Public Health (from Revision document) Flashcards
What is the gini coefficient?
a statistical representation of nation’s income distribution amongst its residents - the lower the coefficient, the greater the equality amongst people. UK has a rather high inequality coefficient compared to Scandinavian countries (Denmark etc)
What were the key findings of the Black Report (1980)?
i Material (environmental causes, might be mediated by behaviour) ii Artefact (an apparent product of how the inequality is measured) iii Cultural/behavioural (poorer people behave in unhealthy ways) Iv Selection (sick people sink socially and economically)
What were the key findings of the Acheson Report (1998)?
i income inequality should be reduced
ii give high priority to the health of families with children
What is proportionate universalism?
i Focusing on the disadvantaged only will not help to reduce the inequality
ii Action must be universal but with a scale and intensity proportional to the disadvantage (hence the name)
iii Fair distribution of wealth is important
What is the psychological theory of causation?
i stress results in inability to respond efficiently to body’s demands
ii impact on blood pressure, cortisol levels and on inflammatory and neuroendocrine responses
What is the neo-material theory of causation?
i more hierarchal societies are less willing to invest into the provision of public goods (this is the fundamental issue in societies such as the United States, hard to justify public goods)
ii poorer people have less material goods, quality of which is generally lower
What is the life-course theory of causation?
i a combination of both Psychosocial and Neo-material explanations
ii critical periods - possess greater impact at certain points in the life course (childhood)
iii accumulation - hazards and their impacts add up -> hard work leads to injuries resulting in disabilities that may lead to more injuries
iv interactions and pathways - sexual abuse in childhood leads to poor partner choice in adulthood
What are the 4 domains of public health?
Health Protection: infectious diseases, chemicals and poisons, pollution, radiation, emergency response
Improving services: clinical effectiveness, efficiency, service planning, equity
Health Improvement: lifestyles, family & community, education, employment, housing, surveillance and monitoring
Addressing the wider determinants of health: seeing the big picture - making sense of data
What are meta-ethics?
exploring fundamental questions:
right/wrong/defining the good life
What are ethical theories?
philosophical attempts to create ethical theories: i virtue ii categorical iii imperative iv utilitarianism v 4 principles
What are applied ethics?
a recent emergence of ethical investigation in specific areas (environmental, medical, public health)
What is a deductive ethical argument?
(one general ethical theory -> all the medical problems)
What is an inductive ethical argument?
(settled medical cases -> generate theory or guides to medical practice)
What is meant by considering what we believe in?
(General ethical theory -> institutions/feelings -> medical problem)
What are the ethical fallacies?
Ad hominem: responding to arguments by attacking person’s character rather than the content of their argument (Latin for: “to the man”)
Authority claims: saying a claim is correct because authority has said so
Begging the question: petitio principii - assuming the initial point of the argument
Dissenters: identifying those who disagree does not itself prove the claim is not valid
Motherhoods: inserting a soft statement to disguise the disputable one: “All humans are equal (so we shouldn’t stop PVS patient treatment). Confusing necessary & sufficient
No true Scotsman: modifying the argument:
i “No Scotsman would do such thing.”
ii “But this one did.”
iii “Well, no true Scotsman would.”
When can confidentiality be disclosed?
- Required by law: Notifiable Disease, Court/judge/police
- Public at risk:
Serious crime
Serious communicable disease
Research/education - Individual is vulnerable to exploitation:
Disabled etc - Patient consent:
-
What is the criteria for disclosure of confidential info?
Anonymous if practicable
Kept to necessary minimum
Meets current laws (data protection)
Patient’s consent
What are the 3 main notifiable diseases?
Yellow Fever, Cholera, Plague
What are 5 lifestyle factors that increase mortality?
Smoking Obesity Sedentary Lifestyle Excess Alcohol Poor diet
What are structural determinants of illness?
i social class ii material deprivation/poverty iii unemployment iv discrimination/ racism v gender and health
What is the biomedical model of health?
i Mind and body are treated separately
ii Body, like a machine, can be repaired
iii This privileges use of technological interventions
iv It neglects social and psychological dimensions of disease
What is health behaviour?
aimed to prevent disease (eating healthily)
What is illness behaviour?
aimed to seek remedy (going to the doctor)
What is sick role behaviour?
aimed at getting well (compliance, resting)
Describe the Health Belief Model (Becker 1974) of behavioural change?
i individuals must believe they are susceptible to the condition
ii individuals must believe it has serious consequences
iii individuals must believe that taking action reduces their risks
iv individuals must believe that the benefits of taking action outweigh the costs
Describe the transtheoretical model of behavioural change?
i Pre-contemplation (no intention giving up smoking) ii Contemplation (considering quitting) iii Preparation (getting ready to quit in the near future) iv Action (engaged in giving up smoking) v Maintenance (steady non-smoker) vi Relapse???
