Public Health 5

Page created on January 4, 2020. Last updated on January 18, 2024 at 14:10

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 NCD 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
  • Incidence and prevalence of a disease
• 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

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

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

• Risk assessment
  • SCORE risk estimation system
    • Two separate systems for high-risk and low-risk European regions
    • Estimates the risk of fatal cardiovascular events in the next 10 years, based on
      • Gender
      • Age
      • Smoking
      • Systolic BP
      • Total cholesterol
    • Very important to learn!
    • SCORE for high-risk European countries
    • SCORE for low-risk European countries
  • Framingham risk scoring
    • Not used in Europe, not so important
    • Points for
      • Age
      • total cholesterol
      • HDL
      • Systolic BP
      • Smoking
    • Sum of points gives risk
• Prevention
  • Primordial – activities which reduce or remove risk factors
    • Improve public transport availability
    • Opportunities for recreational activities
    • Increased socioeconomic development
    • Smoke-free restaurants
  • Primary – reducing the population’s exposure to risk factors
    • Health education programs
    • Anti-smoking campaigns
    • Sports programs
    • Nutritional counselling
  • Secondary – screening
    • Regular check-ups
      • Cholesterol
      • Lipids
      • Glucose
  • Tertiary – prevention of recurrence and treatment of symptomatic patients
    • 5 – 7 x higher risk in those with previous CVD
• 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

• Morbidity
  • Most common for men
    • Prostate
    • Lung
    • CRC
  • Most common for women
    • Breast
    • Lung
    • CRC
• Mortality
  • 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 causes of cancer death in men
    • Lung
    • CRC
    • Prostate
  • Most common causes of cancer death in women
    • Lung
    • Breast
    • CRC
  • 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
  • Causes chronic gastritis -> gastric cancer
• HPV
  • 16, 18, 31, 33 -> carcinogenic (high risk)
  • 6, 11 -> not carcinogenic (low risk)
  • Most common cause of cervical cc
  • Also a cause for throat cancer
  • Recombinant vaccines
    • Bivalent
    • Quadrivalent
• HBV
  • Causes HCC
  • Vaccine
• HCV
  • Causes HCC
  • No vaccine
• EBV
  • Burkitt lymphoma
  • No vaccine
• HIV
  • Kaposi sarcoma
  • Non-Hodgkin lymphoma
  • Increased risk for many other cancers

11. Risk factors of malignant diseases

• Preventable causes of cancer
  • Poor diet is the most common cause 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 -> not a risk factor, may even be protective for gastric and oesophageal cancer
    • Omega-6 intake -> prostate cancer
  • Tobacco
    • Responsible for 22% of cancer deaths
    • Initiator
    • DNA adduct
    • 2^nd 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
  • Inactivity
  • Occupation
    • Asbestos
    • Chimney sweeper
  • Alcohol
    • Cirrhosis
    • Oral, oesophagus, stomach
• Non-preventable risk factors
  • Family history
  • Aging
  • Gender
  • Ethnicity

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
  • Controversial screening
    • May lead to treatment of cases which wouldn’t have been bothersome anyway
  • 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
• Lung
  • People above the age of 50 with at least 20 pack-years
  • Low-dose CT scan
  • National screening programmes are only active in the US and China, but is under consideration in most EU countries

13. Epidemiology and prevention of lung cancer

• Epidemiology
  • Second most common cancer for each gender
  • Causes most cancer deaths in both genders
  • Mainly affects elderly
  • Males > females
• Etiology
  • 90% caused by smoking
    • Half of all smokers in hungary will die as a result of smoking
    • Nicotine
    • PAH
    • N-nitrosamines
  • Non-smoking causes
    • 2^nd hand smoke
    • Radon
      • Natural in soil
    • Air pollution
    • Occupation
      • Asbestos exposure
• Prognosis
  • 5 year-survival 15%
  • Mortality 92%
• Prevention
  • Beta carotene increases cancer risk
  • Stop smoking
  • Reduce air pollution
  • Prevent occupational exposure

14. Epidemiology and prevention of colorectal cancer

• Epidemiology
  • Third most common cancer worldwide
  • Second and third most common causes of cancer deaths in men and women, respectively
  • Males = females
  • Half could be prevented with correct prevention
• Etiology
  • Majority are sporadic 
  • Minority are hereditary
    • 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
• Prognosis
  • 5-year survival: 65%
• Prevention
  • Improve diet
  • Screening (recommendations)
    • Begins at age 50
    • Sigmoidoscopy
    • Colonoscopy
    • CT colonography (virtual colonoscopy)
    • Faecal occult blood test

