Public health 5

1. Importance of non-communicable diseases in developed countries (mortality, morbidity, trends)

  • Most important non-communicable diseases in high-income countries
    • CVD
    • Cancer
    • Chronic respiratory disease
  • NCD
    • cause more than 75% of deaths in high-income countries yearly
    • are more important in high-income than low-income countries
      • due to diet, social status
    • are becoming more important in low-income countries as well (as communicable diseases are becoming less of a problem)
    • In all ages:
      • CVD 48%
      • Cancer 21%
      • Others 16%
    • < 60 year olds
      • CVD 35%
      • Cancer 28%
      • Others 26%
  • Disease adjusted life years (DALY)
    • One DALY is one lost year of “healthy” life
    • DALY = years of life lost + years lost due to disability
    • Most DALYs are in high-income countries
  • Top causes of death in world
    • Ischaemic heart disease – 7 million per year – 13%
    • Stroke, cerebrovascular disease
    • Lower respiratory tract infections
  • Top causes of death in low-income countries
    • Lower RTI
    • Diarrhoeal diseases
    • HIV/AIDS
  • Morbidity – the disease burden in a population
  • Mortality – the occurrence of death in a population
  • Communicable diseases are less important in high-income countries due to vaccines, treatment, etc

2. Epidemiology of ischaemic heart disease

  • Leading cause of death in US and the world
  • Higher risk in men than women
  • Rising tendency in developing countries
  • Accounts for nearly 30% of all disability cases
  • Especially affects middle aged population
  • Proposed theories
    • Lipid theory
      • Decreasing blood cholesterol decreases IHD
      • Oxidized LDL enters vessel wall
    • Blood coagulation theory
      • Increased coagulation tendency
      • Evidence:
        • Increased plasma fibrinogen
        • Increased thromboxane A2/prostaglandin ratio
        • Increased lipoprotein(a) (inhibits fibrinolysis)
    • Blood vessel wall theory
      • Collagen increases, elastic fibres decrease
      • Increases microthrombi formation and lipid infiltration
  • Pathomechanism of atherosclerosis
    • Endothelial dysfunction
      • HT
      • Smoking
      • Diabetes
      • High LDL
      • Aging
    • Leukocyte migration into tunica intima
    • Proliferation of smooth muscle cells in tunica intima
    • Oxidized LDL accumulates, macrophages transform into foam cells
    • Foam cells and smooth muscle cells produce collagen -> forms fibrous plaque
    • Inflammation in fibrous plaque weakens the fibrous cap
    • Plaque ruptures, exposing thrombogenic material

3. Main modifiable risk factors of coronary heart disease

  1. Hypertension
  2. Abnormal blood lipids
    1. High serum cholesterol
    2. High LDL
    3. Low HDL
  3. Tobacco use
    1. Worse risk for women
    2. Genetical sensitivity
  4. Physical inactivity
    1. > 150 minutes /week of moderate intensity
    2. Muscle-strengthening activities
  5. Obesity
  6. Unhealthy diet
  7. Diabetes mellitus

Lower risk in females

  • Protective effect of oestrogen
    • Increases HDL
    • Decreases LDL
    • Decreases Homocysteine
    • Inhibits NF-kB

Seven countries study

  • First major study to investigate diet and lifestyle as risk factors for CVD
  • 1958
  • Included countries with different cultures and standards

European guidelines for cholesterol

  • Total cholesterol < 5 mM
  • LDL < 3 mM
  • HDL > 1 mM
  • Triglycerides < 1,7 mM
  • US guidelines less strict

Cholesterol content of certain foods

  • Chicken liver 750mg / 100g
  • Egg 500mg / 100g

Olive oil

  • Decreases LDL, TG
  • Decreases BP
  • Inhibits LDL oxidation

Decrease TC and LDL:

  • Reduce dietary saturated fat
  • Reduce dietary trans fat
  • Eat phytosterols
  • Reduce dietary cholesterol

Decrease TG

  • Reduce body weight
  • Reduce alcohol intake
  • Reduce mono and disaccharide intake

