Health And Treatment Strategies in Obesity (Advances in Psychosomatic Medicine)


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Bariatric Surgery. Psychosocial Aspects of Obesity. Subject Index. Droits d'auteur. Informations bibliographiques. Health and Treatment Strategies in Obesity Varsha Vaidya Karger Medical and Scientific Publishers - 97 pages 1 Commentaire Obesity has been predicted to become the number one health problem worldwide in the next decade.

Intervening medically, for example, to decrease risk by lowering levels of obesity, as measured by BMI ultimately decreases the proportion of the population with the highest BMIs. However, use of such an intervention would be acceptable only in those whose medical risk was very high. Moreover, interventions in high-risk groups may have a limited effect on population outcomes because the greater proportion of those with moderate risk levels may ultimately translate into more chronic disease or other poor health outcomes.

Because most people are in categories of moderately elevated risk as opposed to very high risk, this strategy offers the greatest benefit in terms of population-attributable risk, assuming that the intervention itself carries little or no risk. The hypothetical example shows what might occur if social policies or other population-wide measures were adopted to promote small decreases in weight in the general population.

The committee embraces this kind of model of disease prevention in the case of policies such as seat belt regulation and the reduction of lead levels in gasoline. The final hypothetical model Figure 2—1c , although not discussed by Rose explicitly, illustrates a reduction in the distributions of those at highest and lowest risk with no change in the distribution of those with a mean level of risk.

This model is appropriate for illustrating phenomena relating to inequality, where redistribution of some good e. One hypothetical example is the association between low income and poor health. In many cases, there is a curvilinear association between these goods and health outcomes, with decreased health gains experienced by those at the upper bounds of the distribution. For example, data on income suggest that there are large differences in the health gains achieved per dollar earned for those at the lower end of the income distribution and fewer differences in the health gains achieved per dollar earned for those at the upper end.

Thus, the curvilinear association, if it were a causal one, would suggest that substantial gains in population-level health outcomes may be achieved by a redistribution of some resources without actual changes in the means. These graphs help to illustrate three different strategies for improving the health of the population. The nation has often endorsed the first strategy without a critical examination of the other two, especially the second one. The American public has grown accustomed to seeing differences in exposures to risk, both environmental and behavioral, and disparities in.

In some ways, conventional public health models e. Enormous gains in the control and eradication of infectious diseases rested upon a deep understanding of the ecology of specific agents and the power of environmental interventions rather than individual or behavioral interventions to control disease. For example, in areas where sanitation and water purification are poor, individual behaviors, such as hand washing and boiling of water, are emphasized to reduce the spread of disease.

The last several decades of research have resulted in a deeper understanding not only of the physical dimensions of the environment that are toxic but also of a broad range of related conditions in the social environment that are factors in creating poor health. These social determinants challenge the discipline of public health to more fully incorporate them.

Over the past decade, several models have been developed to illustrate the determinants of health and the ecological nature of health e.

Stigmatization of obese individuals by human resource professionals: an experimental study

Many of these models have been developed in the United Kingdom, Canada, and Scandinavia, where population approaches have started to shape governmental and public health policies. The committee has built on the Dahlgren-Whitehead model—which also guided the Independent Inquiry into Inequalities in Health in the United Kingdom—modifying it to reflect special issues of relevance in the United States see Figure 2—2.

This figure serves as a useful heuristic to help us think about the multiple determinants of population health. It may, for instance, help to illustrate how the health sector, which includes governmental public health agencies and the health care delivery system, must work with other sectors of government such as education, labor, economic development, and agriculture to. The dotted lines between levels of the model denote interaction effects between and among the various levels of health determinants Worthman, Furthermore, the governmental sector needs to work in partnership with nongovernmental sectors such as academia, the media, business, community-based organizations and communities themselves to create the intersectoral model of the public health system first alluded to in the Institute of Medicine IOM report and established in this report as critical to effective health action.

Behavioral intervention in obese adults

Macro-level or upstream determinants such as policies and societal norms and micro-level determinants such as sex or the virulence of a disease agent interact along complex and dynamic pathways to produce health at a population level. As mentioned above, exposures at the environmental level may have a greater influence on population health than individual vulnerabilities, although at an individual level, personal characteristics including genetic predispositions interact with the environment to produce disease. For instance, smoking is a complex biobehavioral activity with both significant genetic heritability and nongenetic, environmental influences, and many studies have shown an interaction between smoking and specific genes in determining the risk of developing cardiovascular disease and cancers.

It is also important to note that developmental and historical conditions change over time at both a societal level e. In the pages that follow, the committee provides a concise discussion of the key determinants that constitute the ecology of health, including environmental and social determinants, and elaborates in more detail on the social influences on health. This decision was made in recognition of a longer history in studying the ways in which environment shapes population health. Improved water, food, and milk sanitation, reduced physical crowding, improved nutrition, and central heating with cleaner fuels were the developments most responsible for the great advances in public health achieved during the twentieth century.

