Transcript Slide 1

Health
and the Kentucky Woman
Leslie J. Crofford, MD
Gloria W. Singletary Professor of Women’s Health Research
Director, Center for the Advancement of Women’s Health
Advancing women’s health through
comprehensive medical care,
education and outreach,
and research opportunities
http://www.mc.uky.edu/womenshealth/
Mission
– Create new knowledge towards the understanding
and improvement of women’s health through clinical and
basic research initiatives
– Train primary care practitioners in gender-specific
medicine and sensitize all health practitioners to
understand and respond to the health care concerns and
needs of women
– Provide gender-specific diagnostic, treatment and
preventive health care services in a coordinated,
comprehensive and compassionate manner
– Share women's health resources and information
with consumers, communities, health care
professionals, educators, and policy makers
– Enhance the professional development of women at all
academic levels within the University of Kentucky
Chandler Medical Center, and increase recruitment,
retention, promotion and advancement of women faculty
Goals for this Presentation
• Discuss determinants of health
• Review recommendations on how to maintain
good health and prevent disease
• Review behaviors associated with health
• Consider what we can do to promote good
health in our families and our community
• Introduce the Kentucky Women’s Health
Registry
http:// www.kywomensregistry
•Health
– Chronic disease
prevention
– Longevity
– Wellness
Live well, live long
• Determinates of Health
– Genes
– Environment
– Behavior
– Attitude
Genes and Health
• Single gene disorders
– Cystic fibrosis, sickle-cell
anemia, hemophilia, etc
• Chromosomal abnormalities
– Down’s syndrome, etc
• Complex traits
– Heart disease, depression, etc
• Diseases associated with
gene mutation
– Cancer
http://www.ygyh.org/
http://www.dnaftb.org/
• DNA is the building block
for genes
• Genes are inherited from
parents as discreet units
that come in pairs and are
carried on chromosomes
• Simple genetics can be
applied to single-gene
traits that are either
dominant or recessive
• More complex traits and
diseases are associated
with some genes that are
permissive and others that
are protective
Gene/Environment Interactions
• Most chronic diseases are attributable to both
genes and environmental exposures
– Some exposures cannot be avoided, others are the
result of modifiable behaviors
• What counts as environment?
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Natural environment, e.g. sun
Infectious exposures
Chemical or toxin exposures
Trauma and other physical stressors
Psychological stressors
Dietary exposures
Gene/Environment Interactions
• Cancer
• Metabolic diseases
and heart disease
• Autoimmunity
• Depression
• Chronic pain and
fatigue
Genes, Environment, and Health
• Understand your genetic
risk factors
– Family history
• Understand your
environmental risk factors
– Unavoidable exposures
– MODIFYABLE RISKS!!
• Know what kinds of
preventative steps may be
important for you
– Screening that works
Concept of Preventative Health
• Prevention and early detection are essential to
good health
• Potentially infinite lists of advice and tests
– Many have little scientific basis for widespread
implementation
– Preventative strategies should be evaluated in studies
• On what do you base recommendations for
screening?
– Burden of suffering
– Characteristics of screening tests
– Effectiveness of early screening in
reducing morbidity and mortality
Cancer
http://www.insidecancer.org/
• Only about 10% of cancer risk can be
attributable to inherited genes while the other
90% of cancer is associated with mutations
associated with environmental exposures
• Genetic mutations accumulate with age and
exposures, e.g.
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Sun
Diet (saturated fat, fiber)
Chemicals and toxins (tobacco smoke)
Infections (human papillomavirus)
Cancer-Associated Genes
Cancer genes are involved
in cell growth, and their
ability to invade
surrounding tissues or
metastasize
• Presence of genes which allow
uncontrolled growth
• Absence of cells which put the
brakes on growth
• Genes that help cancer cells
avoid removal
• Genes that assist cancer cells
in spreading
Cancer in Women: The Big 3
• Lung Cancer
• Breast Cancer
• Colon Cancer
Lung Cancer in Women
• Lung cancer will kill about 72,130 American women this year
• Kentucky leads the nation in lung cancer deaths
– With a given smoking exposure, women are more likely to get lung
cancer
– Women are more likely than men to die of lung cancer
• Kentucky leads the nation in adult smokers
– 32.6% (#2 is Alaska at 29.4%)
• About 90% of lung cancer deaths in women are related to smoking
– Second hand smoke counts
• A family history of lung cancer, but not other cancers, increases risk
for lung cancer
– The risk of inherited lung cancer is greater for women than men
– The risk is most easily identified in non-smokers
• Those with a family history of lung cancer could be considered highrisk
Lung Cancer Screening?