Increase HDL

  • Reduce trans fat
  • Increase physical activity
  • Reduce body weight

Metabolic syndrome

  • 3 of the following
    • Abdominal circumference
      • Male > 94
      • Female > 80
    • Hypertension
    • Triglycerides
    • Low HDL
    • High fasting blood glucose

4. Other modifiable risk factors of coronary heart disease

  • Low socioeconomic status
  • Mental ill health
    • Depression
  • Psychosocial stress
    • Social isolation
    • Anxiety
  • Heavy alcohol use
    • One or 2 drinks per day reduces heart disease
    • J-shaped curve
  • Certain medications
    • Oral contraceptives
    • Hormonal replacement therapy
  • Lipoprotein(a)
  • Left ventricular hypertrophy

5. Risk factors of coronary heart disease (excluding main and other modifiable risk factors)

  • Non-modifiable risk factors
    • Advanced age
      • Risk of stroke doubles every decade after age 55
    • Family history
      • Increased risk if first-degree had cardiovascular disease at < 55 or <65 years
    • Gender
      • Increased risk for CHD in men
      • Stroke similar for genders
    • Ethnicity
      • Stroke increased in
        • Blacks
        • Hispanics
        • Chinese
        • Japanese
      • Cardiovascular increased in
        • South Asian
        • American blacks
  • Novel risk factors
    • Hyperhomocysteinaemia
      • Occurs in folic acid, pyridoxine or B12 deficiency
      • MTHFR – enzyme involved in homocysteine homeostasis
        • Increased risk in those with lower activity
    • Inflammation
      • High-sensitivity CRP
    • Abnormal blood coagulation
      • Increased fibrinogen, other clotting markers

6. Epidemiology and prevention of cerebrovascular diseases

  • Stroke
    • Ischaemic 80%
      • Thrombotic 50%
      • Embolic
    • Haemorrhage 20%
      • Intracerebral
        • Hypertension
      • Subarachnoid
        • Aneurysms
        • Occurs at any age
        • Different epidemiology than other stroke types
    • Symptoms
      • Sudden numbness or weakness
      • Sudden confusion, trouble speaking
      • Sudden blindness
      • Sudden trouble walking
      • Sudden severe headache
  • Epidemiology
    • 10% of ischaemic strokes -> death in 30 days
    • 40% of haemorrhagic strokes -> death in 30 days
    • Leading cause of long-term disability in US
    • 3rd cause of death in US
  • Risk factors
    • Hypertension x2 risk
    • Atherosclerosis
    • Heart disease
      • 1/10 will develop stroke in 6 years
    • Coagulation disorders
    • Previous TIA, stroke, ami
    • Diabetes
    • Smoking x10 haemorrhagic stroke risk
    • Alcohol
    • Age
    • Genetics

7. Epidemiology and prevention of hypertension

  • Hypertension
    • Systolic > 140 mmHg
    • Diastolic > 90 mmHg
    • Most are primary
    • Symptom-free
  • Epidemiology
    • Most prevalent in eastern Europe, southern Africa
    • More prevalent in blacks
    • More prevalent in lower socioeconomic classes
    • Prevalence increases with age
    • < 50: more frequent among men
    • > 65: more frequent among women
  • Risk factors
    • Familial factors
    • Nutritional
      • Salt intake > 5g/day
        • Hungary has extremely high salt intake (17 g per day)
      • Soft water
      • High tyramine content – sympathetic activation
      • Alcohol
    • Obesity
      • 12% risk increase for each unit BMI
    • Body weight
      • 10 kg increase – 2 systolic, 1 diastolic
    • Physical inactivity
    • Modern lifestyle
      • Lots of stress
    • Diabetes
  • Prevention
    • BMI < 25
      • 5 – 20 mmHg reduction per 10 kg
    • DASH diet
      • Lots of vegetables, fruits
      • Grains
      • Lean meat, low fat dairy
      • Oils, beans, nuts
      • Little sweets
      • reduces 8 – 14 mmHg
    • Salt < 5g/day
      • reduces 2 – 8 mmHg
    • Increase Ca, K, Mg
    • Moderate alcohol consumption
      • reduces 2 – 4 mmHg
    • Stop smoking
    • Physical activity
      • reduces 4 – 9 mmHg
  • Treatment
    • < 5% risk and no organ damage
      • Lifestyle changes for 6 months
        • If successful -> annual control
        • If unsuccessful -> therapy may be necessary
    • < 5% risk with organ damage
      • Lifestyle changes + therapy