These advantages of a developed nation are taken for granted, but in fact, they could deteriorate without adequate support of the governmental public health infrastructure. Environmental health problems, historically local in their effects and short in duration, have changed dramatically within the last 25 years.

Together, global warming, population growth, habitat destruction, loss of green space, and resource depletion have produced a widely acknowledged environmental crisis NRC, These long-term environmental problems are not amenable to quick technical fixes, and their resolution will require community and. At the local and community levels, environmental issues are equally complex and are also related to a range of socioeconomic factors.

A brief look at some of the evidence on environmental determinants of health may help shed some light on why health is not equally shared. The places in which people work and live have an enormous impact on their health. The characteristics of place include the social and economic environments, as well as the natural environment e. Environmental hazards in workplaces and communities may range from tobacco smoke to pesticides to toxic housing. Rural areas may present increased health risks from pesticides and other environmental exposures, whereas some environmental threats to health can occur because of urban living conditions.

More than three-quarters of Americans live in urban areas Bureau of the Census, Although rural Americans experience certain health-related disadvantages e. The negative environmental aspects of urban living—toxic buildings, proximity to industrial parks, and a lack of parks or green spaces, among others—likely affect those who are already at an economic and social disadvantage because of the concentration of such negative aspects in specific pockets of poverty and deprivation Lawrence, ; Maantay, ; Williams and Collins, Urban dwellers may experience higher levels of air pollution, which is associated with higher levels of cardiovascular and respiratory disease Hoek et al.

People who live in aging buildings and in crowded and unsanitary conditions may also experience increased levels of lead in their blood, as well as asthma and allergies Pertowski, ; Pew Environmental Health Commission, ; CDC, a. These examples illustrate some of the profound effects of the physical environment on health.

The places where people live may expose them to harmful factors. The case of methylmercury as an environmental pollutant illustrates the potentially dramatic effects of the physical environment on health. Environmental toxins are a specific form of environmental hazard, caused in most cases by industrial enterprises, and the adverse effects of such toxins on the nervous system have been well documented.

High levels of exposure to certain environmental pollutants are known to cause acute effects including convulsions, paralysis, coma, and death. The effects of lead on health and development have been documented for decades, and policy action regarding leaded gasoline and lead-based paints has been taken, with positive effects on child health. However, there is growing concern about emerging evidence that other ubiquitous pollutants such as polychlorinated biphenyls PCBs and mercury may cause behavioral problems and affect mood and social adjustment.

The adverse impacts of exposure to these pollutants may be most profound during fetal development and early childhood. Amidst growing national concern about developmental disabilities, exposure to mercury in the environment represents an emerging and preventable environmental health threat. The National Research Council NRC report Toxicological Effects of Methylmercury NRC, examined the evidence of adverse health impacts resulting from exposure to mercury, focusing on consumption of seafood contaminated by releases to the environment.

Fossil fuel combustion represents the major source of mercury released to the environment. The deposition of mercury on the land and in surface waters results in conversion to forms that accumulate in the food chain. This bioaccumulation can result in very high concentrations of mercury in some fish, which are the main source of exposure for the population. The developing brain is particularly sensitive to the adverse effects of mercury exposure.

Prenatal exposures may interfere with the growth and development of neurons and cause irreversible damage to the nervous system. Infants whose mothers were exposed to high levels in poisoning episodes in Minamata, Japan, and in Iraq were born with severe disabilities, including mental retardation, cerebral palsy, blindness, and deafness EPA, ; NRC, More recently, epidemiological studies of lower-level exposure from maternal fish consumption have raised concerns about subtle neurodevelopmental deficits.

The NRC report concluded that the evidence of developmental neurotoxic effects from mercury exposure is strong and called for revision of the Environmental Protection Agency EPA reference dose that provides public health guidance on acceptable population exposure levels. This conclusion was based on epidemiological studies of low-level chronic exposure from seafood consumption.

The population at risk consists of women of childbearing age and their children. Frequent consumers, par-. Based upon the available data on fish consumption, the NRC committee estimated that as many as 60, newborns may be at risk for adverse neurodevelopmental effects from in utero exposure to mercury. Currently, 40 states have issued fish consumption advisories to reduce exposure to mercury. EPA and the Food and Drug Administration FDA have also recently revised their guidance concerning consumption of fish species that have been shown to have high levels of mercury.

Ultimately, the threat of mercury can be most effectively reduced through control of the sources of pollution.

1. Dietary changes

However, control of sources from the burning of fossil fuels may be decades away. In the meantime, prevention of adverse public health impacts from mercury will require a partnership among health care providers, public health agencies, and others. The example of methylmercury clearly illustrates the serious impact of just one environmental risk factor. Most states do not track environmental risk factors like pesticides and other hazards or most chronic diseases such as asthma and birth defects Pew Environmental Health Commission, A great deal about health determinants in the built and natural environments has been learned in recent decades, but much more is yet to be examined.

