慢性病的环境因素分析课件

EnvironmentalDriversofChronicDisease

Basedonthereport

EnvironmentalThreatstoHealthyAging

byJillSteinMD,TedSchettlerMD,MPH,MariaValentiandBenRohrer

2010GreaterBostonPhysiciansforSocialResponsibility(/Boston)andTheScienceandEnvironmentalHealthNetwork()1医学PPTWhatWeWillCoverEnvironmentalfactorsarekeydriversofmanycommonchronicdiseasesEnvironmentalfactorsalterkeybiologicalpathwaysleadingtochronicdiseaseImportantenvironmentaldeterminantsofhealthinclude:Foodsystem/nutritionanddietToxicchemicalsBuiltenvironment/physicalactivityPsychological&socioeconomicstressExamplesofcrosscuttingsolutionsforhealthypeople&ahealthyenvironment2医学PPTScope&ContextoftheProblemAcenturyofchangeinnatural,builtandsocialenvironmentshascaused

majorchangesinthepatternsanddistributionofdiseases.Weareseeingdramaticincreasesinchronicdiseases,andatyoungerages,manyofwhich,suchasdiabetes,arethemselvesriskfactorsfordementia.Theover-65populationwillnearlydoubleby2030tomorethan71million,sharplyincreasingthenumberofpeopleatriskofchronicdiseasesofaginglikeAlzheimer’sandParkinson’sdiseases,amongothers.Environmentalfactorsplayakeyroleinhealthacrossthelifespan.Thustheyofferamajorpreventionopportunity.3医学PPTTheChangingEnvironmentand

DiseasePatternsDuringthepastcentury,humanactivityhasalteredvirtuallyallaspectsoftheworld’secosystems:Pervasivespreadofsyntheticchemicals;airandwaterpollution.Industrializedfoodsupply.Destructionofcriticalnaturalhabitats,stressingecosystems.Climatechange.Howwelive,eat,work,playandsocializehavesubstantiallychanged:Builtenvironmentshaveincreasedsocialisolationformanypeople;reducedphysicalactivity.Growingincomegapincreasesdiseaserisk.Diseasesofcivilization-obesity,diabetes,cardiovasculardisease,hypertension.4医学PPTEnvironmentDrivesChronicDiseaseWesternDiseaseClusterDiabetesObesityAbnormalLipidsMetabolicSyndromeCardiovascularDiseaseFoodsystem/DietFossilFuelsSocioeconomicStressChemicalsBuiltEnvironment/TransportationInflammationDisruptedInsulinSignalingOxidativeStress

Alzheimer’sParkinson’sAlteredPathwaysEnvironmentalFactorsChronicDisease5医学PPTProfoundPublicHealthImpact

OfEnvironmentally-DrivenWesternDiseaseClusterObesity/overweight–2/3USadults,prevalencex2in~25yrs/chronicdisease/resources/publications/AAG/obesity.htmPre/Diabetes–40%USadults,prevalenceDM~x2over20yrs

Cowie09,/DDTSTRS/default.aspxCardiovasculardisease–stillleadingcauseofdeath.Hypertensionincreasing./nchs/FASTATS/lcod.htm,Hajjar03Metabolicsyndrome=earlysignsofotherclusterdiseases;35%adults,~55%>60yrsFordES05Alzheimer’sdisease–½>84yrsold,5.3MAlzheimer’sAssoc.6医学PPTAlzheimer’sDisease/dementiaNotaninevitablefeatureofnormalaging.Progressiveimpairmentofmemoryandmultipleothercognitivefunctions,severeenoughtointerferewithdailyfunctioning.Expectedtotriplebymid-centurytoover13million.Likelycausedbyvarying combinationsofgeneticand environmentalfactors.

AnnualcostsinUSover$150billion.7医学PPTParkinson’sDiseaseProgressivemovementdisorderthatincludestremors,stiffness,andslowmovement.Mayleadtoseveredisability.Likelycausedbyvariablecombinationsofgeneticandenvironmentalfactors.About50,000newcasesannuallyinUS.*PrevalenceinUSexpectedtodoubleby2030.**

DuetothelackofregistriesandbaselinedataonParkinson’sDisease,thefiguresusedhereareestimates.