8. Cardiovascular diseases: risk assessment and prevention

  • Prevention
    • Primordial – activities which lead to lowering of risk factors
      • Social activities
      • Legal activities
      • Increased socioeconomic development
      • Smoke-free restaurants
    • Primary – controlling risk factors contributing to CVD
      • Health education programs
      • Anti-smoking campaigns
      • Sports programs
      • Nutritional counselling
      • Regular check-ups
        • Cholesterol
        • Lipids
        • Glucose
    • Secondary – screening and treatment of symptomatic patients
    • Tertiary – prevention of recurrence
      • 5 – 7 x higher risk in those with previous CVD
  • Risk assessment
    • SCORE risk estimation system
      • Two separate systems for high-risk and low-risk European regions
      • Considers
        • Gender
        • Age
        • Smoking
        • Systolic BP
        • Total cholesterol
    • Framingham risk scoring
      • Points for
        • Age
        • total cholesterol
        • HDL
        • Systolic BP
        • Smoking
      • Sum of points gives risk
    • ASCVD risk estimator – calculator online
  • Recommended targets
    • Very high CV risk (SCORE > 10%)
      • LDL < 1,8 mM
    • High risk SCORE > 5%
      • LDL < 2,5 mM
    • Moderate risk
      • LDL < 3,0 mM

9. Morbidity and mortality of malignant diseases

  • Epidemiology
    • Cancer is second leading cause of death globally
    • 10 million deaths in 2018
    • 1 in 6 deaths
    • 70% of deaths in low and middle income countries
    • Most common worldwide
      • Lung
      • Breast
      • CRC
      • Prostate
      • Non-melanoma skin cancer
      • Stomach
    • Most common causes of cancer death
      • Lung
      • CRC
      • Stomach
      • Liver
      • Breast
    • Cancer-related death similar now as 50 years ago
    • 20 – 30% of deaths of non-communicable diseases

10. Role of infectious diseases in tumour development

  • H. pylori
    • Half of the world has it
    • Most commonly gastro-oral or feco-oral transmission
    • Most common cause of gastric cancer
  • HPV
    • 16, 18 -> high risk
    • 6, 11 -> low risk
    • Most common STD
    • Most common cause of cervical cc
    • Also a cause for throat cancer
    • Recombinant vaccines
      • Bivalent
      • Quadrivalent
  • HBV
    • HCC
    • Vaccine
  • HCV
    • HCC
    • No vaccine
  • EBV
    • Burkitt lymphoma
  • HIV
    • Kaposi sarcoma
    • Non-Hodgkin lymphoma
    • Increased risk for many cancers

11. Risk factors of malignant diseases

  • Preventable causes of cancer
    • 30% of cancers due to high BMI, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use
    • Diet
      • Fat intake -> breast cancer
      • Salt intake -> stomach, CRC
      • Spicy food intake -> stomach
    • Tobacco
      • Responsible for 22% of cancer deaths
      • Initiator
      • DNA adduct
      • 2nd hand smoke
        • Sidestream smoke – doesn’t pass through filter
        • mainstream smoke – exhaled smoke
    • Infections
      • 25% of cancers in low and middle-income countries
      • H. pylori
      • HPV
      • HBV
      • HCV
      • EBV
      • HIV
      • HSV
    • Sexual behaviour
    • Occupation
      • Asbestos
      • Chimney sweeper
    • Alcohol
      • Cirrhosis
      • Oral, oesophagus, stomach
  • Smoking
    • Half of all smokers in hungary will die as a result of smoking
    • Nicotine
    • PAH
    • N-nitrosamines

