Module 2

Question 1

Guy who came up with the epidemiologic transition

Answer 1

Omran

Question 2

Major causes of disease globally are cardio disease, cancer, chronic respiratory deaths, and diabetes - who said this and what % of deaths

Answer 2

Lancet editorial 2005
Cardio - 30%
Cancer - 13%
Chronic resp - 7%
Diabetes - 2%

Question 3

Breast cancer survival rate is 82% in developed countries, but no cancer has a survival over 22% in the Gambia - who said this

Answer 3

Sankaranarayanan 2010

Question 4

Melanoma is high in Australia and New Zealand - lots of sun and fair skin. Who said this

Answer 4

Lens 2003

Question 5

Colon cancer is high in the US and lung cancer is high in the UK. Who said this

Answer 5

Parkin 2001

Question 6

Asthma is prevalent in English speaking countries and parts of South America. Who said this

Answer 6

Lai et al 2009

Question 7

Diabetes is increasing in countries which are undergoing epidemiological transition and don’t have the infrastructure to tackle it e.g. South America, Africa, Asia, said who?

Answer 7

Danaei 2011

Question 8

Eastern European countries have increasing rates of cardio disease due to increased alcohol consumption and poor quality diets, said who

Answer 8

Yusuf et al 2001

Question 9

As life expectancy increases, there will be more dementia because there will be more people old enough to get dementia said…

Answer 9

Ferri et al 2005

Question 10

Cardio disease is top cause of death, along with stroke, COPD in high income countries

Answer 10

Lozano et al 2013

Question 11

In middle income countries, NCDs are still important but so are RYAs, COPD

Answer 11

Lozano et al 2013

Question 12

Stomach cancer is associated with H pylori and therefore refrigeration and therefore development

Answer 12

Crew et al 2006

Question 13

Infectious disease is still an important cause of death in low income countries although CVD is important and stroke/COPD are in the top 10

Answer 13

Lozano et al 2013

Question 14

Obesity is in low status people in the UK but high status people in India

Answer 14

McLaren 2007

Question 15

UN 25x25 strategy has 5 overarching actions for 5 goals

Answer 15

Beaglehole et al 2011

Question 16

Conditions targeted by 25x25 account for 87% of mortality from NCDs BUT only 54% of DALYs

Answer 16

Pearce et al 2014

Question 17

25x25 has ‘neglected’ some diseases like mental health problems, these don’t share risk factors with the NCDs they DID choose so there will be problems

Answer 17

Pearce et al 2014

Question 18

25x25 will need structural interventions/improvements to primary care and health systems

Answer 18

Pearce et al 2014

Question 19

New York banned trans fats

Answer 19

Okie 2007

Question 20

Food and drinks manufacturers have a lot of money (more than governments) to spend on marketing

Answer 20

Gallo 1999

Question 21

RE: the 25x25 strategy, we need to think about ‘causes of causes’ like the built environment rather than just inactivity

Answer 21

Vineis and Wild 2014

Question 22

Refugee camps can be hotbed of infectious disease due to lack of sanitation and overcrowding

Answer 22

Connolly et al 2004

Question 23

Malnutrition lowers immunity in a refugee situation, another cause for more infectious diseases

Answer 23

Connolly et al 2004

Question 24

Humanitarian aid needs to provide adequate food rations in refugee camps

Answer 24

Connolly et al 2004

Question 25

Famine causes problems for the offspring/Dutch Hunger Winter

Answer 25

Lumey et al 2007

Question 26

PTSD can be caused by traumatic events in conflict for refugees

Answer 26

Levey and Sidel 2009

Question 27

Violence and gender violence can happen in refugee camps e.g. lots of beatings in Jordanian refugee camps found in this study

Answer 27

Khawaja and Barazi 2005

Question 28

DRC has seen really extreme and horrific sexual violence as a result of conflict

Answer 28

Mukwege and Nangini 2009

Question 29

If you do it properly, reproductive/maternal health care can be better in camps than it was in the country of origin and therefore outcomes are better

Answer 29

Hynes 2002

Question 30

Education can be used to give children skills for avoiding disease and generally is good for them in refugee camps

Answer 30

Sinclair 2001

Question 31

Landmines cause lots of injuries to civilians as well as soldiers

Answer 31

Andersson 1995

Question 32

Need to evaluate what you’re doing in refugee camps

Answer 32

Connolly et al 2004

Question 33

Built environment influences physical activity and diet and therefore physical size and health

Answer 33

Papas et al 2007

Question 34

Migrant studies of colon cancer in Japanese migrants - their risk rose after leaving Japan so something environmental

Answer 34

Haenszel 1967

Question 35

Prostate cancer is higher in the West but more mortality in Africa and Latin America

Answer 35

Parkin 2001

Question 36

Lung cancer incidence is highest in the US and Western Europe but also in China, Russia, and other areas of Asia

Answer 36

Parkin 2001

Question 37

Bladder cancer incidence is highest in NorthAmerica, Europe and Egypt

Answer 37

Parkin 2008

Question 38

Cervical cancer is higher in SSA, Latin America, parts of Asia, due to HPV

Answer 38

Parkin 2001

Question 39

HPV infection is higher in SSA, Latin America, Asia etc

Answer 39

Forman 2012

Question 40

Liver cancer is higher in Africa and Asia - alcohol use, diabetes (?) liver flukes, hepatitis, aflatoxins

Answer 40

Parkin 2001

Question 41

MS has equator to poles gradient

Answer 41

Simpson et al 2011

Question 42

Looking at MS in US servicemen, 66.5% variation explained by latitude and 9% variation explained by having Swedish ancestry

Answer 42

Page et al 2004

Question 43

Migration from low to high risk areas doesn’t increase MS risk in the first generation, but the second generation migrants have MS rates similar to those in the host population

Answer 43

Gale and Martyn 1995

Question 44

MS is v prevalent in Faroe islands, thought it was ‘imported’ perhaps an infection

Answer 44

Kurtzke and Hyllested 1979

Question 45

Didn’t think MS came from Faroe islands; small number of cases and small population and unconvincing theory of transmission

Answer 45

Poser 1988

Question 46

Meta analysis of EBV seropositivity with odds ratio 13.5 in MS patients

Answer 46

Ascherio and Munch 2000

Question 47

Prospective study found significant increase in EBV seropositivity in MS cases, but problems with data e.g. don’t know which came first

Answer 47

Ascherio et al 2001

Question 48

Vitamin D might be related to MS; MS risk is 60% higher in those with low (<100 mol.l) it D serum levels

Answer 48

Munger et al 2006

Question 49

Social meaning given to a war impacts how people cope, what happens to their mental health. E.g. Guatemalan Mayas’ myths and identifies linked to land and maize; destruction of these made them feel like their collective body had been wounded

Answer 49

Summerfield 2000

Question 50

Two main approaches to looking at mental health in a crisis - Western/trauma and disorder focus and the psychosocial approach

Answer 50

Miller and Rasmussen 2010

Question 51

MH care in conflict needs to have some immediate provision, needs to be culturally appropriate

Answer 51

Mollica et al 2004

Question 52

Need to monitor mental health care you are giving in a conflict situation to ensure it’s sufficient and meets the population’s needs

Answer 52

Mollica et al 2004

Question 53

Poverty/economic uncertainty is common in migrant children, may experience racism, these can negatively impact mental health

Answer 53

Fazel et al 2012

Question 54

Two studies that found that there weren’t more emotional or behavioural problems in migrant young people compared to non-migrant young people

Answer 54

Belgium was Berluyn et al

The other one was Stevens and Vollebergh 2008

Question 55

Issues with data quality means some studies find more mental health problems in migrant children, some find less

Answer 55

Stevens and Vollebergh 2008

Question 56

Resilient families migrate

Answer 56

Porter nand Haslam 2005

Question 57

Migrant children have reduced alcohol intake and have higher aspirations so they achieve well in education

Answer 57

Fuligni 1988

Question 58

UASCs have higher experiences of traumatic events and higher rates of PTSD than accompanied children

Answer 58

Hodes et al 2008

Question 59

Review of surveys from 26 high income and 37 LMICs found 1/5 adults experienced common mental disorder in past 12 months; 29.2% experienced a common mental disorder in their lifetime

Answer 59

Z Steel et al 2014

Question 60

Highest 12 months prevalence rates globally were for anxiety disorders, mood disorders, and substance misuse disorders (in that order)

