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PH 150A Final
Terms in this set (90)
What are Social Determinants of Health?
conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national and local levels.
Social Determinants of Health are mostly responsible for
Health inequities, the unfair and avoidable differences in health status within and between countries.
Chair of the WHO Commission on the Social Determinants of Health since 2005
Sir Michael Marmot
How to deal with health inequalities?
-study causes and treatments of major diseases
-improve circumstances in which people live and work (address social determinants of health)
What are the Causes of the Causes?
the social conditions that give rise to high risk of non-communicable disease, whether acting through unhealthy behaviors or through the effects of impossibly stressful lives.
Diagram of Lifecourse and Physical Environment
Individual Risk Factors
Neighborhoods and Communities
Institutions (including medical care)
Social and Economic Policies
What are the Social Determinants as Fundamental Causes of Health?
1) Influence multiple disease outcomes
2) Affects disease outcomes through multiple risk factors
3) Involves access to resources that can be used to avoid risk or to minimize the consequences of disease once it occurs
4) Associations are reproduced over time
What are examples of Social Determinants?
Examples of Psychosocial Determinants
Negative Emotional Stress
-agner and hostility
-natural disasters/mass trauma
Timeline: Influential Reports on Health Disparities
The Black Report (1980)
Secretary's Task Force on Black and Minority Health (1985)
The Acheson Report (1998)
Healthy People (first time disparities added) 2000
IOM Report Unequal Treatment (2002-3)
WHO Commission on Social Determinants (2008)
What is the Heckler Report?
The U.S Department of Health and Human Services released a landmark report, the Report of the Secretary's Task Force on Black and Minority Health (Heckler Report)
-documented the existence of health disparities among racial and ethnic minorities in the U.S
-Office of Minority Health was created in 1986, one of main outcomes of Heckler Report
All Cause Mortality By Race and Ethnicity (age-adjusted)
Black/African American (867.4)
US Average (735.5)
All Cause Mortality By Race and (age-adjusted):
Blacks rate higher than whites
30.7% in 1985
17.8% in 2013
The only 30 years of progress based on rates between blacks and whites?
Cirrhosis (70% higher in blacks to white, now 30% lower in blacks to whites)
Homicide and Accidents (70% for blacks to whites, 10% in blacks to whites)
Infant Mortality Rates Highest to Lowest by Race
Black, American Indian/Alaskan Native, White, Hispanic, and Asian
The Heckler Report: Big Six
Cancer, Cardiovascular Disease & Stroke
Chemical dependency, measured by deaths due to cirrhosis
Homicide and accidents (unintentional injuries)
-social, NOT BIOLOGICAL category
-sharing cultural heritage and ancestry, forged by oppressive systems of race relations, justified by ideology, in which one group benefits from dominating other groups, and defines itself and others through this domination and the possession of selective and arbitrary physical characteristics (for example, skin color)
construct originially intended to discriminate btw "innately" dif groups allegedly belonging to the same overall "race" is now held by some to refer to groups allegedly distinguishable on the basis of "culture;" in practice, however, ethnicity" cannot meaningfully be disentangled from "race" in societies w inequitable race relations, hence the construct
Office of Management and Budget
Guidelines for Measuring Race and Ethinicity
Goal: To create standard classifications for record keeping, collection, and presentation of data on race and ethnicity in Federal program administrative reporting and statistical activities.
-enforce civil rights laws
-to be compatible, nonduplicated, exchangeable racial and ethinic data by Federal agencies
-Not to be interpreted as being scientific or anthropological in nature
Ethnicity (if separate) is usually ...
Not of Hispanic origin
Race Ethnicity: 5 factors
Genetic Ancestry/biological determinism
Racism as a Fundamental Cause
A system of structuring opp and assigning value based on the social interpretation of how one looks ("race")
-unfairly adv other indiv and communities
-unfairly disadv some indiv and communities
-saps strength of whole society through waste of human resources
-initial historical insult
-inaction in face of need
-acts of commission
-acts of omission
-maintains structural barriers
-condoned by societal norms
(continue to be allowed, despite being morally wrong)
-reflects systems of privilege
-reflects societal values
-erodes indiv sense of value
-undermines collective action
Segregation and Public School Education most percentage of black students in intensely segregated minority schools is where?
