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Reminder for FCM: 5th Long Exam on Feb. 09, 2013
(Saturday) 10:00am
Topics are:
1. Alcohol
2. Basic Principles of Exercise
3. Nutrition
4. Family wellness
5. Biostat2
6. Intro to EBM
7. Intro to Epidemiology
8. Population At Risk
HEALTH EFFECTS OF ALCOHOL
Ethyl Alcohol
(CH3CH2OH)
Absorption
Rapidly absorbed from stomach, small intestine, andcolon
Maximal blood concentration within 30 to 90 minutes Can be absorbed through the lungsDistribution
Uniformly distributed throughout tissues and body fluids Readily crosses placenta, to exposure fetusElimination
Urinary Excretion Exhalation MetabolismMetabolism I
(ADH Alcohol Dehydrogenase)
Metabolism II
(ALDH Acetaldehyde Dehydrogenase)
Metabolism III
Acetate Acetyl-CoA Carbon dioxide and water
Ethanol in:
Lite Beer 2.5 - 3.5% Beer 4.0 - 6.0% Wine 10 - 18 % Flavored Liquors 15 - 25% Distilled Liquors 22 - 50%
Proof is double %
One drink equals:
12 ounces beer 5 ounces wine 1.5 ounces distilled liquor
70 kg person metabolizes approximately one drink/hour 7 calories per gram vs. fat @ 9 calories/gmAlcohol Dependence
Craving: A strong need, or compulsion, to drink Loss of control: The inability to limit ones drinking on
any given occasion
Physical dependence: Withdrawal symptoms occur whenalcohol use is stopped after a period of heavy drinking
Tolerance: The need to drink greater amounts of alcoholin order to get high.
Alcohol and Alcoholism
Alcoholism
Addiction to alcohol or abuse of alcohol to a degree thatproduces problems in one or more of these areas:
Health Social relationships Economic status Interpersonal relationships
Phases of alcoholism
Problem drinking Drinks to relieve stress Abstinence does not cause physical symptoms
Alcohol addiction Abstinence produces physical symptoms
Acute Effects
CNS Depressant Depression of inhibitory control Vasodilation, warm, flushed, reddish skin Emotional outbursts Decreased memory & concentration Poor judgment Decreased reflexes Decreased sexual response
Acute Alcohol Effects
Hangover
Mild withdrawal with volume depletion (due to increaseddiuresis)
Treatment Fluids Paracetamol for headache
Stupor-Coma
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Acute overdose Coma Depressed respirations Hypotension Hypothermia
Hypoglycemia
Inhibition of protein to sugar conversion in liver(gluconeogenesis)
Trauma
Drunks fall down and hit their heads. Concussion Subdural hematoma
Mixed drug overdose
Tranquilizers Barbiturates Anti-depressants
Worsening of other problems
Peptic ulcer disease Liver disease Pancreatic disease Heart disease (decreased pump strength)
Long Term Adverse Effects
Obvious Alcoholism, death, cancer (oral cavity,
esophagus, liver), fetal effects (FAS)
Alcoholism
Cirrhosis of liver, appetite loss, poor judgmentSubtle
Lost productivity, impaired performance, motorimpairment, cost to society
Alcoholism - Disulfiram
Alcoholism Treatment with Disulfiram
Inhibits acetaldehyde dehydrogenase (ALDH)
Exposure to EtOH while taking causes sudden, severe
vasodilation:
Hot, flushed face Dizziness Pounding heart, hypotension Nausea, vomiting Headache
Associated Medical Problems
Hepatic cirrhosis
Ascites Jaundice Palmar erythema Spider angiomata, Caput medusa Gynecomastia (males)
Effects
Impaired glucose metabolism, hypoglycemia Portal hypertension, esophageal varices Coagulopathies Hepatic encephalopathy
Pancreatitis
Nausea, vomiting
Severe upper abdominal pain radiating to back Hypovolemic shock Secondary diabetes Pancreatic necrosis and hemorrhageWernickes encephalopathy
Ocular disturbances Changes in mental state Unsteady stance and gaitKorsakoffs syndrome
Anterograde amnesia Apathy Aphasia, apraxia or agnosiaNutritional deficiencies
Beriberi Paresthesias, burning of feet Cardiovascular failure
Peripheral vasodilation Biventricular myocardial failure Na+ and water retention
Fetal Alcohol Syndrome (FAS) Most common preventable cause of adverse CNS
development
4,000-12,000 infants per year in US Characteristics Growth retardation Facial malformations Small head Greatly reduce intelligence Milder form of FAS 7,000-36,000 infants per year in US Characteristics Growth deficiency Learning dysfunction Nervous systems disabilitiesAlcohol & Cancer
Ethanol consumption increases risk of cancer Oral Cavity Pharynx and Larynx Esophagus LiverAlcohol Withdrawal Effects
Tremor Nausea Irritability Agitation Tachycardia Hypertension Seizures Hallucinations
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Basic Principles of Exercise
Exercise stressor
Why do we exercise?
1. Controls weight2. Combats health conditions and diseases3. Improves mood4. Boosts energy5. Promotes better sleep6. Improves sex life
What happens to the body when we exercise?
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Exercise Prescription
Types of Exercise
Anaerobic
intense exercise strength and speed does not need oxygen
aerobic
endurance needs oxygen
How do I know whether I am doing aerobic or anaerobic
exercise?
Heart Rate Monitoring
1. Compute your maximum heart rate. 220 age = MHR
2. Determine your training ranges. warm-up/cool-down: 85% of MHR
MHR =
warm-up =
aerobic =
anaerobic =
Aerobic vs Anaerobic Exercise
Aerobic Exercise
-running
Anaerobic Exercise
-weight lifting
Exercise Prescription
1. Determine the level of fitness of your patient.2. Determine goals for your patient.3. Determine training ranges.4. Advice.
Introduction to Nutrition
Compute your Body Mass Index:BMI = weight (kg)
Height (m)2
Computing for degree of obesity
Underweight 30
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GETTING THE WAIST CIRCUMFERENCE AND THE WAIST TO
HIP RATIO [WHR]
Men waist circumference > 90 cm WHR = > 1
Women waist circumference > 80 cm WHR > 0.85
What is nutrition?
Sum total of processes: intake and utilization of foodsubstances by living organisms
Ingestion Digestion Absorption Transport Metabolism
The Role of Nutrition in Health Promotion What you eat plays an important role in the development
or progression of a variety of chronic diseases:
Coronary artery disease Diabetes High blood pressure Osteoporosis Obesity Cancers
Six major nutrients in food
1. Carbohydrates Provision of energy2. Fats3. Proteins growth and development4. Vitamins Regulate metabolism5. Minerals6. WaterEssential Nutrients
Nutrients that the body needs but cannot produce inadequate quantities
Must be obtained from the food we eatNUTRIENTS ESSENTIAL OR PROBABLY ESSENTIALS TO
HUMANS
CARBOHYDRATES
FiberPROTEINS
Histidine Isoleucine
Leucine Lysine
Methionine Phenylalanine
Threonine TryptophanValine
VITAMINS
Thiamine Riboflavin
Niacin Pyridoxine
Pantothenic Acid Biotin
Folate Cyanocobalamin
C
MINERALS
Calcium Chloride
Magnesium Phosphorus
Potassium Sodium
Sulfur
VITAMINS
A D E KMINERALS
Boron Chromium
Cobalt Copper
Fluorine IodineIron Manganese
Molybdenum Nickel
Selenium Silicon
Vanadium Zinc
WATER
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Nutrients
Macronutrients
Carbohydrates (4 kcal/g)
Proteins (4 kcal/g)
Fats (9 kcal/g)
Micronutrients
Vitamins (13)
Minerals (~ 25)
Chemical Content of Nutrients
Inorganic Nutrients
Water Minerals
Organic Nutrients
Carbohydrates Proteins Lipids (fats) Vitamins
Carbohydrates
main sources of energy 40-80% of the total energy intake
Glycemic Index how much of a rise in circulating blood sugar a
carbohydrate triggers
the higher the number, the greater the bloodsugar response.