Answer 60

Z Steel et al 2014

Question 61

83% of LMICs, no anti-Parkinsonian pharmacotherapy in primary care
25% LMICs, no anti epileptics in primary care
WHO European region has 200x as many psychiatrists as Africa

Answer 61

Collins et al 2011

Question 62

LMICs lack comprehensive mental health service, especially services in primary care or the community

Answer 62

Saxena et al 2007

Question 63

Scarce resources for mental health in LMICs; very little of government spending is put towards them

Answer 63

Jacob et al 2007

Question 64

Health services are not being provided equitably to people with mental disorders; quality of care for mental health needs to be improved, mainly integrate MH awareness into health and social policy, health system planning etc

Answer 64

No health without mental health (WHO)

Question 65

Post natal depression is 10-15% in the UK

Answer 65

Royal College Psychiatrists

Question 66

Rates of post natal depression are 23% and 20% in different regions of India, 28% in Pakistan

Answer 66

Intia 23% - Patel et al 2002
20% in India - Chandran et al 2002
28% Pakistan - Rahman et al 2003

Question 67

Postnatal depression can be linked to abuse, polygamous marriage, giving birth to a daughter in a culture where sons are preferred

Answer 67

Fisher et al 2012

Question 68

Postnatal risks for children’s mental health: premature birth, low birth weight, abuse, psychosocial trauma, parental mental illness

Answer 68

Patel et al 2007

Question 69

Asthma can cause PTSD in children if they experience life threatening events

Answer 69

Kean et al 2007

Question 70

Maternal depression is associated with low birth weight and failure to thrive of the child

Answer 70

Rahman et al 2004

Question 71

Systematic review: small to medium effect of prenatal distress on global development, behaviour, socio emotional development (still issues with evidence quality)

Answer 71

Kingston et al 2013

Question 72

Maternal mental illness affects bonding and attachment

Answer 72

Cummings and Davies 2006

Question 73

Children’s attachment security can predict emotional development and therefore is very important

Answer 73

Kochanska 2001

Question 74

Childhood attachment classification correlates with adult attachment, and adult attachment is associated with depression

Answer 74

Bifulco 2002

Question 75

RCT: compared supplementation and stimulation in stunted children in Jamaica, together they had a benefit at 7 years but only stimulation sustained a benefit at 11 years.Follow up at 18 years only found a significant effect of stimulation on self esteem, depression, anxiety, and attentional problems; effect size not large for individuals but large enough to have a population level impact

Answer 75

Walker et al 2006

Question 76

“If we change our thoughts, we change ourselves” (CBT)

Answer 76

McMullin 2000

Question 77

CBT has evidence for adolescent depression

Answer 77

Klein et al 2007

Question 78

CBT has evidence for childhood and adolescent anxiety disorders

Answer 78

James et al 2013

Question 79

CBT has been used in Pakistan as part of Lady Health Worker community interventions, seems to work there

Answer 79

Rahman et al 2008

Question 80

Neurofibrillary tangles and amyloid plaques are key pathological processes in Alzheimer’s

Answer 80

Ballard et al 2011

Question 81

Tau is major constituent of neurofibrillary tangles in Alzheimer’s, believed to change concentration as a result of toxic amyloid beta concentrations

Answer 81

Ballard et al 2011

Question 82

Midlife cholesterol and blood pressure affect Alzheimer’s risk

Answer 82

Kivipelto et al 2001

Question 83

Amount of Alzheimer’s risk attributable to genetics is estimated to be about 70%

Answer 83

Ballard et al 2011

Question 84

Established genetic causes of Alzheimer’s are mutations of APP (Amyloid precursor protein), presenilin 1 (PSEN1) and PSEN2; cause of Alzheimer’s in only 5% patients who display symptoms usually in midlife

Answer 84

Ballard et al 2011

Question 85

PSEN1 and PSEN2 are part of gamma secretes which cleaves APP to produce amyloid beta

Answer 85

Ballard et al 2011

Question 86

Brain reserve concept - brain reserve modifies association between levels of brain damage and symptoms in Alzheimer’s

Answer 86

Stern 2006

Question 87

Non pharmacological interventions for Alzheimer’s include person centred care training, social interaction, aromatherapy, other conditions and polypharmacy can exacerbate cognitive decline

Answer 87

Ballard et al 2011

Question 88

Recently developed treatments for Alzheimer’s have failed in clinical trials; at the moment there is no drug with proven efficacy that acts directly on amyloid processing

Answer 88

Ballard et al 2011

Question 89

Benefit of antidepressant therapy in Alzheimer’s hasn’t been established although severe depression adds to impairment and disability

Answer 89

Ballard et al 2011

Question 90

At the moment, 60% of people living with dementia are in developing countries, but this is predicted to rise to 71% by 2040

Answer 90

(Ferri et al 2006).

Question 91

There is robust evidence that cognitive reserve (a combination of education, occupation, and mental activities), and physical inactivity are among the most important modifiable risk factors for Alzheimer’s disease

Answer 91

Lindsay et al 2002).

Question 92

There is some evidence that smoking is also a risk factor for Alzheimer’s disease

Answer 92

(Ott et al 1998)

Question 93

A Swedish epidemiological study additionally suggested that better social networks and social activities may reduce the incidence, but this has not been examined using large epidemiological cohorts so may not be strong enough yet to base policy on

Answer 93

Fratiglioni et al, 2004)

Question 94

Brain training games do not seem to give a benefit in people under 60, but specific types of cognitive stimulation may

Answer 94

Ballard et al 2011).

Question 95

There is not enough evidence to support associations with dietary or supplementary antioxidant or B vitamins

Answer 95

(Ballard et al 2011)

Question 96

several cohort studies have reported the potential of a Mediterranean diet to reduce Alzheimer’s

Answer 96

(Scarmeas et al 2006, Ravaglia et al 2008).

Question 97

Many treatable medical conditions are associated with increased risk of Alzheimer’s dementia, including stroke, diabetes, midlife hypertension, and midlife hypercholesterolaemia. The distinction of midlife is important. These probably relate to the lifestyle factors and conditions previously, and will be helped by interventions to encourage healthy living. However, although more intervention trials are needed the effect of management of diabetes and stroke, healthcare systems strengthening in low- and middle-income countries will make it easier to monitor lifestyles and to treat these common conditions in primary care. Randomised Controlled Trials, however, have not consistently shown beneficial effects of statins and antihypertensive drugs on cognitive function or dementia. Further research is needed on these

Answer 97

(Ballard et al 2011).

Question 98

Diabetes has been increasing globally along with a global increase in BMI. This is thought to have been caused by globalisation and the ‘Westernisation’ of traditional diets

Answer 98

(Dooley and Chaisson 2009).

Question 99

The clearest link TB and diabetes is as a result of diabetes’ effects on the immune system. Non-insulin dependent diabetes mellitus (NIDDM) patients have an impaired innate and acquired immune response, also shown in animal models. This increases the risk of patients progressing from a latent TB infection to active disease, as cell-mediated and Th2 immune pathways are crucial to developing effective control of LTBI(

Answer 99

(Dooley and Chaisson 2009).

Question 100

This biological link between TB and diabetes has been shown across epidemiological studies. Those with NIDDM vs control groups have a risk ratio of about 3 to progress to active disease

Answer 100

(Dooley and Chaisson 2009).

Question 101

Differences in management in patients with TB AND diabetes?

Answer 101

The radiological patterns are less specific(Dooley and Chaisson 2009) and there are longer times to sputum culture conversion(Dooley and Chaisson 2009). The risks of treatment failure and mortality are both increased, and there is an association with drug resistance(Dooley and Chaisson 2009). TB worsens glycaemic control(Dooley and Chaisson 2009), and overlapping pharmacological toxicities are a risk due to reciprocally interfering drug metabolism(Dooley and Chaisson 2009).

Question 102

Overall, the population attributable risk of TB with exposure to diabetes is 25%, which is the same as for HIV. Although the relative risk of HIV is higher, diabetes is much more prevalent, making them equivalent at the population level

Answer 102

(Jeon and Murray 2008).

Question 103

Overweight and obesity are now estimated to affect 1.5 adults worldwide, and this is expected to increase to 2.16 billion adults overweight in 2030 and 1.12 billion obese

Answer 103

(Popkin et al 2012).

