Moving Upstream of the Rapids: Population Health, Epigenetics, and the Role of Community Health Workers
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Moving Upstream of the Rapids: Population Health, Epigenetics, and the Role of Community Health Workers
- 1. Tina CastaĂąares, MD Partnering Together for Community Health Going Upstream ACES, DOHad and Epigenetics Community health workers Priester Conference April 2013 in Corvallis, Oregon
- 2. In the wise words of Dr. Don Berwick⌠Founder, Institute for Healthcare Improvement President Obamaâs original director of Medicare and Medicaid (CMS)
- 3. âThe best hospital bed is empty. The best CT scan is the one we donât need. The best doctorâs visit is the one we donât need.â
- 4. % Oregon Population Defined as Obese We know weâre (BMI > 30) 30 in trouble % of Population 20 10 0 1989 1996 2003 2007 Trends in Diabetes in USA Year Measured Data from NHANES, CDC 2009 With thanks to Kent Thornburg, PhD, OHSU
- 5. Moving Upstream of the Rapids Moving Upstream of the Rapids
- 9. CT image of coronary artery disease
- 12. Overall, âupstreamâ population health work: â˘Promotes wellness, prevents disease and improves health status â˘Avoids âblame gamesâ about individual responsibility for health â˘Reduces demand for health care (overall spending, workforce, infrastructure) â˘Raises all boats at once: truly equitable because population- and community-wide
- 13. Population-based Health is⌠âŚmore than twice as responsible historically for health improvement than medical, nursing, oral health and mental health services combined.
- 14. The poor and minorities experience serious health disparities
- 15. âŚ.because of risk factors such as: â˘barriers to physical activity in schools, workplaces, neighborhoods â˘food subsidies making fast and processed foods cheaper â˘environmental contaminants â˘targeted tobacco & alcohol advertising â˘lack of access to fresh foods â˘crowding and substandard housing â˘many other well-documented social factors
- 16. Achieving social equity ⢠âŚis the only real answer to preventable health disparities. ⢠âŚis a goal we have an ethical responsibility to work toward ⌠as citizens, voters, leaders and members of the human commons.
- 17. So now, more upstream stillâŚ. TO THE HEADWATERS
- 18. Early childhood, neonatal, fetal, embryonicâŚ. transgenerational ! ACES DOHaD research Adverse Childhood Developmental Origins Experiences Study of Health and Disease
- 21. âThe Adverse Childhood Experiences Study -- The Largest Public Health Study You Never Heard Ofâ Huffington Post October 2012 3 parts
- 22. So now, more upstream stillâŚ. The Developmental Origins of Health and Disease (DOHaD)
- 23. www.dohadsoc.org
- 24. Low Birth Weight (LBW) ⢠US babies more likely to be LBW than in almost every other developed country. 2 ⢠LBW = 2nd leading cause of infant mortality in the US (after birth defects). ⢠Surviving infants at risk for serious medical conditions and learning disorders. 3
- 25. Unacceptable disparities â˘LBW climbing for minority mothers â˘African-Americans: 2 X likelier than whites, Hispanics for LBW babies â˘Problem is not âin the genesâ âŚand not always linked to current income
- 27. How can this be? Epigenetics is the key. ⢠Our GENES themselves arenât all that different. ⢠People with identical genes turn out differently, get different diseases, etc. ⢠âBehavioral geneticsâ has long sought explanations. ⢠Epigenetics brings biological evidence.
- 28. What does epigenetics tell us? ⢠Gene REGULATION and EXPRESSION are mostly in charge. ⢠Gene regulation is subject to many influences. ⢠âSocialâ influences ď not so very separate from âbiologicalâ influences ⢠Amazing: some gene regulation and expression can be inheritedâŚ. So this is trans- generational.
- 29. Two key epigenetic factors I want to share today : ⢠Maternal and placental nutrition ⢠Maternal and fetal chronic stress (sustained elevated levels of stress hormones ) (A proven, very important third factor is maternal exposure to toxins. Another involves paternal health and age. Doubtless, more will emerge.)
- 30. Poor nutrition or sustained stress hormones: ⢠Developing embryo / fetus biochemistry responds by -- making sub-standard vital organs (mostly smaller ones) -- bigger placenta, lower birthweight
- 32. Risk of chronic disease is predicted epigenetically, right from grandmotherâs preconception health, through grandchildâs early life. So EARLY prevention and corrections are imperative.