8医学PPTAlzheimer’sandParkinson’sDiseasesCharacterizedby:

abnormalproteindepositschronicinflammationabnormaloxidativestressManyneuroscientistsarebeginningtothinkofsomeneurodegenerativediseasesalongacontinuum,withoutclearlydistinctboundariesinclinicalorpathologicalmanifestations

9医学PPTContinuumofAge-AssociatedCognitiveImpairment10医学PPTEnvironmentDrivesChronicDiseaseEarlylifeexperiencescaninfluencelater-lifehealthanddisease.Multiplefactorsinteracttoinfluencehealth&disease.

Environmentalfactorscanalternaturalpathwayswhich

inturncanleadtochronicdisease.

Anecologicalhealthframeworkconsiderstheindividualinthecontextoffamily,community,societyandecosystem.

BasicPrinciples11医学PPTToxicexposuresoxidativestressObesity,hypertension,Cardiovasculardisease,diabetesAlzheimer’s,dementia,Parkinson’sLowbirthweightEarlylifeexperiencescaninfluencelater-lifehealth,diseaseAgingbeginsatconception12医学PPTMultipleFactorsInteracttoInfluenceHealth&Diseasebuilt

environmentdiseasestressenergychemicalsnutrients13医学PPTAnecologicalhealthframeworkconsiderstheindividualinthecontextoffamily,community,society,andecosystem.14医学PPTAlteredPathwaysEnvironmentDrivesChronicDiseaseEnvironmentalFactorsInflammationDisruptedInsulinSignalingOxidativeStressChronicDiseaseMechanismsofAction15医学PPTDefinedbymicroscopic

characteristics&laboratorytest:inflammatorycells&mediatorsCLASSICALCONCEPT

OFINFLAMMATIONDefinedbyappearance.“Calor,dolor,rubor,tumor.”Heat,pain,redness,swelling.TheNewConceptofInflammation“Atherosclerosisisaninflammatorydisease.”(2)Ross,Russell.Atherosclerosis–AnInflammatoryDisease.NEJM1999,340(2);115-126.16医学PPT17医学PPTInsulinSignaling=

NormalMetabolismInsulinsignaling↓

bloodsugar↓

arterydisease↓

triglycerides18医学PPTInsulinsignaling↑bloodsugar

↑

arterydisease

↑

triglyceridesInflammationOxidativestressDisruptedInsulinSignaling=

InflammatoryMetabolism19医学PPTAlteredPathwaysEnvironmentDrivesChronicDiseaseEnvironmentalFactorsChronicDiseaseFoodSystem/Diet20医学PPT

NovelNutrientsArePervasive,PromoteInflammatoryMetabolism21医学PPTWhat’s“Novel”intheWesternDiet?“Hypotheticalschemeoffat,fattyacid(ω6,ω3,transandtotal)intake(aspercentageofcaloriesfromfat)andintakeofvitaminsEandC(mg/d).Datawereextrapolatedfromcross-sectionalanalysesofcontemporaryhunter-gathererpopulationsandfromlongitudinalobservationsandtheirputativechangesduringthepreceding100years[75].”FromAPSimopoulos,Theimportanceoftheratioofomega-6/omega-3essentialfattyacids.Biomedicine&Pharmacotherapy56(2002)365-379.Years%ofcaloriesfromfatmg/day22医学PPTHighGlycemicCarbohydratesIncreasetheRiskofChronicDiseaseHighglycemiccarbohydratesbreakdownquicklyduringdigestion,rapidlyreleasingglucose(sugar)intothebloodstream.ΔPlasmaInsulin,mg/dlTime,minsINSULINEMICRESPONSELowglycemicfoodHighglycemicfood23医学PPT24医学PPTPropertiesofFattyAcids

Omega-3

Omega-6

SaturatedFood

Perishable Durable IncreasedinSystem

Shortshelflife Processedfoodsfactoryfarmed

Increasedin Longshelflifeanimals pasture-fed animals

Immune

Anti-inflammatory

Inflammatory&

InflammatoryProperties

Anti-inflammatory

Evolutionary

Recentmarked

Recentmarked

RecentmarkedContext

decline

increase

increase25医学PPT↓Omega-3,(↑Omega-6)

Insulinsignaling↑bloodsugar

↑

arterydisease

↑

triglyceridesInflammationOxidativestressNovelNutrientsDisruptInsulinSignaling,

DriveInflammatoryMetabolismSaturatedfat↓Antioxidants

HighGlycemicCarbohydratesFructose

26医学PPTIncreaserisks

saturatedandtransfatshighglycemiccarbohydrateslackoffruits/vegetables/omega3sexcessomega6s?Reducerisks

fruits,vegetablesomega3slowglycemiccarbohydratesMediterraneandietInfluenceofNutrition

onChronicDisease

27医学PPTBenefitsofMediterranean-TypeDiet

onChronicDiseaseRiskClinicalinterventionstudies70%↓heartattacks,cardiacdeath&totalmortalityDeLogeril9460%