Define morality?
concern with the distinction between good and evil or right and wrong (rather universal)
Define ethics?
a system of moral principles and a branch of philosophy which defines what is good for individuals and society (may differ in different cultures)
What are explanations and criticisms of utilitarianism/consequentialism?
An act is evaluated solely in term of its consequences
• Maximising good and minimizing harm
• Types: hedonistic, rule, act, preference
• The “greatest happiness principle” of John Stuart Mill
Critique:
Treat minorities unfairly to promote the happiness of majority?
• Carry out ethically questionable research to maximise welfare of society?
What are explanations and criticisms of Kantianism (deontological)?
Features of the act themselves determine worthiness (goodness) of that act
• Following natural laws and rights
• Categorical imperatives - a set of universal moral premises from which the duties are derived (do not lie; do not kill; …)
A person is an end itself, never a means to an end • deon = duty (from the Greek)
Critique:
Key concern is with duties and rights.
• Not about consenquences of actions but acts have intrinsic worthiness
• Can duties conflict?
What are explanations and criticisms of Virtue Ethics (deontological)?
Focus is on the kind of person who is acting, deemphasizes rules
• Is the person in action expressing good character or not?
• We become virtuous only by practicing virtuous actions
• Integration of reason and emotion
• The Five Focal Virtues: i Compassion ii Discernment iii Trustworthiness iv Integrity v Conscientiousness
Critique:
The assessment of virtue is culture-specific? • The notion of virtue is too broad and nonspecific to allow for practical application?
• An emphasis on the moral character of individuals ignores social and communal dimensions – Honesty points to telling the hurtful truth, kindness and compassion to remaining silent or even lying.
What are four principles (prima facie)?
Autonomy:
• (self-rule, the obligation to respect the decisions of our patients)
Ø The decision is intentional
Ø The decision is done with understanding
Ø There are no major controlling influences over the decision
Benevolence:
(providing benefits, balancing the benefits against risks)
Non-maleficence:
(do no harm, reduce or prevent harm)
Justice:
(Utility/QUALY, need vs. benefit, fairness in the distribution of benefits and risks)
What are the ethical duties of a doctor according the GMC?
Protect and promote the health of patients and the public
Provide good standard of practice and care
Recognise and work within the limits of your competence
Work with colleagues in the ways that best serve patients’ interests
Treat patients as individuals and respect their dignity
What are the different forms of assessment for assessing the functional limitations of elderly/frail patients?
The Katz ADL (Activities of Daily Life) Scale
IADL (Instrumental Activities of Daily Living)
The Barthel ADL Index
MMSE (Mini Mental State Examination)
What variables are examined by the Katz ADL scale?
i bathing ii dressing iii toilet use iv transferring (in/out of bed or chair) v urine and bowel continence vi eating
What variables are examined by the IADL?
i use of the telephone
ii travelling by car or using public transport
iii food or clothes shopping
iv meal preparation
v housework
vi medication use (preparing and taking correct dose)
vii management of money (paying bills)
What variables are examined by the Barthel ADL Index?
i feeding ii moving from wheelchair to bed iii grooming iv transferring to and from a toilet v bathing vi walking on level surface vii going up and down stairs viii dressing ix continence of bowels x continence of bladder
What variables are examined by the Mini Mental State Exam (MMSE)?
i orientation, immediate memory
ii short-term memory
iii language functioning
Define Acute Illness?
a disease of short duration that starts quickly and has severe symptoms (often can be cured)
Define Chronic Illness?
a persistent or recurring condition, which may or may not be severe, often starting gradually with slow changes (can’t be cured but can be treated)
Define Polypharmacy?
the use of multiple medications or administration of more medications than are clinically indicated
What are the key public health challenges of an ageing population?
- Strains on pension and social security systems
- Increasing demand for health care
- Bigger need for trained health workforce
- Increasing demand for long-term care
- Pervasive ageism (denying older people the rights and opportunities available for other adults)
What are the causes of the ageing population?
- Improvements in sanitation, housing, nutrition & medical interventions
- Life expectancy is rising around the globe
- Substantial falls in fertility (higher age of first pregnancy?)
- Decline in premature mortality
- More people reaching older age while fewer children are born
What is intrinsic ageing?
natural, universal, inevitable
What is extrinsic ageing?
dependent on external factors (UV ray exposure, smoking, air pollution, etc.)
Give examples of physical changes in later life?