HIGH = 70 or more MEDIUM = 56 69 LOW = 55 or less
Brown.55 Long grain, White.44 Short grain, White.72 Glutinous (Sticky).98 All bran with fiber .38 Oatmeal 43 Raisin bran ..61 Cheerios ..74 Rice krispies 82 Corn flakes 92 Spaghetti, whole wheat..37 Fettuccini ...32 Spiral Pasta43 Linguine..46 Macaroni.47 Rice vermicelli 58Glycemic LoadThe glycemic load (GL) combines quality and quantity of carbs
in one number.
The carbohydrate in watermelon, for example, has ahigh GI. But there isn't a lot of it, so watermelon's
glycemic load is relatively low.
HIGH GL 20 +
MEDIUM GL 11-19
LOW GL 10 or less
Carbohydrates
Sugars
Monosaccharides- glucose, galactose, and fructose Disaccharides- sucrose (table sugar), maltose and lactose
(milk sugar)
Complex carbohydrates (polysacharides)
Starches are polymers of glucose Dietary fibers are mainly indigestible complex
carbohydrates in plant cell walls such as cellulose,
pectins and gums
Dietary Fiber
provides bulk modulation of peristalsis and the prevention of
constipation
soften the stool and hence promote normal elimination may also increase satietySoluble fibers
cholesterol-lowering effects increases fecal excretion of bile acids reduces cholesterol formation in the liver
increase production of short-chain fatty acids byfermentation in the large intestine
Insoluble fibers
found in vegetables, whole wheat grain, andwheat and corn bran
increases bulk in the gastrointestinal tract promotes gastrointestinal motility
Fats
Lipids: water-insoluble include triglycerides (the main constituent of fats and
oils) and sterols such as cholesterol
HDL good cholesterol LDL bad cholesterol
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Proteins
constitute the major part of the body's building blocks function as enzymes and hormones 12% of dietary calories in the Filipino diet
one third: animal sources such as fish, poultry,meat, eggs and milk
rest comes from rice, corn, bread and otherplant sources
Protein from animal sources better than from plantsources
Beans, legumes like mongo and other dried beansincluding soy beans: cheap meat substitutes
Vitamins
Fat-soluble
Vitamins A, D, E, and KWater-soluble
ascorbic acid and the B-complex vitamins
*subnotes
The amount of a vitamin in any specific food depends on two
main factors: the amount originally present in the food and
the amount of the vitamin that is destroyed or lost during
harvesting of plants or slaughtering of animals, and
subsequent storage, processing, and cooking. In general,
vitamin losses are greater at higher temperatures, prolonged
exposure to sunshine and air, and increased length of
storage. Dietary deficiencies are rare in people who eat well-
balanced diets and are usually associated with diets that have
an over-reliance on a restricted range of foods, often with
little or no fresh fruits and vegetables.
Minerals
macro-minerals (e.g. calcium and phosphorus which account
for 0.05% or more of total body weight)
micro-minerals (e.g. iron and iodine which account for much
less than 0.05% of body weight)
*subnotesMinerals are involved in a wide variety of biochemical
processes within the body. A large variety of essential
compounds in the body include mineral atoms or ions as part
of their structure. A few of the key roles are summarized
below for quick reference.
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*subnotes
Because minerals are essentially just atoms or ions, they
cannot be synthesized in they body. So all of the minerals
have to be derived from food or water.
Water most essential of all the nutrients
regulates temperature transports electrolytes and other nutrients excrete waste products from the lungs, skin and
kidneys
lubricate joints cushion the nervous system
Water (fluid) requirement 110 ml/kg for infants (3 glasses) 25 ml/kg body weight for adults (6-8 glasses)
A balanced diet is one that contains all the nutrients andother substances found naturally in food, in proper amounts
and proportions needed by the body to function well. Eating
a diet that includes a wide variety of foods in the right
amounts chosen from different food groups helps individuals
to meet the RDA.
Milk, yogurt, cheese
1 cup of milk or yogurt
1 ounces of cheese
Meat, poultry, fish, dry beans, eggs, and nuts
2-3 ounces of cooked meat, poultry, fish
cup of cooked beans
1 egg
2 tablespoons of peanut butter
Bread, cereal, rice and pasta
1 slice of bread
1 ounce ready-to-eat cereal
cup cooked cereal, rice, pasta
Vegetable
1 cup raw leafy vegetables
cup cooked
cup vegetable juice
Fruit
1 medium banana, apple, orange
cup chopped, cooked or canned fruit
cup fruit juice
Fats, oils and sweets
No serving size
Dietary Reference Intakes
Recommended nutrient intake (RENI) The average amount of a nutrient
considered adequate to meet the known
nutrient needs
Adequate Intake (AI) based on observed or experimentally
determined approximations of nutrient
intake by a group of healthy people
Tolerable Upper Intake Level (UL) highest level of daily nutrient intake that is
likely to pose no risks of adverse health
effect to most individuals in the general
population
Recommended Diet Composition
Carbohydrates
55 - 60 % Fruits, vegetables, grains
Lipids
20-30 % < 10% should be saturated fats Proteins 10-15 % Meat and meat products
*subnotes
The RDAs do not provide the additional nutrients required by
persons afflicted with diseases, traumatic stresses or nutrient
inadequacies. The recommended amounts depend on one's
body size, age, sex, physiological state and level of physical
activity.
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Prescribing Diets
1. Estimate the desirable body weight (DBW) Males: DBW 5 feet is 106 lbs. Add 6 lbs for
every inch above 5 feet
Females: DBW 5 feet is 100 lbs. Add 5 lbsfor every inch above 5 feet
Tannhausers method= [ Ht in cm 100] 10 %
2. Determine the total energy allowance (TEA) of theindividual by multiplying his DBW with the following
values, according to activity
Activity kcal/kg
DBW/day
Bed rest but mobile (hospital patients) 27.5
Sedentary (mostly sitting) 30
Light (tailor, nurse, physician, jeepney driver) 35
Moderate (carpenter, painter, heavy housework 40
Very active (swimming, lumberman) 45
3. Determine the carbohydrates (CHO), proteins (PRO)and fat by percentage distribution
Carbohydrates 55-70% TEA
Proteins 10-15% TEA
Fats 20-30% TEA
4. Calculate the number of grams of CHO, PRO and FATby dividing the equivalent grams per calories for
each nutrient
Carbohydrates 4 Cal/g
Proteins 4 Cal/g
Fats 9 Cal/g
For simplicity and practicality of the diet
prescription, round off calories to the nearest 50, and
carbohydrates, proteins and fats to the nearest 5 grams
5. Design a practical meal pattern by consulting thepatient, taking into consideration patients food
habits, food behavior and preferences
Example:
1. Make a diet prescription for a 5 foot femalesecretary. Assume CHO 65%, PRO 15% and
FAT 20%
The 10 Nutritional Guidelines for Filipinos
1. Eat a variety of foods everyday The human body needs more than 40 different
nutrients for good health.