12. Screening of malignant diseases

  • CRC
    • Begins at age 50
    • Sigmoidoscopy
    • Colonoscopy
    • CT colonography (virtual colonoscopy)
    • Faecal occult blood test
  • Breast
    • Yearly mammogram after 40
    • Clinical breast exam every 3 years after 20
    • Breast self exam
  • Prostate
    • For high-risk people
      • BRCA
      • Black
      • History of prostate cc
    • PSA
    • DRE
  • Cervical
    • 21 – 30
      • Pap smear every 3 years
    • 30 – 65
      • Pap smear every 5 years
      • HPV test every 5 years
    • Over 65
      • Not tested
    • Vaccinated women should also be screened
    • High risk screened more often

13. Epidemiology and prevention of lung cancer

  • 90% caused by smoking
    • Half of all smokers in hungary will die as a result of smoking
    • Nicotine
    • PAH
    • N-nitrosamines
  • 5 year-survival 15%
  • Mortality 92%
  • Non-smoking causes
    • 2nd hand smoke
    • Radon
      • Natural in soil
    • Air pollution
    • Occupation
      • Asbestos
        • Military
        • Mining
        • Construction
        • Firefighters
  • Prevention
    • Beta carotene increases cancer risk
    • Stop smoking

14. Epidemiology and prevention of colorectal cancer

  • Third most common cancer worldwide
  • Equal gender distribution
  • Half could be prevented with correct prevention
  • Sporadic is the majority
    • Family history and hereditary are minorities
    • APC, K-RAS, p53
  • Familial
    • FAP
    • Peutz Jeghers syndrome
  • Risk factors
    • Red meat
    • Low dietary fibre
    • Obesity
    • Smoking
    • High energy intake
  • Protective factors
    • Calcium
    • Vitamin D
    • Fruit, vegetables
    • Physical activity
    • High fibre intake
  • Screening (recommendations)
    • Begins at age 50
    • Sigmoidoscopy
    • Colonoscopy
    • CT colonography (virtual colonoscopy)
    • Faecal occult blood test

15. Epidemiology and prevention of breast cancer

  • high 5-year survival: 85%
  • Much lower in Asian women
  • Familial
    • BRCA1 and 2
      • Increased risk
      • Lower age of onset
  • Sporadic
  • Risk factors
    • Age
    • Genetic factors
    • High fat intake
    • Ethnicity
      • Caucasian > black > asian
    • Increase oestrogen exposure
      • Late menopause
      • Early menarche
      • Late first pregnancy
      • Nulliparity
      • Oral contraceptive
      • Overweight
    • Not breastfeeding
    • Radiation
    • Physical inactivity
  • Screening
    • Yearly mammogram after 40
    • Clinical breast exam every 3 years after 20
    • Breast self exam

16. Epidemiology and prevention of prostate and cervix cancer

Prostate

  • 2nd most common cancer in men
  • Incidence increased recently
  • Mortality stable
  • 5-year survival: 80%
  • Disease of the elderly
  • Risk factors
    • Old age
    • Ethnicity
      • Black > white
    • Family history
    • Androgen exposure
    • Diet
    • Obesity
    • Smoking
    • STD
  • Screening
    • For high-risk people
      • BRCA
      • Black
      • History of prostate cc
    • PSA
    • DRE

Cervix

  • 2nd most common cause of cancer death in females
  • Screening decreased mortality
  • Mean age: 48
  • 5-year survival: 20%
  • Risk factors
    • HPV 95% of cancers
    • Increased number of pregnancies
    • Early start of sexual life
    • Higher number of sexual partners
    • Smoking
    • Obesity
  • Screening
    • 21 – 30
      • Pap smear every 3 years
    • 30 – 65
      • Pap smear every 5 years
      • HPV test every 5 years
    • Over 65
      • Not tested
    • Vaccinated women should also be screened
    • High risk screened more often

17. Epidemiology and prevention of liver-, pancreas- and gastric cancer

Gastric

  • Was most common in 1970s, but now only 4th
    • Perhaps due to decreased prevalence of H. pylori
  • 2nd most common cause of cancer death worldwide
    • 5 year survival: 15%
  • 2x more common in men
  • Risk factors
    • H. pylori
    • Male gender
    • Old age
    • Diet
      • Salt
      • Smoked food
      • Nitrites, nitrates
    • Smoking
    • Obesity
    • Gastritis

