung/Other Respiratory Disease
• When you smoke, additional biological processes like
inflammation, degradation of structural proteins and oxidant
stress are developed, which can cause alveolar injury
• Results in COPD
• Hypoxemia
• Decline in pulmonary function
• Reduction of tracheal mucus velocity

Nicotine Dependence
• 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

■ High-Risk Groups
• 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
• According to the Global Burden of Disease study more than 8 million people
died prematurely as a result of smoking in 2017.
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■ Number of tobacco users global by sex ( WHO,2019)
The number apparently peaked in 2018 at
1093 million tobacco users. Between 2000
and 2005, the number of male tobacco
users increased by 22 million; between
2005 and 2010, the increase slowed to 13
million, and slowed again to a 7 million
increase between 2010 and 2015. The
number of users is projected to decrease
going forward from 2018, decreasing by 2
million to 1 091 million in 2020, then by
another 4 million to 1 087 million in 2025,
assuming countries maintain current
efforts in tobacco control.

Global trends in prevalence of tobacco use by sex ( WHO, 2019)
In 2000, around half of men aged 15 years and
older were current users of some form of tobacco.
By 2015, the proportion of men using tobacco had
declined to 40.3%. By 2025, the rate is projected to
decline to 35.1%.
In 2000, around one in six women (16.7%) aged 15
years and older were current users of some form of
tobacco. By 2015, the proportion of women using
tobacco had declined to under one in ten (9.5%). By
2025, the rate is projected to decline to 6.7%.
any form of tobacco was three times in 2000, the
proportion of males using e proportion of users
among women. By 2015 the rate for males was
more than four times the rate for females. By 2025
the rate for males is expected to be five times the
rate for females.

Trends in current tobacco use among people aged >15 years
P
r
e
v
a
le
n
c
e
(%)

B Time Trends
• 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

B Modifiable Risk Factors
• 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

B Modifiable Risk Factors, contd.
• 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

• 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

■ Population-Attributable Risk
• 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

Prevention and Control
• 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
• Countermarketing campaigns
• Pointed at youth prevention, 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, contd.
• 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

Screening and Treatment
• 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

List of Evidence-Based Interventions
• 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

List of Evidence-Based Interventions, contd.
• Countermarketing campaigns
• Smoke-free policies
• Public and private insurance coverage
• Minors’ access restrictions
• Telephone cessation quitlines
• Usually not enough funding to sustain
• Product changes

■ Future Research and Demonstration
• 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

Chapter 6: Diet and Nutrition

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
Poor Diet/Nutrition:
*High in total calories,
saturated fat, animal
meat, sugar, salt, and
alcohol
*Low in fruit, vegetables,
whole grains, fiber,
unsaturated oils
Consequences
*Obesity
*CHD
*Diabetes
*Selected cancers
*Dental caries
*High blood pressure
*Psychological effect
At-risk Populations
*Infants/elderly
*Poor
*Undereducated
*Urban populations
*Racial/ethnic minorities
*Family with both parents
working outside the home
ri ugj'i 1111n i->giriii11ci veil 11

Significance
• 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

Pathophysiology - Fruits and Vegetables
• 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

Pathophysiology - Dietary Fiber
• 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

■ Pathophysiology - Dietary Fat and Red Meat
• 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, vitamins A, B12, protein
• — risk of colorectal cancer, formation of mutagenic free radicals in stomach

B Pathophysiology - Dairy Products and Milk
• 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

Pathophysiology - Sugar-Sweetened Beverages
• 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

B High-Risk Populations - Sex
• U.S. men - higher intake of red meat, dairy
• U.S. women - higher intake of fruits, vegetables, salts,
cholesterol
• Greater importance on eating healthily

B High-Risk Populations - Age and Life Course
• 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

B High-Risk Populations - Race and Ethnicity
• 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

B High-Risk Populations - Income
• 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

B High-Risk Populations - Education
• 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
r

B High-Risk Populations - Other
• 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)
A

■ Barriers to Healthy Eating
• 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