No single food can provide all the nutrients in theamounts needed
To achieve good nutrition:
Plan and consume a balanced diet from a variety offoods
Eat the recommended amounts of food from eachfood group
Pay particular attention to the increased food needsduring pregnancy and lactation
If you eat convenience foods, choose those withhigher nutritional value and observe the principle of
variety
To achieve good nutrition:
Select fortified foods, whenever possible especiallythose with Sangkap Pinoy seal
Read food labels to make healthier choices Take nutritional supplements only upon expert
advice
Take care of the increased nutritional needs ofadolescents by giving adequate and varied meals to
get them ready for adulthood
2. Breast-feed infants exclusively from birthto 4 to 6 months, and then give appropriate
foods while continuing breast-feeding
Infants and children up to 2 years of age are mostvulnerable to malnutrition
Breastfeeding is one of the most effective strategiesto improve child survival
Nutritional requirements of an infant can beobtained solely from breast milk for the first six
months of life
At the sixth month of life at the latest, breast milkmust be complemented with appropriate foods, and
breastfeeding should be continued for up to two
year of age.
3. Maintain children's normal growth throughproper diet and monitor their growth regularly
Include milk in the child's daily diet or incorporatemilk in other foods
Use fortified foods Provide nutritious meals and snacks Continue feeding a sick child appropriately Encourage nutrient supplementation when
necessary
Take care of the increased nutritional needs ofadolescents by giving adequate and varied meals to
prepare them for adulthood
4. Consume fish, lean meat, poultry ordried beans
not only enhance the protein quality of the diet butalso supply highly absorbable iron, preformed
vitamin A and zinc
Fish, lean meat, poultry without skin and driedbeans, in contrast to fatty meats, are low saturated
fats, which are linked to heart disease.
5. Eat more vegetables, fruitsand root crops
Encourage consumption of at least two to threeservings of vegetables each day Advise intake of two servings of fruit daily, of which
one serving is a vitamin C-rich fruit
Include root crops in your meals at least three timesa week
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6. Eat foods cooked in edible/cookingoil in your daily meals
To increase energy intake of the diet, include somefoods cooked in edible/cooking oil daily
If you are at risk of heart disease, limit your intake ofcholesterol, saturated fats and fatty meats
*subnote
In general, Filipinos use very little oil in their cooking. Boiling
is the most common method of food preparation. Hence, the
total fat and oil consumption in a Filipino diet is low. Fats and
oils are concentrated sources of energy. A low-fat and oil
consumption results in a diet low in energy value,
contributing to chronic energy deficiency. Fats and oils are
also essential for absorption and utilization of fat-soluble
vitamins such as vitamin A, D, E, and K. A low fat intake may
be one of the causes of vitamin A deficiency among Filipinos.
To ensure adequate fat intake, Filipinos should be
encouraged to stir-fry foods in vegetable oil or to add fats and
oils whenever possible in food preparation. This will guard
against chronic energy deficiency and help to lower the risk of
vitamin A deficiency.
The excessive use of saturated fats and oils, however, may
increase the risk of heart disease. The proper choice of fats
and oils therefore is essential.
7. Consume milk, milk products and other calcium-rich foods, such as small fish and dark green leafy
vegetables everyday
Adequate amounts of calcium in the diet startingfrom childhood all through adulthood will help
prevent osteoporosis in later life
Everyone should include milk, milk products in thedaily meals. Otherwise, consume other calcium-rich
foods such as small fishes (eaten with the bones like
"dilis"), sardines, soy bean curd "tokwa" or "tofu",
small shrimps and green vegetables like "malunggay"
leaves, "saluyot", "alugbati" and "mustasa".
8. Use iodized salt, but avoidexcessive intake of salty foods
Helps eradicate goiter and iodine deficiency To help prevent hypertension, limit intake of salt and
salty foods.
When using salt, use iodized salt9. Eat clean and safe foodsTo help prevent food-borne diseases:
Eat clean and safe food. Drink safe water. Practice good personal hygiene. Practice environmental hygiene and sanitation. Clean and sanitize food preparation area. Practice
pest control.
Practice safe food storage, handling, preparation andservice.
10. For a healthy lifestyle and good
nutrition,exercise regularly, do not
smoke and avoid drinking alcoholic beverages
To achieve and maintain desirable body weight,balance food intake with physical activity and
exercise.
To obtain all the benefits of exercise, performaerobic exercise regularly for at least 3 to 5 times a
week for 20-30 minutes or more.
As a further hedge against chronic degenerativedisease, do not smoke. If you have acquired the
habit, stop smoking.
It is strongly advised to drink in moderation, ifalcohol is used at all.
FAMILY WELLNESS
Wellness is
An integrated method offunctioning which is orientedtoward maximizing the potential of which the individual
is capable.
It requires that the individual maintain a continuum ofbalance and purposeful direction within the environment
where he is functioning.
A life-long process of moving toward enhancing yourphysical, intellectual, emotional, social, spiritual, and
environmental well-being.
Composed of six dimensions
How WELLTHYAre You?
Many of us recognize the importance of wellness, but itis easy to get caught up in our busy schedules and find
were not maintaining a holistic regimen that consistently
meets our needs.
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Definitions of Health
"Health is a state of complete physical, mental, and social
well-being and not merely the absence of disease"
(WHO, 1947, p. 1)
GOOD HEALTH MEANS
Preventing premature death Preventing disability Promoting an environment that supports life Cultivating community and family support Enhancing individuals ability to respond and to take
action
Assuring that all people achieve and maintain amaximum level of functioning
The positiveness of health does not lie in the state , but in
the struggle-- the effort to reach a goal
Gordon, I . 1958
Wellness is a choice
Self-regulation
Cornerstone of health and wellness Taking control of ones lifestyle and health behaviors
so that lifestyle is the result of choice and not the
result of chance and ignorance
Conscious, willful, internally directed behavior thatpromotes health and homeostasis
Ingredients of self-regulation
Information and knowledge Decision making Commitment Goals Skill acquisition
GREEN & SHELLENBERGER, 1991
THEORETICAL CONSTRUCTS
CONSUMER INFORMATION SOCIAL LEARNING HEALTH BELIEFS MODEL TRANS - THEORETICAL MODEL
TRANS-THEORETICAL MODEL
CHANGE IS A DYNAMIC CONCEPT.
CHANGING BEHAVIOR GOES THROUGH STAGES
A MODEL OF HEALTH BEHAVIOR CHANGE
PROCHASKA & VELICER, 1997
PRE-CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE TERMINATION
Physician recommendations have been demonstrated to
significantly improve patients efforts to change behaviors.
Rippe J et al., Lifestyle Medicine, 1999
Natural Course of Disease
every consultation is an opportunity for preventive care
WELLNESS GUIDE
What does it include?