Most recently, social epidemiologists and other researchers have focused on identifying the social equivalents of leaded gasoline and environmental tobacco smoke. Among the greatest advances in understanding the factors that shape population health over the last two decades, and clearly. The evidence amassed strongly and consistently points to the importance of these conditions as significant determinants of population health. Additionally, we discuss the evidence related to a fifth condition that has been and that still is the subject of great interest as well as controversy: ecological-level influences, namely, economic inequality and social capital.

A strong and consistent finding of epidemiological research is that there are health differences among socioeconomic groups.

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Lower mortality, morbidity, and disability rates among socioeconomically advantaged people have been observed for hundreds of years; and in recent decades, these observations have been replicated using various indicators of socioeconomic status SES and multiple disease outcomes Syme and Berkman, ; Kaplan and Keil, SES is defined in terms of education, income, and occupation. Furthermore, educational differentials in mortality have increased in the United States over the past three decades, leading to a growing inequality, even though mortality rates have dropped for all groups Feldman et al.

Although it may be measured as level of education or income, SES is a complex phenomenon often based on indicators of relationships to work occupational position or ranking , social class or status, and access to power. From a policy perspective as well as an etiological perspective, it is important to understand which of the components is critical—for instance, if education is found to be important, the policies that may be implemented would differ from the policies needed if income was found to be the most influential factor.


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In fact, most research has not tested such competing hypotheses directly, so in the examples that follow, these have not been disaggregated, although the indicators used in each study are explicitly identified. Several major studies have ascertained that education, income, and occupation, as indicators of SES, are associated with mortality and with mortality due to certain causes. Heart disease, the leading cause of death in the United States, provides a strong example of the association between SES and mortality. Research has documented the relationship between SES and cardiovascular disease NCHS, ; Kaplan and Keil, , and the British Whitehall longitudinal study of civil servants found that those in the lowest grades of employment were at the highest risk for heart disease Marmot et al.

A striking finding that emerges from analyses of occupation- and area-based income measures is the graded and continuous nature of the association between socioeconomic position and mortality, with differences persisting well into the middle socioeconomic ranges Davey Smith et al. For example, in the Whitehall studies Davey Smith et al. Age-adjusted death rates for white men and women ages 25 to 64 with 0 to 4 total years of education that were 66 and 44 percent higher, respectively, than those for men and women with 5 or more years of college.

Among African-American men and women ages 25 to 64, the corresponding increases in mortality were 73 and 78 percent, respectively.

Poor African-American women were 80 percent more likely to die than their wealthier counterparts. Although many of the studies that focused on occupation-, education-, or area-level SES showed a gradient that is virtually linear, studies that focus on income often show somewhat different results. This curvilinear relationship suggests diminishing returns of income as one approaches the highest income categories, although some association may persist. This curvilinear association between income and health is what lays the framework for findings that more egalitarian societies i.

Whether SES has a linear or curvilinear relationship with health has enormous implications for understanding both the etiologic associations and the policy implications of this research. The major reason for this is because there are groups in the moderate-risk categories of working poor and working class who contribute disproportionately large numbers to death rates and poor health outcomes.

SES is linked to health status through multiple pathways such as distribution of health care, psychosocial condition, toxic physical environments, and health-related behaviors , but these relationships have not yet been fully elucidated. It is also likely that some degree of reverse causation influences the strength of these associations.

Studies in which education rather than income or occupation is used as an indicator of SES are stronger in this regard since most people are not influenced by serious chronic diseases related to cardiovascular disease, stroke, or cancer in ways that inhibit their level of educational attainment in their adolescence and early twenties. Furthermore, although many studies have included a broad range of covariates in their multivariable analyses, it is of course possible that unobserved attributes account for some observed disparities.

There is ample evidence that SES is strongly related to access to and the quality of preventive care, ambulatory care, and high-technology procedures Kaplan and Keil, ; but health care appears to account for a small percentage of the variation in health status among different SES groups. It has been argued that differential access to health care programs and services is not entirely. Furthermore, similar gradients persist in countries with universal coverage, such as the United Kingdom.

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It has been proposed, and to some extent documented, that the gap in health status by SES may still be attributable to the effects of crowded and unsanitary housing, air and water pollution, environmental toxins, an inadequate food supply, poor working conditions, and other such deficits that have historically affected and that still disproportionately affect those in the lower socioeconomic strata USPHS, ; Williams, ; Adler et al. Studies that incorporate assessments of material deprivation and aspects of the physical environment will be important to explicate these important potential pathways.

