Reminder for FCM: 5th Long Exam on Feb. 09, 2013 (Saturday) 10:00am Topics are: 1. Alcohol 2.

Basic Principles of Exercise 3. Nutrition 4. Family wellness 5. Biostat2 6. Intro to EBM 7. Intro to Epidemiology 8. Population At Risk HEALTH EFFECTS OF ALCOHOL Ethyl Alcohol (CH3CH2OH)

Ethanol in: Lite Beer Beer Wine Flavored Liquors Distilled Liquors

2.5 - 3.5% 4.0 - 6.0% 10 - 18 % 15 - 25% 22 - 50% Proof is double %

One drink equals: 12 ounces beer 5 ounces wine 1.5 ounces distilled liquor 70 kg person metabolizes approximately one drink/hour 7 calories per gram vs. fat @ 9 calories/gm Alcohol Dependence Craving: A strong need, or compulsion, to drink Loss of control: The inability to limit ones drinking on any given occasion Physical dependence: Withdrawal symptoms occur when alcohol use is stopped after a period of heavy drinking Tolerance: The need to drink greater amounts of alcohol in order to get high. Alcohol and Alcoholism Alcoholism Addiction to alcohol or abuse of alcohol to a degree that produces problems in one or more of these areas: Health Social relationships Economic status Interpersonal relationships Phases of alcoholism Problem drinking Drinks to relieve stress Abstinence does not cause physical symptoms Alcohol addiction Abstinence produces physical symptoms Acute Effects CNS Depressant Depression of inhibitory control Vasodilation, warm, flushed, reddish skin Emotional outbursts Decreased memory & concentration Poor judgment Decreased reflexes Decreased sexual response

Absorption Rapidly absorbed from stomach, small intestine, and colon Maximal blood concentration within 30 to 90 minutes Can be absorbed through the lungs Distribution Uniformly distributed throughout tissues and body fluids Readily crosses placenta, to exposure fetus Elimination Urinary Excretion Exhalation Metabolism Metabolism I

(ADH Alcohol Dehydrogenase) Metabolism II

(ALDH Acetaldehyde Dehydrogenase) Metabolism III Acetate Acetyl-CoA Carbon dioxide and water

Acute Alcohol Effects Hangover Mild withdrawal with volume depletion (due to increased diuresis) Treatment Fluids Paracetamol for headache Stupor-Coma

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Acute overdose Coma Depressed respirations Hypotension Hypothermia Hypoglycemia Inhibition of protein to sugar conversion in liver (gluconeogenesis) Trauma Drunks fall down and hit their heads. Concussion Subdural hematoma Mixed drug overdose Tranquilizers Barbiturates Anti-depressants Worsening of other problems Peptic ulcer disease Liver disease Pancreatic disease Heart disease (decreased pump strength) Long Term Adverse Effects Obvious Alcoholism, death, cancer (oral cavity, esophagus, liver), fetal effects (FAS) Alcoholism Cirrhosis of liver, appetite loss, poor judgment Subtle Lost productivity, impaired performance, motor impairment, cost to society Alcoholism - Disulfiram Alcoholism Treatment with Disulfiram Inhibits acetaldehyde dehydrogenase (ALDH) Exposure to EtOH while taking causes sudden, severe vasodilation: Hot, flushed face Dizziness Pounding heart, hypotension Nausea, vomiting Headache Associated Medical Problems Hepatic cirrhosis Ascites Jaundice Palmar erythema Spider angiomata, Caput medusa Gynecomastia (males) Effects Impaired glucose metabolism, hypoglycemia Portal hypertension, esophageal varices Coagulopathies Hepatic encephalopathy Pancreatitis Nausea, vomiting

Severe upper abdominal pain radiating to back Hypovolemic shock Secondary diabetes Pancreatic necrosis and hemorrhage

Wernickes encephalopathy Ocular disturbances Changes in mental state Unsteady stance and gait Korsakoffs syndrome Anterograde amnesia Apathy Aphasia, apraxia or agnosia Nutritional deficiencies Beriberi Paresthesias, burning of feet Cardiovascular failure Peripheral vasodilation Biventricular myocardial failure Na+ and water retention

Fetal Alcohol Syndrome (FAS) Most common preventable cause of adverse CNS development 4,000-12,000 infants per year in US Characteristics Growth retardation Facial malformations Small head Greatly reduce intelligence Milder form of FAS 7,000-36,000 infants per year in US Characteristics Growth deficiency Learning dysfunction Nervous systems disabilities

Alcohol & Cancer Ethanol consumption increases risk of cancer Oral Cavity Pharynx and Larynx Esophagus Liver Alcohol Withdrawal Effects Tremor Nausea Irritability Agitation Tachycardia Hypertension Seizures Hallucinations

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Basic Principles of Exercise

Exercise stressor Why do we exercise? 1. Controls weight 2. Combats health conditions and diseases 3. Improves mood 4. Boosts energy 5. Promotes better sleep 6. Improves sex life

What happens to the body when we exercise?

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Exercise Prescription

How do I know whether I am doing aerobic or anaerobic exercise? Heart Rate Monitoring 1. Compute your maximum heart rate. 220 age = MHR 2. Determine your training ranges. warm-up/cool-down: <60% of MHR aerobic exercise: 60-85% of MHR anaerobic exercise: >85% of MHR MHR = warm-up = aerobic = anaerobic = Aerobic vs Anaerobic Exercise Aerobic Exercise -running Anaerobic Exercise -weight lifting Exercise Prescription 1. Determine the level of fitness of your patient. 2. Determine goals for your patient. 3. Determine training ranges. 4. Advice.

Types of Exercise Anaerobic intense exercise strength and speed does not need oxygen aerobic endurance needs oxygen

Introduction to Nutrition Compute your Body Mass Index: BMI = weight (kg) Height (m)2 Computing for degree of obesity Underweight <18.5 Normal 18.5-22.9 Overweight 23-24.9 Obese I 25-29.9 Obese II >30

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Six major nutrients in food 1. Carbohydrates Provision of energy 2. Fats 3. Proteins growth and development 4. Vitamins Regulate metabolism 5. Minerals 6. Water Essential Nutrients Nutrients that the body needs but cannot produce in adequate quantities Must be obtained from the food we eat NUTRIENTS ESSENTIAL OR PROBABLY ESSENTIALS TO HUMANS GETTING THE WAIST CIRCUMFERENCE AND THE WAIST TO HIP RATIO [WHR] Men waist circumference > 90 cm WHR = > 1 Women waist circumference > 80 cm WHR > 0.85 CARBOHYDRATES Fiber PROTEINS Histidine Leucine Methionine Threonine Valine VITAMINS Thiamine Niacin Pantothenic Acid Folate C MINERALS Calcium Magnesium Potassium Sulfur VITAMINS A D E K MINERALS Boron Cobalt Fluorine Iron Molybdenum Selenium Vanadium WATER