Risk assessment Counseling for the prevention of disease and
maintenance of health
Screening and health protection packages Immunizations ChemoProphylaxis
RISK ASSESSMENT
Basis is still a comprehensive clinical history Past medical and surgical history (childhood
illnesses) Immunizations given Medications (prescriptions and over the
counter, supplements)
Disabilites / handicaps And pertinent Physical Examination General Data (age, sex, educational level, socio-economic
status)
Family History (genogram) Personal Social History (include lifestyle check, stressors
and coping mechanisms)
TRAVEL HISTORY
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HOME ENVIRONMENT WORK ENVIRONMENT Basic Physical Examination (height, weight, BMI, waist
circumference)
THE WELLNESS GUIDE TO
PREVENTIVE CARE
Education/Counseling about healthy habits and injuryprevention
Screening tests for early detection of disease Immunizations ChemoprophylaxisHow to change a behavior?
- Lifestyle check- Life is about behavior- Do I really have to change everything
Lifestyle - Specific Recommendations
DIET & NUTRITION PHYSICAL ACTIVITY TOBACCO (active, passive) ALCOHOL (# of drinks) Stress Coping and MENTAL HEALTH SLEEP CAFFEINE INTAKE SEXUAL ACTIVITIES
Caffeine
Caffeine contained in two cups of coffee may raise the BP by
5 mm Hg in infrequent users. In habitual users, caffeine has
minor effect on the blood pressure.
Ruhl et al, 2000
Drinking more than five cups of coffee per day was more
common among patients with subarachnoid aneurysmal
hemorrhage (85%) than controls (59%) (p = 0.004).
Isaksen, 2002
SLEEP
At least 8 hours of sleep per day poor sleep with initiation difficulties is an
independent risk factor for cardiac events
among men
reduced stage 3-4 sleep predicted poorer overallhealth
Poorer quality of life was predicted by reduceddeep sleep
Promoting Sleep Hygiene
American Academy of Family Physicians Go to bed and wake up at the same time every day even
if you didn't get enough sleep.
Develop a bedtime routine. Do the same thing everynight before going to sleep.
Use the bedroom only for sleeping or having sex. Don'teat, talk on the phone or watch TV while you're in bed
Make sure the bedroom is quiet and dark. Avoid alcohol, it interrupts the body's sleep rhythms
and can cause sleep disturbances
Avoid caffeine less than six hours before bedtime Avoid eating a big meal too close to bedtime
LIVE SENSIBLY!
Among a thousand people , only one dies a natural death..
the rest succumb to irrational modes of living.
Maimodes 1135-1204 AD
THE WELLNESS GUIDE TO
PREVENTIVE CARE
Screening tests for early detection of disease Education/Counseling about healthy habits and
injury prevention
Immunizations Chemoprophylaxis
Screening
Executive check up
Periodic checkup
WHAT IS IT?
A group of tasks designed either to determine the risk of
subsequent disease or to identify disease in its early
symptomless state.
- Feightner et al., 1995
Periodic Health Examinations
Applying Evidence-Based Medicine in Maintaining Wellness
Periodic Health Examinations:
Is It Needed?
Prevention of Illness Chronic Illness Infectious diseases Malignancies Injuries
Screening Detection of unrecognized health risks Diagnosis of asymptomatic disease
Screening Tests for Men
General Adult Population
Body mass index OR Height in cm and Weight in kg[Yearly]
Waist hip ratio (Waist in cm/Hip circumference incm) [Yearly]
Auscultatory BP [Yearly] Eye examination [Yearly] Smoking history Level of activity
Adults 40 yrs and older
total cholesterol [q 2 yrs] Fasting blood sugar [q 2 yrs
Adults 50 yrs and older
Visual examination of oral cavity [yearly] Fecal occult blood [yearly] DRE, PSA
Adults 60 yrs and older
General health questionnaire [Once] Visual acuity with Snellen Chart [Yearly] Functional reach [Yearly] Colonoscopy
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Men's Health Check-up List
Cholesterol checks: every 5 years, starting at age 35. Ifsmoking, have diabetes or if heart disease runs in the
family, start having cholesterol check at age 20
Depression: feeling "down," sad, or hopeless, and havelittle interest or pleasure in doing things for 2 weeks
straight
Sexually Transmitted DiseasesScreening Tests for Women
General Adult Population
Body mass index OR Height in cm and Weight in kg[Yearly]
Waist hip ratio (Waist in cm/Hip circumference incm) [Yearly]
Auscultatory BP [Yearly] Eye examination [Yearly] Smoking history Level of activity Pap smear
Women 40 59 years old
Clinical breast examination [Yearly] Screening mammography [Yearly]
Adults 40 yrs and older total cholesterol [q 2 yrs] Fasting blood sugar [q 2 yrs
Adults 50 yrs and older
Visual examination of oral cavity [yearly] Fecal occult blood [q 2 yrs]
Adults 60 yrs and older
General health questionnaire [Once] Visual acuity with Snellen Chart [Yearly] Functional reach [Yearly]
Women's Health Check-up List
Depression: feeling "down," sad, or hopeless, and havelittle interest or pleasure in doing things for 2 weeks
straight
Osteoporosis Tests: bone density test at age 65 to screenfor osteoporosis. If between the ages of 60 and 64 and
weigh 154 lbs. or less, talk to HCP
Chlamydia Tests and Tests for Other Sexually TransmittedDiseases
Mammograms: every 1 to 2 years starting at age 40.Optional 40-49, yearly 50-75
Pap Smears: Every 1 to 3 years if sexually active or areolder than 21. Maximum interval every 3 yrs after 3
consecutive normal exams, yearly until 75, >75 optional
Cholesterol checks: At least every 5 years, starting at age35. If smoking, have diabetes, or if heart disease runs inthe family, start cholesterol check at age 20.
Recommended Tests for Selected Populations
Adults in occupational setting
Chest X-ray [Yearly]Healthcare workers
Chest X-ray [Yearly] Mantoux test [Once]
Caregivers
General health questionaire [Yearly]Retirees
General health questionaire [Yearly]Truck and bus drivers, security personnel & pilots
12-L ECGOccupational exposure to noise >85 decibels for 8 hours daily
Pure tone audiometryContacts of active or potentially active TB disease
Chest X-ray [Once] Mantoux test [Once]
Sex with multiple partners
STD panel [Yearly]CSW; partners of patients with STD
STD panel [q 6 mos]Close household contacts
HbsAg and Anti-HBs using enzyme immunoassay[Once]
Anti HAV IgG enzyme immunoassay [Once]Adults who chew or smoke tobacco; Adults who smoke
cigarettes
Visual Examination of the Oral Cavity [Yearly] FBS Ankle-Brachial index
Heavy alcohol drinkers
Visual Examination of the Oral Cavity [Yearly]Family history of early CVD
Fasting Lipid ProfileFamily history of DM
Any of the ff: FBS, RBS, 75g OGTT, FCG or RCG [q 2yrs]
History of Familial dyslipidemia
Ankle brachial index [q 2 yrs] Lipid profile [q 2 yrs] Any of the ff: FBS, RBS, 75g OGTT, FCG or RCG [q 2
yrs]
Family history of gout
Serum uric acid [q 2 yrs]Family history of glaucoma
Intraocular pressure [q 2 yrs]Two or more of the ff on PE: obesity, smoking, HPN
Lipid profile [q 2 yrs] 12 L ECG
Xanthoma
Lipid profile [q 2 yrs]Obesity
Any of the ff: FBS, RBS, 75g OGTT, FCG or RCG [q 2yrs]
THE WELLNESS GUIDE TO
PREVENTIVE CARE
Screening tests for early detection of disease Education/Counseling about healthy habits and
injury prevention
Immunizations Chemoprophylaxis
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Adult immunization
H. Influenza vaccine every year starting at age 50 Tetanus-diphtheria, 3-dose-series for previously
unvaccinated, booster dose every 10 years
Pneumococcal vaccine once at age 65 (earlier if (+) forcertain health problems, such as lung disease)
Hepatitis A & B shots Varicella vaccine for all adults without prior infectionChildren immunization
BCG DPT OPV Measles MMR Hepatitis B Varicella Tetanus-diphtheria boosters(Td)-11-16 yrs Rubella (females > 12 yrs)Adult Immunization
For women aged 19 through 26 years, either HPV2 orquadrivalent (HPV4) can be used for vaccination; alsoused a permissive recommendation for use of HPV4 in
men.