Pancreas

  • Highest lethality
  • 5 yeasr survival: 5%
  • Risk factors
    • Old age
    • Men
    • Blacks
    • Smoking
    • Obesity
    • Chronic pancreatitis
    • Cirrhosis
    • Binge drinking
    • Family history

Liver

  • Developing countries
    • HBV
    • Aflatoxin
  • Developed countries
    • HCV
    • Promiscuity
    • Chronic alcoholism
    • Low socioeconomic status
  • Screening
    • HBV, HCV serology
    • AFP

18. Epidemiology and prevention of head and neck cancers and skin cancers

Head and neck

  • Explosive growth of head and neck tumors in 20th century
  • Death rate 4x increase in last 30 years in hungary
  • 5-year survival 20%
  • Risk factors
    • Smoking
    • High alcohol intake
    • “Smokeless” tobacco
    • Poor oral hygiene
    • Oral infections
    • HPV 16, 18

Skin cancer

  • Melanoma and non-melanoma incidence increasing
  • Melanoma
    • Rare
    • Much more lethal
    • Highest incidence in Australia, US, Europe
    • Lowest in dark-skinned populations
  • Risk factors
    • 290-320 nm UVB radiation
    • History of sunburns (especially in childhood)
    • Solarium before 35
    • Light skin
    • Blue eyes
    • Blond hair
    • Easily sunburnt

19. Epidemiology and prevention of diabetes

  • Type 1
    • 5% of all
    • Peaks at 5 and 12 years
    • Whites
    • Risk factors
      • Genetic factors
      • Autoimmune disease
      • Viral infections
    • Protective factors
      • Breast feeding
      • Vitamin D
    • Prevention
      • Secondary
        • Screening of relatives or high-risk populations
      • Tertiary
        • Glucose control
  • Type 2
    • Prevalence: 9% of US
      • Rising
    • Onset > 40, but age of onset is decreasing
    • 50% are not diagnosed
    • Hispanics, native americans, Asians, blacks
    • Risk factors
      • Genetic factors
        • LPL
        • Insulin receptor
        • Glucose transporter
      • Relatives with diabetes
      • Obesity
      • High calorie diet
      • Physical inactivity
      • Dyslipidaemia
      • Hypertension
      • Socioeconomic factors
    • Scoring
      • FINDRISK
      • AUSDRISK
      • IDRS
    • Prevention
      • Primary
        • Population-based health programmes
        • Prevention of obesity
        • Reduce fat
        • Reduce sugar
        • Increase fruit, vegetables
      • Secondary
        • Screening
      • Tertiary
        • Management of cardiovascular risk factors
        • Glucose control

20. Epidemiology and prevention of osteoporosis

  • 4x in women
    • Women primary osteoporosis
    • Men secondary osteoporosis
  • Age of onset 50 – 70
  • 30 – 50% of women will experience fracture related to osteoporosis during lifetime
  • Asian, Hispanic, European > black
  • Detection: DEXA scan
    • T-score: the number of standard deviations the patient is away from a young female adult
      • Osteopaenia: T-score -2,5 <-> -1
      • Osteoporosis: T-score < -2.5
    • Z-score: the number of standard deviations the patient is away from a similarly aged adult
  • Risk factors
    • Female
    • White
    • Old age
    • Family history
    • Smoking
    • Alcohol
    • Malnutrition
  • Prevention
    • Avoid alcohol
    • Avoid smoking
    • Sufficient intake of Ca
    • Sufficient intake of vitamin D
    • Physical activity – strength training
    • Bisphosphonates