Isoleucine Lysine Phenylalanine Tryptophan

Riboflavin Pyridoxine Biotin Cyanocobalamin

Chloride Phosphorus Sodium

What is nutrition? Sum total of processes: intake and utilization of food substances by living organisms Ingestion Digestion Absorption Transport Metabolism The Role of Nutrition in Health Promotion What you eat plays an important role in the development or progression of a variety of chronic diseases: Coronary artery disease Diabetes High blood pressure Osteoporosis Obesity Cancers

Chromium Copper Iodine Manganese Nickel Silicon Zinc

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Nutrients Macronutrients Carbohydrates (4 kcal/g) Proteins (4 kcal/g) Fats (9 kcal/g) Micronutrients Vitamins (13) Minerals (~ 25) Chemical Content of Nutrients Inorganic Nutrients Water Minerals Organic Nutrients Carbohydrates Proteins Lipids (fats) Vitamins Carbohydrates main sources of energy 40-80% of the total energy intake Glycemic Index how much of a rise in circulating blood sugar a carbohydrate triggers the higher the number, the greater the blood sugar response. HIGH = 70 or more MEDIUM = 56 69 LOW = 55 or less Brown.55 Long grain, White.44 Short grain, White.72 Glutinous (Sticky).98 All bran with fiber .38 Oatmeal 43 Raisin bran ..61 Cheerios ..74 Rice krispies 82 Corn flakes 92 Spaghetti, whole wheat..37 Fettuccini ...32 Spiral Pasta43 Linguine..46 Macaroni.47 Rice vermicelli 58 Glycemic Load The glycemic load (GL) combines quality and quantity of carbs in one number. The carbohydrate in watermelon, for example, has a high GI. But there isn't a lot of it, so watermelon's glycemic load is relatively low. HIGH GL MEDIUM GL LOW GL 20 + 11-19 10 or less

Carbohydrates Sugars Monosaccharides- glucose, galactose, and fructose Disaccharides- sucrose (table sugar), maltose and lactose (milk sugar) Complex carbohydrates (polysacharides) Starches are polymers of glucose Dietary fibers are mainly indigestible complex carbohydrates in plant cell walls such as cellulose, pectins and gums

Dietary Fiber provides bulk modulation of peristalsis and the prevention of constipation soften the stool and hence promote normal elimination may also increase satiety Soluble fibers cholesterol-lowering effects increases fecal excretion of bile acids reduces cholesterol formation in the liver increase production of short-chain fatty acids by fermentation in the large intestine Insoluble fibers found in vegetables, whole wheat grain, and wheat and corn bran increases bulk in the gastrointestinal tract promotes gastrointestinal motility Fats Lipids: water-insoluble include triglycerides (the main constituent of fats and oils) and sterols such as cholesterol HDL good cholesterol LDL bad cholesterol

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Proteins constitute the major part of the body's building blocks function as enzymes and hormones 12% of dietary calories in the Filipino diet one third: animal sources such as fish, poultry, meat, eggs and milk rest comes from rice, corn, bread and other plant sources Protein from animal sources better than from plant sources Beans, legumes like mongo and other dried beans including soy beans: cheap meat substitutes Vitamins Fat-soluble Vitamins A, D, E, and K Water-soluble ascorbic acid and the B-complex vitamins

*subnotes The amount of a vitamin in any specific food depends on two main factors: the amount originally present in the food and the amount of the vitamin that is destroyed or lost during harvesting of plants or slaughtering of animals, and subsequent storage, processing, and cooking. In general, vitamin losses are greater at higher temperatures, prolonged exposure to sunshine and air, and increased length of storage. Dietary deficiencies are rare in people who eat wellbalanced diets and are usually associated with diets that have an over-reliance on a restricted range of foods, often with little or no fresh fruits and vegetables. Minerals macro-minerals (e.g. calcium and phosphorus which account for 0.05% or more of total body weight) micro-minerals (e.g. iron and iodine which account for much less than 0.05% of body weight) *subnotes Minerals are involved in a wide variety of biochemical processes within the body. A large variety of essential compounds in the body include mineral atoms or ions as part of their structure. A few of the key roles are summarized below for quick reference.

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1 cup of milk or yogurt 1 ounces of cheese Meat, poultry, fish, dry beans, eggs, and nuts 2-3 ounces of cooked meat, poultry, fish cup of cooked beans 1 egg 2 tablespoons of peanut butter Bread, cereal, rice and pasta 1 slice of bread 1 ounce ready-to-eat cereal cup cooked cereal, rice, pasta Vegetable 1 cup raw leafy vegetables cup cooked cup vegetable juice Fruit 1 medium banana, apple, orange cup chopped, cooked or canned fruit cup fruit juice Fats, oils and sweets No serving size Dietary Reference Intakes Recommended nutrient intake (RENI) The average amount of a nutrient considered adequate to meet the known nutrient needs Adequate Intake (AI) based on observed or experimentally determined approximations of nutrient intake by a group of healthy people Tolerable Upper Intake Level (UL) highest level of daily nutrient intake that is likely to pose no risks of adverse health effect to most individuals in the general population Recommended Diet Composition Carbohydrates 55 - 60 % Fruits, vegetables, grains Lipids 20-30 % < 10% should be saturated fats Proteins 10-15 % Meat and meat products *subnotes The RDAs do not provide the additional nutrients required by persons afflicted with diseases, traumatic stresses or nutrient inadequacies. The recommended amounts depend on one's body size, age, sex, physiological state and level of physical activity. Milk, yogurt, cheese

*subnotes Because minerals are essentially just atoms or ions, they cannot be synthesized in they body. So all of the minerals have to be derived from food or water.

Water most essential of all the nutrients regulates temperature transports electrolytes and other nutrients excrete waste products from the lungs, skin and kidneys lubricate joints cushion the nervous system Water (fluid) requirement 110 ml/kg for infants (3 glasses) 25 ml/kg body weight for adults (6-8 glasses) A balanced diet is one that contains all the nutrients and other substances found naturally in food, in proper amounts and proportions needed by the body to function well. Eating a diet that includes a wide variety of foods in the right amounts chosen from different food groups helps individuals to meet the RDA.