Considerable evidence links low SES to adverse psychosocial conditions. People in lower socioeconomic positions are not only more materially disadvantaged, but also have higher levels of job and financial insecurity; experience more unemployment, work injuries, lack of control, and other social and environmental stressors; report fewer social supports; and more frequently, have a cynically hostile or fatalistic outlook Berkman and Syme, ; Karasek and Theorell, ; Adler et al. There is most often, especially in the United States, a striking and consistent association between SES and risk-related health behaviors such as cigarette smoking, physical inactivity, a less nutritious diet, and heavy alcohol consumption.

The social environment influences behavior by shaping norms: enforcing patterns of social control which can be health promoting or health damaging ; providing or denying opportunities to engage in particular behaviors; and reducing or producing stress, for which engaging in specific behaviors such as smoking might be an effective short-term coping strategy Berkman and Kawachi, Both physical and social environments place constraints on individual choice.

Over time, those with more economic and social resources have tended to adopt health-promoting behaviors and reduce risky behaviors at a faster rate than those with fewer economic resources. Socioeconomic disparities in health in the United States are large, are persistent, and appear to be increasing over recent decades, despite the general improvements in many health outcomes. The most advantaged American men and women experience levels of longevity that are the highest in the world.

However, less advantaged groups experience levels of health comparable to those of average men and women in developing nations of Africa and Asia or to Americans about half a century ago Berkman and Lochner, Furthermore, these wide disparities coupled with the large numbers of people in these least-advantaged groups contribute to the low overall health ranking of the United States among developed, industrialized nations. A major opportunity for us to improve the health of the U. A substantial body of research documents the relationship between racial and ethnic disparities and differences in health status.

Numerous studies have shown that minority populations may experience burdens of disease and health risk at disproportionate rates because of complex and poorly understood interactions among socioeconomic, psychosocial, behavioral, and health care-related factors NCHS, ; DHHS, ; IOM, Although Americans in general experienced substantial improvements in life expectancy at all ages throughout the twentieth century, substantial gaps in life expectancy, morbidity, and functional status remain between white and minority populations.

Life expectancy at birth for African Americans in was the same as that for whites in Even after controlling for income, African-American men and women have lower life expectancies than white men and women at every income level for example, see Geronimus et al.

Background

When indicators of SES are considered, these differences, which are often substantial across a diversity of health outcomes, are commonly reduced but remain significant. Few studies have adequately controlled for SES in terms of the inclusion of economic indicators of wealth, homeownership, or other sources of income. Although these indicators should be included, they are unlikely to reduce disparities between African Americans and whites because data suggest that there are even greater disparities in wealth all assets than in household income between these two groups Ostrove et al.

This phenomenon has led researchers to investigate the health effects of discrimination itself. Aspects of discrimination might influence health through any number of mechanisms, including SES. However, conceptualizing discrimination whether it applies to racial or ethnic minori. The acknowledgment of disparities itself may generalize or aggregate groups that are highly heterogeneous because of variations ranging from the date of immigration and level of acculturation to genetic, social, and cultural differences Williams and Collins, ; Korenbrot and Moss, African Americans and other minority populations experience worse health from infancy to old age.

Although the national infant mortality rate has decreased over the years to about 7 per 1,, the rate among African-American infants is nearly twice as high, 14 per 1,, and that among American Indians is 9. Rates of illness such as asthma are much higher among African Americans than among whites, as are levels of obesity, diabetes, and other cardiovascular risk factors that are often established in adolescence and young adulthood. For example, the prevalence of obesity among African Americans is In , the rate of diabetes-related mortality in non-Hispanic African Americans was Some of the racial and ethnic differences in health status may be associated with the fact that minority populations often encounter the health care system in very different ways in terms of both access and quality of care Fiscella et al.

For a variety of reasons—both structural having to do with the health care system itself and financial or cultural—racial and ethnic minorities encounter barriers to health care that often result in less than optimal care and worse outcomes Carlisle et al. For example, many studies have concluded that African-American patients are significantly less likely than white patients to receive certain revascularization procedures to treat coronary artery disease Epstein and Ayanian, Barriers to care may include linguistic differences, a lack of insurance or difficulties with payment, immigration status, social issues such as trust and some pervasive but subtle forms of racism and discrimination, and even logistical problems related to distance and transportation Thomas, ; IOM, African-American and Hispanic children are more likely to.

Recent research indicates that disparities in access persist even after controlling for socioeconomic circumstances and health insurance coverage status Roetzheim et al. Among other disparities in health care, African Americans have been shown to be less likely to receive certain diagnostic testing; adequate pain medication; early-stage diagnoses of cancer; dialysis as initial treatment for end-stage renal disease, placement on a kidney transplant waiting list, or a kidney transplant; and preventive rather than acute asthma control measures IOM, Hispanics are also likely to experience similarly unequal access to health care services IOM, This is in the context of the fact that HIV infection is spreading more rapidly among African Americans and Hispanics than among whites.

