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Chapter 9
Social and Behavioral Epidemiology
Learning Objectives
• Give two examples of how lifestyle is
associated with negative health outcomes
• State the linkage between tobacco use and
adverse health outcomes
• Describe the epidemiology of one form of
substance abuse
• Describe the epidemiology of two important
mental disorders
Introduction
• Social and behavioral dimensions that impact
human health include social adversities, stress,
and lifestyle practices.
• Social adversities:
– Poverty
– Discrimination
Definition: Lifestyle
• The choice of behavioral factors that affect
how we live
– These choices often are a function of social
influences.
– Personal behavior is associated with many chronic
diseases.
– The impact of the factors is not fully recognized.
Mental Disorders
• Can be a consequence of social factors, e.g.,
stress
• Can affect lifestyle choices, e.g., inactivity
Social and Behavioral
Epidemiology
• Social epidemiology is the discipline that
examines “…the social distribution and social
determinants of states of health.”
• Behavioral epidemiology is defined as the
study of the role of behavioral factors in
health.
Stress and Health
• Stress is “…a physical, chemical, or emotional
factor that causes bodily or mental tension and
may be a factor in disease causation.”
• Examples of conditions studied as outcomes of
stress:
– Cardiovascular disease
– Posttraumatic stress disorder
– Work-related anxiety and neurotic disorders
Stressful Life Events
• Stressors (sources of stress) that arise from
happenings such as job loss, financial
problems, and death of a close family member
• Types of events:
– Positive and negative life events
– Chronic strains
Stressful Life Events (cont.)
• Negative life events are those associated
with adverse life circumstances.
─ Examples: being fired from work or being
arrested and incarcerated
• Positive life events
─ Examples: graduation from school, marriage,
and birth of a new child
Chronic Strains
• Life events that are sustained over a long
period of time
Brain Under Stress
Source: Reprinted from National Institutes of Health, National Institute on Drug Abuse (NIDA). Available at:
http://www.drugabuse.gov/DrugPages/PSAartcards/stress.pdf. Accessed July 23, 2008.
Posttraumatic Stress Disorder
(PTSD)
• “…an anxiety disorder that some people
develop after seeing or living through an event
that caused or threatened serious harm or
death….”
Symptoms of PTSD*
•
•
•
•
•
•
“Flashbacks or bad dreams
Emotional numbness
Intense guilt or worry
Angry outbursts
Feeling ‘on edge’
Avoiding thoughts and situations that remind
them [people] of the trauma”
* Modified from NIH, NIMH. Post traumatic stress disorder research fact
sheet.
Social Support
• Refers to help received from other people
when one is under stress.
– Friends, relatives, and significant others often are
able to provide material and emotional support
during times of stress.
Coping Skills
• Techniques for managing or removing sources
of stress
• Effective coping skills help mitigate the effects
of stress.
Work-Related Stress
• This category includes work overload, time
pressures, threat of job layoff and
unemployment, interpersonal conflicts, and
inadequate compensation.
Annual rates of anxiety, stress, and neurotic
disorder cases involving days away from
work in private industry, 1992-2001
Source: Reprinted from Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Worker
Health Chartbook, 2004. Cincinnati, OH: DHHS (NIOSH) Publication No. 2004-146. September 2004:35.
Tobacco Use
• Cigarette smoking and other forms of tobacco
use increase the risk of many forms of adverse
health outcomes.
– Examples: lung diseases, coronary heart disease,
stroke, and cancer
– Lung cancer is the leading cause of cancer death
among both men and women in the U.S.
Tobacco Use (cont.)
• Prevalence of adult current smokers (U.S.)
– Among adult men, prevalence declined from more
than 50% to about 23% (between 1965 and 2005).
– Among adult women, prevalence declined from
about 30% to about 19% (between 1965 and
2005).
– In 2007, 22.7% of men and 17.4% of women were
current smokers.
• Prevalence of smoking among high school
students was 22.5% overall (2002).
Cigarette smoking among men, women,
high school students, and mothers during
pregnancy: United States, 1965-2005
Source: Reprinted from National Center for Health Statistics. Health, United States, 2006, with Chartbook on Trends in the Health of
Americans. Hyattsville, MD: National Center for Health Statistics; 2006:33.
Secondhand Smoke
• Related term is passive smoking (sidestream
exposure to cigarette smoke).
– Refers to the involuntary breathing of cigarette smoke by
nonsmokers in an environment where there are cigarette
smokers present.
• In 2006, the U.S. Surgeon General concluded that
“Secondhand smoke exposure causes disease and
premature death in children and in adults who do not
smoke.”
Alcohol Consumption
• Data from CDC’s National Center for Health
Statistics indicate that alcohol consumption is
a significant cause of mortality in the United
States.
• “In 2005, a total of 21,634 persons died of
alcohol-induced causes in the United
States….” The age-adjusted death rate for
alcohol-induced causes was 7.3 per 100,000
population.
Alcohol Terms
• Heavy drinking
– Women: more than one drink per day on average
– Men: more than two drinks per day on average
• Binge drinking
– Women: more than three drinks during a single
occasion
– Men: more than four drinks during a single
occasion
Alcohol Consumption (cont.)