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Prescribing Diets 1. Estimate the desirable body weight (DBW) Males: DBW 5 feet is 106 lbs. Add 6 lbs for every inch above 5 feet Females: DBW 5 feet is 100 lbs. Add 5 lbs for every inch above 5 feet Tannhausers method = [ Ht in cm 100] 10 % 2. Determine the total energy allowance (TEA) of the individual by multiplying his DBW with the following values, according to activity Activity kcal/kg DBW/day Bed rest but mobile (hospital patients) 27.5 Sedentary (mostly sitting) 30 Light (tailor, nurse, physician, jeepney driver) 35 Moderate (carpenter, painter, heavy housework 40 Very active (swimming, lumberman) 45 3. Determine the carbohydrates (CHO), proteins (PRO) and fat by percentage distribution Carbohydrates 55-70% TEA Proteins 10-15% TEA Fats 20-30% TEA

Select fortified foods, whenever possible especially those with Sangkap Pinoy seal Read food labels to make healthier choices Take nutritional supplements only upon expert advice Take care of the increased nutritional needs of adolescents by giving adequate and varied meals to get them ready for adulthood

2. Breast-feed infants exclusively from birth to 4 to 6 months, and then give appropriate foods while continuing breast-feeding Infants and children up to 2 years of age are most vulnerable to malnutrition Breastfeeding is one of the most effective strategies to improve child survival Nutritional requirements of an infant can be obtained solely from breast milk for the first six months of life At the sixth month of life at the latest, breast milk must be complemented with appropriate foods, and breastfeeding should be continued for up to two year of age. 3. Maintain children's normal growth through proper diet and monitor their growth regularly Include milk in the child's daily diet or incorporate milk in other foods Use fortified foods Provide nutritious meals and snacks Continue feeding a sick child appropriately Encourage nutrient supplementation when necessary Take care of the increased nutritional needs of adolescents by giving adequate and varied meals to prepare them for adulthood 4. Consume fish, lean meat, poultry or dried beans not only enhance the protein quality of the diet but also supply highly absorbable iron, preformed vitamin A and zinc Fish, lean meat, poultry without skin and dried beans, in contrast to fatty meats, are low saturated fats, which are linked to heart disease. 5. Eat more vegetables, fruits and root crops Encourage consumption of at least two to three servings of vegetables each day Advise intake of two servings of fruit daily, of which one serving is a vitamin C-rich fruit Include root crops in your meals at least three times a week

Calculate the number of grams of CHO, PRO and FAT by dividing the equivalent grams per calories for each nutrient Carbohydrates 4 Cal/g Proteins 4 Cal/g Fats 9 Cal/g For simplicity and practicality of the diet prescription, round off calories to the nearest 50, and carbohydrates, proteins and fats to the nearest 5 grams 5. Design a practical meal pattern by consulting the patient, taking into consideration patients food habits, food behavior and preferences Example: 1. Make a diet prescription for a 5 foot female secretary. Assume CHO 65%, PRO 15% and FAT 20% The 10 Nutritional Guidelines for Filipinos 1. Eat a variety of foods everyday The human body needs more than 40 different nutrients for good health. No single food can provide all the nutrients in the amounts needed To achieve good nutrition: Plan and consume a balanced diet from a variety of foods Eat the recommended amounts of food from each food group Pay particular attention to the increased food needs during pregnancy and lactation If you eat convenience foods, choose those with higher nutritional value and observe the principle of variety To achieve good nutrition:

4.

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6. Eat foods cooked in edible/cooking oil in your daily meals To increase energy intake of the diet, include some foods cooked in edible/cooking oil daily If you are at risk of heart disease, limit your intake of cholesterol, saturated fats and fatty meats *subnote In general, Filipinos use very little oil in their cooking. Boiling is the most common method of food preparation. Hence, the total fat and oil consumption in a Filipino diet is low. Fats and oils are concentrated sources of energy. A low-fat and oil consumption results in a diet low in energy value, contributing to chronic energy deficiency. Fats and oils are also essential for absorption and utilization of fat-soluble vitamins such as vitamin A, D, E, and K. A low fat intake may be one of the causes of vitamin A deficiency among Filipinos. To ensure adequate fat intake, Filipinos should be encouraged to stir-fry foods in vegetable oil or to add fats and oils whenever possible in food preparation. This will guard against chronic energy deficiency and help to lower the risk of vitamin A deficiency. The excessive use of saturated fats and oils, however, may increase the risk of heart disease. The proper choice of fats and oils therefore is essential. 7. Consume milk, milk products and other calciumrich foods, such as small fish and dark green leafy vegetables everyday Adequate amounts of calcium in the diet starting from childhood all through adulthood will help prevent osteoporosis in later life Everyone should include milk, milk products in the daily meals. Otherwise, consume other calcium-rich foods such as small fishes (eaten with the bones like "dilis"), sardines, soy bean curd "tokwa" or "tofu", small shrimps and green vegetables like "malunggay" leaves, "saluyot", "alugbati" and "mustasa". 8. Use iodized salt, but avoid excessive intake of salty foods Helps eradicate goiter and iodine deficiency To help prevent hypertension, limit intake of salt and salty foods. When using salt, use iodized salt 9. Eat clean and safe foods To help prevent food-borne diseases: Eat clean and safe food. Drink safe water. Practice good personal hygiene. Practice environmental hygiene and sanitation. Clean and sanitize food preparation area. Practice pest control. Practice safe food storage, handling, preparation and service.

nutrition,exercise regularly, do not smoke and avoid drinking alcoholic beverages To achieve and maintain desirable body weight, balance food intake with physical activity and exercise. To obtain all the benefits of exercise, perform aerobic exercise regularly for at least 3 to 5 times a week for 20-30 minutes or more. As a further hedge against chronic degenerative disease, do not smoke. If you have acquired the habit, stop smoking. It is strongly advised to drink in moderation, if alcohol is used at all. FAMILY WELLNESS Wellness is An integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable. It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning. A life-long process of moving toward enhancing your physical, intellectual, emotional, social, spiritual, and environmental well-being. Composed of six dimensions

How WELLTHY Are You? Many of us recognize the importance of wellness, but it is easy to get caught up in our busy schedules and find were not maintaining a holistic regimen that consistently meets our needs.

10. For a healthy lifestyle and good

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Definitions of Health "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease" (WHO, 1947, p. 1) GOOD HEALTH MEANS Preventing premature death Preventing disability Promoting an environment that supports life Cultivating community and family support Enhancing individuals ability to respond and to take action Assuring that all people achieve and maintain a maximum level of functioning The positiveness of health does not lie in the state , but in the struggle-- the effort to reach a goal Gordon, I . 1958

TRANS-THEORETICAL MODEL CHANGE IS A DYNAMIC CONCEPT. CHANGING BEHAVIOR GOES THROUGH STAGES A MODEL OF HEALTH BEHAVIOR CHANGE PROCHASKA & VELICER, 1997 PRE-CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE TERMINATION Physician recommendations have been demonstrated to significantly improve patients efforts to change behaviors. Rippe J et al., Lifestyle Medicine, 1999 Natural Course of Disease

