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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
In the wise words of Dr. Don Berwick…
Founder, Institute for Healthcare Improvement
President Obama’s original director of Medicare and Medicaid (CMS)
“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.”
% 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
Moving Upstream of the Rapids
Moving Upstream of the Rapids
CT image of coronary artery disease
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
Population-based Health is…
…more than twice as responsible historically for health improvement
than medical, nursing, oral health and mental health services
combined.
The poor and minorities experience serious health disparities
….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
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.
So now, more upstream still….
TO THE HEADWATERS
ACESAdverse Childhood Experiences Study
DOHaD researchDevelopmental Origins of Health and Disease
Early childhood, neonatal, fetal, embryonic…. transgenerational !
“The Adverse Childhood
Experiences Study -- The Largest Public Health Study You Never Heard Of”
Huffington Post October 2012 3 parts
So now, more upstream still….
The Developmental Origins of Health and Disease (DOHaD)
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
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
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.
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.
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.)
Poor nutrition or sustained stress hormones:
• Developing embryo / fetus biochemistry responds by
-- making sub-standard vital organs (mostly smaller ones)
-- bigger placenta, lower birthweight
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.
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.
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!
Why should we do these things?
The future of human health is at stake.
What can Extension do?
• 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
.
CHWs (health promoters) with whom I’ve been privileged to
work
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
I welcome your feedback.
Thank you, Extension! You do so much
for our communities….
and for population health, way upstream!