21. Epidemiology and prevention of chronic obstructive pulmonary disease

  • Fourth most common cause of death worldwide
  • Leading cause of morbidity in developed countries
  • 6% in USA
  • Increasing incidence in last 20 years
  • Diagnosed by spirometry
    • Decreased Tiffeneau index < 70%
    • <12% amelioration by bronchodilators
  • Risk factors
    • Smoking
      • 20 – 30 pack years gives 80-90% risk
    • Passive smoking
    • Air pollution
    • Occupational exposure to dust
    • Respiratory tract infections
    • Low birth weight
    • Asthma
    • Low socioeconomic status
    • Physical inactivity
    • Alpha-1-antitrypsin deficiency
  • Scoring
    • GOLD – groups according to risk and symptoms
    • BODE index – prognosis
    • mMRC dyspnoea scale
  • Prevention
    • Primary
      • Health education
      • Promote smoking prevention
      • Air pollution control
    • Secondary
      • Screening for A1ATD – family members too
      • Screening of symptomatic or high-risk individuals
      • Smoking cessation
    • Tertiary
      • Treatment
      • Pulmonary rehabilitation
      • Vaccination
        • Influenza
        • Pneumococcus
      • Exercise

22. Epidemiology and prevention of asthma

  • 7% in world
  • Black > white
  • Mostly in children
  • Increasing prevalence
  • Allergic asthma – childhood onset
  • Nonallergic asthma – > 40 onset
  • Developing countries have fewer medications and options for treatment -> higher mortality and morbidity
    • Therapy is expensive
    • 80% of deaths in low income countries
  • Risk factors
    • Atopy
      • Allergic rhinitis
      • Eczema
    • Genetic factors
    • Air pollution
    • Allergens
      • Mold
      • Dust mite
    • Food additives
    • Respiratory infections in childhood
    • High socioeconomic status
    • Obesity
  • Prevention
    • Primary
      • Prevention of development of atopy
      • Breastfeeding
      • Prevention of passive smoking
      • Adequate control of childhood infections
    • Secondary
      • Prevention of triggers
    • Tertiary
      • Effective medication and management

23. Epidemiology and prevention of allergic rhinitis

  • Most important atopic disease
  • Prevalence 3 – 19%
  • Most frequent disease among children and teens
    • 80% of cases 0 – 20 years
  • Forms
    • Seasonal – outdoor allergens
      • Pollen
        • Ragweed
        • Grass
        • Tree
      • Mold
        • Fungus
    • Perennial – indoor allergens
      • Pets
      • Dust
      • Mites
      • Molds
  • Risk factors
    • Genetic factors
    • Second hand smoke
    • Exposure to allergens
    • Atopy
    • Male gender
    • Urbanization
  • Prevention
    • Breastfeeding
    • Elimination, avoiding allergen
      • Avoid dust mites
        • Reduce indoor humidity
        • Wash bed sheets
        • Use bedding encasements
    • Medical treatment

24. Epidemiology and prevention of hepatic cirrhosis

  • 0,02% prevalence
  • 10th leading cause of death for men
  • 10-year mortality: 50%
  • 2x in men
  • Etiology
    • Alcohol 70%
      • 40 – 80g/day for 20 years
      • Alcoholic hepatitis: Large amounts occasionally
    • HBV
    • HCV
    • Fatty liver
  • Risk factors
    • ADH
    • ALDH
    • CYP2E1
  • Prevention
    • Primary
      • Prevention of alcohol abuse
      • HBV vaccination
      • Needle exchange programme – give clean needles to IV drug users
      • Promote healthy diet
    • Secondary
      • Liver function control
    • Tertiary
      • Prevention of complication

25. Epidemiology and prevention of ulcer disease

  • 0,1 – 0,3% in Europe
  • 6 – 10x increased risk in H. pylori
  • Lifetime risk 10% in H. P negatives and 20% in positives
  • Men > women
  • 25 – 60 years
  • Duodenal ulcers 4x more common than gastric, more common in younger
  • Incidence dropping globally
  • Aggressive factors
    • HCl
    • Pepsin
    • Decreased motility
    • H. pylori
    • Chemical insult
  • Protective factors – prostaglandins
    • Mucosal blood flow
    • Mucin
    • Bicarbonate secretion
    • Restitution
    • Regeneration
  • Etiology:
    • H. pylori
      • oral-to-oral
      • faecal-oral
      • 50% of the world
      • Ammonia, toxin
    • NSAIDs
    • Smoking – vascular injury, increased HCl
    • Alcohol
    • Caffeine
    • Stress – decreased perfusion
    • Zollinger-Ellison
    • Blood type 0
  • Prevention
    • Primary
      • Enhancement of protective factors
      • Elimination of aggressive factors
      • Increased fibre
      • Avoid spicy food
      • Decrease caffeine
      • Decrease alcohol
      • Avoid smoking
    • Secondary – screening
      • Urea breath test
      • Blood antibody test
      • Gastroscopy
    • Tertiary – treatment