Wellness is a choice Self-regulation Cornerstone of health and wellness Taking control of ones lifestyle and health behaviors so that lifestyle is the result of choice and not the result of chance and ignorance Conscious, willful, internally directed behavior that promotes health and homeostasis Ingredients of self-regulation Information and knowledge Decision making Commitment Goals Skill acquisition GREEN & SHELLENBERGER, 1991 THEORETICAL CONSTRUCTS CONSUMER INFORMATION SOCIAL LEARNING HEALTH BELIEFS MODEL TRANS - THEORETICAL MODEL

every consultation is an opportunity for preventive care WELLNESS GUIDE What does it include? Risk assessment Counseling for the prevention of disease and maintenance of health Screening and health protection packages Immunizations ChemoProphylaxis RISK ASSESSMENT Basis is still a comprehensive clinical history Past medical and surgical history (childhood illnesses) Immunizations given Medications (prescriptions and over the counter, supplements) Disabilites / handicaps And pertinent Physical Examination General Data (age, sex, educational level, socio-economic status) Family History (genogram) Personal Social History (include lifestyle check, stressors and coping mechanisms) TRAVEL HISTORY

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 HOME ENVIRONMENT WORK ENVIRONMENT Basic Physical Examination (height, weight, BMI, waist circumference) THE WELLNESS GUIDE TO PREVENTIVE CARE Education/Counseling about healthy habits and injury prevention Screening tests for early detection of disease Immunizations Chemoprophylaxis How to change a behavior? - Lifestyle check - Life is about behavior - Do I really have to change everything Lifestyle - Specific Recommendations DIET & NUTRITION PHYSICAL ACTIVITY TOBACCO (active, passive) ALCOHOL (# of drinks) Stress Coping and MENTAL HEALTH SLEEP CAFFEINE INTAKE SEXUAL ACTIVITIES Caffeine Caffeine contained in two cups of coffee may raise the BP by 5 mm Hg in infrequent users. In habitual users, caffeine has minor effect on the blood pressure. Ruhl et al, 2000 Drinking more than five cups of coffee per day was more common among patients with subarachnoid aneurysmal hemorrhage (85%) than controls (59%) (p = 0.004). Isaksen, 2002 SLEEP At least 8 hours of sleep per day poor sleep with initiation difficulties is an independent risk factor for cardiac events among men reduced stage 3-4 sleep predicted poorer overall health Poorer quality of life was predicted by reduced deep sleep Promoting Sleep Hygiene American Academy of Family Physicians Go to bed and wake up at the same time every day even if you didn't get enough sleep. Develop a bedtime routine. Do the same thing every night before going to sleep. Use the bedroom only for sleeping or having sex. Don't eat, talk on the phone or watch TV while you're in bed Make sure the bedroom is quiet and dark. Avoid alcohol, it interrupts the body's sleep rhythms and can cause sleep disturbances Avoid caffeine less than six hours before bedtime Avoid eating a big meal too close to bedtime

LIVE SENSIBLY! Among a thousand people , only one dies a natural death.. the rest succumb to irrational modes of living. Maimodes 1135-1204 AD THE WELLNESS GUIDE TO PREVENTIVE CARE Screening tests for early detection of disease Education/Counseling about healthy habits and injury prevention Immunizations Chemoprophylaxis Screening Executive check up Periodic checkup WHAT IS IT? A group of tasks designed either to determine the risk of subsequent disease or to identify disease in its early symptomless state. - Feightner et al., 1995 Periodic Health Examinations Applying Evidence-Based Medicine in Maintaining Wellness

Periodic Health Examinations: Is It Needed? Prevention of Illness Chronic Illness Infectious diseases Malignancies Injuries Screening Detection of unrecognized health risks Diagnosis of asymptomatic disease Screening Tests for Men General Adult Population Body mass index OR Height in cm and Weight in kg [Yearly] Waist hip ratio (Waist in cm/Hip circumference in cm) [Yearly] Auscultatory BP [Yearly] Eye examination [Yearly] Smoking history Level of activity Adults 40 yrs and older total cholesterol [q 2 yrs] Fasting blood sugar [q 2 yrs Adults 50 yrs and older Visual examination of oral cavity [yearly] Fecal occult blood [yearly] DRE, PSA Adults 60 yrs and older General health questionnaire [Once] Visual acuity with Snellen Chart [Yearly] Functional reach [Yearly] Colonoscopy

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Men's Health Check-up List Cholesterol checks: every 5 years, starting at age 35. If smoking, have diabetes or if heart disease runs in the family, start having cholesterol check at age 20 Depression: feeling "down," sad, or hopeless, and have little interest or pleasure in doing things for 2 weeks straight Sexually Transmitted Diseases Screening Tests for Women General Adult Population Body mass index OR Height in cm and Weight in kg [Yearly] Waist hip ratio (Waist in cm/Hip circumference in cm) [Yearly] Auscultatory BP [Yearly] Eye examination [Yearly] Smoking history Level of activity Pap smear Women 40 59 years old Clinical breast examination [Yearly] Screening mammography [Yearly] Adults 40 yrs and older total cholesterol [q 2 yrs] Fasting blood sugar [q 2 yrs Adults 50 yrs and older Visual examination of oral cavity [yearly] Fecal occult blood [q 2 yrs] Adults 60 yrs and older General health questionnaire [Once] Visual acuity with Snellen Chart [Yearly] Functional reach [Yearly] Women's Health Check-up List Depression: feeling "down," sad, or hopeless, and have little interest or pleasure in doing things for 2 weeks straight Osteoporosis Tests: bone density test at age 65 to screen for osteoporosis. If between the ages of 60 and 64 and weigh 154 lbs. or less, talk to HCP Chlamydia Tests and Tests for Other Sexually Transmitted Diseases Mammograms: every 1 to 2 years starting at age 40. Optional 40-49, yearly 50-75 Pap Smears: Every 1 to 3 years if sexually active or are older than 21. Maximum interval every 3 yrs after 3 consecutive normal exams, yearly until 75, >75 optional Cholesterol checks: At least every 5 years, starting at age 35. If smoking, have diabetes, or if heart disease runs in the family, start cholesterol check at age 20.

Caregivers General health questionaire [Yearly] Retirees General health questionaire [Yearly] Truck and bus drivers, security personnel & pilots 12-L ECG Occupational exposure to noise >85 decibels for 8 hours daily Pure tone audiometry Contacts of active or potentially active TB disease Chest X-ray [Once] Mantoux test [Once] Sex with multiple partners STD panel [Yearly] CSW; partners of patients with STD STD panel [q 6 mos] Close household contacts HbsAg and Anti-HBs using enzyme immunoassay [Once] Anti HAV IgG enzyme immunoassay [Once] Adults who chew or smoke tobacco; Adults who smoke cigarettes Visual Examination of the Oral Cavity [Yearly] FBS Ankle-Brachial index Heavy alcohol drinkers Visual Examination of the Oral Cavity [Yearly] Family history of early CVD Fasting Lipid Profile Family history of DM Any of the ff: FBS, RBS, 75g OGTT, FCG or RCG [q 2 yrs] History of Familial dyslipidemia Ankle brachial index [q 2 yrs] Lipid profile [q 2 yrs] Any of the ff: FBS, RBS, 75g OGTT, FCG or RCG [q 2 yrs] Family history of gout Serum uric acid [q 2 yrs] Family history of glaucoma Intraocular pressure [q 2 yrs] Two or more of the ff on PE: obesity, smoking, HPN Lipid profile [q 2 yrs] 12 L ECG Xanthoma Lipid profile [q 2 yrs] Obesity Any of the ff: FBS, RBS, 75g OGTT, FCG or RCG [q 2 yrs]