Primary Prevention Policy
• 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” An early nutritional guide developed in the 1940s by the U.S.
Department of Agriculture, CC BY 2.0, via Wikimedia Commons
cij itjj’i 1111n nginii11ci veil 11

H Primary Prevention Policy, contd.
Food Pyramid nutritional policy, developed in 1992 by the USDA.
Image by the USDA College, Public Domain, via Wikimedia
The current nutritional policy, MyPlate, developed in 2011.
Image by OpenStax College, CC BY 3.0, via Wikimedia Commons
Commons
A

Surveillance
• Various nutritional analyses that make up the
National Nutrition Monitoring System
• Food disappearance programs chart the available
consumable foods
• 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

Large-Scale Initiatives
• Origins in the 1980s - National Cancer Institute/Kelloggs
Campaign
• National Fruit and Vegetable Program
• 1% or Less Campaign
• Site-based interventions
• Workplace
• Schools
• Faith-based

Large-Scale Initiatives, contd.
• 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.
• Policy approaches
• Agricultural policies - which crops are produced
• Nutrition right-to-know - advocacy groups attempt to make
nutritional assessments in restaurants more accessible
• School wellness policies - improved physical activity programs and
healthy food options in vending machines
• Advertising to children
o

Chapter 7: Physical Activity

Consequences
• Affects physiological, psychological, societal of
health
• Reduces chance of premature death, developing
CHD/diabetes/colon cancer
• Promotes healthy bones and joints
• Less falls and functional dependency in older adults
r

Consequences, contd.
Causes
*Psychosocial (motivation
*Self-efficacy
*Social/cultural factors
*Physical environment
*Perceptions of
competence in sports
*Enjoyment
Consequences
*Obesity
*CHD
*Diabetes
*Colon cancer
*High blood pressure
*Falls/osteoporosis
*Psychological effects
At-risk Populations
*Older adults
*Adolescents
*Women
*Those with low incomes
*Overweight adults
*Those with conditions
that limit movement
*Injured or disabled
individuals Adapted from Remington et al. (2010)
A

Pathophysiology
• Physical activity - movement produced by
skeletomuscular system that burns energy
• Occupational and nonoccupational
• 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

Pathophysiology, contd.
• Intensity
• METs - Metabolic cost divided by resting metabolic rate
• MET-minutes - MET multiplied by minutes
• Kcal - MET-minutes times body weight
• Light intensity - <3 METs
• Moderate intensity - 3 to 6 METs
• Vigorous intensity - >6 METs
• Activity dose
• Leisure - free choice periods of PA
• Occupation PA - done during paid employment

• 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
A

B Distribution
• Needs constant updating to chart meaningful activity
patterns
• Two primary population-based surveys used to
measure physical activity:
• National Health Interview Survey
• Household survey
• Frequency, self-assessed intensity, duration
• Behavioral Risk Factor Surveillance System
• Phone-based survey
• Type, frequency, duration

■ Distribution, contd.
• 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 doing moderate- to
vigorous-intensity workouts, but infrequent levels
• Inactivity - Less than 10 minutes/week spent doing moderate- to
vigorous-intensity workouts

• 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

Geographic Distribution
• 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.
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o

B Time Trends
• Though promoted thoroughly, proportion of
adults who regularly exercise hasn’t undergone
major growth over the years
• Adolescents have the same trend over time

• 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
r

Prevention
• In the United States, national health objectives are
developed to set guidelines for activity objectives
• Healthy People 2010
• US Preventative Services Task Force
• 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.
A

Environmental and Policy Factors
• 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

B Public Health Interventions
• 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
traditional group took exercise programs offered by the health
club
• By the end of the study, smaller decline in home exercise group

B Public Health Interventions, contd.
• Work sites, schools, assisted living facilities - all are options
for intervention-based programs
• Transdisciplinary partnerships are very effective ways of
promotion
• Example - teams from the 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
• President’s Council on Physical Fitness and Sports
• State Governor’s Council on Physical Fitness
• State Health Department Physical Activity Initiatives and Campaigns
A

Measurement of Physical Activity - Future Research
• 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

Adolescent Physical Activity - Future Research
• 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