- 33. Epigenetic risk factors are preventable and even reversible. ⢠The earlier, the better ⢠First 1000 days post-conception ⢠Pre-conception too Interventions must improve maternal (community !!!!) nutritional status, and prevent or reverse chronic stress.
- 34. This is good news, not bad news⌠and not âbiological determinismâ ⢠new scientific evidence to guide social policy, strategies, and investments ! ⢠hope for better health for our society â a reversal of the last 100 years of downward health trends!
- 35. Why should we do these things? The future of human health is at stake.
- 36. What can Extension do?
- 37. I am passionate about Community Health Workers ⢠Peer-to-peer ⢠Culturally competent: understanding from within the culture or subculture ⢠Natural leadership ď Community-building. Community asset forever. ⢠Special learning and teaching tools/pedagogy (popular education, motivational interviewing) ⢠knowledge not restricted; infinite ⢠role carefully defined, supported: a prestigious and valued position ď stable staff
- 38. CHWs (health promoters) with whom Iâve been privileged to work .
- 40. Imagine that we live in a regionâŚ. âŚwhich is the best place in the world for every baby to be born âŚwhich is the best place in the world for every child to grow up
- 41. Thank you, Extension! You do so much for our communitiesâŚ. and for population health, way upstream! I welcome your feedback. tina.castanares@gorge.net
Editor's Notes
- I want to focus on two areas of research with profound, paradigm-shifting implications for us allâŚ.as scientists, ethicists, health care and public health professionals, and members of the human community. The first is the ACES, the Adverse Childhood Experiences Study. As Iâll talk about briefly, we have very, very solid evidence that certain adverse experiences during early childhood are strong predictors of learning disabilities, some mental illness, and numerous other chronic illnesses during later childhood and throughout adult life. Many of the correlated conditions donât appear until decades after the childhood traumas -- in other words, the horse has long ago left the barn. So Iâll speak more about that first. But my great passion, recent, life-changing new information for me, is even more involved with DOHaD, a very rapidly emerging field of research, and Iâll want to spend evenn more time on that today.So get ready, because here we go upstream, to learn about causes, and more causes, and to reflect together, I hope, about the implications.
- The ACES was started at Kaiser Permanente in the 1990s though a suggestive predecessor study was conducted earlier in the Kaiser system. Dr. Vincent Felitti looked at 18,00 adults in ACES, asking them to answer a very simple survey â 10 simple questions â about their early childhoods. He was then able to demonstrate a significant correlation between early childhood trauma experiences and severe obesity, heart disease, depression and other psychiatric disorders, diabetes and many other ailments later in life. According to the Oregon Public Health Division, 16% of adult Oregonians had an ACE score of 4 or higherâŚ16% (you get one point for every answer âyesâ in the questionnaire). Compared to people with ACE scores of 0, those with an ACE score or 4 or higher are now known to be twice as likely to smoke, 7 times more likely to have alcoholism, 10 times more likely to inject street drugs, and 12 times more likely to commit suicide. But thatâs not all â you see other chronic diseases in this very dramatic bar graph (above)
- And more illnesses and disabilities continue to be associated with ACES scoresâŚCOPD, GI disorders, GU disorders, STIs, sexual dysfunction, and pre-term deliveryâŚ.
- The original ACES work has its own CDC website now, has been internationally received, validated and applied, and the data from the original as well as newer cohorts are behind very robustly studied to see if there are even more chronic health and social conditions that appear after, and correlate with, adverse childhood experiences. I urge you to research ACES for yourself if itâs new to you â the CDC website is a fine place to start. This slide shows a headline from the online newspaper The Huffington Post, which ran a good series of 3 articles for the general public last fall about ACES. But while itâs true that ACES may be the largest public health study you never heard of, I would argue that this is even more true of DOHaD research â itâs just that DOHaD work hasnât come as closely under the umbrella of public health OR social science research yetâŚ.so itâs even less widely known.
- So letâs go to DOHaD. If thereâs one thing I hope youâll take away from this morning plenary, itâs that the Developmental Origins of Health and Disease â and more broadly, the field and discoveries of epigenetics that are a part of DOHaD, are standing on its head our former knowledge of genetics, nature and nurture. As I said, paradigm-shifting, and with profound implications for healthcare, public health, the law, social policy and ethics.