Recommended Tests for Selected Populations Adults in occupational setting Chest X-ray [Yearly] Healthcare workers Chest X-ray [Yearly] Mantoux test [Once]

THE WELLNESS GUIDE TO PREVENTIVE CARE Screening tests for early detection of disease Education/Counseling about healthy habits and injury prevention Immunizations Chemoprophylaxis

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Adult immunization H. Influenza vaccine every year starting at age 50 Tetanus-diphtheria, 3-dose-series for previously unvaccinated, booster dose every 10 years Pneumococcal vaccine once at age 65 (earlier if (+) for certain health problems, such as lung disease) Hepatitis A & B shots Varicella vaccine for all adults without prior infection Children immunization BCG DPT OPV Measles MMR Hepatitis B Varicella Tetanus-diphtheria boosters(Td)-11-16 yrs Rubella (females > 12 yrs) Adult Immunization For women aged 19 through 26 years, either HPV2 or quadrivalent (HPV4) can be used for vaccination; also used a permissive recommendation for use of HPV4 in men. Revision to the measles, mumps, rubella (MMR) footnote now notes in the beginning of the footnote that adults born before 1957 generally are immune. Further revisions clarify which adults born during or after 1957 do not need 1 or more doses of MMR for the measles and mumps components. New interval dosing information states that a second dose of MMR should be given 4 weeks after the first dose. Another revision to this footnote highlights that women in whom rubella vaccination is not documented should receive a dose of MMR. A new section added to this footnote provides guidelines for vaccinating healthcare personnel born before 1957 routinely and during outbreaks. Revision to the hepatitis A footnote now includes an indication for administering this vaccine to unvaccinated persons who expect to be in close contact with an international adoptee. Revision to the hepatitis B footnote now includes schedule information for the 3-dose hepatitis B vaccine. Revision to the meningococcal vaccine footnote explains that the meningococcal conjugate vaccine is preferred for adults not older than 55 years and that the meningococcal polysaccharide vaccine is preferred for adults who are at least 56 years or older For adults previously vaccinated with meningococcal conjugate vaccine or meningococcal polysaccharide vaccine, revaccination with meningococcal conjugate vaccine is recommended. Revision to the selected conditions portion of the H. influenzae type B footnote now elucidates which highrisk persons can receive 1 dose of H. influenzae type B vaccine.

Chemoprophylaxis THE WELLNESS GUIDE TO PREVENTIVE CARE Screening tests for early detection of disease Education/Counseling about healthy habits and injury prevention Immunizations Chemoprophylaxis Aspirin older than 40 or younger than 40 who have high blood pressure, high cholesterol, diabetes, or if smoking Hormonal Replacement Therapy risks of taking the combined hormones estrogen and progestin after menopause to prevent long-term illnesses outweigh the benefits Iron in pregnant women helps both the mother and baby's blood carry oxygen Folic acid -women of child bearing age- 400 micrograms (or 0.4 mg) every day could prevent up to 70 percent of neural tube defects Calcium Guidelines from the National Academy of Sciences says that the Adequate Intakes (AIs), in milligrams (mg), each day for calcium are: Infants 0-6 mo - 210 mg 7-12 mo - 270 mg Children 1-3 yrs - 500 mg 4-8 yrs - 800 mg 9-13 yrs - 1,300 mg 4-18 yrs - 1,300 mg Adults 19-50 yrs - 1,000 mg Over 51 yrs - 1,200 mg During Pregnancy & Lactation Under 18 yrs - 1,300 mg 19 yrs and older - 1,000 mg Calcium and Vitamin D A serving of milk or yogurt contains around 300 mg calcium Vitamin D is needed to help the body absorb calcium correctly FAMILY WELLNESS Family wellness is a bigger picture than personal wellness. And while it includes the same individual wellness factors for each member of your family, it also includes the wellness factors of the family as a group.

Family well-being depends on the quality of the communication and time shared between everyone in the family.

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How to know if the family is healthy? Using tools of family assessment - Genogram - Family apgar - Lifestyle - DIET - ACTIVITIES FOR FITNESS - Life cycle stage - History of diseases - History of dysfunctions - FAMILY MAPPING BIOSTATISTICS in EPIDEMIOLOGY Definitions Statistics is the science and art of collecting, summarizing, and analyzing data that are subject to random variation (Last, 1995). Biostatistics is the application of statistics to biological problems. Review of Concepts Data refers to a collection of items of information. A variable is any quantity that varies. It is any attribute, phenomenon, or event that can have different values. Uses of statistics Statistics is an indispensable tool in medicine and health. Almost all medical and health studies rely on the quantification of health and disease events in populations. Data collected in medical and health studies usually involve several observations on several variables. Analyzing and presenting such large volumes of raw data can be very cumbersome and painful. Describe large data sets using only few numbers (like mean, range, etc.,) Generalize the results of a small sample to the larger population from which the sample is drawn (extrapolation) Compare different variables and test an underlying hypothesis Types of measurements The basic building blocks of any study are the data - the measurements which describe the factors being studied Nominal variables are observations which can be classified into one of a number of mutually exclusive categories Ordinal variables are slightly more sophisticated measures than nominal data Ratio and interval scales are called continuous data. The most sophisticated measures are those where individuals are placed on a scale of continuous scale in which the distance between two measurements are well define Summarizing data Measures of central tendency mean, median and mode Measures of dispersion 2 Variance (s ) is the mean square deviation

Standard deviation (s) is nothing but the square root of the variance. Inferential Biostatistics Estimation Why do we need to study samples? In an ideal world, if one had find out, say, the mean birth weight of all babies born in India during a year, one would weigh all the babies born in India during a year. By using samples we may able to estimate a value that will represent the mean birth weight of all babies in India. Hypothesis-testing Hypothesis testing (tests of significance) involves ascertaining whether an observed difference could have occurred purely due to chance. This probability is quantified as a P-value. In hypothesis testing, one first starts with the assumption that the observed difference is not a real difference but one produced merely due to play of chance. This is called the null hypothesis One then tries to disprove the null hypothesis by calculating the probability of the observed difference being due to chance. This probability is given by the P value If the P value is lower than a predetermined figure (0.05 by convention) obtained from the statistical table for normal distribution, then one infers that the observed difference is real and cannot be explained purely by chance. The null hypothesis is thus rejected. The P value tells us only whether there is a statistical significance or not.

