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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