- Loss of skin elasticity and hair colouring
- Decrease in size and weight
- Loss of joint flexibility
- Increased susceptibility to illness
- Decline in learning ability and less efficient memory
Describe the age-related reduction in sensory effectiveness?
Visual:
i Need 3x more light
ii Depth/colour perception
iii Narrowing of visual field
Hearing:
i High frequency loss
ii Speech comprehension 20%
Taste and Smell:
i 50% loss of taste buds
What is the gender bias of ageing?
- Women live longer than men
- In very old age, the ration of women:men is 2:1
- Causes are: approx. 20% biological – premenopausal women are protected from heart disease by hormones § 80% environmental – men take more lifestyle risks than women
What are the consequences of higher life expectancy?
- Pensions will have higher pay outs than those currently planned
- Chronic and comorbid conditions will prevail
- Rising inequalities as more affluent groups will use health services for longer
What are the different types of dementia and what percentage of the total do each of them make?
Alzheimer’s disease: 62%
Vascular Dementia: 17%
Mixed Alzheimer and Vascular: 10%
Lewy bodies: 6%
Fronto-temporal:2%
Other types: 3%
What are alternatives to hospital admission for elderly patients?
- Supporting discharge from inpatient hospital care
- Providing alternatives in acute care within the community
- Supporting chronic disease management within the community
What is the institutionalisation of death?
60% of people die in hospital (but 70% want to die at home)
What is the medicalisation of death?
death as failure, curative endeavour of biomedicine, prolonging life at any cost, death as natural part of our life challenged
What were the 4 awareness contexts identified by Glaser and Strauss (1965) awareness of dying?
i Closed awareness
ii Suspicion awareness
iii Mutual Pretence
iv Open awareness
What is social death?
when people die in social and interpersonal terms before their actual biological death - lonely, impersonal death
What is meant by good death?
palliative care became a specialty, aiming to demedicalise death - a reaction against the impersonal medical city
What is death the hospice way?
i open awareness, compassion, honesty
ii multi-disciplinary teams
iii emotion and relationships - modeled on a family approach
iv holistic care
What is the chain of infection?
• Susceptible host - low immunity, low white cell count, imbalance in normal flora, invasive procedures
• Causative micro-organism - increase number in hospital, resistant strains
• Reservoir - patients, visitors, stuff, fomites -> where the spread originates
Portal of entry/exit - respiratory tract, GI tract, GeUri tract, broken skin
Mode of transmission:
i exogenous spread (direct/indirect contact, vector spread, airborne)
ii endogenous spread (self spread)
How can you break the chain of infection?
• removing transient hand flora i staphylococcus aureus ii streptococci iii viruses • reducing number of resident flora i anaerobic cocci ii staphylococcus epidermidis
What are the different levels of hand washing?
- Routine handwash
- Hygienic hand antisepsis
- Surgical handscrub
What is alcohol gel?
destroys most transient organisms (MRSA) but does not kill Norovirus or Clostridium difficile
What is antimicrobial liquid soap?
removes all transient organisms
What are the types of waste?
Household waste:
paper, plastic bottles, containers
Clinical waste: sharps, soiled dressings, blood, body fluids (must be traceable back to the source!)
Sharp bins -
What are STANDARD INFECTION CONTROL PRECAUTIONS?
gloves and aprons, hand hygiene
correct sharps manipulation
correct clinical waste and linen handling
What are the physiological effects of nicotine?
activation of nicotinic ACh receptors in the brain
causing dopamine release in the NAcc (nucleus accumbens)
stimulant, tolerance and withdrawal
What is the epidemiological impact of smoking?
the greatest single cause of illness and premature death in the UK
100,000 deaths/year due to smoking
cancers, COPD, CHD
a great economic impact of smoking
What are health problems associated with smoking?
cardiovascular problems (strokes, heart attacks, DVTs)
other cancers (stomach, kidney, pancreas, bladder, mouth, throat,…)
stomach ulcers
impotence
diabetes
oral health (gum disease)
cataracts
What are key laws and dates regarding smoking?
1908-Children Act: sale of tobacco under 16s prohibited
1950-Richard Doll & Austin Bradford Hill: Smoking & Lung Carcinoma
1965: Parliament bans cigarette advertising on TV
2007: Smoking in public banned + legal min. raised to 18 in the UK
2015: Smoking in car with children banned in the UK
What are the two main options for smoking cessation?
NRT (Nicotine Replacement Therapy): i patches, gums, nasal spray, microtab, inhalator
Non-nicotine pharmacotherapy: i Varenicline (Champix) ii Bupropion (Zyban)
What are the 3As in smoking cessation?