Environmental and Policy Changes - Future Research
• Continued efforts required to effect policy changes
designed to promote activity in communities
• Working with neighborhood coalitions
• Writing to local papers
• Lobbying for changes made by city planners
• Forming position statements for agencies
• Funding is required to research effectiveness of already
established programs, especially those in
disadvantaged communities

■ Older Adults - Future Research
• Baby boomer generation in need of study to understand
efficacy and effectiveness of policies centered around
the elderly
o

Chapter 10: Diabetes

Significance
• 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
By Blausen.com Staff. "Blausen gallery 2014".
Wikiversity Journal of Medicine. (Own work) CC BY
3.0, via Wikimedia Commons
cijigji 1111n i~>giriii11ci veil 11
r

B Diabetes Mellitus
Diabetes is a chronic disease that occurs when the pancreas is no longer
able to make insulin, or when the body cannot make good use of the
insulin it produces.
Insulin is a hormone made by the pancreas, that acts like a key to let
glucose from the food we eat pass from the blood stream into the cells
in the body to produce energy. All carbohydrate foods are broken down
into glucose in the blood. Insulin helps glucose get into the cells.
Not being able to produce insulin or use it effectively leads to raised
glucose levels in the blood (known as hyperglycaemia). Over the long
term high glucose levels are associated with damage to the body and
failure of various organs and tissues.
A

■ Significance of Diabetes Mellitus
About 422 million people worldwide have diabetes, the majority living in
low-and middle-income countries, and 1.6 million deaths are directly
attributed to diabetes each year. Both the number of cases and the
prevalence of diabetes have been steadily increasing over the past few
decades. There is a globally agreed target to halt the rise in diabetes and
obesity by 2025.(WHO, 2020)
Types of Diabetes Mellitus:-
1- Type 1 Diabetes
2- Type 2 Diabetes
3- Gestational Diabetes

Significance, contd.
• 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

Pathophysiology
• 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
A

Descriptive Epidemiology
• 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

• 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, contd.
• 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
• 2.4 times greater odds of acquiring Type II when there is a
moderate familial risk
• 5.8 times greater when there is a high familial risk

• 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
o

B Time Trends
• 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

B Modifiable Risk Factors - Type I
• 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

B Modifiable Risk Factors - Type II
• 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
PHC 331: Chronic Disease Epidemiology and Prevention
Saudi Electronic niversity 14
A

B Modifiable Risk Factors - Type II, contd.
• 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

Risk factors of Gestational Diabetes Mellitus
Gestational
Diabetes
in Previous
Pregnancies
Overweight
or Obese
(BMI >30)
Gestational
Diabetes
Asian or
Middle-Eastern
Experience
Excessive Weight Gain
During Pregnancy

B Symptoms of Type 1 Diabetes
A

Symptoms of Type 2 Diabetes

Complications
• 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
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Major complications of Diabetes

Causes, Consequences, Risk Populations Chart
Consequences
*Coronary heart disease
*Stroke
*Peripheral vascular
disease
*End-stage renal disease
*Blindness
*Lower leg amputations
*Disability
*Depression
*Poor pregnancy
outcomes
*Premature mortality
o

Prevention and Control - Type I
• Prevention starts with
identification of disease
• Diabetes Prevention Trial
(DPT)
• Locating effective
prevention strategies isn’t
currently economical or
relatively easy

Prevention and Control - Type II
Unlike Type I, there are clear
plans for prevention - both
lifestyle and pharmacological
interventions
Studies in both China, Finland
DIABETES MELLITUS type 2
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and the United States, where
screenings of diabetics were
calculated and then controlled
High Woodlugar
through differing variables -
exercise, diet, etc.
• Results were conclusive - reduction in
diabetes after a few years of
participation
Signsand symptoms Complications
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Prevention and Control in Youth - Type II
• Not many studies conducted to
research Type II diabetes in youth
because so few cases exist
• Interventions done in school systems to
increase physical activity were enforced,
but insulin levels were not measured
• There has been increased
development in plans to prevent
Type II, as opposed to treat it in
youth
• Early detection of prediabetes
A