Although many studies indicate that certain racial differences in health persist among people of similar SES, it is also true that many minority groups are likely to be poorer and more disadvantaged than whites. In terms of the association between poverty and minority status, in , for instance, 10 percent of non-Hispanic white children lived in poverty, whereas When health outcomes are examined by level of education of the mother, family income, and ethnicity and race, enormous differences emerge between the least-advantaged African-American children and the most advantaged white children.

For instance, among African-American children living below the poverty line, 22 percent have elevated blood lead levels, whereas 6 percent of African-American children in high-income families and slightly more than 2 percent of white children in high-income families have elevated blood lead levels. These patterns are persistent and are seen for other outcomes such as low birth weight and hospitalizations for asthma NCHS, Such pronounced disparities have led to a presidential initiative targeted at ethnic and racial health disparities in six specific areas White House, ; Office of Minority Health, The association between social connectedness and health has received much attention in recent years.

Concepts of social connectedness relate to. Social connectedness may be conceptualized as a societal characteristic related to civic trust and social capital. This area-level experience is discussed in a later section. This section reviews the evidence that the structure of social ties is related to health outcomes and discusses pathways that may link such social experiences to health. People form ties to others the moment they are born.

The survival of newborns depends upon their attachment to and nurturance by others over an extended period of time Baumeister and Leary, The need to belong does not stop in infancy, but rather, affiliation and nurturing social relationships are essential for physical and psychological well-being throughout life.

Over the past 20 years, 13 large prospective cohort studies in the United States, Scandinavia, and Japan have shown that people who are isolated or disconnected from others are at increased risk of dying prematurely from various causes, including heart disease, cerebrovascular disease, cancer, and respiratory and gastrointestinal conditions Berkman and Syme, ; Blazer, ; House et al. Studies of large cohorts of people enrolled in health maintenance organizations or occupational cohorts also report that social integration is critical to survival, although it may not be as critical an influence on the onset of disease Vogt et al.

Powerful epidemiological evidence supports the notion that social support, especially intimate ties and the emotional support provided by them, is associated with increased survival and a better prognosis among people with serious cardiovascular disease Orth-Gomer et al. The lack of social support, expressed in terms of conflict or loss of intimate ties, is also associated with health outcomes and risk factors such as neuroendocrine changes in women Kiecolt-Glaser et al. Caregivers of relatives with progressive dementia are characterized by impaired wound healing Kiecolt-Glaser et al.

Social conflicts have been shown to increase susceptibility to infection Cohen et al. Several studies have recently shown that older men and women with high levels of social engagement and networks have slower rates of cognitive decline Bassuk et al. The pathways by which social networks might influence health are multiple and include. For instance, evidence suggests that, in general, social network size or connectedness is inversely related to risk-related behaviors.

People who are socially isolated are more likely to engage in such behaviors as tobacco and alcohol consumption, to be physically inactive, and to be overweight Berkman and Glass, Behavioral pathways such as these do not appear to account for a large part of the association between social isolation and poor health, but they are important to consider. It is important to note that networks themselves have generally been shown to exert powerful influences on the behavior of both adolescents and adults, so that networks can either promote health or increase risk depending on the norms of the networks themselves.

Experimental work with animals and humans indicates that social isolation can have a direct effect on physiologic function and subsequent diseases. Animals that are isolated in adulthood, that experience maternal separation, or that are not nurtured in infancy develop more atherosclerosis; have poor, inefficient, or exaggerated neuroendocrine responses; and may have higher levels of immunosuppression Nerem, ; Shively et al. Among humans and primates, those who lack affiliation and strong social networks have been shown to be more likely to develop colds, have stronger stress responses in terms of neuroendocrine reactions and higher levels of cardiovascular reactivity, and have altered immune responses Glaser et al.

There is limited research on whether access to material goods and resources is a mechanism through which social networks might influence health, and this is an important area for investigation. We do know, however, that networks have the capacity to provide informational and instrumental support effectively. Although much of the research in this area examines the effects of close relationships and social support, there is also evidence that weak social ties may also have indirect positive effects on health and well-being.

For instance, a classic investigation of how people find jobs suggests that weak ties to others may be more helpful in enabling people to find jobs, providing access to one of the most critical life opportunities. Instrumental and informational support, two critical components of the support paradigm, relate to help with practical matters such as grocery shopping; rides to the doctor; and information about health care, behavior, and risk.

Finally, many of the observational data linking social connectedness to health. More experimental work is needed to answer these questions completely. Much of the experimental work cited here supports the concept that social isolation increases the risk for poor health. However, a recent clinical trial, Enhancing Recovery in Coronary Heart Disease, aimed at improving social support to reduce mortality and reinfarction among subjects after myocardial infarction, found no effect NIH, Developing both clinical and population-based experimental studies is the next step in this work.