OBSERVATIONAL STUDY DESIGNS Descriptive studies or case series A descriptive study is the weakest epidemiological design. The investigators merely describe the health status of a population or characteristic of a number of patients. Description is usually done with respect to time place and person Cohort Studies Cohort studies are considered the strongest of all observational designs. A cohort study is conceptually very straightforward. The idea is to measure and compare the incidence of disease in two or more study cohorts Cohort studies are usually prospective or forward looking

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Cohort Studies New cases of the disease are picked up during follow up and the incidence of the disease is computed on the basis of the exposure status. The incidence in the exposed cohort is then compared with the incidence in the unexposed cohort. This ratio is called Relative Risk (RR) or Risk Ratio Relative Risk = Incidence in the exposed cohort /Incidence in the unexposed cohort The relative risk is a measure of association between the exposure and the outcome. The larger the RR, the stronger the association. As it can be seen, the cohort study is the only study design in which the true incidence of a disease can be estimated. The RR therefore is considered the best measure of association Relative Risk Data for relative risk for myocardial infarction in patients taking aspirin

The OR is the ratio of the odds (chance) of exposure among cases in favor of exposure among controls

Odds Ratio Data for odds ratio for stroke with history of drug abuse

73/214 = 0.518 18/214 =0.092 141/214 196/214 OR = 0.518/0.092=5.64 therefore the patient who has had a stroke is almost 6 times more likely to have abused drugs than the patient who has not had a stroke If the disease is rare, then the OR tends to be a good approximation of the Relative risk (RR). However, true incidence estimates can not be generated from a case control study.

RR= 139/11,037 0.0126 = 0.581 239/11,034 0.0217 The Relative Risk is less than 1

Case Control Studies Conceptually, case control studies are more difficult to comprehend than cohort studies In a cohort study, disease free exposed and nonexposed cohorts are followed up and then outcome events are picked up as and when they occur. In a case control design, sampling starts with diseased and non-diseased individuals They are called-cases and controls The exposure status is then determined by looking backward in time (using documentation of exposures or recall of historical events). For this reason, case control studies are also called as retrospective studies The measure of association in a case control study is called an Odds Ratio (OR).

CLINICAL TRIALS The Randomized Controlled Trial (RCT) The RCT is widely held as the ultimate study design; the "gold standard" against which all other designs. The subjects are usually chosen from a large number of potential subjects. Sampling includes prescreening using a set of inclusion and exclusion criteria. After this, an informed consent is obtained from each participant. Randomization is then done to allocate subjects to either the treatment group or the placebo group Ideally, intervention should be done in a blinded fashion. Neither the investigator nor the subject should know the nature of the treatment that is being administered. After the intervention, the key outcomes that are being studied need to be measured by a blinded investigator Analysis involves looking for differences in the outcome rates in the two arms of the clinical trial

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Double-Blind Cross-Over Design

Why Doctors Bother With EBM? Doctors are unable to read original research article or fully understand the results; This inability to critically appraise a study and grasp all that is implied in its findings limits the doctors independence; thus, There is reliance on expert opinion, the practices of colleagues and the pharmaceutical industry. With the enormous volume of literature, doctors apply EBM to clinical practice in order to differentiate a good study from a trash; that is, a study that is valid with credible results that they can apply to their patients. EBM A AQUIRE THE SKILLS The 3 skills of EBM: how to acquire the information, appraise articles and apply the evidence. VALIDITY versus RELIABILITY Validity Validity refers to how close we think the study results are to the truth Accuracy Reliability Reliability means hitting the same objective consistently. Precision Intra-observer or inter-observer EBM B BIAS In general, the key word in the understanding of the concept of bias is different. If the way in which participants are selected into the study is different for example. Similarly, if the manner in which information is obtained, reported, or interpreted is different between groups in the study, then an inaccurate impression of the true relationship may be obtained. In Summary: There are 2 general types of observation bias, depending on the source of non-comparability: 1. recall bias 2. interviewer bias EBM C CLINICAL TRIALS Randomized controlled trials or RCTs The Role of Bias in Clinical Trials Achieve control for any influence of unknown variables due to randomization (controlled biases). The favorable impression (good) that this design strategy may have on those reading the published results of a trial. How about those trials not published? Publication bias The burden of proof is on the investigator to show that all possible biases in the allocation of patients to a study group or confounding effects of known or unknown factors that may differ between the study groups did not account for the observed result.

What are the phases of clinical trials? Clinical trials are conducted in phases. The trials at each phase have a different purpose and help scientists answer different questions: In Phase I trials, researchers test a experimental drug or treatment in a small group of people (20-80) for the first time to evaluate its safety, determine a safe dosage range, and identify side effects. Initial studies to determine the metabolism and pharmacologic actions of drugs in humans, the side effects associated with increasing doses, and to gain early evidence of effectiveness; may include healthy participants and/or patients. In Phase II trials, the experimental study drug or treatment is given to a larger group of people (100300) to see if it is effective and to further evaluate its safety. Controlled clinical studies conducted to evaluate the effectiveness of the drug for a particular indication or indications in patients with the disease or condition under study and to determine the common short-term side effects and risks. In Phase III trials, the experimental study drug or treatment is given to large groups of people (1,0003,000) to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the experimental drug or treatment to be used safely. In Phase IV trials, post marketing studies delineate additional information including the drug's risks, benefits, and optimal use

THE ABCs of EVIDENCE-BASED MEDICINE (EBM)

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Subjects in a trial of medical therapy may deviate from the protocol for a variety of reasons. Developing side effects, forgetting to take their medication, or simply withdrawing their consent after randomization. Randomized patient rapidly worsens to the point where therapy becomes contraindicated. The extent of non-compliance in any trial is related to the length of time that participants are expected to adhere to the intervention, as well as to the complexity of the study protocol. EBM D Design of the study STUDY METHODOLOGY STUDY BLINDS BLINDING is an attempt to make the treatments being compared indistinguishable. Allocation concealment is an attempt to preserve the random order by which the patients are assigned to the groups. Blinding is impossible when the interventions involve diet, educational maneuvers or surgical procedures. Single blind versus double-blind RANDOMIZATION Random assignment of patients to treatment groups in a trial is the best technique to ensure that treatment groups are truly comparable. Such that each individual will have an equal chance of being selected. Known as well as unknown factors are equally distributed to the groups. Appraisal Form for Therapy Directness Validity Results Applicability Directness Population Intervention or exposure Outcome Population Children Adults Elderly Certain class or severity of illnesses Exposures Behaviors Treatments Patient characteristics Outcomes Treatment or cure Alleviation of symptoms or symptom control Quality of life Survival Morbidity Mortality Adverse events or harm

Were patients randomly assigned to treatment groups? Was allocation concealed? Were baseline characteristics similar at the start of the trial? Were patients blinded to treatment assignment? Were caregivers blinded to treatment assignment? Were outcome assessors blinded to treatment assignment? Were all patients analyzed in the groups to which they were originally randomized? Was follow-up rate adequate?