Prevention and control of Gastetional diabetes

Screening and Early Detection
• Prediabetes - blood glucose between
100-126 mg/dL
• Type I - not recommended
• Type II - not cost effective, but utilized
in “high risk” groups; fasting glucose
>126mg/dL considered diagnostic
• Gestational Diabetes - shown to reduce
fetal morbidity/mortality;
recommended for “high risk” groups;
100g OGTT administered upon positive
test
Investigation
Condition 2 hour glucose Fasting glucose
Normal <7.8(<140) <6.1(<110)
Diabetes mellitus >11.1 (>200) >7.0(>126)

Treatment, Rehab, Recovery
• Type I
• Diabetes Control and Complications Trial
• Physical activity an important goal for
treatment
• Type II
• Weight management, caloric restriction,
physical activity
• Pharmacotherapy - BP, tobacco nonuse,
aspiration may be just as important as
glucose control in many cases
• Treatment involves hands-on patient
interaction
uent evaluations
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Saudi Electronic University PHC 331: Chronic Disease Epidemiology and Prevention 15
A

B Public Interventions
• National Diabetes Prevention and Control Program
• Defining the Diabetes Burden
• Conducting Applied Translation Research
• State-Based Diabetes Control Programs
• National Diabetes Partnerships and Programs
• Prevention Research Centers, Racial and Ethnic Approaches to
Community Health, Steps to a Healthier US
• Indian Health Service Division of Diabetes Treatment/Prevention
• Diabetes Research and Training Centers

Chapter 11: High Blood
Pressure

Significance
Hypertension - or elevated blood pressure - is a serious medical
condition that significantly increases the risks of heart, brain, kidney
and other diseases.
An estimated 1.13 billion people worldwide have hypertension, most
(two-thirds) living in low- and middle-income countries. In 2015, 1 in
4 men and 1 in 5 women had hypertension. Fewer than 1 in 5 people
with hypertension have the problem under control (WHO,2019)

I Blood Pressure
Hypertension is a major cause of premature death worldwide.
One of the global targets for no communicable diseases is to reduce
the prevalence of hypertension by 25% by 2025 (baseline 2010).
Blood pressure is the force exerted by circulating blood against the
walls of the body’s arteries, the major blood vessels in the body.
Hypertension is when blood pressure is too high.
Blood pressure is written as two numbers. The first (systolic) number
represents the pressure in blood vessels when the heart contracts or
beats.
o

The second (diastolic) number represents the pressure in the
vessels when the heart rests between beats.
Hypertension is diagnosed if, when it is measured on two
different days, the systolic blood pressure readings on both
days is >140 mmHg and/or the diastolic blood pressure
readings on both days is >90 mmHg.(WHO,2019)

Causes, Consequences, High-Risk Groups
Causes
*Obesity
*Physical inactivity
*Alcohol intake
*Dietary sodium and
potassium intake
*Genetics
r

Pathophysiology
“Mean arterial pressure is the product
of cardiac output...and systematic
vascular resistance” (Remington et al.
2010).
Kidney, sympathetic nervous system,
renin-angiotensin system all play
central roles BP regulation
A “normal” body maintains intake anc
output in equilibrium
Pathogenesis of Renovascular HTN:
A

The various types of
hypertension exhibit impaired
pressure natriuresis
• Either intra-or extrarenal
Increased activity of the
sympathetic nervous system also
associated with hypertension
Vasoconstriction/sodium
retention
Mechanisms of Hypertension
• Renin-Angiotensin-
Aldosterone
- Vasoconstrictor
properties of
angiotensin II
- Sodium-retaining
properties of
aldosterone

Significance
• Across all populations, HBP is a severe issue for
healthcare workers
• Second largest contributor to disease in developed and developing
countries
• 7.1 million of annual deaths are attributed to high
blood pressure
• The correlation between HBP and CV mortality higher
in younger subjects, though mortality naturally occurs
in older populations