• At this time, there is
insufficient evidence that
screening of asymptomatic
persons improves survival
• High false negatives on
chest X-ray
• High false positives on CT
Scan
• Poor sensitivity when
screening sputum for cancer
cells
Prevention is Essential
Breast Cancer
• Breast cancer is the second leading cause of cancer deaths in all
women, and the leading cause in young women
– 1 in 8.2 women will develop breast cancer in their lifetime
– 1 in 30 women will die from breast cancer
• Risks
– Genes
• Mutations in BRCA1 and BRCA2, cancer suppressing genes, are associated
with breast, ovarian, and prostate cancer
– Environmental Risks
• Estrogen
– Early menarche, late menopause, nulliparity
– Hormone replacement therapy (2002 WHI study and 2006 NHS)
» 24% increased risk after 5 years for combination estrogen-progestin
» Significant risk for estrogen only after 15-20 years (42% after 20 years)
» Especially significant risk for thin women
• High-dose radiation, obesity, heavy alcohol use
• Protection from risk
– Exercise, diet
Breast Cancer Screening
• Screening mammography should be
performed every 1-2 years for women
aged 40 and older
– Little evidence separating 12-33 month
intervals
– With or without clinical breast exam
– Insufficient evidence for breast self-exam
• Evidence that digital mammography
superior to traditional mammography
• Effectiveness of early detection
– Strongest for women aged 50-69
– Most, but not all studies, show reduction in
mortality for women 40-49
– One study demonstrating reduced mortality
for women 65-74
Colon Cancer
• Colorectal cancer effects women and men
equally and is the 3rd leading cause of cancer
death in women
• 60% of patients with colorectal cancer have
regional or distant metastases at the time of
diagnosis
• 5-year survival
– 91% for localized disease
– 60% for regional disease
– 6% for distant metastatic disease
Risk Factors for Colon Cancer
• Family history
– Familial syndromes account for 6% of
colorectal cancers
– Family history increases the risk by up to 4x in
those 40-60
• Prior diagnosis of endometrial, breast or
ovarian cancer
• Personal history of polyps
• Diets high in fat, low in fiber
Colon Cancer Screening
• Should begin at age 50
– Yearly test for blood in the
stool
– Flexible sigmoidoscopy
– Colonoscopy
• Especially important for
women as cancers tend to be
in the proximal colon 64.8% of
the time
• Screen earlier in high-risk
patients
Diabetes, Hypertension, Hyperlipidemia,
and Heart Disease
• Genes and exposures control
risks for metabolic diseases
• Metabolic diseases (and
smoking) are the most
important risks for heart disease
– Heart disease is the #1 killer of
women
• Preventing these chronic
diseases is essential for health,
wellness and longevity
• Behavioral factors are critical
for preventing these diseases
Preventing Metabolic
and Heart Diseases
• Know your family history
• Maintain a normal body weight
– Exercise regularly
– Eat healthy foods
• Control blood pressure, blood sugar and
cholesterol
– Use medications if needed
• Don’t smoke
– More than ½ of heart attacks in women under 50 are
related to smoking
Screening for Metabolic Diseases
Associated with Heart Disease
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Diabetes
– Screen for type 2 diabetes in adults with hypertension or hyperlipidemia
– Yearly fasting glucose for all starting at 45 years of age and younger for those
with risk factors
• Family history of type 2 diabetes, overweight, and hypertension
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Hypertension
– Screen in adults aged 18 or older
– Weight reduction, exercise and reduced salt intake helpful
– Early treatment and good follow-up reduces all cause mortality 17%
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Hyperlipidemia
– Women should be screened starting at age 45 (men at age 30)
– Screen earlier if other risk factors for heart disease present
• Women age 20 or higher
• Measure total cholesterol LDL (bad) and HDL (good) cholesterol
– Diet can lower cholesterol, but drug treatment lowers risk of death
• Treat to LDL <100 (<70 if other risk factors)
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Routine screening for coronary artery disease in asymptomatic women is
not recommended
What about Body Weight?