15. Epidemiology and prevention of breast cancer

• Epidemiology
  • Most common cancer in females
  • Second most common cause of cancer-death in female
• Etiology
  • Age
  • 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
  • Familial
    • BRCA1 and 2
• Prognosis
  • High 5-year survival: 85%
    • Much lower in Asian women
• Prevention
  • Screening
    • Yearly mammogram after 40
    • Clinical breast exam every 3 years after 20
    • Breast self exam
  • Prevent obesity
  • Physical activity

16. Epidemiology and prevention of prostate and cervix cancer

Prostate

• Epidemiology
  • Most common cancer in men
  • Third most common cause of cancer death in men
  • Incidence increased recently
  • A disease of elderly
• Etiology
  • Old age
  • Ethnicity
    • Black > white
  • Family history
  • Androgen exposure
  • Diet
    • Omega-6 intake
  • Obesity
  • Smoking
  • STD
• Prognosis
  • Mortality stable
  • 5-year survival: 80%
• Prevention
  • Prevent obesity
  • Increase omega-3, reduce omega-6
  • Don’t smoke
  • Screening
    • For high-risk people
      • BRCA
      • Black
      • History of prostate cc
    • PSA
    • DRE

Cervix

• Epidemiology
  • 4th most common cancer in females
  • 6th most common cause of cancer death in females
  • In 35 – 50 years old
  • Deaths mainly occur in countries without access to screening and vaccines
• Etiology
  • HPV 95% of cancers
  • Increased number of pregnancies
  • Early start of sexual life
  • Higher number of sexual partners
  • Smoking
  • Obesity
• Prognosis
  • Screening decreased mortality
  • 5-year survival: 20%
• Prevention
  • Safe sex
  • No smoking
  • Prevent obesity
  • Vaccination against HPV
  • 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

• Epidemiology
  • Was most common cancer in 1970s, but now much less common
    • Perhaps due to decreased prevalence of H. pylori
  • Male > female
  • Strong geographical differences in incidence
    • High incidence in Korea and Japan
    • Declining incidence in Western countries
• Etiology
  • Male gender
  • Old age
  • Diet
    • Salt
    • Smoked food
    • Nitrites, nitrates
  • Smoking
  • Obesity
  • Chronic gastritis
    • H. pylori
• Prognosis
  • 5 year survival: 15%
• Prevention
  • Treat H. pylori
  • Improve diet
  • Stop smoking
  • Treat gastritis
  • Prevent obesity

Pancreas

• Epidemiology
  • Rare but fatal cancer
  • Male > female
  • Age of onset: 60 – 80
  • Accounts for only 3% of cancers in US
• Etiology
  • Old age
  • Men
  • Blacks
  • Smoking
  • Obesity
  • Chronic pancreatitis
  • Cirrhosis
  • Binge drinking
  • Family history
• Prognosis
  • 5 year survival: 5%
  • Highest lethality of all cancers
• Prevention
  • Avoid avoidable risk factors

Liver

• Epidemiology
  • Male > female
  • Age of onset in Western countries: 70 years
  • Highest incidence in Asia, Africa
    • Due to endemic HBV, HCV
• Etiology
  • In developing countries
    • HBV
    • HCV
    • Aflatoxin
  • In developed countries
    • HCV
    • Promiscuity
    • Chronic alcoholism
    • Non-alcoholic fatty liver disease
    • Low socioeconomic status
• Prognosis
  • 5-year survival < 50%
• Prevention
  • Avoid alcohol
  • Avoid obesity
  • Safe sex
  • Screening
    • In high-risk patients (cirrhosis, chronic hepatitis)
    • HBV, HCV serology
    • AFP

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

Head and neck

• Epidemiology
  • Explosive growth in incidence of head and neck tumors in 20^th century
  • Accounts for 3% of cancers in Western world
  • Male > female
• Etiology
  • Smoking
  • High alcohol intake
  • “Smokeless” tobacco
  • Poor oral hygiene
  • Oral infections
  • HPV 16, 18
• Prognosis
  • Death rate 4x increase in last 30 years in hungary
  • 5-year survival 20%
• Prevention
  • Stop smoking
  • Improve oral hygiene
  • HPV vaccination