Significance, contd.
• HBP is the leading contributor to stroke - shown
as consistent across a variety of studies
• More than twice as high in hypertensive category
• Nondependent on race/sex
• Higher chance of congestive heart failure
• Higher chance of cardiovascular disease
• The effects of high blood pressure do vary slightly
depending on race, age, regions
A

B High-Risk Populations
• Age
• As we age, our average blood pressure increases across most
populations
• True for both men and women
• Systolic blood pressure increases throughout lifespan
• Diastolic blood pressure Increases until 50 years old, and then
remains constant and then decreases
• Data is limited because lack of followup
• Those with starting SBP < 140 mmHg and DBP 85-89
mmHg are more likely to develop HBP

B Time Trends
• Over time, 1971-1991 a steady decline in both
systolic and diastolic BP had been seen across all
observable age groups, races, sexes
• Omitting African American men, 50+, who suffered a small
increase
• This downward movement indicates that
environmental/behavioral effects mitigated higher BP
• Increase began after 1991 in the United States,
especially in the elderly ad in women
• Corollary to increased BMI

Causes - Genetic Factors
• Those predisposed to high blood pressure are
susceptible
• Difficult to assess genetic causes
• Alteration of specific non-allelic gene difficult to trace
because HBP looks the same in everyone
• Alleles and haplotypes inspection is compromised 90% of the
time

■ Causes - Obesity
• In the United States, those with higher BMIs
progressively experience blood pressure problems
• 50% of new cases attributable to being overweight
• Corroborated by nonpharmacological interventions
n1111n ingviii11d vd 711
o

■ Causes - Salt Intake
• Sodium chloride intake attributable to the
development of HBP
• Salt compromises kidneys
• After a long exposure to high salt intake, no longer able
to excrete sodium, which leads to increased volume of
blood in the body
• Confirmed by random control testing of sodium
reduction in diets

Causes - Potassium Intake
• Increased potassium - lower blood pressure
• SBP and DBP
• “Administration of dietary potassium increases renal
sodium and chloride excretion, reduces blood volume,
and decreases blood pressure” (Remington et al. 2010)

B Causes - Alcohol Intake
• Unclear direct link between high blood pressure
and high alcohol intake, but hypertensive effects
of extensive alcohol use shown in various
studies
• When a reduction in alcohol intake is reported,
lower blood pressure is also reported
A

Symptoms of Hypertension

Screening and Early Prevention
• Screening is beneficial because
testing methods are reliable and
effective for those with
hypertension
• Screening is inexpensive, but
should be targeted toward high-
risk patients in particular
• 76% of hypertension victims are
aware of their condition, despite
readily available testing By National Heart Lung and Blood Insitute (NIH)
[Public Domain], via Wikimedia Commons
njigjj 1111ri ngvui11ci veil 11

Types of Hyptersion
BLOOD PRESSURE SYSTOLIC mm Hg DIASTOLIC mm Hg
CATEGORY (upper number) (lower number)
NORMAL LESS THAN 120 and LESS THAN 80
ELEVATED 120-129 and LESS THAN 80
HIGH BLOOD PRESSURE
(HYPERTENSION)
STAGE 1
130-139 or 80 - 89
HIGH BLOOD PRESSURE
(HYPERTENSION)
STAGE 2
140 OR HIGHER or 90 OR HIGHER
HYPERTENSIVE CRISIS
(consult your doctor
immediately)
HIGHER THAN 180 and/or HIGHER THAN 120
A

Complications of Hypertension

■ Lifestyle Changes, contd.
• Nonpharmacological, lifestyle choices, contd.
• Dietary pattern - not one factor that influences diet, but large-
scale changes
• DASH Trial: three various diets observed for 11 weeks; one - low
fruits, veggies, dairy, average United States fat content; two -
fruits and vegetables; three - DASH diet (high fruits, vegetables,
low-fat dairy, reduced saturated and total fat
• DASH diet effective for those with HBP
• DASH diet current recommendation for lowering high blood
pressure

■ Lifestyle Changes
• Nonpharmacological, lifestyle choices
• Weight reduction - less drug therapy needed if following a diet
aimed at fat/weight reduction
• Salt reduction - especially effective for hypertensive as opposed to
normotensive
• Less drug therapy needed for those with a low-salt diet
• Increase in dietary potassium - inverse relationship with higher
potassium consumption and blood pressure in various meta
analyses
• Especially effective for hypertensive and African Americans