Underweight is associated with smoking and osteoporosis;
overweight with diabetes, hypertension, and heart disease
N Engl J Med. 2006 Aug 24;355(8):763-78
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1995, 2005
(*BMI 30, or about 30 lbs overweight for 5’4” person)
1990
1995
2005
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Why this Epidemic?
http://www.cdc.gov
• Overweight and obesity result from an energy
imbalance. This involves eating too many calories and
not getting enough physical activity.
• Body weight is the result of genes, metabolism, behavior,
environment, culture, and socioeconomic status.
• Behavior and environment play a large role causing
people to be overweight and obese. These are the
greatest areas for prevention and treatment actions.
• “Despite obesity having strong genetic determinants, the
genetic composition of the population does not change
rapidly. Therefore, the large increase in . . . [obesity]
must reflect major changes in non-genetic factors.”
Obesity in Kentucky
• The epidemic in Kentucky
– 63% of adults in Kentucky are obese or overweight
– 30% of Kentucky high school children are overweight
or at risk of becoming overweight
– 35%of lower-income children between the ages of 2
and 5 are overweight or at risk of becoming
overweight
• Kentucky nutrition and physical activity plan
– New standards for nutrition and physical activity in
schools through legislation (Senate Bill 172) passed
in March 2005, the state’s first public policy created in
direct response to the obesity epidemic
Impacting Obesity
Location
Home
Steps to Prevent and Decrease
Overweight and Obesity
Reduce time spent watching TV and other sedentary
activities; build physical activity into regular routines
Schools
Assure that meal programs meet nutrition standards;
provide food options low in fat, calories, and added sugar;
provide children with quality daily physical education
Work
Create more opportunities for physical activity at work sites
Community
Promote healthier food choices; encourage food service
providers to decrease portion sizes and provide healthier
options; encourage opportunities for physical activities
Aspirin?
• Aspirin thins the blood to reduce blood
clots that can cause heart attack and
stroke
• The benefits of low-dose aspirin differ in
men and women
• In women aged 40-65, aspirin did NOT
reduce the risk of a first heart attack, but
did reduce the risk of stroke (more
common in women)
• After age 65, aspirin use decreased the
risk of heart attack by 34%
• Remember that aspirin can cause ulcers
and bleeding, a side effect that increases
with age and with the use of other nonsteroidal drugs (ibuprofen, naproxen)
Other Issues of Preventative Health
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Osteoporosis
– Risk factors
• Female, advanced age, Caucasian
race, low-body weight, surgical removal
of ovaries before menopause, smoking,
alcohol use, glucocorticoid use
– 50% of post-menopausal women will
develop a spontaneous fracture
– 15% of women will sustain a hip
fracture
– Screening
• All women aged 65 and older should be
screened
• Women with risk factors should be
screened at age 60
– Prevention
• Calcium and vitamin D – lifelong!!
• Weight-bearing exercise
• Estrogen – increased bone density and
reduces fractures
Hormone Replacement Therapy
• Benefits and Harms
– Benefits
• Reduced osteoporosis and fractures
• Reduced colon cancer
– Harms
• Breast cancer
• Contraindications
– Absolute
• Undiagnosed vaginal bleeding, breast or endometrial cancer, recent
blood clot
– Relative
• Liver disease, melanoma, gallstones, increased triglycerides,
endometriosis, fibroids, history of blood clots
Vitamins and Supplements
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Eating a wide variety of foods, including fruits, vegetables, whole grains, legumes and
lean meats
Vitamin and mineral supplements may be needed if:
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Folic Acid
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All women during reproductive years
Multivitamin or breakfast cereal
Calcium and Vitamin D
Iron
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Poor dietary habits
Less than 1,200 calories a day
Problems with absorption
If heavy menstrual bleeding
Pregnant or trying to become pregnant
Other vitamins, minerals or supplements?
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Omega-3 Fatty Acids
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Fish or supplements
Reduces inflammation and heart disease
Fiber
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Promotes healthy bowel function, reduces colon cancer, and may decrease risk of health disease
Vaccinations
• Influenza A: Yearly
– For those at risk or who care for those at risk
– Adverse effects rare
• Pneumococcal: Every 5 years
– Elderly (>65), chronically ill or immunocompromised
• Tetanus and diptheria: Every 10 years
• Measles, mumps, rubella: One time
• Hepatitis B: One time
– All under 18 and high risk groups
• Meningiococcal
– High risk groups (including residents of dormitories)
• Human papilloma virus?