Non-melanoma skin cancer

• Epidemiology
  • Non-melanoma incidence increasing
  • Male > female
  • More common than melanoma
  • Highest incidence in Australia, US, Europe
  • Lowest in dark-skinned populations
• Etiology
  • Sun exposure
  • Tanning beds
  • Skin types I and II
    • Light skin
    • Blue eyes
    • Blond hair
    • Easily sunburnt
  • Arsenic exposure
• Prognosis
  • 5-year survival almost 100%
• Prevention
  • Sunscreen
  • Clothes in the sun
  • Don’t do tanning beds

Melanoma

• Epidemiology
  • Only 2% of cancer incidence
• Etiology
  • Sun exposure
    • Especially sunburn in childhood
  • Tanning bed
  • Congenital nevi
  • Skin types I and II
    • Light skin
    • Blue eyes
    • Blond hair
    • Easily sunburnt
• Prognosis
  • Vary variable depending on stage at diagnosis
  • 5-year survival
    • T1 > 90%
    • N1, M0 20 – 40%
    • M1 < 5%
• Prevention
  • Sunscreen
  • Clothes in the sun
  • Don’t do tanning beds

19. Epidemiology and prevention of diabetes

Diabetes mellitus type 1

• Epidemiology
  • 5% of all diabetes cases
  • Onset in childhood
  • Most prevalent in white
• Etiology
  • Genetic factors
  • Autoimmune disease
  • Viral infections
• Protective factors
  • Breast feeding
  • Vitamin D
• Prevention
  • Secondary
    • Screening of relatives or high-risk populations
  • Tertiary
    • Glucose control

Diabetes mellitus type 2

• Epidemiology
  • Worldwide prevalence rising
  • Becoming more and more of a problem in developing countries as well
  • Prevalence: 9% of US
    • Rising
  • Onset > 40, but age of onset is decreasing
  • Hispanics, native americans, Asians, blacks > whites
• Etiology
  • Associated with metabolic syndrome
  • Family history
  • Obesity
  • High calorie diet
  • Physical inactivity
  • Dyslipidaemia
  • Hypertension
  • Genetic factors
    • LPL
    • Insulin receptor
    • Glucose transporter
  • Socioeconomic factors
• Scoring systems
  • Gives the risk of developing type 2 diabetes
  • FINDRISK
  • AUSDRISK
• 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

• Epidemiology
  • 4x in women
    • Women mostly primary osteoporosis
    • Men mostly secondary osteoporosis
  • Age of onset 50 – 70
  • Asian, Hispanic, European > black
• Etiology
  • Female
  • White
  • Old age
  • Malnutrition
    • Poor protein, calcium, vitamin D intake
  • Family history
  • Smoking
  • Alcohol
• Diagnosis:
  • DEXA scan, which measures the bone mineral density (BMD)
  • T-score: the number of standard deviations the patient’s BMD is away from the BMD of 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
• Prognosis
  • 30 – 50% of women will experience fracture related to osteoporosis during lifetime
• 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

• Epidemiology
  • Fourth most common cause of death worldwide
  • Leading cause of morbidity in developed countries
  • Male > female
  • 6% prevalence in US
• Etiology
  • Smoking
    • 20 – 30 pack years gives 80-90% risk
  • Passive smoking
  • Air pollution
  • Occupational exposure to dust
  • Respiratory tract infections
  • Premature birth
  • Asthma
  • Low socioeconomic status
  • Physical inactivity
  • Alpha-1-antitrypsin deficiency
• Diagnosed by spirometry
  • Decreased Tiffeneau index < 70%
  • <12% amelioration by bronchodilators
• 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 high-risk individuals
  • Tertiary
    • Stop smoking
    • Oxygen therapy
    • Pulmonary rehabilitation
    • Vaccination
      • Influenza
      • Pneumococcus
    • Exercise

22. Epidemiology and prevention of asthma

• Epidemiology
  • Prevalence: 7% in world
    • Increasing
  • Black > white
  • Mostly in children
  • Allergic asthma – childhood onset
  • Nonallergic asthma – adulthood onset
• Etiology
  • For allergic asthma
    • Atopy
      • Allergic rhinitis
      • Eczema
    • Air pollution
    • Allergies
      • Mold
      • Dust mite
  • For non-allergic asthma
    • Respiratory infections in childhood
  • Both
    • Smoking or second-hand smoke
    • Low socioeconomic status
    • Obesity
    • Occupational air pollution exposure
• Prognosis
  • Developing countries have fewer medications and options for treatment -> higher mortality and morbidity
  • Therapy is expensive
  • 80% of deaths in low income countries
• Prevention
  • Primary
    • Prevention of development of atopy
    • Breastfeeding
    • Prevention of passive smoking
    • Adequate control of childhood infections
  • Secondary
    • Screen high-risk 
  • Tertiary
    • Avoid triggers
    • Get vaccinations
    • Effective medication and management