↓cardiaceventsinCVDpatients*Ornish98~50%↓metabolicsyndromeEsposito0439%↓inCRPEsposito04↓insulinresistanceEsposito04↓weightEsposito04Prospectiveobservationstudies80%↓diabetesMartinez-Gonzalez08~31%↓all-cause&cardiovascularmortality,22%↓cancermortality**calculatedfromSofi08

73%Alzheimer’smortality

Scarmeas0725-30%↓Parkinson’sdiseaseGao0778%↓childhoodasthmamaternaldietChatzi08*10%lowfat,vegetariandiet+exercise,stressreduction**Forevery2pointincreaseinadherence(ona9pointscale),riskreductionswereobservedof0.91forallcausemortality,0.91forCVmortality,0.94foroccurrenceandmortalityfromneoplasm.Toconveytheimplicationsofthesefindings,wehaveappliedtheriskreductionsacrossa9pointadherencescaletoyieldacalculated~31%↓all-cause&CVmortalityanda22%↓incancermortality.28医学PPTBenefitsof

Sustainably-ProducedFoodNutritionalbenefits:Generallyhigherlevelsofvitamins,mineralsandphytochemicals(oftendependentonsoilquality)

HigherOmega-3contentOrganicsamplescontainedhigherconcentrationsofpolyphenolsandantioxidantsin75%ofthematchedpairsrepresentingthosenutrients

Benefitsforfarmworkersandcommunities:Reducedexposuretopesticides

29医学PPTAlteredPathwaysEnvironmentDrivesChronicDiseaseEnvironmentalFactorsChronicDiseaseToxicChemicalsAirpollution,Leadandotherheavymetals,somePesticides,BisphenolAandotherEndocrineDisruptors30医学PPT31医学PPTLeadCumulativeoccupationalexposure↑cognitiveimpairmentShih20072xriskParkinson’sCoon2006Cumulativecommunityexposure

↑cognitiveimpairmentShih2006Upto15yearscognitiveagingWeisskopf2004AnimalstudiesofearlylifeexposureLate-lifeAlzheimer’smarkersBasha2005,Lahiri2007

32医学PPTPesticidesParkinson’sDiseaseHumanstudies-24/31studiesshow↑risksforPD.(OR1.6-7)Brown2006Animals-Rotenone¶quatdamagedopaminergicneuronsinstriatalregionofbrainUverskyVN2004-Combinationsofmanebandparaquat;prenatalexposure“primes”thebrain,increasingadultsusceptibilityCory-Slechta2005Cognitivedecline/dementiaLowlevelfungicidesinvineyards3.5xpoorattention,memoryBaldi2001

Occupationalexposureinmenassociatedwith2xriskofdevelopingADBaldi2003InsulinResistance,metabolicsyndrome

Lee2006,2007,2007Somepersistentpesticidesshowstrongdose-responserelationtoinsulinresistance andmetabolicsyndrome.

33医学PPTFoundinpolycarbonateplastic,resins,sealants.Exposuresarenearlyubiquitous.Endocrinedisruptor,oxidativestress.Causesfataccumulation&insulin

resistanceatlowlevels(animals).Alanso-Magdelena2006,Wada20073-fold↑Cardiovasculardisease.Lang20082-fold↑InsulinResistance.Lang2008

BisphenolA

polycarbonate34医学PPTInsulinsignaling↑bloodsugar

↑

arterydisease

↑

triglyceridesInflammationOxidativestressEnvironmentalFactorsDisruptInsulinSignaling,

DriveInflammatoryMetabolismEndocrine

Disruptors-BPA,dioxins,PCBs,somepesticides

SaturatedfatHighGlycemicCarbohydratesAirPollution↓Antioxidants

↓Omega-3

Fructose

SomePesticidesLead,otherheavymetals35医学PPTAlteredPathwaysEnvironmentDrivesChronicDiseaseEnvironmentalFactorsChronicDiseaseBuiltEnvironmentPhysicalActivity36医学PPTHealthBenefitsofPhysicalActivityReducedongoinglevelsofoxidativestressandinflammatoryburden.