■ Lifestyle Changes, contd.
• Nonpharmacological, lifestyle choices, contd.
• Alcohol intake moderation - 25% reduction lowers SBP by 3.3
mmHg and DPB by 2.0 mmHg
• Limited intake to 2 drinks per day (men) and 1 drink per day
(women and low-weight individuals
• Physical activity - SBP reduction 3.5 mmHg and DBP reduction
2.5 mmHg
• Study of physical activity currently limited; inconclusive toward
women, African Americans, and weight training (aerobic only)
o

Prevention and Control of Hypertension

Secondary Prevention: Pharmacological Treatment
• Goal of secondary prevention: avoiding the negative
effects of HBP
• Recommended for both hypertensive individuals
with no complications (risk factors)
• Thiazide diuretic initially
• Calcium channel blockers
• Angiotensin-converting enzyme inhibitors
• Angiotensin type I receptor blockers
• Beta-blockers

Population-level Changes
• Aim of intervention is to lower blood
pressure across an entire population
• Various community-based projects
aim to translation research into
action and management of blood
pressure
• The processes for lowering blood
pressure at a population-level are the
same as those outlined in individual
based programs, outline above
A

Chapter 12: High Blood
Cholesterol

Cholesterol

■ Cholesterol
Definition :- is a waxy, fat-like substance that's found in all the cells in
your body. Your body needs some cholesterol to make hormones,
vitamin D, and substances that help you digest foods.
Cholesterol is transmitted in the blood through Lipoprotein
A

Lipoprotien
cholesterolTtrigl^^rides^ranspor^^^^^^^^^^^^^^|
trigiyceride^^^^^^^^^^^^^^^^^^^^^^^^^^^^^J
^^^^7DL7Towd^ns^/ôns^t^f^^hât,Tow7rote^^^^^^^^^^^^^^^^^^^^|
^^^^^DL7îghênsitY±Qwât,HghpQtei^^^^^^^^^^^^^^^^^^^^^^^^^|

Lipoprotein

Fat

Significance
• Many different people are at risk for coronary heart
disease
• Hypercholesterolemia
• 16.5% of population between 20-74 have high
cholesterol in the United States, and nationally high
average
• Many healthcare resources needed to be expended to
screen and treat hypercholesterolemia
o

Pathophysiology and Genetics
• Insoluble in water
• Transported in lipoproteins throughout bloodstream
• Lipids + apoproteins = lipoproteins
• 4 types of lipoproteins:
• Low density - integral to atherosclerotic development
• Very low density - triglycerides
• Intermediate density - cholesterol + triglycerides transport
• High density - cholesterol removed from the body transport
• Inverse correlation between high density lipoproteins and coronary
heart disease
n1111 n ingviii11d vd 711

Pathophysiology and Genetics, contd.
• Cholesterol is needed to maintain regular bodily
function
• Problems arise when abundance of cholesterol is
present
• Accumulates in artery walls
• Plaque can develop
• Fatty streaks are earliest signs of accumulation
• Atheromas are advanced
• Can be calcified, hemorrhage, ulcerate
• Genetics important to assigning cholesterol levels
• Abnormalities include hyperlipidemia/dyslipidemia
r

Causes, Consequences, High-Risk Groups
Causes
*Diets with high saturated
fats
*Genetics
*Obesity and metabolic
disorders
*Physical inactivity
*Smoking
*Hypothyroidism
*Renal disease
*Diabetes mellitus
*Steroid therapy
Saudi Electronic niversity
At-risk Populations
*Men 45 and older
*Women 55 and older
*Low socioeconomic status
*Diabetics
*Those with:
-Known atherosclerosis
-Genetic lipid disorder
-Chronic kidney disease
-History of a prior stroke
-History of coronary artery disease
Consequences
*Coronary heart disease
*Atherosclerosis
*Stroke
*End organ damage
*Premature death and
disability
*High health care costs
and treatment
A

