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1、Environmental Drivers of Chronic Disease Based on the report Environmental Threats to Healthy Aging by Jill Stein MD, Ted Schettler MD, MPH, Maria Valenti and Ben Rohrer 2010,Greater Boston Physicians for Social Responsibility (www.psr.org/Boston) and The Science and Environmental Health Network (ww
2、w.sehn.org),What We Will Cover,Environmental factors are key drivers of many common chronic diseases Environmental factors alter key biological pathways leading to chronic disease Important environmental determinants of health include: Food system/nutrition and diet Toxic chemicals Built environment
3、 / physical activity Psychological & socioeconomic stress Examples of cross cutting solutions for healthy people & a healthy environment,Scope & Context of the Problem,A century of change in natural, built and social environments has caused major changes in the patterns and distribution of diseases.
4、 We are seeing dramatic increases in chronic diseases, and at younger ages, many of which, such as diabetes, are themselves risk factors for dementia. The over- 65 population will nearly double by 2030 to more than 71 million, sharply increasing the number of people at risk of chronic diseases of ag
5、ing like Alzheimers and Parkinsons diseases, among others. Environmental factors play a key role in health across the lifespan. Thus they offer a major prevention opportunity.,The Changing Environment and Disease Patterns,During the past century, human activity has altered virtually all aspects of t
6、he worlds ecosystems: Pervasive spread of synthetic chemicals; air and water pollution. Industrialized food supply. Destruction of critical natural habitats, stressing ecosystems. Climate change. How we live, eat, work, play and socialize have substantially changed: Built environments have increased
7、 social isolation for many people; reduced physical activity. Growing income gap increases disease risk. Diseases of civilization - obesity, diabetes, cardiovascular disease, hypertension.,Environment Drives Chronic Disease,Western Disease Cluster Diabetes Obesity Abnormal Lipids Metabolic Syndrome
8、Cardiovascular Disease,Food system/Diet Fossil Fuels Socioeconomic Stress Chemicals Built Environment/ Transportation,Inflammation Disrupted Insulin Signaling Oxidative Stress,Alzheimers,Parkinsons,Altered Pathways,Environmental Factors,Chronic Disease,Profound Public Health Impact Of Environmentall
9、y-Driven Western Disease Cluster,Obesity/overweight 2/3 US adults, prevalence x2 in 25 yrs http:/www.cdc.gov/chronicdisease/resources/publications/AAG/obesity.htm Pre/Diabetes 40% US adults, prevalence DM x2 over 20 yrs Cowie 09, http:/apps.nccd.cdc.gov/DDTSTRS/default.aspx Cardiovascular disease st
10、ill leading cause of death. Hypertension increasing. http:/www.cdc.gov/nchs/FASTATS/lcod.htm, Hajjar 03 Metabolic syndrome = early signs of other cluster diseases; 35% adults, 55%60 yrs Ford ES 05 Alzheimers disease 84 yrs old, 5.3M Alzheimers Assoc.,Alzheimers Disease/dementia,Not an inevitable fea
11、ture of normal aging. Progressive impairment of memory and multiple other cognitive functions, severe enough to interfere with daily functioning. Expected to triple by mid-century to over 13 million. Likely caused by varying combinations of genetic and environmental factors. Annual costs in US over
12、$150 billion.,Parkinsons Disease,Progressive movement disorder that includes tremors, stiffness, and slow movement. May lead to severe disability. Likely caused by variable combinations of genetic and environmental factors. About 50,000 new cases annually in US.* Prevalence in US expected to double
13、by 2030.*,* Due to the lack of registries and baseline data on Parkinsons Disease, the figures used here are estimates.,Alzheimers and Parkinsons Diseases,Characterized by: abnormal protein deposits chronic inflammation abnormal oxidative stress Many neuroscientists are beginning to think of some ne
14、urodegenerative diseases along a continuum, without clearly distinct boundaries in clinical or pathological manifestations,Continuum of Age-Associated Cognitive Impairment,Environment Drives Chronic Disease,Early life experiences can influence later-life health and disease. Multiple factors interact
15、 to influence health & disease. Environmental factors can alter natural pathways which in turn can lead to chronic disease. An ecological health framework considers the individual in the context of family, community, society and ecosystem.,Basic Principles,Toxic exposures oxidative stress,Obesity, h
16、ypertension, Cardiovascular disease, diabetes,Alzheimers, dementia, Parkinsons,Low birth weight,Early life experiences can influence later-life health, disease,Aging begins at conception,Multiple Factors Interact to Influence Health & Disease,built environment,disease,stress,energy,chemicals,nutrien