– Example of policy issue
– Detectable in 75-95% of cervical cancer
Risk Behaviors are Established
Early in Life
• Smoking
– More than 1 in 5 high school students are current smokers
• Unhealthy dietary behaviors
– Almost 80% of high school students do not eat the recommended 5
servings of fruits and vegetables
• Inadequate physical activity
– Nearly 1 and 3 children and adolescents are overweight or at risk of
becoming overweight
• Alcohol an other drug use
• Sexual behaviors that may results in HIV infection, other sexually
transmitted diseases, unintended pregnancy
– Every year, more than 870,000 adolescents become pregnant and over
3 million become infected with a sexually transmitted disease
• Behaviors that contribute to unintentional injuries and violence
– Not wearing seat belts, riding with a driver drinking alcohol, carrying a
weapon
Concept of “Wellness” in Health
• Incorporates concepts of
being physically and
mentally healthy
– Exclusive of specific disease
• Includes some components
of functional capacity or
activity
• Adds positive psychological
constructs of happiness and
life satisfaction
Health-Related Quality of Life
• Americans said they feel unhealthy (physically or mentally) about 6
days per month
• Americans said they feel "healthy and full of energy" about 19 days
per month
• Nearly one-third of Americans say they suffer from some mental or
emotional problem every month—including 10 percent who said
their mental health was not good for 14 or more days a month
• Younger American adults, aged 18–24 years, suffered the most
mental health distress
• Older adults suffered the most poor physical health and activity
limitation
• Adults with the lowest income or education reported
more unhealthy days than did those with higher
income or education
• Americans with chronic diseases or disabilities
reported high levels of unhealthy days
Mean Number of Unhealthy Days by
State: Kentucky Leads the Nation
Main Factors Associated with
Health and Activity Limitations
• Depression/anxiety/
emotional problems
• Cancer
• Diabetes
• Stoke
• High blood pressure
• Back or neck
problems
• Heart problems
• Lung/breathing
problems
• Walking problem
• Fracture/joint injury
• Arthritis/rheumatism
• Eye/vision problem
• Hearing problem
What Kinds of Things
Cause Stress?
Then
• Predators
And Now
– Escaping
– Surviving attack
• Weather extremes
– Drought
– Heat
– Cold
• Starvation
• Parasites
• Deadlines
– Too much to do; to little time
• Conflicts at home
– Divorce
– Illness
– Worries about children
• Discord at work
– Interpersonal conflicts
– Lack of respect/control
• Money worries
• Daily hassles
– Traffic, rude behavior
Stress and Adaptation
Learning
Genetics
Life Experience
Context
Individual
Response
Stressor
Allostasis
Coping Style
Determinants of the Stress Response
– Childhood maltreatment
– Deprivation
– Family stress
• Chronic stress
– Social hierarchy
– Instability
• Coping
– Glass half full/empty: Optimism
– Locus of control
– Learned helplessness
Circadian
Rhythm
Stress
Hypothalamus
CRH
Pituitary
ACTH
Cortisol
Adrenal
Cortex
Slow
wave sleep
20
Cortisol
mg/dL
• Genetics
• Early life experiences
10
0
700 1300 1900 100
Time
700
• Exposure to violence is an important
cause of physical and mental health
problems
– 12-14% prevalence in Emergency Rooms
– 21-37% prevalence in primary care settings
• Associated with stress-associated disorders
– Continues during pregnancy
• Important cause of injury and death during
and after pregnancy
– Mental health conditions associated with
interpersonal victimization
• Depression, anxiety, post-traumatic stress
disorder, suicidality, hopelessness and low
self-esteem
Exposure to Intimate Partner Violence
in Kentucky
• 75% reported multiple forms of
IVP
• 74% injured and 69% more
than one type of injury
• 44% report children present
during abuse
• 40% of perpetrators use
children to threaten
• 39% abuse increased
throughout relationship
• 20% abused during pregnancy
• 15% perpetrator harmed a pet
• 5% perpetrator killed a pet
Healthy Aging
Myth
Health inevitably declines as
we get older
Reality
People of any age can
improve their health by
adopting healthy behaviors
Insights from Centenarians: “the older you
get, the healthier you’ve been”
Thomas Perls, MD, MPH
• Genetics is important
– Absence of disease-causing genes and presence of longevity-enabling
genes
• Siblings live longer
• Children have lower mortality
– Lower prevalence of age-related chronic disease
– Lower body mass index
• Healthy cognitive functioning is a better predictor of independence
than physical health
– Some people markedly delay or escape age-associated brain diseases
• Impact of chronic diseases important
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Diabetes, heart disease, cancer, etc
20% completely escape chronic disease
40% have marked delay until after age 85
40% develop diseases before 65, but survive long after diagnosis
Longevity & Frailty
• Longevity
– Genes are important BUT….