High-risk populations
• Highest risk - known atherosclerotic cardiovascular
disease
• Rate increases when prior CV event occurs
• Older are at more risk
• Especially men older than 45 and women older than 55

• Beijing, China had the lowest hypercholesterolemia
among men/women
• Ticino, Switzerland / Novi Sa, Yugoslavia had the
highest
• European countries in general are more disposed to
high serum cholesterol levels

B Time Trends
• Steadily decreasing in the United States since
the 60s
• Contributed directly to the decline in coronary
heart diseases in the United States in recent
years
A

• Biggest modification - reduction in dietary
fat/saturated fat
• Dose response relationship among saturated/trans fat intake and
low-density lipoprotein levels
• Three types of fat:
• Saturated - saturated with hydrogen; no double bonds
• Monounsaturated - one double bond
• Polyunsaturated - two or more bonds
• Saturated fatty acids raise cholesterol levels by
decreasing activity of low density lipoprotein receptors

• Polyunsaturated fatty acids - omega-6 and omega-3
• Omega-6 lowers LDLs and some HDLs
• Omega-3 lowers triglyceride and LDL levels
• Monounsaturated fatty acids
• Reduces LDLs and minimally reduces HDL
• Trans fatty acids
• Raises LDLs and lower HDLs, raises triglycerides
• Obesity is also positive-corollary to total cholesterol
levels
• Smoking/inactivity - lower HDLs and higher risk of
CHD

Prevention
• Diet is the cornerstone for change when it
comes to lowering cholesterol levels, however:
• Cholesterol-lowering medication also substantially
beneficial
• Two approaches to prevention:
• Population strategy - lifestyle alteration
• Clinical strategy - addressing the needs of those with
direct cause for cholesterol reduction

■ Top food to increase (HDL) Cholesterol
o

Screening
• Screening is a fivefold process with treatment,
nutritional changes, weight management, increased
physical activity
• Lipid panels are obtained in a fasting state
• Recommended for those over 20 years old, every five years
• Baseline total cholesterol levels vary by 5 mg/dL on a
given day
• HDL levels by 1.5 mg/dL

Treatment - Population-based
• An emphasis is placed first on community education
• Dietary Guidelines for Americans details goals to
decrease diseases like coronary heart disease
• Recommended for use starting as early as two years old
• Those with immediate cholesterol disorder, or those
who have had a recent CHD event should be stricter
and should follow a more rigid clinical approach
r

■ Treatment - Patient-based
• Lipoprotein count should be gathered if:
• 200 mg/dL cholesterol or higher
• HDL cholesterol lower than 40 mg/dL
• CHD risk factors (3+)
• Framingham 10-year Risk Score measures the risk
percentage of having a CHD event based on risk
factors, and outlines a goal level of low-density
lipoproteins to have
A

B Treatment - Antioxidants
• Historically, antioxidant use has been shown to
decrease oxidation of LDLs
• However, now shown that antioxidants do not
decrease atherosclerotic burden or prevent CHD
events; further, vitamin intake with antioxidants may
increase an event, and increase chance of lung cancer
• No longer recommended for lipid therapy

Treatment - Hormone Replacement Therapy
• Not recommended for lipid disorder treatment
• Increased risk suggested

B Treatment - Children and Adolescents
• Atherosclerosis begins in childhood; progression linked
to later high cholesterol
• High cholesterol is maintained in familial setting due
to similar genetics and home environment
• Population approach - the same change in diet as
adults, with an emphasis on fruits/vegetables
• Individualized approach - designed for at-risk youth
A

B Public Health Interventions
• Public education, screening, intervention
• Community interventions from various groups
• Stanford Five City Project
• Pawtucket Heart Health Program
• Minnesota Heart Health Program

■ Future Research
• Due to substantial variation in medication benefits
across a span of variables, more research needed to
find a more even fit
• Optimal diet research
• Cholesterol disorders need further evaluation
• Behavior change and adherence need further
initiatives

Chapter 13: Cardiovascular
Disease

B Types of Heart diseases
o

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