26. Epidemiology and prevention of inflammatory bowel diseases

  • IBD
    • No cure
    • Lifetime of care
    • Requires many physician visits, hospitalizations
    • Major cause of disability
    • White, Ashkenazi Jews
    • Mortality similar to healthy
    • Risk factors
      • Genetics
      • Diet
        • Low intake of fibre
        • High intake of saturated fat
        • Low intake of unsaturated fat
        • Vitamin deficiencies
      • Hygiene hypothesis
        • Extremely hygienic environments predispose to immunological diseases
        • Helminths
      • Psychosocial factors
      • Dysregulated immune response
      • High socioeconomic status
      • Urbanization
      • Drugs
        • Contraceptives
        • NSAIDs
  • Crohns
    • Prevalence: 300 / 100 000
    • Incidence: 24 / 100 000
    • Age of onset 15 – 30
    • Women > men
    • 75% require surgery
    • Risk factors
      • Smoking
      • NOD2
  • UC
    • Prevalence: 500 / 100 000
    • Incidence: 12 / 100 000
    • 25% require surgery
    • Risk factors
      • Not smoking

27. Epidemiology and prevention of suicide

  • 44000 every year in US
  • 3rd leading cause of death in 15 – 24
  • 80% in low and middle income countries
  • Peak incidence: 45 – 65
  • 25 attempts for each success
    • 3:1 in older
    • 100:1 in younger
  • Male > female
  • Suicide attempts more common in women
  • >90% have psychiatric illness or substance abuse disorder
  • 20 – 50% have alcohol or drug use problems
  • 60% of us will personally know someone who dies by suicide
  • Countries
    • Korea
    • Hungary
    • Russia
  • Individual risk factors
    • Mood disorders
      • Depression
    • Alcoholism
    • Previous attempt
    • Schizophrenia
    • Life crisis
    • Partner problems
    • Chronic pain or illness
    • Impulsivity
    • Isolation
    • Lack of social support
    • Trauma or abuse
  • Socio-cultural risk factors
    • Lack of social support
    • Stigma associated with seeking help
    • Decreased access to health care
    • The belief that suicide is noble
    • Copycat effect
  • Protective factors
    • Easy access to mental health care
    • Strong connection to friends and family
    • Restricted access to means of suicide
    • Problem-solving skills
    • Sense of belonging
    • Positive self-esteem
  • Prevention
    • Restrict access to means of suicide
    • Low-threshold access to help
    • Hotlines
    • Improve social circumstances

28. Epidemiology and prevention of depression and mood disorders

  • Depression is the most common mood disorder
  • 20 million people every year
  • Female > male
  • Criteria for major depression
    • Depressed mood
    • Diminished interest
    • Weight changes
    • Sleep disturbances
    • Loss of energy
    • Feelings of worthlessness
    • Feelings of excessive guilt
    • Problems concentrating
  • Risk factors
    • Biological factors
      • Genetic predisposition (concordance 50%)
      • Dysfunction of HPA
      • Increased level of stress hormones
    • Psychosocial factors
      • Trauma
      • Stress
      • Learned helplessness
    • Comorbidities
      • Chronic illnesses
      • Chronic pain
  • Prevention
    • Teach problem-solving skills
      • Break problems into smaller chunks
    • Teach emotion-coping skills
      • Challenge irrational thoughts
      • Acknowledge and express emotions
    • Decrease stigma associated with depression
    • Increase availability of help services

29. Epidemiology and prevention of anxiety disorders

  • Common in adolescents
  • Most prevalent psychiatric disorders
  • 22% of young people
  • Impairment, high health-care utilization, economic burden
  • Women > men
  • Risk factors
    • Neurobiological factors
    • Substance abuse
    • Stress
    • Smoking
    • Psychological trauma
    • Comorbidities
  • Subtypes
    • Generalized anxiety disorder
      • Most common in elderly
    • Post-traumatic stress disorder
    • Panic disorder
    • Social anxiety disorder
    • Specific phobias
  • Treatment
    • Cognitive behavioural therapy
    • Medication