23. Epidemiology and prevention of allergic rhinitis

• Epidemiology
  • Prevalence 10 – 30% of industrialized countries
  • Most frequent disease among children and teens
    • 80% of cases 0 – 20 years
  • Prevalence increasing, especially in urban areas
• Forms
  • Seasonal – outdoor allergens
    • Pollen
      • Ragweed
      • Grass
      • Tree
    • Mold
      • Fungus
  • Perennial – indoor allergens
    • Pets
    • Dust
    • Mites
    • Molds
• Etiology
  • Second hand smoke
  • Exposure to allergens
  • Atopy or family history of it
  • 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

• Epidemiology
  • 0,02% prevalence
  • 10^th leading cause of death for men
  • 10-year mortality: 50%
  • Men > women
  • In developed countries – mostly due to alcohol, non-alcoholic fatty liver disease
  • In developing countries – mostly due to HBV, HCV, aflatoxin
• Etiology
  • Alcohol liver disease
    • 70% of cases
    • 40 – 80g/day for 20 years
    • Especially large amounts occasionally
  • HBV
  • HCV
  • Non-alcoholic fatty liver disease
    • Obesity
    • Diabetes type 2
  • Aflatoxin
  • Alpha-1 antitrypsin deficiency
• Prognosis
  • Good in compensated cirrhosis
  • Poor in decompensated cirrhosis
• Prevention
  • Primary
    • Prevention of alcohol abuse
    • HBV vaccination
    • Needle exchange programme – give clean needles to IV drug users
    • Safe sex
    • Promote healthy diet
  • Secondary
    • Screen high-risk groups
  • Tertiary
    • Treat underlying disease
    • Prevention of complication

25. Epidemiology and prevention of ulcer disease

• Epidemiology
  • 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
    • 6 – 10x increased risk in H. pylori
    • 50% of the world is infected
    • Lifetime risk 10% in H. P negatives and 20% in positives
• Protective factors
  • Thanks to prostaglandins
  • Mucosal blood flow
  • Mucin
  • Bicarbonate secretion
  • Restitution
  • Regeneration
• Etiology
  • Old age
  • Long-term NSAID
  • Long-term steroid
  • Smoking
  • Alcohol
  • H. pylori infection
  • Stress
• Prevention
  • Primary
    • Enhancement of protective factors
    • Elimination of aggressive factors
    • Increased fibre
    • Decrease caffeine
    • Decrease alcohol
    • Prevent smoking
  • Secondary – screening
    • Urea breath test
    • Blood antibody test
    • Gastroscopy
  • Tertiary – treatment
    • PPIs, H2 blockers
    • Eradicate H. pylori
    • Stop NSAIDs, steroids
    • Improve diet
    • Stop smoking

26. Epidemiology and prevention of inflammatory bowel diseases

• IBD
  • Epidemiology
    • More common in urbanized areas of Western countries
    • Higher incidence in northern than southern countries
    • White, Ashkenazi Jews
    • Age of onset 15 – 30
    • Women = men
  • Etiology
    • Physical inactivity
    • Diet
      • Low intake of fibre
      • High intake of fat
      • Vitamin D deficiency
    • Hygiene hypothesis
      • Extremely hygienic environments predispose to immunological diseases
    • Family history
    • High socioeconomic status
    • Urbanization
    • Drugs
      • Contraceptives
      • NSAIDs
  • Prognosis
    • No cure
    • Mortality similar to healthy
    • Needs a lifetime of care
    • Requires many physician visits, hospitalizations
    • Major cause of disability
  • Prevention
    • Tertiary
• Crohns
  • Epidemiology
    • Prevalence: 300 / 100 000
    • Incidence: 24 / 100 000
  • Specific risk factors
    • Smoking
    • NOD2
  • Prognosis
    • 75% require surgery
• UC
  • Epidemiology
    • Prevalence: 500 / 100 000
    • Incidence: 12 / 100 000
  • Specific risk factors
    • Not smoking
  • Prognosis
    • 25% require surgery

27. Epidemiology and prevention of suicide

• Epidemiology
  • 1 million worldwide every year
  • 3^rd leading cause of death in 15 – 24 age group
  • 80% occur 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
• Countries
  • Korea
  • Hungary
  • Russia
  • Japan
  • China
• Individual risk factors
  • Mood disorders
    • Depression
  • Alcoholism
  • Previous attempt
  • Schizophrenia
  • Life crisis
  • Partner problems
  • Chronic pain or illness
  • Impulsivity
  • Isolation
  • 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
  • Programmes in school
  • Screening for mental well-being at GP