Question 104

In developed countries, it is more common in low socioeconomic status groups as health education and promotion have more success in high socioeconomic groups in high income countries. Therefore, in countries such as the UK and the US, those with higher incomes do more physical exercise and are leaner. In low- and middle-income countries, obesity rates are higher in high socioeconomic status groups due to their decline in activity levels and the Westernisation of their diets

Answer 104

(Popkin et al 2012).

Question 105

Physical activity has been decreasing worldwide due to industrialisation

Answer 105

(Popkin et al 2012).

Question 106

In terms of genetic risks for obesity, there is a strong evidence base to suggest that foetal nutritional insufficiency triggers changes to enable the child to survive in a ‘resource poor’ environment. Postnatally, these changes may increase the risk of obesity and overweight. This is of particular concern for low- and middle-income countries where there is likely to be a mismatch between the maternal food environment (scarcity) and the food environment where the child will live as an adult (plenty)

Answer 106

(Popkin et al 2012).

Question 107

A study of Hmong refugee immigrants showed higher rates of central obesity among those raised in a war zone, with the effects greater in those who migrated o the United States

Answer 107

(Clarkin 2008).

Question 108

Who did the Dutch Hunger Winter study

Answer 108

Ravelli et al 1976

Question 109

Effective interventions for weight loss are varied; they include calorie deficit diets, low fat diets

Answer 109

(Ayyad and Anderson 2000)

Question 110

Adding meal replacements to a low-fat diet (with and without exercise and behaviour therapy) has been shown to produce a significant improvement in weight

Answer 110

(Noakes et al 2004).

Question 111

What is the problem with all the evidence about which diets to use for obesity

Answer 111

Only in rich people and often only short term success

Question 112

Modelling has shown that a 20% tax on sugary drinks in the UK would cut the number of obese adults by 180,000 and those who are overweight by 285,000

Answer 112

(Briggs et al 2014)

Question 113

South Korea is a very high income country which has a much lower prevalence of obesity than might be expected. One intervention implemented there was to have large-scale training of housewives in preparing traditional low-fat, high-vegetable cuisine, combined with strong social marketing. This led to high vegetable and low fat intake

Answer 113

(Popkin et al 2012)

Question 114

They also stated that in their research from around the world, most facilities and budgets were given to urban areas - “major urban hospitals received around two-thirds of all government health budgets, despite serving just 10% to 20% of the population”.

Answer 114

WHO report

Question 115

What are some of the barriers to providing care in rural Guyana

Answer 115

Long travel distances
Lack of transport
Communicaiton difficulties with rural villages
Adverse weather conditions can further limit access
Limited economic resources/user’s fee
Culturally appropriate services needed
Shortage of healthcare providers
Poor quality facilities/limited supplies
Overlap of personal and professional roles/confidentiality concerns

Question 116

Advantages of cohort studies

Answer 116

the exposure is measured before the outcome, so the quality and validity of the assessment is unlikely to be associated with the disease status. They are an efficient approach to investigate rare exposures and multiple outcomes, and the incidence of the disease can be measured in exposed and unexposed subjects. The national history can be uncovered with a cohort study, with a tight follow up of the affected individuals.

Question 117

Disadvantages of cohort studies

Answer 117

inefficient in the investigation of rare diseases as you would need a very large sample size in order to ensure that some people in the cohort would actually develop the disease. They can be very expensive and time consuming, with the exception of some historical cohorts. Changes in the exposure over time are difficult to assess, for example if someone stops smoking during follow up, and information on possible confounders is usually not available in historical cohorts. The knowledge of the subjects’ exposure status may influence the ascertainment of the outcome.

Question 118

Advantages of case control study

Answer 118

cheaper than a cohort study, is efficient (uses a small sample size), and is useful for studying infrequent events. A wide screen and study of many risk factors simultaneously is possible. Additionally, there are no drop outs and consistent techniques can be used.

Question 119

Disadvantages of case control study

Answer 119

you cannot draw a temporal relationship between exposure and outcome. They are prone to bias, and you can only study one outcome. You cannot measure the incidence, as you can with a cohort study. Finally, there is a large false negative potential.

Question 120

the definition of hypertension itself has changed - it is now much lower than it was a few decades ago

Answer 120

(MacMahon et al 2005).

Question 121

Describe blood pressure trends globally

Answer 121

In terms of trends, it seems that blood pressure is not changing much over time, although it is steadily decreasing at the moment by about 1mmHg/decade(Danaei et al 2011). Australian and Western European women have had the largest declines, whereas for men this is North America (Danaei et al 2011).
There is less data and more uncertainty for lower income regions, but we believe it is decreasing more slowly in Latin America and East Asia. It is not really changing in South Asia, and is increasing in East Africa.

Question 122

One of the major effects of raised blood pressure is ischaemic heart disease. This association exists at different ages, but it is the higher ages who generally have a higher risk of heart disease. The relationship is virtually linear as low as the blood pressure can get - even those at 140 systolic BP could benefit at any age from having a lower blood pressure

Answer 122

(Prospective Studies Collaboration, Lancet 2002).

Question 123

A study of a new ‘polypill’ to tackle multiple cardiovascular risk factors estimated that there would be a population level benefit of preventing 88% of heart attacks and 80% of strokes, with 1 in 3 people taking it directly benefitting even without measuring risk factors (just giving it to a particular age bracket

Answer 123

(Wald and Law 2003).

Question 124

It is thought that diet is part of the reason why we see an increase in blood pressure with age in the West, but not in groups with plant-based diets low in salt who are physically active

Answer 124

(Carvalho et al 1989 - BP in v rural populations).

Question 125

For people with larger BMIs, a study found there was a larger gain from changing CVD risk factors than for those of a lower BMI. This means that these groups should perhaps be targeted for treatment of hypertension.

Answer 125

Gregg et al

Question 126

Similarly, in the US, blood pressure tends to be higher in Native Americans and blacks, particularly in the rural South

Answer 126

(Danaei et al 2010 - 8 Americas).

Question 127

Study set up to look at the ecologic association across populations to see if Dahl’s ideas that a high salt diet led to high blood pressure were true, and also to look at the individual level by measuring blood pressrun 10,000 people between 20-59 years. Everything was done in a standardised way. In each population, an estimate was created of the rise in blood pressure with age. In some populations, blood pressure doesn’t rise with age, but in most places it does. They found that the higher the sodium intake, the greater the rise in blood pressure with age.

Answer 127

INTERSALT

Question 128

found that there was a strong relationship between dietary sodium and systolic and diastolic blood pressure which was even higher than the original INTERSALT results had found. They also found that higher dietary sodium was associated with greater differences in systolic and diastolic blood pressure in middle age than in youth.

Answer 128

(Elliott et al 1996) - INTERSALT revisited

Question 129

found that the risk of mortality from cardiovascular disease was higher in those with a higher salt intake, but there can be a lot of bias when looking at this sort of data.

Answer 129

A Finnish study

Question 130

Salt/BP evidence during the 90s

Answer 130

During the 90s, there were multiple attempts to look at trial data and produce meta-analyses. However, there were problems with data quality, such as trials being of very short duration and hence not physiological. Some found that sodium was associated with blood pressure and should be reduced (Cutler), but others found that the effect was so small in normotensive people that there would be little benefit (Midgley).

Question 131

One trial treated the issue like a drug trial, and participants were randomised into getting sodium pills or placebos. Blood pressure increased with the higher sodium intake, and came back down when the sodium intake decreased. Essentially, there was a dose response effect just like in the chimpanzee studies.

Answer 131

(Mascioli et al 1991)

Question 132

Major modifiable risk factors for CVD

Answer 132

high blood pressure, abnormal blood lipids, tobacco use, physical inactivity, obesity, unhealthy diets (low fruit and vegetable intake and high saturated fat intake) and diabetes mellitus.

Question 133

Other (not as strong) modifiable risk factors for CVD

Answer 133

low socioeconomic status, mental ill health, psychosocial stress, alcohol use, use of certain medications (such as some contraceptive pills and HRT), lipoprotein (a), especially int he presence of high LDL cholesterol, and left ventricular hypertrophy.

Question 134

Non modifiable risk factors for CVD

Answer 134

advancing age (most powerful independent risk factor), heredity or family history, gender (men more than women), and ethnicity or race (increased stroke noted from black, some Hispanic, Chinese and Japanese populations, and increased cardiovascular disease for South Asians and American blacks).