30. Epidemiology and prevention of schizophrenia and dementias

  • Schizophrenia
    • Positive and negative symptoms
    • Young adults
    • Too much dopamine?
    • Risk factors
      • Stress
      • Psychosocial factors
      • Cannabis abuse
      • Family history
    • Treatment
      • Avoid validation of delusions
      • Avoid confronting patients about delusions
    • Prevention
      • Maintaining healthy relationships and friendships
      • Avoiding cannabis
      • Seeking therapy for depression early
      • Teach stress and anxiety coping
      • Promote exercise
  • Dementia
    • Disease of elderly
    • Neurodegenerative disease
    • Cerebrovascular disease
    • Risk factor
      • Age
      • Female
      • Family history
      • CVD risk factors
    • Prevention
      • No smoking
      • Healthy weight
      • Exercise
      • Healthy diet
      • Reduce comorbidity
      • Stay mentally alert
      • Maintain social relationships

31. Epidemiology and prevention of addictions

  • Addictions cause accidents, violence, abuse
  • Addiction = Chronic problem which causes drug seeking, despite harmful consequences
  • 6% of the world
  • Most drug-related deaths are in North America
  • Etiology
    • Physical dependence
      • Avoidance of withdrawal
    • Psychological dependence
      • Drug-seeking behaviour

Smoking

  • Largest epidemiological proglem
  • Risk factors
    • Low socioeconomic status
    • Male > female
  • Fagerstrøm nicotine dependence scale
  • 5 R
    • Relevance – tailor advice to each patient
    • Risks – inform of risks of continuing
    • Rewards – inform of rewards of stopping
    • Roadblocks – identify roadblocks
    • Repetition – repeat messages
  • 5 A of minimal intervention
    • Ask – about tobacco use
    • Advise – tobacco users to quit
    • Assess – readiness to attempt quitting
    • Assist – with quitting
    • Arrange – follow up care
  • Prevention
    • Primary
      • Campaigns
      • Ban advertisements
      • Decrease availability
      • Encourage cessation
      • Decrease second hand smoking
    • Secondary
      • Drugs
      • Therapy
        • Bupropion
        • Nicotine replacement
    • Tertiary
      • Disulfiram
      • Naltrexone

Other drugs

  • Designer drugs
  • 4% of worlds adult population used psychoactive substances
  • Cannabis, amphetamines, cocaine, opioids
  • Comorbidity of addiction
    • Depression
    • Suicide (20x risk)
    • Antisocial personality disorder
    • Infections
  • Prevention

Alcohol

  • 3 million deaths every year
  • causes 200 diseases
  • Max 2 units every day
  • Excessive alcohol consumption is the 2nd most important epidemiological problem after smoking
  • AUDIT test – alcohol use disorders identification test
    • Gives points based on risk
  • There is no safe amount of alcohol
  • Risk factor
    • High and low socioeconomic status (not middle)
  • Prevention
    • Legislation
    • Taxes
    • Mental health promotion
    • No ads
    • Awareness campaign

32. Recommended and compulsory screening methods for non-communicable diseases (excluding cancers)

  • NCD – 75% of deaths
  • NCD – >50% of disability worldwide
  • Main risk factors
    • Tobacco
    • Physical inactivity
    • Alcohol
    • Unhealthy diet
  • Recommended physical activity
    • Children – 60 minutes daily
    • Adults – 150 moderate intensity weekly
    • Elderly – same
  • Maternal obesity -> T2DM in offspring
  • Screening
    • CVD
      • BP, cholesterol, weight, waist, glucose, smoking, physical activity, diet
      • Start at 20
      • Every 2 – 4 years
    • Osteoporosis
      • DEXA
      • In women > 65
    • Cognitive impairment
      • No recommendation for screening
    • Depression
      • Simple screening questions
    • STD
      • Annually for sexually active

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