What are the results? 1. How large was the effect of treatment? 2. How precise was the estimate of the treatment effect? -- p-value -- confidence interval -- standard error RR, ARR, NNT A measurement of how large was the effect of treatment (RR, ARR and NNT) RR is relative risk or comparison (ratio) of the risk of outcome in the treatment and control groups. RRR is relative risk reduction or 1-RR. ARR is absolute risk reduction is difference in risk in the control and treatment groups. NNT is number-needed-to-treat and is the reciprocal of the ARR. Can the results be applied to my patient care? 1. Are there biologic issues that may affect applicability of treatment? 2. Are there socio-economic issues affecting applicability of treatment? Individualizing the Results What is the likely effect of the treatment on your individual patient? EBM E EVIDENCE What is the level of evidence? HIERARCHY OF EVIDENCES (Strength of evidence for treatment decisions) N of 1 randomized controlled trial Systematic reviews of randomized trials (metaanalysis) Single randomized trial Systematic review of observational studies Single observational study Physiologic studies Unsystematic clinical observations

ASSESSMENT OF VALIDITY

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Statistical versus clinical significance Statistical significance means the study has enough power to detect a difference between or among treatment groups and that means, p-value is less than 0.05. Clinical significance means that the study did not reach enough power to detect a difference but in the real-world scenario, there is a difference or at least a trend along this line. EPIDEMIOLOGY Greek words: epi (upon) demos (people) Definition The study of both the distribution of diseases in human populations and the determinants of the observed distribution It began as the study of infectious diseases but has expanded to include the study of chronic diseases, health care organization, health care delivery, occupational and environmental health COMPONENTS

STUDIES ARE DONE IN HUMAN POPULATIONS EPIDEMIOLOGY MAY BE VIEWED AS BASED ON TWO FUNDAMENTAL ASSUMPTIONS 2 BASIC ASSUMPTIONS 1. That human disease does not occur at random 2. That human disease has causal and preventive factors that can be identified through systematic investigation of different populations or subgroups of individuals within a population in different places or at different times. HISTORY OF EPIDEMIOLOGY Hippocrates, Graunt, and Farr each contributed to an increasing sophistication in the understanding of disease frequency and distribution - two of the three components of the definition of epidemiology. HIPPOCRATES THE DEVELOPMENT OF HUMAN DISEASE RELATED TO THE EXTERNAL & PERSONAL ENVIRONMENT OF THE INDIVIDUAL Whoever wishes to investigate medicine properly should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produce. Then the winds, the hot and the cold... the waters which the inhabitants use... The mode in which they live, what are their pursuits, whether they are fond of drinking and eating in excess, and given to indolence, or are fond of exercise and labor. - HIPPOCRATES JOHN GRAUNT In 1662, published The Nature and Political Observations Made Upon the Bills of Mortality Analyzed the weekly reports of births and deaths in London For the first time, quantified patterns of disease in a population Noted an excess of men for both births and deaths, high infant mortality and the seasonal variations in mortality Attempted to provide a numerical assessment of the impact of plaque on the population of the city Examined characteristics of the years in which such outbreaks occurred Recognized the value of routinely collected data in providing information about human illness (forms the basis of modern epidemiology) WILLIAM FARR In 1839, responsible for medical statistics in the Office of the Registrar General for England and Wales Set up a system for routine compilation of the number and causes of deaths Established a tradition of careful application of vital statistical data to the evaluation of health problems of the general public Recognized that data collected from human populations could be used to learn about illness

DISEASE FREQUENCY The measurement of disease frequency involves quantification of the existence or occurrence of disease The availability of such data is a prerequisite for any systematic investigation of patterns of disease occurrence in human populations DISTRIBUTION OF DISEASE Considers such questions as who is getting the disease within a population as well as where and when the disease is occurring Derives from the first two since the knowledge of frequency and distribution of disease is necessary to test an epidemiologic hypothesis Describe patterns of disease as well as to formulate hypotheses concerning possible causal or preventive factors

FOURTH ASPECT OF THE DEFINITION OF EPIDEMIOLOGY

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Compared mortality patterns of married and single persons and workers in different occupations (metal mines & earthenware industry) Noted the association between the elevation above sea level and deaths from cholera Attempted to ascertain the effect of imprisonment on mortality Addressed many major methodologic issues relevant to modern epidemiology Defined the exact population at risk Chose an appropriate comparison group Considered whether other factors could affect the results such as age, duration of exposure or general health status

HISTORY OF EPIDEMIOLOGY Two decades after Farr began his work, the availability of routinely collected data on the population and mortality patterns of England enabled another British physician, John Snow, to formulate and test a hypothesis concerning the origins of an epidemic of cholera in London. On the basis of the available descriptive data, including the observations made by Farr, Snow postulated that cholera was transmitted by contaminated water through a then unknown mechanism. He observed that death rates from cholera were particularly high in areas of London that were supplied with water by the Lambeth Company or the Southwark and Vauxhall Company, both of which drew their water from the Thames River at a point heavily polluted with sewage. HISTORY OF EPIDEMIOLOGY Between 1849 and 1854, the Lambeth Company changed its source to an area of the Thames where the water was quite free from the sewage of London. The rates of cholera declined in those area of the city supplied by the Lambeth Company, while there was no change in those areas receiving water from the Southwark and Vauxhall Company. In 1854, Snow noted that the most terrible outbreak of cholera which ever occurred in this kingdom, is probably that which took place in Broad Street, Golden Square and the adjoining streets, a few weeks ago. Within two hundred and fifty yards of the spots where Cambridge Streets joins Broad Street, there were 500 fatal attacks of cholera in ten days. Snow tabulated the number of deaths from cholera that occurred from the commencement of the epidemic in August 1853 to January 1854 according to the two water companies supplying the various sub-districts of London. The areas of London supplied entirely by the Southwark and Vauxhall Company experienced a rate of 114 deaths from cholera per 100,000 persons, whereas there were no deaths from cholera

during that time in the districts supplied entirely by the Lambeth Company. A large area supplied by both companies experienced a rate midway between those for the districts supplied by either alone. These observations were consistent with Snows hypothesis that drinking water supplied by the Southwark and Vauxhall Company increased the risk of cholera compared with water from Lambeth Company. Snow also recognized the possibility that many factors other than the water supply differed between the two geographic areas and thus could account for the observed variation in cholera rates. His unique contribution to epidemiology lies in his recognition of an opportunity to test the hypothesis implicating the water supply. Snow outlined his natural experiment in his book On the Mode of Communication of Cholera: In the subdistricts as being supplied by both companies, the mixing of the supply is of the most intimate kind. The pipes of each Company go down all the streets, and into nearly all the courts and alleys. A few houses are supplied by one Company and a few by the other, according to the decision of the owner or occupier at that time when the Water Companies were in active competition. In many cases a single house has a supply different from that on either side. Each company supplies both rich and poor, both large houses and small; there is no difference either in the condition or occupation of the persons receiving the water of the different Companies. Now it must be evident that, if the diminution of cholera, in the districts partly supplied with the improved water, depended on this supply, the houses receiving it would be the houses enjoying the whole benefit of the diminution of the malady, whilst the houses supplied with the water from Battersea Fields (Southwark & Vauxhall Co.). These houses supplied by the Southwark and Vauxhall Company would suffer the same mortality as they would if the improved supply did not exist at all. As there is no difference whatever, either in the houses or the people receiving the supply of the two Water Companies, or in any of the physical conditions with which they are surrounded, it is obvious that no experiment could have been devised which would more thoroughly test the effect of water supply on the progress of cholera than this, which circumstances placed ready made before the observer. The experiment, too, was on the grandest scale. No fewer than 300,000 people of both sexes, of every age and occupation, and of every rank and station, from gentlefolks down to the very poor, were divided into 2 groups without their choice, and, in most cases, without their knowledge...