A large body of evidence accumulated over the last two decades consistently points to the importance of social connectedness, and incorporation of this evidence would involve the inclusion of nurturing community and social networks. As we think of broad social determinants of health that could be influenced to improve health, social connections may be one example that has the support of a number of sectors. Because social relationships influence health through such a myriad of pathways, broad health improvements may be facilitated by considering and enacting policies that support social connections.

Two decades of research show that the workplace not only generates adverse health effects due to economic circumstances such as downsizing and unemployment or to work conditions such as job demands, control, latitude, and threatened job loss Karasek and Theorell, , but also generates protective health effects such as social ties that may help counteract the physical and mental adverse effects of work stressors Buunk and Verhoeven, It has been hypothesized that job strain the combination of a psychologically demanding workplace and a low level of job control leads to adverse health outcomes, and findings show that job control is an important component of health-promoting work environments Johnson et al.

Schnall and colleagues found that lower levels of job control the opportunity to use and develop skills and to exert authority over workplace decisions were predictive of adverse cardiovascular disease outcomes in 17 of 25 studies, whereas high psychological demands of work had similarly negative effects in only 8 of 23 studies. European researchers and, to a somewhat more limited extent, U. Although longitudinal studies of European populations have demonstrated a significant relationship between unemployment and higher standardized mortality ratios SMRs , even after adjusting for age and social status Moser et al.

National Longitudinal Mortality Study Sorlie and Rogot, have shown no significant association between age, education, and income-adjusted SMRs and unemployment for either men or women. However, other U. Analysis of panel data from the U. Epidemiologic Catchment Area study suggested that the 1-year incidence of clinically significant alcohol abuse was greater among those who had been laid off than among those who had not Catalano et al.

Examination of cases of job loss due to factory closures is important because worker characteristics in such cases have no effect on the loss of jobs. Morris and Cook reviewed longitudinal studies of factory closures and found that the job loss experience exerts a negative effect on physical health. The impact of threatened job loss has received increased attention recently.

European studies found negative effects on health because of threatened job loss or organizational change, although there were no significant differential trends in weight, blood pressure, or blood glucose over time. Longitudinal data on male Swedish shipyard workers threatened with job loss and on stably employed controls Mattiasson et al.

In a study of Finnish government workers Vahtera et al. Among American automobile workers Heaney et al. However, workers who remain in an organization after a downsizing do not experience a decline in well-being, despite an increase in work demands Parker et al. Contrary to work conditions related to involuntary job loss, retirement does not appear to have negative health consequences Moen, ; Kasl and Jones, Social characteristics of individuals are closely related to health.

Among the most important findings to emerge from public health research over recent years is the extent to which characteristics of areas exert independent effects on health. This ecological 4 approach has been rediscovered and is now embedded in a multilevel framework. The major idea is that characteristics of places—neighborhoods, schools, work sites, and even nations— carry with them health risks for the individuals who live in those environments. The health risk conferred by these places is above and beyond the risk that individuals carry with them.

Thus, we might view characteristics of physical environments e. In this section, the committee reviews evidence related to two aspects of places—economic inequality and social capital— that are assessed at an ecological level to examine their effects on health. These findings are relatively new and undoubtedly will be refined with further research. Economic inequality may exert an effect on health in addition to the effect of individual income on health.

Such an effect may be particularly robust for people in the United States who are at the lower ends of the distribution. The United States is among the richest countries in the world, yet it is also one of the most and increasingly unequal in terms of the distribution of its wealth as measured by a wide and growing gap between the best-off and the worst-off quintiles Weinberg, ; Jencks, see Box 2—2. At a national level, the hypothesis linking income inequalities and health would predict that two countries with the same average income but different income distributions would experience different patterns of mortality, with the country with the more even distribution having a longer life expectancy overall.

Cross-national studies initially supported an association between income equality and population longevity, but more recent research, which includes newer and more accurate data for more countries, suggests that the area-level effects of inequality across nations may not hold over time Lynch et al. Recent studies have shown the cross-national correlation between economic inequality and mortality to be very weak or virtually nonexistent Kunst et al.

Furthermore, in several countries Canada, for example , inequalities at the level of provinces or neighborhoods within cities often have been found to be not significant in terms of health status. In the United. In , the wealthiest 20 percent of U. In , the poverty rate was States, however, data are more consistent in supporting the area-level effect of inequality net of individual effect. For example, Kaplan and colleagues and Kennedy and colleagues independently found that the degree of household income inequality in the 50 states was associated with the state-level variation in total mortality, as well as with the state-level variations in infant mortality and rates of death from coronary heart disease, cancer, and homicide.

The findings persisted after controlling for urban—rural proportion and for health behavior variables such as cigarette smoking rates. Lynch and colleagues observed a relationship between income inequality and mortality at the level of U. There is also evidence of a contextual effect of income inequality directly on individual health Wilkinson, ; Kennedy et al. Kennedy and colleagues reported that people residing in states with the greatest income inequality were 1. The effect of income inequality was statistically significant and independent of absolute income levels.