Question 135

Novel risk factors for CVD

Answer 135

These include excess homocysteine in the blood, inflammation (such as elevated CRP), and abnormal blood coagulation (especially elevated blood levels of fibrinogen).

Question 136

Where does dietary salt come from

Answer 136

Most salt in diets today comes from food processing, as opposed to salt that we add ourselves in cooking or at the table. The same is, worryingly, true of children’s diets. Worldwide, increases in salt intake are associated with the ‘nutrition transition’ and an increase in processed foods. In developed countries such as the UK, intake is now gradually decreasing as the evidence about the health effects of salt and public health messages increase. Salt can also come from soy sauce (a major source of salt intake in Asia), seafood, and when used as a preservative (so areas without refrigeration are more likely to have a high salt intake from food preservation)

Question 137

epidemiological study in Northern Japan where sodium intake was very high due to soy sauce consumption. High blood pressure was very common, as was stroke, whereas areas with a relatively lower salt intake such as the Marshall Islands had a lower % of hypertensives.

Answer 137

Dahl (1960)

Question 138

Definitions of malnutrition

Answer 138

Severe malnutrition is defined by the WHO as a weight for height more than 3 standard deviations from the mean, and a mid upper arm circumference of 6 months old.

Question 139

What is marasmus

Answer 139

Severe protein energy malnutrition usually leads to marasmus. The markers will indicate severe malnutrition, as above. The child will have a wasted, wizened appearance with no oedema and may often be withdrawn and apathetic.

Question 140

What is Kwashiorkor

Answer 140

another manifestation of severe protein malnutrition. However, in this case there is generalised oedema as well as severe wasting. This means that there will be a reduced weight for age, but weight may not be as markedly reduced as in marasmus because of the oedema. Other clinical features may appear in kwashiorkor. These can include:
Flaky paint skin rash with hyperkeratosis (Thickened skin) and desquamation
Distended abdomen and enlarged liver (usually due to fatty infiltration)
Angular stomatitis
Hair which is sparse and depigmented
Diarrhoea, hypothermia, bradycardia, and hypotension
Low plasma albumin, potassium, glucose, and magnesium

Question 141

Why do some children get kwashiorkor and some marasmus

Answer 141

unclear why some children develop marasmus and some develop kwashiorkor; both are a form of protein energy malnutrition. Marasmus tends to appear in famine, or when there is no food. By contrast, kwashiorkor tends to happen in infants not weaned from the breast until about 12 months of age. The subsequent diet may be low in protein but relatively high in starch. It can also often develop after an acute intercurrent infection such s measles or gastroenteritis.

Question 142

Vitamin A deficiency may cause blindness, zinc deficiency increases the risk of diarrhoea, pneumonia and malaria, anaemia impacts upon cognition, and iodine deficiency can cause goitre, congenital hypothyroidism, and developmental disability

Answer 142

(Black et al 2008).

Question 143

Globally, over 1/3 of child deaths are attributable to undernutrition in some way, such as susceptibility to infections

Answer 143

(Horton 2008).

Question 144

In 2005, 20% of children under 5 in low and middle income countries had a weight-for-age score of less than -2, indicating undernutrition

Answer 144

(Black et al, 2008).

Question 145

The prevalences were highest in south-central Asia and eastern Africa, where 33% and 28% respectively were underweight

Answer 145

(Black et al, 2008);

Question 146

The recommendation is for children to be breastfed exclusively for the first 6 months of life, and continued through the second year of life. In Africa, Asia, Latin America and the Caribbean, only 47-57% of infants younger than 2 months are exclusively breastfed

Answer 146

(Black et al 2008)

Question 147

Most incident stunting and wasting outside of famine situations happens in the first 2 years of life

Answer 147

(Black et al 2008)

Question 148

Specific educational messages for mothers, i.e. in areas of micronutrient deficiencies providing food supplements with micronutrient fortification, seem to have been the most effective in improving linear growth

Answer 148

(Black et al 2008).

Question 149

There is said to be a ‘golden interval’ for intervention from pregnancy to 2 years of age, after which undernutrition will have caused irreversible damage for future development towards adulthood

Answer 149

(Horton 2008

Question 150

Breastfeeding reduces mortality for children

Answer 150

(Bhutta et al 2008).

Question 151

How to promote breastfeeding?

Answer 151

In terms of how to promote breastfeeding, a Cochrane review of 34 trials found that all forms of extra support increased the duration of ‘any breastfeeding’, and all forms of extra support (such as professional support and individual counselling), together the affected the duration of exclusive breastfeeding more strongly than the likelihood of any breastfeeding (Bhutta et al 2008). Even a mass media campaign in Honduras was shown to have a beneficial effect on rates of breastfeeding (Bhutta et al 2008).

Question 152

in three studies, nutritional education in food secure populations produced an increase in height for age, and seven studies in food-insecure populations showed that height for age increased in a group given food supplements, with or without education. However, there are concerns about the overall effect size and very high energy intake in one supplementation trial. Overall, education strategies alone were found to be of most benefit in populations which had sufficient means to procure food; without this condition, educational interventions were of benefit when combined with food supplements.

Answer 152

(Bhutta et al 2008).

Question 153

found that total mortality among men with the highest education level is reduced by 43% compared to men with the lowest. Among women, the difference was 29%. The risk reduction was attenuated by 7% in men and 3% in women by the introduction of smoking, and to a lesser extent by introducing body mass index, and other variations such as alcohol consumption, leisure physical activity, and fruit and vegetable intake

Answer 153

Gallo et al (2012)

Question 154

found hypomethylation of NFATC1 with low socioeconomic status, although this time in humans. The gene was inflammatory in humans as well. NFATC1 is involved in the expression of cytokine genes in T cells, especially in the induction of the IL-2 or IL04 gene transcription. It regulates not only the activation and proliferation but also the differentiation and programmed death of T-lymphocytes as well as lymphoid and non-lymphoid cells.

Answer 154

EPIC-Torino cohort (currently unpublished)

Question 155

How does smoking cause epigenetic changes

Answer 155

Smoking has been found to cause changes in the methylation of AHRR, which is a suppressor of the ADH receptor, one of the key molecules regulating traffic between the external environment and the cell. For example, when you are exposed to tobacco smoke, it regulates the entry of molecules within the smoke. There is a cumulative risk dependent on the length of exposure - there is a relationship between methylation status and the number of cigarettes smoked. However, methylation will go back to the level of ‘never smoked’ some time after cessation of smoking. Therefore, we can see that environmental exposures impact upon methylation and epigenetics.

Question 156

Epigenetic findings of the dutch hunger winter study

Answer 156

DNA methylation was studied some 60 years after the famine. 60 individuals pre-natally exposed to the famine were compared with matched, unexposed siblings. They investigated several genes involved in metabolism, and found increase methylation in exposed individuals for a number of genetic markers relating to metabolism, including IFG DMR, which led to an increased risk of metabolic disease and cardiovascular disease. This persisted into adulthood from a peri-conceptional exposure, showing that although not all do, DNA methylation changes can persist over the life course.

Question 157

Findings of ISAAC phase I

Answer 157

English speaking countries had the highest asthma prevalences in the world, and there was little variation within the English speaking countries. Some countries in Latin America also had high prevalence. There was a north west - south east gradient within Europe, with rates being higher in the north west. They found an inconsistent correlation of asthma prevalence with affluence, and there were some areas (West/East Germany, Hong Kong/Guangzhou) with major prevalence differences even within the same ethnic group. There was a weak and inconsistent association between asthma prevalences and ‘traditional’ associated factors, cha s rhinitis and eczema. Although there were international differences in prevalence, again these did not in general correlate strongly with recognised ‘risk factors’ for the disease. There were actually negative associations (or no association) with air pollution, smoking, pollens, antibiotics, or immunisation. There were positive associations with GNP, tuberculosis, trans fatty acids, a lack of vegetables, paracetamol, and indoor humidity.

Question 158

Findings of ISAAC phase III

Answer 158

It seemed that there was little change in overall prevalence, but the international differences in asthma symptom prevalence had reduced with decreases in English speaking countries and increases in some (but not all) regions where prevalence was previously low. There were increases in diagnosed asthma in most regions, but particularly in Africa, Latin America, and parts of Asia. It was now clear that asthma was not a disease only of ‘English speaking countries’.