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... One group being supplied with water containing the sewage of London, and amongst it, whatever might have come from the cholera patients, the other group having water quite free from the impurity. To turn this grand experiment to account, all that was required was to learn the supply of water to each individual house where a fatal attack of cholera might occur. Within the area supplied by both companies, Snow walked from house to house and, for every dwelling in which a cholera death had occurred, was able to determine which company supplied the water. The data provided convincing evidence that water supplied by the Southwark & Vauxhall Co. was responsible for the outbreak of cholera in London. Thus, Snow charted the frequency and distribution of cholera and also ascertained a cause, or determinant, of the outbreak. Snow was the first investigator to draw together all 3 components of the definition of epidemiology Snows approach in the investigation of the cholera epidemic of 1853 to 1854 was applied primarily to outbreaks of infectious diseases throughout the 19th and early 20th centuries. Thus the term epidemiology was originally used almost exclusively to mean the study of epidemics of infectious disease. EPIDEMICS Over the past 80 years, patterns of mortality in developed countries have changed markedly, with chronic diseases assuming increasing importance. As a consequence, the concept of an epidemic has become much broader and more complex, necessitating more advanced methods than the first developed by Snow. During the 20th century, changes in disease distributions have resulted in a broadening of the term epidemic to include any disease, infectious or chronic, occurring at a greater frequency than usually expected. DEFINITION OF TERMS Epidemic the occurrence of an illness, in a specified geographic area, that clearly exceeds the normal, expected incidence (new cases). Ex. HIV Hyperendemic a situation in which there is a persistent transmission of a disease among most of a population. Ex. Malaria in certain parts of Africa Endemic the constant presence of a disease in a specific geographic area. Ex. Schistosomiasis in Samar Pandemic the worldwide spread of an epidemic disease. Ex. SARS In the U.S., coronary heart disease is clearly epidemic. Despite a recent period of decline, mortality from this disease remains the chief cause of death among both men and women, occurring at one of the highest rate in the world. ANOTHER EXAMPLE Lung cancer in the U.S. today is also epidemic, since the overall mortality rate from this disease tripled

between 1950 and 1983, rising from 12.8 to 38.1 per 100,000 population, even after taking into account the increasing age of the general population. DEVELOPMENTS IN MODERN EPIDEMIOLOGY 1. DESIGN OF STUDIES AND TECHNIQUES FOR COLLECTING AND ANALYZING DATA TO FACILITATE THE EVALUATION OF RISK FACTORS FOR CHRONIC DISEASES. 2. APPLICATION OF EPIDEMIOLOGIC PRINCIPLES AND METHODS TO THE DESIGN, CONDUCT AND ANALYSIS OF CLINICAL TRIALS, STUDIES IN WHICH THE INVESTIGATORS THEMSELVES ALLOCATE TO PARTICIPANTS THE EXPOSURES BEING STUDIED.

BROAD CATEGORIES 0F DESIGN STRATEGIES IN EPIDEMIOLOGIC RESEARCH 1. DESCRIPTIVE EPIDEMIOLOGY 2. ANALYTIC EPIDEMIOLOGY Descriptive Epidemiology Is concerned with the distribution of disease, including consideration of what populations or subgroups do or do not develop a disease, in what geographic areas it is most or least common, and how the frequency of occurrence varies over time. Analytic Epidemiology Focuses on the determinants of disease by testing the hypotheses formulated from descriptive studies, with the ultimate goal of judging whether a particular exposure causes or prevents disease.

Population At Risk: Health Risks And Risk Assessment POLLUTION Land Pollution harmful substances introduced to the soil May be consequences of: unsanitary habits various agricultural practices Ex. soil fertilizers incorrect methods of waste disposal Prevention: Education of farmers on the effects of nitrates in fertilizers Instruction to follow sound practices in their use Pesticide formulation should be registered before being allowed in the market Training of health care workers in the recognition and management of poisoning Air Pollution Smog a.k.a phytochemical haze Oxidation of hydrocarbons and nitrogen oxide Mild: Irritate eyes, nose and throat Danger: sulfur dioxide and other materials generated by burning of fuels Prevention: Implementation of strict regulation Covering of mouth and nose whenever exposed Clean Air Act of 1999 or Republic Act No. 8749

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Holistic national program of air pollution management Emphasis: prevention rather than control, public information and education and cooperation and self-regulation among citizens

Water Pollution any change in natural water which may impair their future use Causes: Dirty drainage systems Dirty recreational water Dirty sewage Industrial waste Effects: Change in temperature of water Introduction of organic or inorganic substances Depletion of oxygen: death of aquatic life World Health Organization (WHO): 80% of all disease are related to drinking contaminated water 10million people worldwide die from waterrelated diseases 50% are infants and children Control measures: Physical treatment by filtration Chemical treatment using coagulants Biologic treatment by transformation in the earths crust RADIATION Emission of discrete particles or rays from a substance Produces charge ions that produce abnormal chemical reactions Early effects in large doses cause complete halt in blood cell formation Prolonged and continuous exposure lead to physical and genetic defect OCCUPATIONAL HAZARDS - Disease resulting from exposure to toxic chemical agents o Ex: Asbestosis, silicosis, lead, arsenic and organophosphate poisoning - Disease due to physical agents o Ex: Asphyxia, Caissons disease, altitude sickness, heat stroke - Diseases due to mechanical factors o Ex: postural problems and back pains - Diseases due to infectious agents o Ex: Tetanus, rabies, ringworm, erysipelas - Control measures: o Isolation o Substitution o Alteration of work processes o Ventilation o Proper waste disposal o Adequate sanitary facilities o Personal protective devices

PESTS Belong to the group of mans natural enemies that cause damage, discomfort and displeasure to life: Bee and wasp stings anaphylactic shock Rats rat-bite fever Ticks, mites, bedbugs, cockroaches and mosquitoes itchiness Houseflies - diarrhea POVERTY Common denominator of various diseases: malnutrition, tuberculosis, venereal diseases Higher rates of infant and perinatal mortality Prominent environmental hazards due to poor housing Overcrowding: fire hazard Poorly lighted streets and lack of safe area for children in the community breed crime and accidents Infrequent garbage collection and improper disposal give rise to breeding place for rats and insects

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