Background for SES
-societies are structured like ladders
-position on the ladder predicts how long you live and how healthy you are during your lifetime
Defining Socioeconomic Position
-an aggregate concept that includes both resource-based and prestige-based measures, as linked to both childhood and adult social class position
material and social resources and assests, including income, wealth and educational credential; terms used to describe inadequate resources include "poverty" and "deprivation"
individuals' rank or status in social hierarchy, typically evaluated with reference to people's access to an consumption of goods, services, and knowledge, as linked to their occupational prestige, income, and educational level
Highest Median annual household income by race
Highest Percent living below poverty
Lowest Median annual household income by race
Lowest Percent living below poverty
Higher Income, Longer life
Adult Life expectancy increases with increasing income. Men and women in the highest-income group can expect to live at least six and a half years longer than poor men and women.
-to investigate complex relationships among income, work status, psychosocial support, health behaviors, and resulting morbidity and mortality
-19019 British Civil Servants were recruited from 1976-1970 aged
County Health Rankings Key Findings Report
People living in unequal communities are more likely to prematurely die (before age of 75) than people in more equal communities
For every one-point increase in the ratio btw high and low earners in a county, about _____________ were lost for __________
5 years of life for every 1000 peple
T or F
Place matters for health
T or F
Number living in high poverty neighborhoods is highest from 2009-2013
and has been increasing since 1990
T for first part, F for second part, has not been increasing, but did shoot up in 2009-2013
What is the WHO Commission approach on how to create social conditions that will ensure good health for the entire population?
-policies that harm human health need to be identified and, where possible, changed
Healthy People 2000 defines health equity as
attainment of highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities
Why study genes in epi?
In order to prevent and treat disease:
1) we must take into account the contribution of (host) genetic factors
2) we must examine interaction btw genetic susceptibility and exposure to env factors
*disease dos not necessarily develop in everyone exposed to an env risk factor
Genetic Epi in 21st century
-primary focus on role of inherited factors in disease etiology
-characterization of single gene disorders; now more complex genetic disorders
-interface of genetic and env interaction in disease
-better therapeutic strategies, personalized/precision medicine
-lifestyle intervention, prevention strategies
Watson & Crick DNA
What do we know about human genome?
-3,000,000,000 bases A, T, G, C
-22,500 proteins coded in genes
-2000 differences affect stxr of proteins
-120 expected to be deleterious; 20 completely inactivated
-about 80 new gene variants are created each generation
-non coding regions are exciting
Evidence for a familial effect?
familial aggregation (family history)
-most common CA repeats identified by length, very ---informative, some tehnical difficulties
linkage maps grew from 400 markers to 5000 markers by late 90s
-measure co-segregtion of marker and disease in pedigree
-based on detection of recombination events (meiosis)
-positional cloning successfully used to identifty >2500 Mendelian diseases vs. 100 in late 80s
Screen the _________ to find the _________
genome to find the disease gene
CFTR gene on ________ has _______
ch. 7 has > 1500 different forms or mutations
Cystic Fibrosis Transmembarne Conductance Regulator
CFTR Modulator Therapies
designed to correct the function of defective protein made by the CF gene; only 2 FDA-approved: ivacaftor (Kalydeco) and lumacafor + ivacaftor (Orkambi)
2 FDA approved CFTR modulators
-moves the defective CFTR protein to the correct place on cell surface
-increases protein's activity once it is in place
T or F Linking studies are useful for complex diseases.
"First" linkage study of a complex disease
genone-wide search for human type 1 diabetes susceptibility genes
Single Nucleotide Polymorphism
-defined as a single base change in a DNA sequence that occurs in a significant proportion (more than 1 percent) of a large population
How many SNPS do we know now?
> 11 million
What is Genome Wide Association Study (GWAS)?
Compare DNA of patients and non-patients to discover SNPS associated with diseases
GWAS became possible in 2005: allowing
-completion of human genome sequence
-millions of SNPs available in public databases
-completion of Hap Map project and availability of informative SNPs
-Major advances in genotyping technologies <$1000/person-$400/person ...$100/person
What is GWAS?
-an investigation of association btw common genetic variation and disease-"hypothesis free"
-requires dense set of markers: 550,000 to >2M+ that capture common variation
-Choosing right SNPs allows for knowledge about >80% of common variants (>5%) to be extracted across the genome
What does whole genome information when combined with clinical and other phenotype data offer?