Question 159

What was the ‘old dogma’ of asthma?

Answer 159

that asthma was an allergic disease. It was thought that allergen exposure, particularly in infancy, produced atopic sensitisation and continued exposure would result in asthma through the development of bronchial hyper-responsiveness, airway inflammation, and reversible airway obstruction.

Question 160

What is the evidence against the ‘old dogma’?

Answer 160

less than half of asthma cases actually involve allergic mechanisms. It is true that in Western countries there is a consistent association between atopy and asthma, but there is almost no association in low and middle income countries. Most asthmatics are atopic (over 50%), but many non-asthmatics are atopic also. The proportion of cases attributable to atopy is less than 40% in both children and adults, and the fact that we don’t see the association everywhere suggests that it may not be causal.

Question 161

What’s the hygiene hypothesis?

Answer 161

This suggests that the increases could be due to increased susceptibility to the development of sensitisation and/or asthma due to other exposures (or absence of exposures) in utero and in infancy. In particular, it could be because our cleaner environment means that we have lost the previous protective effect of infant infections.

Question 162

Evidence against the hygiene hypothesis

Answer 162

we are simply replacing the old dogma with a new one without much support from evidence. It is not clear that the “new” risk factors suggested are strong enough to account for the prevalence increases (though the whole “package” of risk factors might be). Asthma prevalence is higher in Latin American countries than in places like Spain or Portugal, which would not really fit with the theory as they presumably have higher rates of infections. The hygiene hypothesis is conceptualised in the Th1/Th2 paradigm which appears to only account for about half of cases. Non eosinophilic (non atopic/allergic) mechanisms may account for the rest of cases.

Question 163

Global burden of maternal/reproductive problems

Answer 163

Maternal deaths and the maternal mortality ratio (MMR) have both decreased since 1980. However, the decline has only been about 1.8% until 1990 and then 1.5% afterwards, as the HIV epidemic slowed the decline in maternal mortality. There are still 939 maternal deaths each day - the equivalent of 3 Boeing 777 crashes every day.

There are also inequalities in maternal mortality. Only 1% of maternal deaths occur in high income countries. The MMR is higher in rural areas, and is higher among low educated mothers even within a particular countries.

Question 164

Trends in maternal mortality

Answer 164

maternal mortality is actually increasing in some high income countries as well as low income countries. For the high income countries, this could just be due to differences in ICD coding, i.e. it is not that the deaths have increased but more that deaths are now being classified as maternal mortality which may previously have been classified as something else. In other areas, such as Afghanistan, this is more likely to be a real increase. An increase may have occurred in some areas in Africa due to the HIV epidemic.

Question 165

Most prevalent cause of maternal mortality

Answer 165

severe bleeding. Risk factors for this, as with other pregnancy complications, is a lack of access to healthcare both before and during labour; it is a problem that is often controlled in developed countries using oxytocin and manual compression.

Question 166

Intervention for maternal mortality with strongest evidence base?

Answer 166

improve the availability of intra-partum care at a health centre. There is strong evidence that this can reduce maternal mortality, but may be the most expensive intervention to put into place, as well as being vulnerable to distance and cultural barriers to its implementation. Therefore, we need to consider other options.

Question 167

Second strongest evidence base intervention for maternal mortality?

Answer 167

Home services provide an alternative to health centre-based care, where there is skilled birth attendance at home in preference to community health workers or relatives and traditional birth attendants. There is, however, much less evidence for this as a successful intervention despite there being demand for it and it is more appropriate for remote areas.

Question 168

Maternal mortality interventions in Brazil?

Answer 168

In Fortaleza, Brazil, the maternal mortality ratio was reduced greatly using traditional birth attendants, but there was something of a compromise. Although 55% of home based deliveries had only a traditional birth attendant present, there was a good system of referrals to hospitals or clinics by the birth attendant. This was achieved mainly by making the birth attendants feel ‘part of the team’ with training, provided uniforms, support, and telephones. This could represent a good model for other countries as it combines the acceptability and low cost of home based care with the safety of hospital referrals when needed.

Question 169

Maternal mortality interventions in Malaysia?

Answer 169

more of a Western method where traditional birth attendants have been replaced by midwives. The traditional birth attendants have switched to a family supportive role. This meant that in 1995 only 1% of births were attended by a traditional birth attendant, and the expansion of free health services to the rural population has led to adequate provision of drugs and safer birthing practices. However, an important element of this intervention is that the midwives were based in village clinics with a attached housing. This may have made them more part of the community and helped them to bridge the gap between Western medicine and traditional practices.

Question 170

MAternal mortality interventions in Sri Lanka?

Answer 170

successfully increased birth attendance so that in 1996 over 94% of births took place in a hospital. They did this by providing free transportation and services, and there is a primary care unit within 5km of every home. They also ensured there was awareness of the facilities and good quality.

Question 171

Burden of FGM

Answer 171

FGM is most prevalent in Africa and the Middle East. 130-140 million women worldwide are affected by FGM; some 3 million girls will be at risk of undergoing some kind of FGM each year in Africa alone. Somalia has the highest rate of FGM.

However, FGM is an issue for Europe as well. It is difficult to know how many women are affected in the EU, but the figure of 500,000 victims is often cited. 180,000 girls in the EU are estimated to be at risk despite FGM being prosecutable in all EU member states.

Question 172

Burden of FGM in the UK

Answer 172

a report based on 2011 census data stated that about 60,000 girls were both in England and Wales to mothers who had undergone FGM, and about 103,000 women aged 15-49, and 24,000 women over the age of 50 are living with the consequences of FGM. About 10,000 girls under the age of 15 are likely to have undergone FGM. Somalian women are most commonly seen with FGM in the UK.

Question 173

Shorter term consequences of FGM

Answer 173

The procedure itself is often carried out with dirty instruments and a lack of anaesthesia. Not only does it violate the human rights of girls and women and constitute an extremely traumatic event, but it can cause serious bleeding and even death during the procedure.

In the short term, death may result from bleeding or infections. Severe bleeding is thought to be the commonest cause of death due to FGM. It can also cause severe pain and infections (local or systemic), urinary retention, and can cause the spread of blood borne diseases such as HIV and hepatitis.

Question 174

Long term risks of FGM

Answer 174

FGM can cause urinary tract or vaginal infections, pelvic pain, PID, infertility, apareunia/dyspareunia, pregnancy complications, psychosexual complications, increased risk of STI acquisition including HIV (which may be related to a higher incidence of traumatic sexual experiences). Women with FGM are at an increased risk of obstetric complications and STI/blood borne virus acquisition.

This is all compounded by the stigma and social pressure women suffer which may make it shameful for them to attend clinics and seek help.

Question 175

Social measures for FGM

Answer 175

Social measures are necessary because FGM has social causes. It is practiced generally as a matter of social convention and is often linked to the ritual marking of the coming of age and initiation to womanhood. These values and norms can be deeply entrenched, and so tackling them will take action from many sectors, especially with engagement of community groups and nongovernmental organisations. Programmes are best led by communities in a participatory, as opposed to authoritarian, way.

Question 176

Legal/political measures for FGM

Answer 176

Legal and political measures are more simple. As in the UK, FGM can be made illegal. Legislative measures can be made to protect future generations of women from FGM and enable states to act to protect girls at risk.

Question 177

Medicalisation of FGM - details

Answer 177

The medicalisation of FGM should also be tackled as it seems to be rising and could create a sense of legitimacy, and the incorrect idea that FGM is harmless. Policies should be made and education given to healthcare workers in countries where it is endemic so that they are aware that the practice is extremely harmful and constitutes a break in medical professionalism and ethical responsibility.

Question 178

What is a chemical hazard

Answer 178

A hazard is something which has the potential to do harm. OSHA describes a hazardous chemical as “any chemical whose presence or use is a physical hazard or a health hazard”. Those which are physical hazards include flammables and organic peroxides, amongst many others. Chemicals defined as health hazards are those which “cause either acute or chronic health effects due to exposure by inhalation, ingestion, or direct skin or eye contact”. These include carcinogens, irritants, corrosives and others.

Question 179

Describe the burden of asbestos

Answer 179

This was used as a building material as it has favourable physical properties such as tensile strength and heat resistance. IT was mined until the early 1990s.