• More than one-tenth of alcohol consumed in
the U.S. is by persons under age 21.
– 90% of this consumption takes place as binge
drinking.
• Among high school students, more than 30%
of males and 25% of females engaged in binge
drinking (2005).
• In 2005, 19.5% of full-time college students
and 13.0% of part-time college students were
heavy drinkers.
Binge drinking among high school
students, by sex, grade level, and year:
United States, 1991, 1993, 2003, and 2005
Note: Binge drinking is drinking five or more drinks of alcohol in a row on one or
more of the 30 days preceding the Youth Risk Behavior Survey.
Source: Adapted and reprinted from National Center for Health Statistics. Health, United States, 2006, with Chartbook on Trends in
the Health of Americans. Hyattsville, MD: National Center for Health Statistics; 2006:35.
Heavy alcohol use among adults aged 18
to 22, by college enrollment: 2002-2006
Source: Reprinted from Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on
Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293).
Rockville, MD; 2007:36
Substance Abuse
• Illicit drugs include:
– Marijuana
• The most commonly used illicit drug among persons
aged 12 or older (2006)
– Methamphetamines
– Heroin
• Other abused drugs include:
– Prescribed painkillers
Source: Reprinted from Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on
Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293).
Rockville, MD; 2007:17.
Methamphetamines
• Methamphetamines are highly addictive
substances.
• Use may result in:
– Rise in body temperature
– Psychotic symptoms
– Crank bug
– Meth mouth
Meth Mouth
• A condition that contributes to decay and loss
of teeth
• Attributed to:
– Reduced output of saliva
– Increased sugar consumption
– Neglect of personal hygiene
Use of Methamphetamines
• In U.S., 1.4 million persons aged 12 or older
reported past year use (2004).
• Among U.S. high school students, the lifetime
use of methamphetamines was 4.4% (2007).
Source: Reprinted from U.S. Department of Health and Human Services, Substance Abuse & Mental Health
Services Administration, Office of Applied Studies. The NSDUH Report: Methamphetamine Use, Abuse, and
Dependence: 2002, 2003, and 2004. September 16, 2005. Available at: http://oas.samhsa.gov/2k5/meth/meth.pdf.
Accessed August 31, 2008
Overweight and Obesity
• Overweight and obesity are increasing in
prevalence in the United States.
• Being overweight or obese impacts the quality
of one’s life and increases the risk of chronic
diseases.
• Sedentary lifestyle and consumption of highcalorie foods are associated with overweight
and obesity.
Body Mass Index
(BMI)
• A measure of overweight and obesity that
takes into account both a person’s weight and
height
• Defined as body weight in kilograms divided
by height in meters squared.
• Overweight: BMI ≥ 25 and ≤ 29.9
• Obesity: BMI ≥ 30.
Trends in child and adolescent overweight
Epidemiology and Mental
Health
• One of the important applications of
epidemiology
• Mental disorders have characteristic
distributions according to the categories of
person, place, and time.
Psychiatric Epidemiology
• Studies the occurrence of mental disorders in
the population
– Variables include age, sex, and social class.
– The discipline measures the frequency of
occurrence of mental disorders and factors related
to their etiology.
• DSM-IV-TR (2000)
– Manual used for the classification of psychiatric
disorders
Types of Mental Disorders
• Anxiety disorders
• Mood disorders
– Major depressive episode
– Dysthymia
– Bipolar disorder
• Impulse-control disorders
• Substance use disorders
• More than 25% of U.S. population is afflicted
with a mental disorder during a given year.
Lifetime prevalence (standard error) of
mood disorders among 17- to 39-year-old
respondents by sex
Source: Reprinted from Jonas BS, Brody D, Roper M, Narrow W. Mood disorder prevalence among young men and women in the
United States. In: Center for Mental Health Services. Mental Health, United States, 2004. Manderscheid RW and Berry JT, eds.
DHHS Pub No. (SMA)-06-4195. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2006:185.
Psychiatric Comorbidity
• Defined as the co-occurrence of two or more
mental disorders
– For example, major depression and substance use
disorder
Autism
• Autism (autism spectrum disorder-ASD) is a
condition that impairs functioning in the social,
communication, and behavioral domains.
• Generally appears by 3 years of age
• Manifested by difficulties in:
– Cognitive functioning
– Learning
– Processing sensory information
• Prevalence in U.S. about 4.5 to 9.9 per 1,000
children
Source: Reprinted from Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders—Autism and
Developmental Disabilities Monitoring Network, six sites, United States, 2000. In: Surveillance Summaries, 2007. MMWR
2007;56(No. SS-1):5
Conclusion
• Social factors and lifestyle practices (which are
modifiable) play a significant role in health.
–
–
–
–
Tobacco use, excessive alcohol consumption
Substance abuse
Sedentary habits
Stress
• Mental disorders are an important topic for
epidemiologic studies.
– High prevalence of mental disorders
– Contributions of psychiatric epidemiology