Revision to the measles, mumps, rubella (MMR) footnotenow notes in the beginning of the footnote that adults
born before 1957 generally are immune.
Further revisions clarify which adults born during or after1957 do not need 1 or more doses of MMR for the
measles and mumps components.
New interval dosing information states that a seconddose of MMR should be given 4 weeks after the first
dose.
Another revision to this footnote highlights that womenin whom rubella vaccination is not documented should
receive a dose of MMR.
A new section added to this footnote provides guidelinesfor vaccinating healthcare personnel born before 1957
routinely and during outbreaks.
Revision to the hepatitis A footnote now includes anindication for administering this vaccine to unvaccinated
persons who expect to be in close contact with an
international adoptee.
Revision to the hepatitis B footnote now includesschedule information for the 3-dose hepatitis B vaccine.
Revision to the meningococcal vaccine footnote explainsthat the meningococcal conjugate vaccine is preferredfor adults not older than 55 years and that the
meningococcal polysaccharide vaccine is preferred for
adults who are at least 56 years or older
For adults previously vaccinated with meningococcalconjugate vaccine or meningococcal polysaccharide
vaccine, revaccination with meningococcal conjugate
vaccine is recommended.
Revision to the selected conditions portion of the H.influenzae type B footnote now elucidates which high-
risk persons can receive 1 dose ofH. influenzae type B
vaccine.
Chemoprophylaxis
THE WELLNESS GUIDE TO PREVENTIVE CARE
Screening tests for early detection of disease Education/Counseling about healthy habits and
injury prevention
Immunizations Chemoprophylaxis
Aspirin
older than 40 or younger than 40 who have highblood pressure, high cholesterol, diabetes, or if
smoking
Hormonal Replacement Therapy
risks of taking the combined hormones estrogen andprogestin after menopause to prevent long-term
illnesses outweigh the benefits
Iron
in pregnant women helps both the mother andbaby's blood carry oxygen
Folic acid
-women of child bearing age- 400 micrograms (or 0.4mg) every day could prevent up to 70 percent of
neural tube defects
CalciumGuidelines from the National Academy of Sciences says that
the Adequate Intakes (AIs), in milligrams (mg), each day for
calcium are:
Infants 0-6 mo - 210 mg7-12 mo - 270 mg
Children 1-3 yrs - 500 mg4-8 yrs - 800 mg
9-13 yrs - 1,300 mg
4-18 yrs - 1,300 mg
Adults 19-50 yrs - 1,000 mgOver 51 yrs - 1,200 mg
During Pregnancy & LactationUnder 18 yrs - 1,300 mg
19 yrs and older - 1,000 mg
Calcium and Vitamin D
A serving of milk or yogurt contains around 300 mgcalcium
Vitamin D is needed to help the body absorb calciumcorrectly
FAMILY WELLNESS
Family wellness is a bigger picture than personal
wellness. And while it includes the same individual wellness
factors for each member of your family, it also includes the
wellness factors of the family as a group.
Family well-being depends on the quality of the
communication and time shared between everyone
in the family.
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How to know if the family is healthy?
Using tools of family assessment
- Genogram- Family apgar- Lifestyle- DIET- ACTIVITIES FOR FITNESS- Life cycle stage- History of diseases- History of dysfunctions- FAMILY MAPPING
BIOSTATISTICS in EPIDEMIOLOGY
Definitions
Statistics is the science and art of collecting,summarizing, and analyzing data that are subject to
random variation (Last, 1995).
Biostatisticsis the application of statistics tobiological problems.
Review of Concepts
Data refers to a collection of items of information. A variable is any quantity that varies. It is any
attribute, phenomenon, or event that can havedifferent values.
Uses of statistics
Statistics is an indispensable tool in medicine andhealth.
Almost all medical and health studies rely on thequantification of health and disease events in
populations.
Data collected in medical and health studies usuallyinvolve several observations on several variables.
Analyzing and presenting such large volumes of rawdata can be very cumbersome and painful.
Describe large data sets using only few numbers (likemean, range, etc.,)
Generalize the results of a small sample to the largerpopulation from which the sample is drawn
(extrapolation)
Compare different variables and test an underlyinghypothesis
Types of measurements
The basic building blocks of any study are the data - the
measurements which describe the factors being studied
Nominalvariables are observations which can beclassified into one of a number of mutually exclusive
categories
Ordinal variables are slightly more sophisticatedmeasures than nominal data Ratio and intervalscales are called continuous data.
The most sophisticated measures are those where
individuals are placed on a scale of continuous scale
in which the distance between two measurements
are well define
Summarizing data
Measures of central tendencymean, median and mode
Measures of dispersionVariance (s
2) is the mean square deviation
Standard deviation (s) is nothing but the square root
of the variance.
Inferential Biostatistics
Estimation
Why do we need to study samples? In an ideal world, if one
had find out, say, the mean birth weight of all babies born in
India during a year, one would weigh allthe babies born in
India during a year. By using samples we may able to
estimate a value that will represent the mean birth weight of
all babies in India.
Hypothesis-testing
Hypothesis testing (tests of significance)
involves ascertaining whether an
observed difference could have occurred
purely due to chance. This probability is
quantified as a P-value.
In hypothesis testing, one first starts with theassumption that the observed difference is not a rea
difference but one produced merely due to play of
chance. This is called the null hypothesis
One then tries to disprove the null hypothesis bycalculating the probability of the observed differencebeing due to chance. This probability is given by the
P value
If the P value is lower than a predetermined figure(0.05 by convention) obtained from the statistical
table for normal distribution, then one infers that
the observed difference is real and cannot be
explained purely by chance. The null hypothesis is
thus rejected.
The P value tells us only whether there is astatistical significance or not.
OBSERVATIONAL STUDY DESIGNS
Descriptive studies or case series
A descriptive study is the weakest epidemiologicaldesign.
The investigators merely describe the health statusof a population or characteristic of a number of
patients.
Description is usually done with respect to timeplace and person
Cohort Studies
Cohort studies are considered the strongest of allobservational designs.
A cohort study is conceptually very straightforward. The idea is to measure and compare the incidence ofdisease in two or more study cohorts Cohort studies are usually prospective or forward
looking
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Cohort Studies
New cases of the disease are picked up during followup and the incidence of the disease is computed on
the basis of the exposure status.
The incidence in the exposed cohort is thencompared with the incidence in the unexposed
cohort.
