castañares partnering together for community health
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Partnering Together for Community Health
Going UpstreamACES, DOHad and Epigenetics
Community health workers
Priester Conference
April 2013 in Corvallis, Oregon
Tina Castañares, MD
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In the wise words of Dr. Don Berwick…
Founder, Institute for Healthcare Improvement
President Obama’s original director of Medicare and Medicaid (CMS)
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“The best hospital bed
is empty.
The best CT scan
is the one we don’t need.
The best doctor’s visit
is the one we don’t need.”
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% Oregon Population Defined as Obese(BMI > 30)
1989 1996 2003 20070
10
20
30
Year Measured
% o
f P
op
ula
tio
n
Data from NHANES, CDC 2009
Trends in Diabetes in USA
We know we’re in trouble
With thanks to Kent Thornburg, PhD, OHSU
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Moving Upstream of the Rapids
Moving Upstream of the Rapids
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CT image of coronary artery disease
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Overall, “upstream” population health work:
• Promotes wellness, prevents disease and improves health status
• Avoids “blame games” about individual responsibility for health
• Reduces demand for health care (overall spending, workforce, infrastructure)
• Raises all boats at once: truly equitable because population- and community-
wide
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Population-based Health is…
…more than twice as responsible historically for health improvement
than medical, nursing, oral health and mental health services
combined.
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The poor and minorities experience serious health disparities
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….because of risk factors such as:
• barriers to physical activity in schools, workplaces,
neighborhoods• food subsidies making fast and processed foods cheaper
• environmental contaminants• targeted tobacco & alcohol advertising• lack of access to fresh foods• crowding and substandard housing• many other well-documented social factors
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Achieving social equity
• …is the only real answer to preventable health disparities.
• …is a goal we have an ethical responsibility to work
toward… as citizens, voters, leaders
and members of the human commons.
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So now, more upstream still….
TO THE HEADWATERS
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ACESAdverse Childhood Experiences Study
DOHaD researchDevelopmental Origins of Health and Disease
Early childhood, neonatal, fetal, embryonic…. transgenerational !
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“The Adverse Childhood
Experiences Study -- The Largest Public Health Study You Never Heard Of”
Huffington Post October 2012 3 parts
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So now, more upstream still….
The Developmental Origins of Health and Disease (DOHaD)
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Low Birth Weight (LBW)
• US babies more likely to be LBW than in almost every other developed country.2
• LBW = 2nd leading cause of infant mortality in the US (after birth defects).
• Surviving infants at risk for serious medical conditions and learning disorders.3
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Unacceptable disparities
•LBW climbing for minority mothers
•African-Americans: 2 X likelier than whites, Hispanics for LBW babies
•Problem is not “in the genes” …and not always linked to current income
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How can this be? Epigenetics is the
key.
• Our GENES themselves aren’t all that different.
• People with identical genes turn out differently, get different diseases, etc.
• “Behavioral genetics” has long sought explanations.
• Epigenetics brings biological evidence.
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What does epigenetics tell us?
• Gene REGULATION and EXPRESSION are mostly in charge.
• Gene regulation is subject to many influences.
• “Social” influences not so very separate from “biological” influences
• Amazing: some gene regulation and expression can be inherited…. So this is trans- generational.
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Two key epigenetic factors I want to share today :
• Maternal and placental nutrition
• Maternal and fetal chronic stress (sustained elevated levels of stress hormones )
(A proven, very important third factor is maternal exposure to toxins.
Another involves paternal health and age. Doubtless, more will emerge.)
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Poor nutrition or sustained stress hormones:
• Developing embryo / fetus biochemistry responds by
-- making sub-standard vital organs (mostly smaller ones)
-- bigger placenta, lower birthweight
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Risk of chronic disease is predicted epigenetically, right from grandmother’s
preconception health, through
grandchild’s early life.
So EARLY prevention and corrections are
imperative.
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Epigenetic risk factors are preventable and even reversible.
• The earlier, the better• First 1000 days post-conception • Pre-conception too
Interventions must improve maternal (community !!!!) nutritional status, and prevent or reverse chronic stress.
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This is good news, not bad news… and not “biological
determinism”
• new scientific evidence to guide social policy, strategies, and investments !
• hope for better health for our society – a reversal of the last 100 years of downward health trends!
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Why should we do these things?
The future of human health is at stake.
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What can Extension do?
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• Peer-to-peer• Culturally competent: understanding from
within the culture or subculture• Natural leadership Community-building.
Community asset forever.• Special learning and teaching
tools/pedagogy (popular education, motivational interviewing)
• knowledge not restricted; infinite• role carefully defined, supported: a
prestigious and valued position stable staff
I am passionate about Community Health
Workers
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.
CHWs (health promoters) with whom I’ve been privileged to
work
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Imagine that we live in a region….
…which is the best place in the world for every baby to be born
…which is the best place in the world for every child to grow up
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I welcome your feedback.
Thank you, Extension! You do so much
for our communities….
and for population health, way upstream!