ASK: your patient about smoking
Advise: your patient on cessation methods available
Assist: your patient and refer to local NHS Stop Smoking Service
What are the 8 Millennium Development Goals?
- Eradicate Extreme Poverty & Hunger
- Achieve Universal Primary Education
- Promote Gender Equality & Empower Women
- Reduce Child Mortality
- Improve Maternal Health
- Combat HIV/AIDS, Malaria and Other Diseases
- Ensure Environmental Sustainability
- Develop a Global Partnership for Development
What are the 3 leadings causes of death in children in the developing world?
- Pneumonia
- Diarrhoea
- Malaria
What are the key actors in global health and what are examples of each?
UN Agencies: UNICEF / UNAIDS / WHO
Foundations: i The Rockefeller Foundation ii The Bill & Melinda Gates Foundation
NGOs: i Doctors Without Borders (MSF) ii Save the Children
Multilateral Development Banks: i The World Bank ii Asian Development Bank iii Inter-American Development Bank
Bilateral Agencies: USAID, CIDA, DFID
What are examples of global environmental change?
CFCs and stratospheric ozone depletion Loss of biodiversity within ecosystems Freshwater decline and land degradation Loss of natural fisheries Increasing desertification
What are global health issues?
Common health problems Health problems that cross borders International migration International political crises International agreements Global environmental change migrant health
What are migrants?
asylum seekers, refugees, trafficked people
migrant workers, family workers
family joiners, international students
How is a migrant defined?
Country of birth
Country of nationality
Duration of stay
What are causes of vulnerability in migrants?
Persecution, war, political and social unrest
Exploitation, torture, rape, bereavement
Burden of disease and socio-economic status
What are the NHS goals of equality?
Equity of access
Reducing gap in health inequalities
Providing services for the vulnerable
Ensuring the services are appropriate and accessible
Define Sustainability?
Being able to meet the needs of today without compromising the ability of future generations to meet the needs of tomorrow.
What are the core facts of climate change?
350 million years-worth of carbon locked away in burning fossil fuels over the last 150 years
greenhouse effect -> irreversible heating of the planet
Bradford Hill Criteria i a group of minimal conditions necessary to provide adequate evidence of a causal relationship ii aka “criteria for causation”: § strength § consistency § specificity § temporality § biological gradient § coherence § analogy
Possible consequences: i heatwaves (bacteria happier, desertification, more diarrhoea) ii sea level rise iii new diseases iv scarcity of resources -> migration -> war (?)
Solutions? i Control world population ii Reduce energy consumption iii Get our energy from renewable resources
Define Screening?
A process which sorts out apparently well people who probably have a disease from those who probably do not
The main purpose is PREVENTION
What are primary, secondary, and tertiary prevention?
Primary prevention - to prevent a disease from occurring
Secondary prevention - detection of early disease in order to alter the course of the disease and maximize the chances of a complete recovery
Tertiary prevention - trying to slow down the progression of the disease
With screening, what is meant by sensitivity?
a / a+c : the proportion of people with the disease who are correctly identified by the screening test
With screening, what is meant by specificity?
d / b+d : the proportion of people without the disease who are correctly excluded by the screening test
With screening, what is the positive predictive value?
a / a+b : the proportion of people with a positive test result who actually have the disease
With screening, what is the negative predictive value?
d / c+d : the proportion of people with a negative test result who do not have the disease
What is prevalence?
the proportion of a population found to have the disease
What is incidence?
the number of new cases within a specified time period divided by the size of the population initially at risk
What are the WILSON AND JUNGNER CRITERIA FOR SCREENING?
The Condition:
i it should be an serious health problem
ii the aetiology should be well undestood iii there should be a detectable early stage
The Treatment:
i there should be an accepted treatment for the disease
ii facilities for diagnosis and treatment should be available
iii there can’t be an unmanageable extra clinical workload
The Test:
i a suitable test should be devised for the early stage
ii the test should be acceptable for the patients
iii intervals for repeating the test should be determined
Benefits:
i there should be an agreed policy on whom to treat
ii the cost should be balanced against the benefits
What is selection bias?
people who choose to participate in screening programmes may be different from those who do not
What is lead time bias?
screening merely identifies the disease earlier than before and thus gives the impression that survival is prolonged (but survival time unchanged!)
What is length time bias?
diseases with longer period of presentation are more likely to be detected by screening than the ones with shorter time of presentation.
What is error?
is any preventable event that may cause or lead to patient harm
What is medical error?
leads to one of two outcomes:
i adverse event: an incident which results in harm to a patient
ii near miss: an event which has the potential to cause harm but fails to develop further, thereby avoiding harm
What are the types of error?