17、ts,An ecological health framework considers the individual in the context of family, community, society, and ecosystem.,Altered Pathways,Environment Drives Chronic Disease,Environmental Factors,Inflammation Disrupted Insulin Signaling Oxidative Stress,Chronic Disease,Mechanisms of Action,Defined by
18、microscopic characteristics & laboratory test: inflammatory cells & mediators,CLASSICAL CONCEPT OF INFLAMMATION,Defined by appearance. “Calor, dolor, rubor, tumor.” Heat, pain, redness, swelling.,The New Concept of Inflammation,“Atherosclerosis is an inflammatory disease.” (2) Ross, Russell. Atheros
19、clerosis An Inflammatory Disease. NEJM 1999, 340(2); 115-126.,Insulin Signaling = Normal Metabolism,Disrupted Insulin Signaling = Inflammatory Metabolism,Altered Pathways,Environment Drives Chronic Disease,Environmental Factors,Chronic Disease,Food System/Diet,Novel Nutrients Are Pervasive, Promote
20、Inflammatory Metabolism,Whats “Novel” in the Western Diet?,“Hypothetical scheme of fat, fatty acid (6, 3, trans and total) intake (as percentage of calories from fat) and intake of vitamins E and C (mg/d). Data were extrapolated from cross-sectional analyses of contemporary hunter-gatherer populatio
21、ns and from longitudinal observations and their putative changes during the preceding 100 years 75.” From AP Simopoulos, The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomedicine & Pharmacotherapy 56 (2002) 365-379.,Years,% of calories from fat,mg/day,High Glycemic Carbohydra
22、tes Increase the Risk of Chronic Disease,High glycemic carbohydrates break down quickly during digestion, rapidly releasing glucose (sugar) into the bloodstream., Plasma Insulin,mg/dl,Time, mins,INSULINEMIC RESPONSE,Low glycemic food,High glycemic food,Properties of Fatty Acids,Omega-3 Omega-6 Satur
23、ated Food Perishable Durable Increased in System Short shelf life Processed foods factory farmed Increased in Long shelf life animals pasture- fed animals Immune Anti-inflammatory Inflammatory & Inflammatory Properties Anti-inflammatory Evolutionary Recent marked Recent marked Recent marked Context
24、decline increase increase,Novel Nutrients Disrupt Insulin Signaling, Drive Inflammatory Metabolism,Saturated fat,Antioxidants,High Glycemic Carbohydrates,Increase risks saturated and trans fats high glycemic carbohydrates lack of fruits/vegetables/omega 3s excess omega 6s? Reduce risks fruits, veget
25、ables omega 3s low glycemic carbohydrates Mediterranean diet,Influence of Nutrition on Chronic Disease,Benefits of Mediterranean-Type Diet on Chronic Disease Risk,Clinical intervention studies 70% heart attacks, cardiac death & total mortality DeLogeril 94 60% cardiac events in CVD patients* Ornish
26、98 50% metabolic syndrome Esposito 04 39% in CRP Esposito 04 insulin resistance Esposito 04 weight Esposito 04 Prospective observation studies 80% diabetes Martinez-Gonzalez 08 31% all-cause & cardiovascular mortality, 22% cancer mortality*calculated from Sofi 08 73% Alzheimers mortality Scarmeas 07
27、 25-30% Parkinsons disease Gao 07 78% childhood asthma maternal diet Chatzi 08,*10% low fat, vegetarian diet + exercise, stress reduction,*For every 2 point increase in adherence (on a 9 point scale), risk reductions were observed of 0.91 for all cause mortality, 0.91 for CV mortality, 0.94 for occu
28、rrence and mortality from neoplasm. To convey the implications of these findings, we have applied the risk reductions across a 9 point adherence scale to yield a calculated 31% all-cause & CV mortality and a 22% in cancer mortality.,Benefits of Sustainably-Produced Food,Nutritional benefits: General
29、ly higher levels of vitamins, minerals and phytochemicals (often dependent on soil quality) Higher Omega-3 content Organic samples contained higher concentrations of polyphenols and antioxidants in 75% of the matched pairs representing those nutrients Benefits for farm workers and communities: Reduc
30、ed exposure to pesticides,Altered Pathways,Environment Drives Chronic Disease,Environmental Factors,Chronic Disease,Toxic Chemicals,Air pollution, Lead and other heavy metals, some Pesticides, Bisphenol A and other Endocrine Disruptors,Lead,Cumulative occupational exposure cognitive impairment Shih
31、2007 2x risk Parkinsons Coon 2006 Cumulative community exposure cognitive impairment Shih 2006 Up to 15 years cognitive aging Weisskopf 2004 Animal studies of early life exposure Late-life Alzheimers markers Basha 2005, Lahiri 2007,Pesticides,Parkinsons Disease Human studies - 24/31 studies show ris
32、ks for PD. (OR 1.6-7) Brown 2006 Animals - Rotenone prenatal exposure “primes” the brain, increasing adult susceptibility Cory-Slechta 2005 Cognitive decline/dementia Low level fungicides in vineyards 3.5x poor attention, memory Baldi 2001 Occupational exposure in men associated with 2x risk of deve