Unfortunately, some/most forms are toxic. The fibres can cause lung damage, leading to mesothelioma. This is particularly true of blue asbestos. The long latency of asbestos-related mesothelioma and other diseases mean that cessation of use will affect disease rates but not for many years. Asbestos is no longer used or mined in the UK - there is an EU-wide ban on import, production, and use of the material.

However, asbestos is still mined in some areas of the world. Only 60 countries have banned its use despite health implications. This is a clear example of how scientific knowledge has led to the banning of a dangerous chemical in developed countries, which will reduce death rates from its use, but this has not yet trickled down to the developing world, where people will die for years to come as a result of asbestos exposure.

Question 180

Problems with REACH

Answer 180

recent legislation has come into effect to ensure that all chemicals, including historic ones, are tested for safety. This seems a noble idea, but unfortunately the number of chemicals that need to be tested were severely underestimated. It may not be possible to follow through with the legislation as this would require 54 million vertebrate animals and a cost of 9.5 billion euros over the next 10 years (Hartung and Rovida 2009). This highlights the need for new testing protocols to ensure we have the capacity to test safety as new chemicals emerge.

Question 181

Why is tobacco such a big issue

Answer 181

Tobacco is a major global health issue that causes a huge burden of ill health across the world. It also is now spreading to low-income countries which are being targeted by tobacco companies, making it a source of inequality as well. Tobacco use is strongly linked with lung cancer, and chronic diseases including Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular disease, among others.

It is estimated that tobacco will kill half of all current smokers, which would mean 650 million deaths. The death toll in the 20th century was estimated at 100 million, and given current trends it will reach 1 billion in the 21st century. The burden of tobacco-related mortality and morbidity will move increasingly towards the developing world as tobacco companies target them. Lopez et al (1994) wrote that there are 4 phases of a tobacco epidemic, whereby usage increases until it reaches a peak, and then slowly starts to decline. They thought that the government could curtail the progression, and pointed out the lag between rates of smoking and mortality which can ‘muddle the waters’ in tobacco policy debates.

Question 182

What effect has climate change had in Bangladesh?

Answer 182

Rising sea levels in the Bay of Bengal have caused salinisation, affecting 20 million people to varying degrees. In 2005, about 6 million people were exposed to very high levels of salinity and this will increase. In the last 50 years alone, salinity has risen by 45%.

As a result of the salinity, the prevalence of hypertensive disorders in women attending antenatal check ups in Bangladesh has increased, which has led some to believe that rising salinity might be a cause. A case control study of over 2000 pregnant women found that they were exposed to different sodium levels depending on their water source (Tubewells having the highest sodium), which in turn led to different levels of urinary sodium. Those receiving water from the Tubewells had higher mean systolic and diastolic blood pressure, and higher rates of pre-eclampsia.

Question 183

Burden of solid fuel use

Answer 183

One way in which energy supply needs to change to support development is in household fuels. Household air pollution from solid fuels is the third leading risk factor for global disease after high blood pressure and smoking. This accounted for 3.5 million deaths in 2010. The largest populations relying on traditional biomass fuels for cooking are developing countries, mostly in Asia. Around 3/4 of the burden is in just 10 countries including India and China. Governments need to find a sustainable, cleaner fuel for household use to support health.

Question 184

How does arsenic get into water

Answer 184

Arsenic is found in groundwater in some areas of the world. Groundwater is basically just mineralised rainwater, and arsenic can be found in it due to natural contamination. Arsenic poisoning affects about 70 countries. In Asian deltas, >80% of the population rely on groundwater for drinking water. It may now be getting into the food chain. Arsenic poisoning in Asia has ben called ‘the largest mass poisoning of a population in history’, and is particularly problematic as these populations are unlikely to be able to afford water treatment to remove it.

Question 185

What are the effects of arsenic contamination

Answer 185

Arsenic can be absorbed via inhalation or digestion, meaning that those who drink arsenic contaminated water will absorb it. It is transferred via the bloodstream to all organs, causing systemic damage.

Arsenic is dangerous because of its cellular effects. It replaces phosphate, causing cells to die. It also inhibits oxidative phosphorylation in the ATP energy cycle, and replaces S in thiol groups, inhibiting protein function.

Long term, low level exposure causes hyper pigmentation (black spots) followed by skin malignancy, peripheral arteriosclerosis (black foot disease). Lung, liver, and kidney cancer develop over time. Acute arsenic exposure results in vomiting, abdominal pain, bloody diarrhoea and death.

Question 186

Prevalence of arsenic contamination

Answer 186

More than 100 million people worldwide are exposed to elevated arsenic level sin their drinking water. Epidemiologic studies in Bangladesh, Chile, Argentina, Taiwan and the US have estimated about 4.51 additional lung cancer cases per 100,000 people with increased arsenic levels in water. Bangladesh in particular suffers to a high number of DALYs due to skin lesions from arsenic contamination. The majority of patients in Bangladesh are probably still in the second stage or arsenic poisoning and it is expected that lung and bladder cancer rates will increase in the future.

Question 187

How can we solve arsenic contamination

Answer 187

Arsenic contamination can be solved by understanding the distribution of arsenic in the aquifer, and avoiding the polluted zone or wells.

Question 188

How common is fluoride contamination

Answer 188

Fluoride is another contaminant of groundwater that is widespread in many low income countries. It particularly occurs in the north of Africa, and parts of Asia and Latin America. About 200 million people in 30 countries worldwide are drinking water with elevated fluoride; in India alone, endemic fluorosis is a major problem in 17 out of 22 states.

Question 189

How does fluoride get into water

Answer 189

Fluorine is the 13th most abundant element in the earth’s crust, and exists in trace amounts in almost all groundwater globally. Its presence in groundwater is associated with particular kinds of rock. Water-rock interaction leads to fluoride in solution, which is why groundwater is much more vulnerable to fluoride enrichment than surface waters.

People may be exposed to fluoride from other sources, including tea, pesticides, processed foods and beverages, pharmaceuticals, toothpaste, and teflon pans.

Question 190

What are the health effects of fluoride

Answer 190

Fluoride is an essential element for humans and there is an ‘optimum’ level which is required to avoid limited growth and fertility and dental caries. However, too much fluoride can cause fluorosis which affects the teeth and skeleton. Children in high fluoride areas have been found to have significantly lower IQ scores than those living in low fluoride areas. Dietary deficiencies in calcium and vitamin C are recognised as major exacerbating factors. Young children are at risk and once fluorosis develops, the problem is irreversible. The link between hypertension and fluoride may be confounded by sodium.

Question 191

How can we solve fluoride contamination

Answer 191

Resolving the fluoride problem in drinking water is a challenge. It tends to occur in arid regions with limited resources. Water treatment is technically feasible but has had limited success in developing countries, perhaps due to difficulties with maintenance, availability and cost of raw materials, or a lack of community participation.

Fluoride removal can broadly be done in four different ways. It can be precipitated with calcium and aluminium salts, adsorption and ion exchange, membrane filtration (reverse osmosis) or distillation.

Question 192

How is water salinity caused

Answer 192

In coastal regions, seawater was deposited together with sediments and is still present in the interstices, unless it has been flushed afterwards. Groundwater originates from laterally intruded seawater because of the interaction between the seas and hydraulically connected coastal aquifers. Coastal lowlands become flooded by the sea during marine transgression periods and seawater flows downwards because of density differences, and may have turned originally fresh coastal aquifers into saline groundwater.

Question 193

How can we solve high water salinity

Answer 193

Salinity can be reduced by increasing the height of the embankments, reducing the risk of overtopping and related salinisation of drinking water. Rainwater harvesting, identifying freshwater zones, and managed aquifer recharge can all be used to provide low salt drinking water. Finally, desalinisation could be an option to produce fresh water from saline water.