These findings pose the challenge of explaining why the effects of inequality are more significant and conclusive in the United States than in other developed nations. Some Kawachi and Kennedy, have argued that inequality is associated with a lack of investment in education, devel-. Some countries buffer the effects of inequality with stronger social service programs.

Investigators have argued that U. These questions remain challenges to a new field. No one has disputed the strong and consistent effects of SES on individual health. New research on area-level efforts related to neighborhoods, work sites, and states and even across countries poses considerable methodological challenges Deaton, Nonetheless, such research holds great potential to help us understand the ways in which both the social and the physical built and natural environments may affect health and behavior. Social participation and integration can also be conceived of as both individual and societal characteristics Kawachi and Kennedy, Some investigators have started to conceptualize these dimensions at an ecological or group level.

This has led investigators to examine the area-level effects of these domains. Particular interest has been focused on the relationship between social capital and health. At a group level, more socially integrated societies seem to have lower rates of crime, suicide, and mortality from all causes and a better overall quality of life Wilkinson, ; Kawachi and Kennedy, ; Kawachi and Berkman, Kawachi and colleagues analyzed social capital indicators across the United States in relation to state-level death rates.

The per capita density of membership in voluntary groups was inversely correlated with age-adjusted mortality from all causes. Density of civic association, group membership, and levels of interpersonal trust i. Kawachi and colleagues also carried out a multilevel study of the relationship between the above indicators of state-level social capital and individual self-rated health. A strength of this study was the availability of information on individual medical and behavioral confounding variables, including health insurance coverage, cigarette smoking, and being overweight, and on sociodemographic characteristics, such as household in.

Even after adjustment for these variables, people residing in states with low levels of social capital were more likely to report fair or poor health. The odds ratio for fair or poor health in association with living in areas with the lowest levels of interpersonal trust as opposed to the highest levels of interpersonal trust was 1. There are several plausible mechanisms by which social cohesion might influence health through contextual effects.

At the neighborhood level, social capital might influence health behaviors by promoting the more rapid diffusion of health information. Neighborhood social capital also could affect health by increasing access to local services and amenities Sampson et al. Finally, neighborhood social capital could influence health through direct psychosocial pathways by providing social support and acting as the source of self-esteem and mutual respect.

Although there has been a great deal of interest in these area-level studies of social capital, there has also been a fair amount of skepticism regarding their validity. Several social scientists Portes and Landolt, ; Sandefur and Laumann, ; Durlauf, have voiced concerns about the ambiguity of the concept, the potential for social capital to lead to undesirable outcomes related to the exclusion of certain groups, and insufficient attention to the determinants of social capital itself or the causal patterning between it and other social conditions.

Future studies will be strengthened with the addition of items tapping the conceptual richness of the domain of social capital and the capacity to distinguish it from other closely related constructs of social networks and SES. The evidence presented and discussed in this chapter aims to demonstrate that taking into account the environmental and social determinants of health is essential to creating effective population-level interventions for health improvement.

There have been few empirical tests of population-based approaches to health promotion that focused on risk-related social conditions, but in an effort to understand how such approaches might work, several examples are presented to illustrate the effectiveness and efficiency e. Preventive interventions at the population level may be classified as universal, selective, and indicated, borrowing the classification developed by Gordon IOM, b.

A universal measure is one that would be desirable for everyone in an eligible population. It would focus on shifting the entire population distribution rather than on targeting only relatively high-risk individuals, as illustrated earlier in this chapter. It would likely involve an agreed-on public policy requiring broad-based public understanding and political support.

A selective preventive measure is one that is desirable only when an individual is a member of a subgroup of the population whose risk of becoming ill is above average. These are the more traditional population-oriented public health education interventions targeted toward the high-risk segments of the population. Finally, an indicated preventive measure is one that is applicable to persons who, on examination, manifest a risk factor, condition, or abnormality that identifies them individually as being at high risk for the future development of a disease. This type of intervention, usually provided in the context of clinical practice, deals only with individuals diagnosed with a disease, not with the nameless statistical subset of a population as in selective preventive measures.

For example, a universal preventive measure for heart disease could include the provision of general advice to consume a diet low in fat accompanied by a regulatory policy requiring food labeling. A selective intervention could include a program focusing on diet and behavioral changes for overweight individuals who do not exercise regularly, and an indicated preventive measure might include antihypertensive medication for those diagnosed as hypertensive.

Although many studies have looked at the effectiveness of preventive measures, few have studied universal, population-level strategies. In some cases, however, such as tobacco use prevention and automobile-related injury prevention population-based strategies e. Acting on the most upstream level of determinants of health typically means the level of national policy. This may help shift national norms and values that lead to the passage, adoption, and ultimately, success of the respective legislation, as in the case of seat belt legislation, which has steadily and gradually normalized this behavior across America, or tobacco policy, which has curbed the use of tobacco e.