This ratio is called Relative Risk (RR) or Risk RatioRelative Risk = Incidence in the exposed cohort
/Incidence in the unexposed cohort
The relative risk is a measure of association betweenthe exposure and the outcome.
The larger the RR, the stronger the association. As it can be seen, the cohort study is the only study
design in which the true incidence of a disease can
be estimated.
The RR therefore is considered the best measure ofassociation
Relative Risk
Data for relative risk for myocardial infarction in patients
taking aspirin
RR= 139/11,037 0.0126 = 0.581
239/11,034 0.0217
The Relative Risk is less than 1
Case Control Studies
Conceptually, case control studies are more difficultto comprehend than cohort studies
In a cohort study, disease free exposed and non-exposed cohorts are followed up and then outcome
events are picked up as and when they occur. In a
case control design, sampling starts with diseased
and non-diseased individuals
They are called-cases and controls The exposure status is then determined by looking
backward in time (using documentation of exposures
or recall of historical events). For this reason, case
control studies are also called as retrospective
studies
The measure of association in a case control study iscalled an Odds Ratio (OR).
The OR is the ratio of the odds (chance) of exposureamong cases in favor of exposure among controls
Odds Ratio
Data for odds ratio for stroke with history of drug abuse
73/214 = 0.518 18/214 =0.092
141/214 196/214
OR = 0.518/0.092=5.64 therefore the patient who has had a
stroke is almost 6 times more likely to have abused drugs
than the patient who has not had a stroke
If the disease is rare, then the OR tends to be a goodapproximation of the Relative risk (RR). However, true
incidence estimates can not be generated from a case
control study.
CLINICAL TRIALSThe Randomized Controlled Trial (RCT)
The RCT is widely held as the ultimate study design;the "gold standard" against which all other designs.
The subjects are usually chosen from a large numberof potential subjects.
Sampling includes prescreening using a set ofinclusion and exclusion criteria.
After this, an informed consent is obtained fromeach participant.
Randomization is then done to allocate subjects toeither the treatment group or the placebo group
Ideally, intervention should be done in a blindedfashion.
Neither the investigator nor the subject should knowthe nature of the treatment that is being
administered.
After the intervention, the key outcomes that arebeing studied need to be measured by a blinded
investigator
Analysis involves looking for differences in theoutcome rates in the two arms of the clinical trial
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Double-Blind Cross-Over Design
What are the phases of clinical trials?
Clinical trials are conducted in phases. The trials at each
phase have a different purpose and help scientists answer
different questions:
InPhase I trials, researchers test a experimental drugor treatment in a small group of people (20-80) for
the first time to evaluate its safety, determine a safe
dosage range, and identify side effects.
Initial studies to determine the metabolism andpharmacologic actions of drugs in humans, the side
effects associated with increasing doses, and to gain
early evidence of effectiveness; may include healthyparticipants and/or patients.
InPhase II trials, the experimental study drug ortreatment is given to a larger group of people (100-
300) to see if it is effective and to further evaluate its
safety.
Controlled clinical studies conducted to evaluate theeffectiveness of the drug for a particular indication
or indications in patients with the disease or
condition under study and to determine the
common short-term side effects and risks.
InPhase III trials, the experimental study drug ortreatment is given to large groups of people (1,000-3,000) to confirm its effectiveness, monitor side
effects, compare it to commonly used treatments,
and collect information that will allow the
experimental drug or treatment to be used safely.
InPhase IV trials, post marketing studies delineateadditional information including the drug's risks,
benefits, and optimal use
THE ABCs of EVIDENCE-BASED MEDICINE (EBM)
Why Doctors Bother With EBM?
Doctors are unable to read original research articleor fully understand the results;
This inability to critically appraise a study and graspall that is implied in its findings limits the doctors
independence; thus,
There is reliance on expert opinion, the practices ofcolleagues and the pharmaceutical industry.
With the enormous volume of l iterature, doctorsapply EBM to clinical practice in order to
differentiate a good study from a trash; that is, a
study that is valid with credible results that they can
apply to their patients.
EBM A AQUIRE THE SKILLS
The 3 skills of EBM: how to acquire the information,appraise articles and apply the evidence.
VALIDITY versus RELIABILITY
Validity
Validity refers to how close we think the studyresults are to the truth
AccuracyReliability
Reliability means hitting the same objectiveconsistently.
Precision Intra-observer or inter-observer
EBM B BIAS
In general, the key word in the understanding of theconcept of bias is different.
If the way in which participants are selected into thestudy is different for example.
Similarly, if the manner in which information isobtained, reported, or interpreted is different
between groups in the study, then an inaccurate
impression of the true relationship may be obtained
In Summary:
There are 2 general types of observation bias,depending on the source of non-comparability:
1. recall bias 2. interviewer bias
EBM C CLINICAL TRIALS
Randomized controlled trials or RCTsThe Role of Bias in Clinical Trials
Achieve control for any influence of unknownvariables due to randomization (controlled biases).
The favorable impression (good) that this designstrategy may have on those reading the publishedresults of a trial.
How about those trials not published? Publication bias The burden of proof is on the investigator to show
that all possible biases in the allocation of patients to
a study group or confounding effects of known or
unknown factors that may differ between the study
groups did not account for the observed result.
http://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossaryhttp://clinicaltrials.gov/ct/info/glossary7/29/2019 Module 5 Reviewer
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Subjects in a trial of medical therapy may deviatefrom the protocol for a variety of reasons.
Developing side effects, forgetting to take theirmedication, or simply withdrawing their consent
after randomization.
Randomized patient rapidly worsens to the pointwhere therapy becomes contraindicated.
The extent of non-compliance in any trial is relatedto the length of time that participants are expected
to adhere to the intervention, as well as to the
complexity of the study protocol.
EBM D Design of the study
STUDY METHODOLOGYSTUDY BLINDS
BLINDING is an attempt to make the treatmentsbeing compared indistinguishable.
Allocation concealment is an attempt to preservethe random order by which the patients are assigned
to the groups.
Blinding is impossible when the interventions involvediet, educational maneuvers or surgical procedures.
Single blind versus double-blindRANDOMIZATION
Random assignment of patients to treatment groupsin a trial is the best technique to ensure that
treatment groups are truly comparable.
Such that each individual will have an equal chanceof being selected.
Known as well as unknown factors are equallydistributed to the groups.
Appraisal Form for Therapy
Directness Validity Results Applicability
Directness
Population Intervention or exposure Outcome
Population
Children Adults Elderly Certain class or severity of illnesses
Exposures
Behaviors Treatments Patient characteristicsOutcomes Treatment or cure Alleviation of symptoms or symptom control Quality of life Survival Morbidity Mortality Adverse events or harm
ASSESSMENT OF VALIDITY
Were patients randomly assigned to treatmentgroups?
Was allocation concealed? Were baseline characteristics similar at the start of
the trial?
Were patients blinded to treatment assignment? Were caregivers blinded to treatment assignment? Were outcome assessors blinded to treatment
assignment?
Were all patients analyzed in the groups to whichthey were originally randomized?
Was follow-up rate adequate?What are the results?
1. How large was the effect of treatment?2. How precise was the estimate of the treatment
effect?
-- p-value
-- confidence interval
-- standard error
RR, ARR, NNT
A measurement of how large was the effect oftreatment (RR, ARR and NNT)
RR is relative risk or comparison (ratio) of the risk ofoutcome in the treatment and control groups.