Question 194

NCDs account for a half of global disability

Answer 194

Beaglehole et al 2011

Question 195

10% rise in rate of NCDs à 0.5% reduction in rates of yearly economic growth

Underlying main risk factors – socioeconomic determinants: poverty, inequality, unemployment, social instability, unfair trade, global imbalances

Answer 195

Beaglehole et al 2011

Question 196

Lessons from HIV/AIDS for NCDs – integrated approach, development of methods, strategies and systems to support HIV programmes and train workers, task shifting and delivery of drugs/technologies for prevention and long-term care

Answer 196

Beaglehole et al 2011

Question 197

What are incidence studies

Answer 197

Subtype of longitudinal study, outcome measure is dichotomous (i.e. one thing or another – dead or alive).
Collect and analyse data on exposure and disease experience of entire source population.
Measures of disease incidence:
- person-time incidence rate (hazard rate, force of mortality or incidence density)
- incidence proportion or average risk – proportion of people who experience outcome at any point
- incidence odds – ratio of no. of people who experience outcome to no. people who do not

Question 198

Vit A – immune protection role against TB. Vit D – immunity, resp health and insulin resistance (amongst calcium and phosphate control)
· Previous trial – single oral dose enhance immunity to mycobacteria
· Vit D – regulate Beta cell function in pancreatic islet. Vit A à regulation cellular metabolisms, key role in glucose metabolism.

Answer 198

Wang et al

Question 199

Armed conflict has direct effects on mental health (this has been over-estimated and has led to a particular focus on alleviating PTSD rather than other factors).
Also indirect effects of daily stressors: poverty, social marginalization, isolation, inadequate housing, changes in family structure and functioning, fear of deportation à these can be caused by or just worsened by conflict

Answer 199

Miller and Rasmussen 2009

Question 200

Effect of daily stressors is cumulative even in non-war settings. Evidence that the ‘less dramatic but more enduring stressful conditions of everyday life that eventually take toll on people’s psychological wellbeing.’

Answer 200

Miller and Rasmussen 2009

Question 201

Why are daily stressors in conflict stressful?

Answer 201

1. Chronic stress exposure à continual activation of stress response system à increased risk physical and emotional disorder
2. Beyond control – i.e.over the lack of clean water or social situation. Perception of events changes to ‘stressful’. (Hence methods that foster greater sense of control are most effective)
3. Pervasive with conflict-affected population i.e. ALL displaced or affected, not all seen war
4. Encompasses wide range of events – some potentially traumatic experiences (e.g. abuse)
   Miller and Rasmussen 2009

Question 202

In armed conflicts: Need to bridge gap: not only focus on psychosocial interventions but also strengthen families and communities – promote positive outcomes in children.

Answer 202

Miller and Rasmussen 2009

Question 203

Blacks had a much higer obesity prevalence but a smaller magnitude
· Black women > black men but white men > white women
· For whites QALYs lost due to obesity men = women

Answer 203

Jia and Lubetkin 2010

Question 204

Many blood pressure lowering drugs are approved for the treatment of hypertension but not for the prevention of blood pressure related cardiovascular disease
· The global hypertention market in 2002 was worth about $36 billion
· Powerful commercial incentive exists to maintain the status quo

Answer 204

MacMahon et al 2005

Question 205

with the recent large increase in the consumption of highly salted processed foods, salt intake is now increasing again.
o Humans are genetically programmed to a salt intake of less than 0.25 g/d. The recent changes (in evolutionary terms) to a high salt intake present a major challenge to the physiologic systems to excrete these large amounts of salt through the kidneys
o The average salt intake in most countries around the world is approximately 9 to 12 g/d, with many Asian countries having mean intakes more than 12 g/d

Answer 205

Feng and MacGregor 2010

Question 206

Reducing salt from the current intake of 9 to 12 g/d to the recommended level of 5 to 6 g/d will have a major effect on BP and thereby CVD and may have other beneficial effects on health
o approximately 80% of salt is developed countries: hidden in foods, that is, added by the food industry
o In many developing countries, where most of the salt consumed comes from salt either added during cooking or comes from sauces, public health campaigns are needed to encourage consumers to use less salt.

Answer 206

Feng and MacGregor 2010

Question 207

The strong, positive association of urinary sodium with systolic pressure of individuals
concurs with Intersalt cross population findings and results of other studies. Higher urinary sodium is also associated with substantially greater differences in blood pressure in middle age compared with young adulthood. These results support recommendations for reduction of high salt intake in populations for prevention and control of adverse blood pressure levels.

Answer 207

Elliott et al

Question 208

Cross-sectional study in Glasgow:
o Hypomethylation found in the most socially deprived
o Hypomethylation also associated with higher inflammatory markers
o Chronic disease prevalence was higher among disadvantaged which is explained by high levels of chronic inflammation which leads to aberrant DNA methylation
· Study on men drawn from extremes of socio-economic status in childhood and adulthood:
o Stronger associations found with childhood than adult socio-economic position
o Different patterns of hyper- and hypomethylation found for different functional pathways in immunity

Answer 208

Ebrahim 2012

Question 209

Key themes of nutrition transition:
· Urbanization major driving force in global obesity
· Overweight and obesity emerging in low and middle income countries (LMIC)
· Changes in edible oil production created cheap vegetable oils that allowed LMIC to increase energy consumption at very low income levels

Answer 209

Popkin 2012

Question 210

The burden of obesity is greater in Asia, Latin America, Middle East and Africa due to differences in fat patterning and body composition and the cardio-metabolic effects of BMI at levels far below standard BMI overweight cutoffs of 25, hence why:
· In india => high prevalence of diabetes and impaired fasting glucose
· In china => high prevalence of hypertension and diabetes

Answer 210

Popkin 2012

Question 211

Shifts in energy balance and entire structure of the diet:
o Change from diets rich in legumes, other vegetables and coarse grains to “western diet” with refined carbs, added, sugar, fats and animal-source food

Answer 211

Popkin 2012

Question 212

o Modern food distribution and sales:
§ Disappearance of fresh market as the major source of food and instead replaced by supermarkets which are part of multinational chains or domestic chains
ú Benefits of this trend:
· E.g. UHT milk => give milk a long shelf life and provide a safe source of milk for all income groups
· Supermarkets key players in setting food safety standards
· Supermarkets solved the cold chain problem
ú Disadvantages of this trend:
· Increased access to cheaper, processed, fatty, sugary and salty food
o Freer flow in food trade:
§ E.g. barriers to edible oil imports have been reduced

Answer 212

Popkin 2012

Question 213

Interventions for critical nutrition window for children include:
§ Those to optimize the health and nutrition status of young women prior to pregnancy:
ú Minimize excess gains in adiposity
ú Establish health patterns of diet and physical activity
§ Those during mother’s pregnancy ensure:
ú High diet quality
ú Optimizing appropriate pregnancy weight gain
§ Breastfeeding = promotes healthy growth and reduces stunting but minimal effects on reducing the risk of child obesity
Taxation of selected foods and beverages
· Proving health food for those working in the public sector
· Stopping unhealthy food marketing to children through media control
· Increasing our knowledge on specific components of trade agreements that might adversely affect our diet
· Promoting home economics and gardening in children to teach people about healthy food and healthy food preparation
· In many countries the medical sector represents a major contact point for individuals and they are also held in high esteem and hence they should be used to provide guidance related to obesity to their patients

Answer 213

Popkin 2012

Question 214

Consequences of malnutrition:
· Impairs immunity => delayed wound healing and increased operative morbidity and mortality
· Worsens the outcome of illness e.g. respiratory muscle dysfunction may delay a child being weaned from mechanical ventilation
· Lead to behavioral abnormalities = Children less active, less exploratory, apathetic (if malnutrition prolonged and profound can cause permanent delay in intellectual development)

Answer 214

Lissauer and Clayden 2011

Question 215

In Dutch Hunger Winter:
Peri-conception was associated with a 5.2% lower methylation
No difference in IGFII DMR methylation between exposed individuals and their unexposed siblings
Peri-conceptional exposure to famine associated with lower methylation of IGF2 DMR:
o maybe related to a deficiency in methyl donors e.g. amino acid methionine
· Exposure to famine late in gestation not associated with IGF2 DMR methylation (indicates that the association between exposure and IGF2 DMR methylation is time-specific):
Time-dependency of the association observed related to the timing of tissue development

Answer 215

Heijmans 2008

Question 216

No single intervention alone can address the diverse range of causes of maternal death as some problems require multiple interventions (package of interventions)

Answer 216

Campbell et al 2006

Question 217

Packages of interventions:
· If the same package of intervention can be distributed via several means e.g. through social marketing, outreach by community workers through mobile clinics, health posts and clinics the likelihood of achieving high coverage is increased
· For a given effectiveness the lower the skill requirement of the component interventions and the easier the package is to distribute the more likely it is to attain high quality and coverage
Best bet strategy = effective package of intervention + effective means of distribution that have the potential to achieve high coverage + bought into by populations and government