33、loping AD Baldi 2003 Insulin Resistance, metabolic syndrome Lee 2006, 2007, 2007 Some persistent pesticides show strong dose-response relation to insulin resistance and metabolic syndrome.,Found in polycarbonate plastic, resins, sealants. Exposures are nearly ubiquitous. Endocrine disruptor, oxidati
34、ve stress. Causes fat accumulation & insulin resistance at low levels (animals). Alanso-Magdelena 2006, Wada 2007 3-fold Cardiovascular disease. Lang 2008 2-fold Insulin Resistance. Lang 2008,Bisphenol A,polycarbonate,Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism,End
35、ocrine Disruptors - BPA, dioxins, PCBs, some pesticides,Saturated fat,High Glycemic Carbohydrates,Air Pollution,Some Pesticides,Lead, other heavy metals,Altered Pathways,Environment Drives Chronic Disease,Environmental Factors,Chronic Disease,Built Environment Physical Activity,Health Benefits of Ph
36、ysical Activity,Reduced ongoing levels of oxidative stress and inflammatory burden. Brooks 2008, Attipoe 2008 Inversely associated with the risks of Alzheimers/dementia and cognitive decline. Rovio 2005 Subjects at risk for AD who walked 150 min. per week showed improvements in cognition while the c
37、ontrol group showed no net change from baseline at 1.5 yrs. Lautenschlager 2008,Increasing physical activity at any age improves physical and emotional wellbeing.,Walkable Cities Projects Community Gardens Farmers Markets Rails to Trails,Livable Communities Enhance Healthy Aging,Cuba- lost fossil fu
38、els biking, walking, local plant-based food physical activity 50% obesity 50% mortality: DM 51%, CVD 35%, stroke 20%, all cause 18%,Franco M et al. Impact of Energy Intake, Physical Activity, and Population-wide Weight Loss on Cardiovascular Disease and Diabetes Mortality in Cuba, 1980-2005. AJE 166
39、, 12; Sept. 19, 2007,Sustainable Food & Transportation Solutions: The Cuba Example,Green Space Reduces Stress, Mortality, Improves Cognitive Function,Shortens post surgical recovery time, reduces need for pain medications. Ulrich 84 Attention deficits improve after a walk in the park. Effect = methy
40、lphenidate. Taylor 08 Access to green space reduces the effect of poverty on mortality by 50%. Mitchell 08,Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism,Obesity,Endocrine Disruptors - BPA, dioxins, PCBs, some pesticides,Inactivity,Saturated fat,High Glycemic Carbohyd
41、rates,Air Pollution,Antioxidants,Lead, other heavy metals,Some Pesticides,Altered Pathways,Environment Drives Chronic Disease,Environmental Factors,Chronic Disease,Socio-Economic Stress,Depression, poverty, violence, inadequate health care,Socioeconomic, Psychosocial Stressors,Stress, depression ris
42、k for CVD, AD Sesso, Kario, Ownby People with lower SE status are at risk for exposure to multiple environmental hazards damage. Lead + stress cognitive impairment Glass 2009 Lead + air pollution CV autonomic dysfunction Park 2008,People who live in neighborhoods that lack social cohesion, sidewalks
43、, or safety limit their exercise and have an increased risk of depression and possibly obesity. Berke EM 07, Molnar BE 04,Effects of the Built Environment on Health,Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism,Obesity,Endocrine Disruptors - BPA, dioxins, PCBs, some
44、pesticides,Inactivity,Saturated fat,High Glycemic Carbohydrates,Air Pollution,Antioxidants,Lead, other heavy metals,Some Pesticides,Stress,Multiple Factors Interact to Influence Health & Disease,Environmental Factors,Chronic Disease,Altered Biological Pathways, Greenhouse Gases,Climate Crisis Heat,
45、drought, storms, fires, ice sheet instability, sea level rise, loss of glacial irrigation, refugees, food insecurity/starvation, tropical diseases,Environmental Factors Drive Chronic Disease and the Climate Crisis,Solutions for Healthy People & A Healthy Planet,Major Illnesses Are Preventable Person
46、al Actions to Profoundly Reduce Risks,Personal Level “Approaches to Healthy Living”,Eat healthy whole, fresh, unprocessed, plant based foods Avoid toxicants whenever possible Exercise Be socially engaged,Localized, diversified and sustainable food production Clean, renewable energy air pollution, ch
47、emical exposures Mass transit that connects with bike paths and sidewalks can reduce air pollution job creation Universal health care disease prevention & equitable health care.,Major Illnesses Are Preventable Policy Initiatives to Profoundly Reduce Risks,Major Illnesses Are Preventable Policy Initi
48、atives to Profoundly Reduce Risks,Examples of Specific Initiatives: Nutrition Reform agricultural subsidies to be directed toward programs and practices that provide sufficient nutritious, sustainably produced food and restore ecosystems that have been degraded by agricultural activities. Toxic Chemicals Reform the national Toxic Substances Control Act to include phase out of persistent, bioaccumulative, or highly toxic chemicals. Activity/Nature Incorporate indoor and outdoor green spaces and exercise areas into designs of nur