RRR is relative risk reduction or 1-RR. ARR is absolute risk reduction is difference in risk in
the control and treatment groups.
NNT is number-needed-to-treat and is the reciprocalof the ARR.
Can the results be applied to my patient care?
1. Are there biologic issues that may affect applicabilityof treatment?
2. Are there socio-economic issues affectingapplicability of treatment?
Individualizing the Results
What is the likely effect of the treatment on yourindividual patient?
EBM E EVIDENCE
What is the level of evidence?HIERARCHY OF EVIDENCES
(Strength of evidence for treatment decisions)
N of 1 randomized controlled trial Systematic reviews of randomized trials (meta-
analysis)
Single randomized trial Systematic review of observational studies Single observational study Physiologic studies Unsystematic clinical observations
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Statistical versus clinical significance
Statistical significance means the study has enoughpower to detect a difference between or among
treatment groups and that means, p-value is less
than 0.05.
Clinical significance means that the study did notreach enough power to detect a difference but in
the real-world scenario, there is a difference or at
least a trend along this line.
EPIDEMIOLOGY
Greek words: epi(upon)
demos (people)
Definition
The study of both the distribution of diseases inhuman populations and the determinants of the
observed distribution
It began as the study of infectious diseases but hasexpanded to include the study of chronic diseases,
health care organization, health care delivery,
occupational and environmental health
COMPONENTS
DISEASE FREQUENCY
The measurement of disease frequency involvesquantification of the existence or occurrence of
disease
The availability of such data is a prerequisite for anysystematic investigation of patterns of disease
occurrence in human populations
DISTRIBUTION OF DISEASE
Considers such questions as who is getting thedisease within a population as well as where and
when the disease is occurring
Derives from the first two since the knowledge offrequency and distribution of disease is necessary to
test an epidemiologic hypothesis
Describe patterns of disease as well as to formulatehypotheses concerning possible causal or preventive
factors
FOURTH ASPECT OF THE DEFINITION OF EPIDEMIOLOGY
STUDIES ARE DONE IN HUMAN POPULATIONS EPIDEMIOLOGY MAY BE VIEWED AS BASED ON TWO
FUNDAMENTAL ASSUMPTIONS
2 BASIC ASSUMPTIONS
1. That human disease does not occur at random 2. That human disease has causal and preventive
factors that can be identified through systematic
investigation of different populations or subgroups
of individuals within a population in different places
or at different times.
HISTORY OF EPIDEMIOLOGY
Hippocrates, Graunt, and Farr each contributed to anincreasing sophistication in the understanding of
disease frequency and distribution - two of the three
components of the definition of epidemiology.
HIPPOCRATES
THE DEVELOPMENT OF HUMAN DISEASE RELATEDTO THE EXTERNAL & PERSONAL ENVIRONMENT OF
THE INDIVIDUAL
Whoever wishes to investigate medicine properly should
proceed thus: in the first place to consider the seasons of
the year, and what effects each of them produce. Thenthe winds, the hot and the cold... the waters which the
inhabitants use... The mode in which they live, what are
their pursuits, whether they are fond of drinking and
eating in excess, and given to indolence, or are fond of
exercise and labor. - HIPPOCRATES
JOHN GRAUNT
In 1662, published The Nature and PoliticalObservations Made Upon the Bills of Mortality
Analyzed the weekly reports of births and deaths inLondon
For the first time, quantified patterns of disease in apopulation
Noted an excess of men for both births and deaths,high infant mortality and the seasonal variations in
mortality
Attempted to provide a numerical assessment of theimpact of plaque on the population of the city
Examined characteristics of the years in which suchoutbreaks occurred
Recognized the value of routinely collected data inproviding information about human illness (forms
the basis of modern epidemiology)
WILLIAM FARR In 1839, responsible for medical statistics in the
Office of the Registrar General for England and
Wales
Set up a system for routine compilation of thenumber and causes of deaths
Established a tradition of careful application of vitalstatistical data to the evaluation of health problems
of the general public
Recognized that data collected from humanpopulations could be used to learn about illness
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Compared mortality patterns of married and singlepersons and workers in different occupations (metal
mines & earthenware industry)
Noted the association between the elevation abovesea level and deaths from cholera
Attempted to ascertain the effect of imprisonmenton mortality
Addressed many major methodologic issues relevantto modern epidemiology
Defined the exact population at risk Chose an appropriate comparison group Considered whether other factors could affect the
results such as age, duration of exposure or general
health status
HISTORY OF EPIDEMIOLOGY
Two decades after Farr began his work, theavailability of routinely collected data on the
population and mortality patterns of England
enabled another British physician, John Snow, to
formulate and test a hypothesis concerning the
origins of an epidemic of cholera in London.
On the basis of the available descriptive data,including the observations made by Farr, Snowpostulated that cholera was transmitted by
contaminated water through a then unknown
mechanism.
He observed that death rates from cholera wereparticularly high in areas of London that were
supplied with water by the Lambeth Company or
the Southwark and Vauxhall Company, both of which
drew their water from the Thames River at a point
heavily polluted with sewage.
HISTORY OF EPIDEMIOLOGY
Between 1849 and 1854, the Lambeth Companychanged its source to an area of the Thames where
the water was quite free from the sewage of
London. The rates of cholera declined in those area
of the city supplied by the Lambeth Company, while
there was no change in those areas receiving water
from the Southwark and Vauxhall Company.
In 1854, Snow noted that the most terribleoutbreak of cholera which ever occurred in this
kingdom, is probably that which took place in Broad
Street, Golden Square and the adjoining streets, a
few weeks ago. Within two hundred and fifty yards
of the spots where Cambridge Streets joins Broad
Street, there were 500 fatal attacks of cholera in tendays.
Snow tabulated the number of deaths from cholerathat occurred from the commencement of the
epidemic in August 1853 to January 1854 according
to the two water companies supplying the various
sub-districts of London.
The areas of London supplied entirely by theSouthwark and Vauxhall Company experienced a
rate of 114 deaths from cholera per 100,000
persons, whereas there were no deaths from cholera
during that time in the districts supplied entirely by
the Lambeth Company.
A large area supplied by both companiesexperienced a rate midway between those for the
districts supplied by either alone.
These observations were consistent with Snowshypothesis that drinking water supplied by the
Southwark and Vauxhall Company increased the risk
of cholera compared with water from Lambeth
Company.
Snow also recognized the possibility that manyfactors other than the water supply differed
between the two geographic areas and thus could
account for the observed variation in cholera rates.
His unique contribution to epidemiology lies in his
recognition of an opportunity to test the hypothesis
implicating the water supply.
Snow outlined his natural experiment in his book Onthe Mode of Communication of Cholera: In the sub-
districts as being supplied by both companies, the
mixing of the supply is of the most intimate kind. The
pipes of each Company go down all the streets, and
into nearly all the courts and alleys.
A few houses are supplied by one Company and afew by the other, according to the decision of the
owner or occupier at that time when the Water
Companies were in active competition. In many cases
a single house has a supply different from that on
either side.
Each company supplies both rich and poor, bothlarge houses and small; there is no difference either
in the condition or occupation of the persons
receiving the water of the different Companies.
Now it must be evident that, if the diminution ofcholera, in the districts partly supplied with the
improved water, depended on this supply, the houses
receiving it would be the houses enjoying the whole
benefit of the diminution of the malady, whilst the
houses supplied with the water from Battersea Fields
(Southwark & Vauxhall Co.).