Brooks2008,Attipoe2008InverselyassociatedwiththerisksofAlzheimer’s/dementiaandcognitivedecline.Rovio2005SubjectsatriskforADwhowalked150min.perweekshowedimprovementsincognitionwhilethecontrolgroupshowednonetchangefrombaselineat1.5yrs.Lautenschlager2008Increasingphysicalactivityatanyageimprovesphysicalandemotionalwellbeing.37医学PPTWalkableCitiesProjectsCommunityGardensFarmer’sMarketsRailstoTrailsLivableCommunitiesEnhanceHealthyAging38医学PPTCuba-lostfossilfuels↑biking,walking,localplant-basedfood↑physicalactivity

50%↓obesity50%↓mortality:DM51%,CVD35%,stroke20%,allcause18%FrancoMetal.ImpactofEnergyIntake,PhysicalActivity,andPopulation-wideWeightLossonCardiovascularDiseaseandDiabetesMortalityinCuba,1980-2005.AJE166,12;Sept.19,2007SustainableFood&TransportationSolutions:

TheCubaExample39医学PPTGreenSpace

ReducesStress,Mortality,ImprovesCognitiveFunctionShortenspostsurgicalrecoverytime,reducesneedforpainmedications.

Ulrich‘84Attentiondeficitsimproveafterawalkinthepark.Effect=methylphenidate.

Taylor’08Accesstogreenspacereducestheeffectofpovertyonmortalityby~50%.Mitchell‘0840医学PPTInsulinsignaling↑bloodsugar

↑

arterydisease

↑

triglyceridesInflammationOxidativestressEnvironmentalFactorsDisruptInsulinSignaling,

DriveInflammatoryMetabolismObesityEndocrine

Disruptors-BPA,dioxins,PCBs,somepesticides

InactivitySaturatedfatHighGlycemicCarbohydratesAirPollution↓Antioxidants

↓Omega-3

Fructose

Lead,otherheavymetalsSomePesticides41医学PPTAlteredPathwaysEnvironmentDrivesChronicDiseaseEnvironmentalFactorsChronicDiseaseSocio-Economic

StressDepression,poverty,violence,inadequatehealthcare42医学PPTSocioeconomic,PsychosocialStressorsStress,depressionriskfor CVD,AD

Sesso,Kario,OwnbyPeoplewithlowerSEstatusareatriskforexposuretomultipleenvironmentalhazards↑damage.Lead+stress

↑cognitiveimpairment

Glass2009Lead+airpollution↑CVautonomicdysfunctionPark200843医学PPT

Peoplewholiveinneighborhoodsthatlacksocialcohesion,sidewalks,orsafetylimittheirexerciseandhaveanincreasedriskofdepressionandpossiblyobesity.

BerkeEM07,MolnarBE04EffectsoftheBuiltEnvironmentonHealth44医学PPTInsulinsignaling↑bloodsugar

↑

arterydisease

↑

triglyceridesInflammationOxidativestressEnvironmentalFactorsDisruptInsulinSignaling,

DriveInflammatoryMetabolismObesityEndocrine

Disruptors-BPA,dioxins,PCBs,somepesticides

InactivitySaturatedfatHighGlycemicCarbohydratesAirPollution↓Antioxidants

↓Omega-3

Fructose

Lead,otherheavymetalsSomePesticidesStress45医学PPTMultipleFactorsInteracttoInfluence

Health

&

Disease46医学PPTEnvironmentalFactorsChronicDisease

AlteredBiologicalPathways↑GreenhouseGasesClimateCrisis

Heat,drought,storms,fires,icesheetinstability,sealevelrise,lossofglacialirrigation,refugees,foodinsecurity/starvation,tropicaldiseases

EnvironmentalFactorsDriveChronicDiseaseandtheClimateCrisis

47医学PPTSolutions

for

HealthyPeople&AHealthyPlanet48医学PPTMajorIllnessesArePreventable

PersonalActionstoProfoundlyReduceRisks

PersonalLevel–“ApproachestoHealthyLiving”Eathealthy–whole,fresh,unprocessed,plantbasedfoodsAvoidtoxicantswheneverpossibleExerciseBesociallyengaged

49医学PPTLocalized,diversifiedandsustainablefoodproduction

Clean,renewableenergy

↓airpollution,chemicalexposuresMasstransitthatconnectswithbikepathsandsidewalks

canreduce

airpollution&obesityChemicalregulatoryreform“Safersubstitute”programsandgreenproductdesign↓toxicexposures,ecosystem,wildlifecontamination;jobcreationUniversalhealthc