Alternately, upstream policy interventions may also refer to modifying the broader, social determinants of health such as income e. Policy making at the national, state, and local levels has the potential to positively shape population health by addressing specific elements of the determinants of health, such as inadequate housing, unavailability of family-friendly social and work policies, lack of public transportation, lack of safe public spaces, and so forth.

The health consequences of contaminated water and leaded gasoline have been well elaborated. It is now time to determine their social equivalents—elements of the social environment that influence health status—and take action to shape them in support of population health. Such action may focus not only on education, decent housing, and a living wage but also on the political choices that move the broad social and other determinants of health in a positive direction.

For example, certain health care disparities e. Federal legislation has been an important strategy in reducing motor vehicle injuries IOM, Between and , highway safety acts authorized the federal government to set safety standards for new vehicles and equipment e. A number of early studies found seat belts to be cost-effective Warner, A more recent report outlines the benefits of safety belts based on medical and financial information from the Crash Outcome Data Evaluation System. A report to Congress revealed that safety belts are highly effective in reducing morbidity and mortality and in decreasing the severity of injuries e.

Other evidence suggests smaller, although still significant, differences between injuries experienced by belted and unbelted accident victims. Although there are ethnic differences in seat belt use, rates of seat belt use are higher in states that implement and enforce restraint laws Davis et al. Seat belt laws have had a significant impact on modifying behavior and thus decreasing risk and improving health outcomes across the population. Such strong effects for any single piece of legislation illustrate that this orientation can be effective.

A meta-analysis of research regarding the effectiveness of interventions to. The benefit—cost ratio per quality-adjusted life year showed that all three interventions offered net cost savings Miller, The case of seat belt legislation demonstrates that such upstream or population-level measures aiming to prevent disease and disability may be effective in transforming social norms and ultimately changing behavior. Tobacco prevention and cessation efforts have offered many lessons about the links between behavior and disease and how to intervene effectively to improve population health.

Effective antismoking campaigns are generally comprehensive, multidimensional interventions involving several aspects of prevention and control.


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One of the most important lessons learned from the tobacco experience is that the social context or social environment serves as a potent force in shaping smoking behavior. School-based antismoking interventions constitute an effective prevention strategy, although one that is resource intensive and thus not sufficiently accessible , given the state-of-the-art programs needed to assure success DHHS, ; Warner, The Growing Up Tobacco Free report IOM, a has detailed three categories of tobacco prevention strategies: information dissemination approaches, effective education approaches, and social influence approaches.

According to that report, the former two strategies fail to address the relationship between the acquisition of knowledge and behavior and the addictive nature of tobacco, nor do they address the social context in which smoking occurs, which often involves peer pressure and norms about use. The third strategy the social influence approach was developed to address the deficiencies of earlier strategies, and in a meta-analysis of adolescent drug use prevention.

Multiple levels of influence and multiple determinants affect the uptake of smoking, from individual characteristics and behaviors to population-level advertising and availability. Also, as noted earlier in the context of generic population health improvement, upstream approaches, including action at the community or population level, may be more cost-effective than downstream approaches directed at specific individuals Corbett, Such measures, it seems, make use of the characteristics of social networks and relationships that may be used as elements to further protect health.

Although recognizing the importance of approaches that go beyond individuals and their behavior, use of a social influences strategy may not work well if it is used alone, as in the case of the Hutchinson Smoking Prevention Project, a long-term randomized trial that used a school-based social influences approach and concluded that it lacked long-term effectiveness to deter smoking Peterson et al.

According to Warner , success is more likely when a broad array of multisectoral, multilevel, upstream interventions is used. Such upstream measures include taxation of cigarettes, which appears to affect tobacco consumption among youth and adults and both the initiation and the cessation of tobacco-smoking Chaloupka et al. It also appears to have a more powerful impact among lower-income groups than higher-income groups, an important concept because most of the educational interventions are believed to be more effective among more highly educated groups Evans and Farelly, ; Warner, Overall, on average it appears that an approximately 10 percent increase in the price of cigarettes will produce a 4 percent reduction in demand.

Policies based on taxation have the potential to have a significant impact on smoking rates nationwide Warner, , although the effectiveness of taxation on teenagers becomes somewhat attenuated in adulthood, underscoring the need for interventions on several fronts Glied, An added benefit of tax increases is the production of revenue while the level of consumption declines. Cigarette taxation is an excellent example of a cost-effective preventive strategy aimed at the entire population.

It is serving to broaden the face of policy interventions in public health, leading to consideration of taxation in relation to alcohol consumption, unhealthy diets, and even gun control. Old Password. New Password. Password Changed Successfully Your password has been changed. Returning user. Forget yout Password? If the address matches an existing account you will receive an email with instructions to reset your password Close.

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