These houses supplied by the Southwark andVauxhall Company would suffer the same mortality
as they would if the improved supply did not exist at
all.
As there is no difference whatever, either in thehouses or the people receiving the supply of the two
Water Companies, or in any of the physical
conditions with which they are surrounded, it is
obvious that no experiment could have been devisedwhich would more thoroughly test the effect of
water supply on the progress of cholera than this,
which circumstances placed ready made before the
observer.
The experiment, too, was on the grandest scale. Nofewer than 300,000 people of both sexes, of every
age and occupation, and of every rank and station,
from gentlefolks down to the very poor, were divided
into 2 groups without their choice, and, in most
cases, without their knowledge...
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... One group being supplied with water containingthe sewage of London, and amongst it, whatever
might have come from the cholera patients, the
other group having water quite free from the
impurity. To turn this grand experiment to account,
all that was required was to learn the supply of
water to each individual house where a fatal attack
of cholera might occur.
Within the area supplied by both companies, Snowwalked from house to house and, for every dwelling
in which a cholera death had occurred, was able to
determine which company supplied the water.
The data provided convincing evidence that watersupplied by the Southwark & Vauxhall Co. was
responsible for the outbreak of cholera in London.
Thus, Snow charted the frequency and distributionof cholera and also ascertained a cause, or
determinant, of the outbreak.
Snow was the first investigator to draw together all 3components of the definition of epidemiology
Snows approach in the investigation of the choleraepidemic of 1853 to 1854 was applied primarily to
outbreaks of infectious diseases throughout the 19th
and early 20th
centuries. Thus the term epidemiologywas originally used
almost exclusively to mean the study ofepidemics of
infectious disease.
EPIDEMICS
Over the past 80 years, patterns of mortality indeveloped countries have changed markedly, with
chronic diseases assuming increasing importance.
As a consequence, the concept of an epidemic hasbecome much broader and more complex,
necessitating more advanced methods than the first
developed by Snow.
During the 20th century, changes in diseasedistributions have resulted in a broadening of the
term epidemic to include any disease, infectious or
chronic, occurring at a greater frequency than
usually expected.
DEFINITION OF TERMS
Epidemic the occurrence of an illness, in a specifiedgeographic area, that clearly exceeds the normal,
expected incidence (new cases). Ex. HIV
Hyperendemic a situation in which there is apersistent transmission of a disease among most of a
population. Ex. Malaria in certain parts of Africa
Endemic the constant presence of a disease in aspecific geographic area. Ex. Schistosomiasis inSamar
Pandemic the worldwide spread of an epidemicdisease. Ex. SARS
In the U.S., coronary heart disease is clearlyepidemic. Despite a recent period of decline,
mortality from this disease remains the chief cause
of death among both men and women, occurring at
one of the highest rate in the world.
ANOTHER EXAMPLE
Lung cancer in the U.S. today is also epidemic, sincethe overall mortality rate from this disease tripled
between 1950 and 1983, rising from 12.8 to 38.1 per
100,000 population, even after taking into account
the increasing age of the general population.
DEVELOPMENTS IN MODERN EPIDEMIOLOGY
1. DESIGN OF STUDIES AND TECHNIQUES FOR
COLLECTING AND ANALYZING DATA TO FACILITATE THE
EVALUATION OF RISK FACTORS FOR CHRONIC DISEASES.
2. APPLICATION OF EPIDEMIOLOGIC PRINCIPLES AND
METHODS TO THE DESIGN, CONDUCT AND ANALYSIS OF
CLINICAL TRIALS, STUDIES IN WHICH THE INVESTIGATORS
THEMSELVES ALLOCATE TO PARTICIPANTS THE
EXPOSURES BEING STUDIED.
BROAD CATEGORIES 0F DESIGN STRATEGIES IN
EPIDEMIOLOGIC RESEARCH
1. DESCRIPTIVE EPIDEMIOLOGY
2. ANALYTIC EPIDEMIOLOGY
Descriptive Epidemiology
Is concerned with the distribution of disease,including consideration of what populations or
subgroups do or do not develop a disease, in what
geographic areas it is most or least common, andhow the frequency of occurrence varies over time.
Analytic Epidemiology
Focuses on the determinants of disease by testingthe hypotheses formulated from descriptive studies,
with the ultimate goal of judging whether a
particular exposure causes or prevents disease.
Population At Risk: Health Risks And Risk Assessment
POLLUTION
Land Pollution
harmful substances introduced to the soil
May be consequences of: unsanitary habits various agricultural practices
Ex. soil fertilizers incorrect methods of waste disposal
Prevention: Education of farmers on the effects of nitrates in
fertilizers
Instruction to follow sound practices in their use Pesticide formulation should be registered
before being allowed in the market
Training of health care workers in the recognition andmanagement of poisoning
Air Pollution
Smog a.k.a phytochemical haze Oxidation of hydrocarbons and nitrogen oxide Mild: Irritate eyes, nose and throat Danger: sulfur dioxide and other materials
generated by burning of fuels
Prevention: Implementation of strict regulation Covering of mouth and nose whenever exposed
Clean Air Act of 1999 or Republic Act No. 8749
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Holistic national program of air pollutionmanagement
Emphasis: prevention rather than control, publicinformation and education and cooperation and
self-regulation among citizens
Water Pollution
any change in natural water which may impair their future
use
Causes: Dirty drainage systems Dirty recreational water Dirty sewage Industrial waste
Effects: Change in temperature of water Introduction of organic or inorganic substances Depletion of oxygen: death of aquatic life
World Health Organization (WHO): 80% of all disease are related to drinking
contaminated water
10million people worldwide die from water-related diseases
50% are infants and children Control measures:
Physical treatment by filtration Chemical treatment using coagulants Biologic treatment by transformation in the
earths crust
RADIATION
Emission of discrete particles or rays from asubstance
Produces charge ions that produce abnormalchemical reactions
Early effects in large doses cause complete halt inblood cell formation
Prolonged and continuous exposure lead to physicaland genetic defect
OCCUPATIONAL HAZARDS
- Disease resulting from exposure to toxic chemical agentso Ex: Asbestosis, silicosis, lead, arsenic and
organophosphate poisoning
- Disease due to physical agentso Ex: Asphyxia, Caissons disease, altitude
sickness, heat stroke
- Diseases due to mechanical factorso Ex: postural problems and back pains
- Diseases due to infectious agentso Ex: Tetanus, rabies, ringworm, erysipelas
- Control measures:o Isolationo Substitutiono Alteration of work processeso Ventilationo Proper waste disposalo Adequate sanitary facilitieso Personal protective devices
PESTS
Belong to the group of mans natural enemies that causedamage, discomfort and displeasure to life:
Bee and wasp stings anaphylactic shock Rats rat-bite fever Ticks, mites, bedbugs, cockroaches and
mosquitoes itchiness
Houseflies - diarrheaPOVERTY
Common denominator of various diseases: malnutrition,tuberculosis, venereal diseases
Higher rates of infant and perinatal mortality Prominent environmental hazards due to poor
housing
Overcrowding: fire hazard Poorly lighted streets and lack of safe area for
children in the community breed crime and
accidents
Infrequent garbage collection and improperdisposal give rise to breeding place for rats and
insects