-increased understanding of biological processes affecting human health
-improvement in prediction of disease and patient care
-realization of promise of personalized medicine (pharmacogenetics or genetic determinants of drug response)...precision medicine
What are some issues with GWA studies?
-strategy for study design, interpretation of results
-multiple comparisons/significance criteria
-how to address underlying diferences in genetic ancestry btw cases and controls
-replication; multiple populations, meta-analyses
____________ error in Genetic Epi
Type 1 error (False Positives); try to keep this below 5% commonly
Maximum acceptable risk of error as
We reject null hypothesis whenever p
What is P-value?
probability of obtaining a similar or more extreme result (compared to observed) if the null hypothesis were true
-prob of obtaining a value of the test stat as a large or larger than the one computed from the data when in reality there is no difference between the two groups
Small p-values indicate
statistical significance; result is unlikely to be due to chance
Type _______ rate for GWAS
set at 5 x 10-8
reject null hypothesis only if p <5 x 10-8
Tremendous impact on study design
Power to detect an association is a function of
-magnitude or size or effect you are trying to detect (OR)
-type 1 error type
Case-Control Design for GWAS
Begin with outcome (1000 cases with disease of interest) & (1000 controls w/o disease of interest)
Each will lead to have allele/genotype + and Allele/genotype -
OR For Case-Control
a/c / b/d = axd / bxc
Case-control study in genetic epi interpretation of measure of association
-the odds of carrying a particular genotype is X times greater for cases (disease) compared to controls (no disease)
-allelic odds ratio (per allele risk)
GWAS progress to date
hundreds of disease/traits studies
-NIH has been tracking weekly since 2007
Common disease-common variant hypothesis
-Foundation of GWAS approaches
-Rare Mendelian diseases: one major gene vs. Common, interacting disease alleles underlie most common diseases, perhaps in association with environmental factors
Very Modest effects
of many genes in diseases
parts of DNA that not actual genes containing instructions for proteins, actually is a complex system that controls genes.
T or F
Genetic overlap across diseases identified from GWA studies
Lessons from GWAS
Variants so far identified by GWAS together explain only a small fraction of overall inherited risk of each disease or trait
-More disease loci remain to be identified; low power in previous studies; need Consortia effort
Some disease loci will contain ONLY rare variants ... DNA sequencing
-Genes show limited value in predicting disease
T or F NIH GWAS data is usually shared
What is the 1000 Genomes Project
-began in 2008
-major sequencing effort to produce the most detailed and medically useful map of human genetic variation
-driven by technology advances and GWAS
-all data made publicly available
At least ______ of all genetic variants make up
at least 20%; structural variation in human genome
Factor V is important for
does not determine whether you will develop AD. It is a marker of risk, like high cholesterol and heart disease.
Are we protected from genetic discrimination?
GINA= Genetic Information Nondiscrimination Act of 2008 -Bush signs effective 2009
Protection GINA provides
Group and indiv health insurerers cannot use a person's genetic information to set eligibility requirements or establish premium or contribution amounts
; or request or require that a person undergo a genetic test
Under GINA employers cannot use a person's genetic info in decisions about hiring, firing, job, assignments, or promotions and request, require or purchase genetic information about an employee or family member
GINA does not provide protections against or apply to
a condition that is already diagnosed and manifest, even if that condition is genetic (changes now under ACA)
-life, disability, or long-term care insurers information about current health status.
Perserving Employee Wellness Programs Act
exempts from limitations under American Disabilities Act, prohibition on collecting genetic information with issuing health ins, limitations under Genetic Info Nondiscrimination Act
Republican backed bill in house
IOM Report on Unequal Treatment
-assess extent of disparities in types and quality of health services
-explore factors that may contribute to inequities in care
-recommend policies and practices to eliminate these inequities
presence of a variable other than the exposure of interest which influences the estimate of the effect of the exposure on an outcome
-muddles relationship btw exposure of interest and outcome
-can either exaggerate the true association or hide it (negative confounding)
A confounding variable
associated with both the exposure and outcome
when not considered, lack of control of the confounding factor makes the exposure and outcome look related when they are not
Characteristics of Confounding
-potential confounder is known risk factor for outcome
-potential confounder associated with exposure but not result of exposure
-potential confounder is not on the causual path in the true relationship between exposure and outcome