– Healthy lifestyle is also essential
• Living long AND healthy is the goal
– Frailty is characterized by:
• Exhaustion, weakness, weight loss,
loss of muscle mass & strength
– Increases with age:
• 9.5% age 75-79
• 16% age 80-84
• ~25% age 85-89
• Preventing frailty
– Exercise
– Reduce cardiovascular disease
– Positive mental outlook regarding
aging
Brain-Body Medicine:
Attitude and Health
• How strongly do you believe good (or bad) things will
happen to you in your future?
– Almost 80% of people are somewhat to very optimistic
– Optimism is associated with extroversion, persistence, and
positive mood; while pessimism is associated with neuroticism
and negative mood
• Optimism is associated with being engaged with life’s
goals
• Optimism is often associated with better health and
better outcomes when confronting illness
• Although optimism is likely to be related to genes, family,
culture, the power to define personality may also be
related to behaviors
Suzanne Segerstrom “Breaking Murphy’s Law”, 2006 The Guilford Press, NY
Health as an Advocacy
and Policy Concern
Health Related Activism and Advocacy
•
Education
– Reduce socioeconomic deprivation
• Social position and its attendant assets are the most powerful determinants of health
– Modify risk behaviors
• Nutrition and physical activity in schools
– Train health care providers
•
Biomedical Research
– Support health care related research
– National Institutes of Health (NIH)
•
Preventative Health Care and Epidemiology
– Centers for Disease Control and Prevention (CDC)
– Health Resource Services Administration (HRSA)
•
Environmental Concerns
– Pollution
– Global warming
•
Health Care Policy
– Access to preventative services and chronic disease care
– Mental health services
Education and Health
• Better educated people are healthier (and more poorly educated
people are less healthy)
• Is it education, occupation or income?
– Strongly interdependent
• Why?
– Influences work and economic conditions
– Enhances social and psychological resources
• Making judgments; increasing self-control, self-efficacy, and resilience;
positive effects of social support
– Enables lifestyle and health behaviors
• Education is strongly associated with reduced risk behaviors and vice versa
– Direct effect by unknown mechanisms
• Genetic endowment
• Inclination to postpone gratification
• Public policy to promote early childhood development can protect
children from the negative effects of low socioeconomic status and
low parental education
Why do some diseases affect
women more than men? Why do
women respond to some drugs
and treatment differently than
men? What environmental
factors and behaviors most
influence women’s health?
We don’t know. But we want to
find out. And we need your help.
The Kentucky Women’s Health
Registry Survey is now
available on-line!
Registry Participants
and Data Collected
• Female residents of the Commonwealth of Kentucky
between the ages of 18 and 89
• Information collected:
– Self-report
– Demographic
– Socioeconomic
• Education, work status
• Personal and family resources
– General health and symptoms
• Focus on chronic pain, fatigue, stress
– Health behaviors
• Exercise, food behavior, smoking, alcohol, drugs of abuse
– Medical diagnoses
– Psychiatric symptoms and exposure to violence
• Mission:
– To improve the understanding of diseases or illnesses affecting
the women of Kentucky
• Objectives:
– To increase understanding of variables and exposures that
contribute to health problems at a local level
– To learn where to target programs and assess the effectiveness
of programs
– To provide women with accurate information and educational
opportunities about volunteering for medical research
– To facilitate comfortable, convenient initial contact between the
investigator and interested research participants
Thank you!