28. Epidemiology and prevention of depression and mood disorders

• Epidemiology
  • Depression is the most common mood disorder
  • 20 million people every year
  • Female > male
  • Major cause of disability in young
• 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

• Epidemiology
  • 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
    • Most common in middle-aged
  • Social anxiety disorder
    • Most common in young
  • Specific phobias
• Treatment
  • Cognitive behavioural therapy
  • Medication

30. Epidemiology and prevention of schizophrenia and dementias

• Schizophrenia
  • Epidemiology
    • Males = females
    • Onset in 20s – 30s
  • Clinical features
    • Positive and negative symptoms
  • 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
  • Epidemiology
    • Disease of elderly
    • Female > male
  • Causes
    • Neurodegenerative disease
    • Cerebrovascular disease
  • Risk factor
    • Age
    • Female
    • Family history
    • CVD risk factors
    • Lack of physical activity
  • Prevention
    • No smoking
    • Healthy weight
    • Exercise
    • Healthy diet
    • Reduce comorbidity
    • Stay mentally alert
    • Maintain social relationships

31. Epidemiology and prevention of addictions

• Addiction = Chronic problem which causes drug seeking, despite harmful consequences
• Addictions cause accidents, violence, abuse
• Epidemiology
  • 6% of the world
  • Most drug-related deaths are in North America
• Physical dependence
  • Avoidance of withdrawal
• Psychological dependence
  • Drug-seeking behaviour
• Comorbidity of addiction
  • Depression
  • Suicide
  • Antisocial personality disorder
  • Infections

Smoking

• Epidemiology
  • One of the most important public health issues
  • Most smoking in Eastern Europe
    • Greece
    • Serbia
    • Croatia
    • Etc.
  • Male > female
  • Almost all adult smokers had their first cigarette before 20
• Risk factors
  • Low socioeconomic status
  • Peer pressure
  • Family who smokes
• Fagerstrøm nicotine dependence scale
• 5 A of smoking cessation
  • Ask – about tobacco use
  • Advise – tobacco users to quit
  • Assess – readiness to attempt quitting
  • Assist – with quitting
  • Arrange – follow up care
• 5 R’s – for patients unwilling to quit at this time
  • Relevance – tailor advice to each patient
  • Risks – inform of risks of continuing
  • Rewards – inform of rewards of stopping
  • Roadblocks – identify roadblocks
  • Repetition – repeat messages
• Prevention
  • Primary
    • Campaigns
    • Ban advertisements
    • Decrease availability
    • Encourage cessation
    • Decrease second hand smoking
    • School programs
  • Secondary
    • Ask patient about substance disorder
  • Tertiary
    • Support groups
    • Bupropion
    • Nicotine replacement

Alcohol

• Epidemiology
  • Alcohol consumption causes 3 million deaths every year
  • Excessive alcohol consumption is the 2^nd most important epidemiological problem after smoking
  • More common in minorities
  • Peak incidence 20s – 30s
  • Male > female
• 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)
  • Depression
  • Anxiety
  • Abuse of other substances
• Prevention
  • Legislation
  • Taxes
  • Mental health promotion
  • No ads
  • Awareness campaign

Other drugs

• Designer drugs
• 4% of worlds adult population used psychoactive substances
• Cannabis, amphetamines, cocaine, opioids

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

• DM2 screening in children
  • Recommended by ADA
  • In those who are overweight for their age and gender, and who have any of the following risk factors
    • Family history
    • Specific ethnicity
    • Signs of insulin resistance
  • Begin at age 10, repeat every 2 years
• CVD in adults
  • BP, cholesterol, weight, waist, glucose, smoking, physical activity, diet
  • Start at 20
  • Every 2 – 4 years
• Diabetic eye screening
  • Annually to people with diabetes
• Osteoporosis
  • Bone mineral density measurement by DEXA
  • In women > 65, or younger if they have risk factors
• Abdominal aortic aneurysm
  • For men > 65
  • With ultrasound
• Cognitive impairment
  • No universal recommendation for screening
• Depression
  • Adults > 18
  • Screening with simple screening questions
• Antenatal screening
  • Haemoglobinopathies
  • Down syndrome
  • Infectious diseases
    • Syphilis
    • HBV
    • HIV
    • Rubella
• Newborn screening
  • Hearing loss
  • Metabolic diseases