Answer 217

Campbell et al 2006

Question 218

Total Fertility Rate had the strongest relation with maternal mortality (greater fertility -> higher mortality)

Answer 218

Hogan et al 2010

Question 219

Maternal mortality globally has had a yearly rate of decline of 1.5% since 1980
HIV epidemic in early 1990s slowed the decline
To meet the MDG target there would need to be a yearly rate of decline of 5.5%

Answer 219

Hogan et al 2010

Question 220

Proportion of maternal deaths shifted to sub-Saharan Africa; from 23% in 1980 to 52% in 2008 (increased due to HIV, and deaths in Asia decreased to produce this effect)

Answer 220

Hogan et al 2010

Question 221

“4 powerful drivers of maternal mortality are improving in most countries”:
Total fertility rate
Income per head is increasing especially in Asia and Latin America
Maternal educational attainment has been rising
Rise in coverage of skilled birth attendance

Answer 221

Hogan et al 2010

Question 222

“Chronic non-communicable diseases (CNCDs)… cause the greatest global share of death and disability, accounting for around 60% of all deaths worldwide”
“Some 80% of chronic-disease deaths occur in low- and middle-income countries”
“They account for 44% of premature deaths worldwide”

Answer 222

Daar et al 2007

Question 223

Panel’s ‘grand challenges’ for NCDs:
Raise public awareness
Enhance economic, legal, and environmental policies
Modify risk factors
Engage businesses and community
Mitigate health impacts of poverty and urbanisation
Reorientate health systems

Answer 223

Daar et al 2007

Question 224

“The prevalence of risk factors such as alcohol consumption and smoking is generally higher in former socialist countries in the eastern part of Europe than in the west”

“Worldwide, the highest proportion of heavy drinkers (18.9%) is in the region of Russia and the Ukraine”

Answer 224

Deckert et al 2007

Question 225

MARG (Mining Awareness Resource Group) had sent several letters to leading publications warning of unspecified “consequences” if the journals were to publish papers from a US government study into lung cancer and diesel exhaust.
They requested that the papers were not published until the resolution of a court case
Since 1992, the Diesel Exhaust Miners Study (DEMS) has been investigating the link between diesel exhaust and lung cancer while MARG has lobbied against them and demanded they share their data.
At the time of writing, DEMS were appealing a contempt of court ruling where MARG had alleged that DEMS had withheld data. If the appeal goes through, the papers can be published
But, if the ruling is upheld, then the publication of these papers may be delayed indefinitely.
The IARC (International Agency for Research in Cancer) can only make evaluations based on published papers so cannot change their listing for diesel exhaust unless these papers get published.
There is potential for these type of threat tactics to journals to become another strategy for industry to use to influence the scientific data in the public domain and could have a huge impact on the legitimacy of scientific literature.

Answer 225

Lancet 2012

Question 226

Study concluded that the majority of factors influencing cancers were environmental. However, they found that genetics play an important part particularly in some cancers which suggested that we still have many gaps in our understanding of genetic involvement in cancers which still need to be investigated.

Answer 226

Lichtenstein 2000

Question 227

In conclusion, this study shows that relatively low environmental exposure to asbestos such as that in an industrial area can increase risk of developing mesothelioma.

Answer 227

Magnani et al 2000

Question 228

Alcohol and tobacco:
Both industries face similar legislature such as advertising and retail restrictions.
Documents from tobacco company archives (forced to be made public due to laws passed in 1998) show that there have been consultations between alcohol and tobacco companies discussing how best to deal with these restrictions.
Similarly, they have both used the same techniques for opposing tax increases on their respective products (increased tax leads to decreased demand).

Answer 228

Bond et al 2010

Question 229

One example is both targeting youth despite denials that this is their intention, alcohol through alcopops and tobacco through flavoured cigarettes while also attempting to block the increase in minimum drinking age in several American states.
The companies also develop counter-productive “health awareness campaigns” in order to appear socially responsible. These campaigns are however ineffective.
This paper concludes that documents from alcohol companies now need to be made available (just like for tobacco companies) so that more of these strategies can be uncovered.

Answer 229

Bond et al 2010

Question 230

Floods and droughts are the main impacts of climate change on water availability. Besides these quantitative impacts, surface water quality is also affected by climate change

Answer 230

Delpa 2009

Question 231

1. Climate change is widely perceived as a threat rather than an opportunity.
   There may be significant overall benefits to health and development in adapting to
   climate change.
   • Efforts to adapt to climate change would create a stimulus to aim directly for higher levels of service for those currently unserved, without passing through the intermediate step of communal levels of services.

Answer 231

WHO Vision 2030

Question 232

• A focus on adaptation to climate change puts greater emphasis on the need to address water source sustainability from the outset of new programmes and not simply as an afterthought.
• Concern about adapting to climate change creates stronger pressure to rationalize the choice of technologies to be used to deliver sustainable and effective services.

Answer 232

WHO Vision 2030

Question 233

Reducing water use and better demand management will be critical in managing increased piped water supply and waterusing sanitation, especially where rainfall declines.
• Community-managed drinking-water sources and supplies fail early and are frequently contaminated. Climate change will aggravate this.

Answer 233

WHO Vision 2030

Question 234

Potential adaptive capacity is high but rarely achieved.
Resilience needs to be integrated into drinking-water and sanitation management to cope with present climate variability.
It will be critical in controlling adverse impacts of future variability.

Answer 234

WHO Vision 2030

Question 235

• I n sub-Saharan Africa, access to basic water supply and sanitation is low, and early adaptation is required to avert a decline in progress. In many countries this implies technology shifts.
• I n North Africa and the eastern Mediterranean, already dry regions with high coverage and service levels, there is an urgent need to manage services and water resources to avoid further water scarcity.
• I n Asia, drinking-water coverage is high with much rural reliance on protected wells. Flooding and decreasing reliability of surface waters may become major challenges.
• I n central and northern South America projections suggest drying combined with infrastructure damage from extreme events.

Answer 235

WHO Vision 2030

Question 236

extremes of temperature and rainfall, such as heat waves, floods and drought, have direct immediate effects on mortality as well as longer term effects. For example, populations that have experienced flooding may suffer from sustained increases in common mental disorders.
o also likely to affect biodiversity and the ecosystem goods and services that we rely on for human health. Changes in temperature and rainfall may also affect the distribution of disease vectors, e.g. those of malaria and dengue, and the incidence of diarrhoeal diseases.

Answer 236

Haines 2006

Question 237

Climate can affect levels of air pollutants, for example tropospheric ozone pollution may be higher in some areas of Europe, and lower in others but the relationships are still imperfectly understood

Answer 237

Haines 2006

Question 238

A recent paper demonstrates the potential benefits of converting all US on-road vehicles to hydrogen fuel-cell vehicles. Such vehicles powered by hydrogen from renewable energy sources such as wind power could save 3700–6400 lives annually from reduced air pollution as well as benefiting climate change

Answer 238

Haines 2006

Question 239

· Furthermore, the global economy is based on unsustainable foundations, not only because of a dysfunctional global financial system but also because human activities are undermining the planetary life support systems that sustain human health and development.

Answer 239

Haines 2012

Question 240

Decisive action is needed to cut global emissions by at least 50% by 2050. This figure implies a cut of at least 80% for a developed country such as the UK,6 which has benefited historically from access to affordable fossil fuels.

Answer 240

Haines 2012

Question 241

According to one measure, the benefits over time of approaches to move the world on to a low carbon path could be around $2.5 trillion (£1.6 trillion; €1.9 trillion) annually

Answer 241

Haines 2012

Question 242

WHO estimates that in 2004 over half the cases of pneumonia in children were related to exposure to indoor smoke from the combustion of biomass or coal in inefficient cook stoves or open fires
· Thus improved efficiency cook stoves or the use of biogas, for example, can greatly reduce indoor air pollution as well as helping to mitigate climate change.

Answer 242

Haines 2012

Question 243

Motorised transport is responsible for the vast majority of the deaths from road traffic injuries (1.3 million a year)11 and makes a substantial contribution to urban air pollution

Answer 243

Haines 2012

Question 244

· A systematic review of interventions to promote physical activity found that urban planning interventions in land use and transport were among the most effective—and better than other health promotion approaches focused on individuals

Answer 244

Haines 2012