Errors of Omission
Errors of Commission
Errors of Negligence
Skill Based Errors
Rule/Knowledge Based Errors
Violations
What are errors of omission?
required action delayed/not taken
What are errors of commission?
wrong action is taken
What are errors of negligence?
the actions or omissions do not meet the standard of an ordinary, skilled person professing
What are skill based errors?
i when performing a routine task that is well learnt (automatic) ii little attention given, thus if distracted - slips of actioin / memory lapses
What are rule/knowledge based errors?
i an incorrect plan or course of action is chosen (no experience) ii mistakes more likely when the tasks are more complex
What are violations?
deliberate deviations from practices, procedures and standards or rules • types: i routine (cutting the corners) ii necessary (to get the job done - sometimes unavoidable) iii optimising (personal gain, selfish)
What are information processing limitations?
automaticity cognitive interference selective attention cognitive bias transferring our expectations from familiar situations to similar new ones
What are the two approaches to managing errors?
The Person Approach
- individual
- errors are the products of wayward mental processes of individual people in the system
The system Approach
organisational
- adverse events are product of many causal factors (Swiss-cheese theory)
- the whole system is to blame
What makes an effective team?
optimal team size good team dynamic a common purpose an identified team leader shared knowledge and experiences
What are the benefits of teamwork?
improving the service delivery
improving the decision-making
reducing the error
What are the obstacles to good teamwork?
organisational (different offices/shifts/rotation posts)
location (ward based/ visiting/ based elsewhere)
management (different employers/sub-teams)
other commitments of the team members
What is the SBAR checklist for reporting an error?
S Situation
B Background
A Assessment
R Recommendation
What is the WHO defintion of mental health?
Mental health is a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is bale to make a contribution to his or her community.
What are the common mental health problems(CMHPs)?
Depression Generalised Anxiety Disorder Panic disorder Phobias Social Anxiety Disorder Obsessive-compulsive disorder (OCD) Post-traumatic stress disorder (PTSD)
What are the numbers of mental health?
350 million people worldwide have depression at any one time
24 million people have a severe mental illness (schizophrenia etc.)
1 million people commit suicide
10-20% of children have a mental disorder
nearly 1/3 of doctors have some kind of mental disorder
up to 20% of doctors are depressed at some point and have higher suicide risk than general population:
i 42% work-related fatigue
ii 29% depression
iii 26% anxiety
iv 15% PTSD (especially females) v 6% burn out syndrome
Why are CMHPs dangerous?
They have a negative impact on quality of life (employment, ADLs, family)
They increase the risk of physical illness (chronic conditions)
They increase mortality from physical illness (e.g. heart disease)
Depression is a major risk factor for suicide
There is a correlation between household income and the incidence of CMHPs - better-off men are three times less likely to suffer from CMHP.
What are the interventions for CMHPs?
Community level Service organization level Individual level IAPT service model (Improving Access to Psychological Therapies): i high intensity care ii low intensity care
What is stress?
Stress occurs when the demands made upon an individual are greater than their ability to cope. (Atkinson, 1999)
What is distress?
a negative stress which is damaging and harmful
What is eustress?
a positive stress which is beneficial and motivating
What are stressors?
acute - noise, danger, infections, injuries, hunger etc.
chronic - health, home, finances, work, family, friends etc.
internal stressors i physical (inflammation, infection) ii psychological (attitudes, believes, personal expectations, worries)
external stressors (environment, work, social & cultural pressures)
What are the different responses to stress in the body?
Lungs
take in more oxygen (rapid breathing)
Blood Flow
increasing up to 400%
Skeletal Muscles
tense
Spleen
more RBCs discharged
Skin
blood flow directed away to support skeletal muscles and heart
Mouth
drier as saliva and mucus dry up
Immune System
WBCs redistributed
What is general adaptational syndrome?
Alarm: when threat /stressor identified
Adaptation/Resistance: defensive countermeasures engaged
Exhaustion: the body begins to run out of defences
What are the five signs of stress?
Biochemical: endorphin and cortisol levels altered
Psychological: shallow breathing, raised BP, more HCL produced
Behavioural: over-eating, anorexia, insomnia, more alcohol or smoking
Cognitive: negative thoughts, no concentration, worse memory, tension headaches
Emotional: mood swings, irritability, aggression, boredom, apathy, tearfulness
What is the diagnostic criteria for PTSD?
The person experienced an event that involved actual or threatened death or serious injury or a threat to physical integrity
The person’s response involved intense fear, helplessness, or horror.
What are the symptoms of PTSD?
The event is persistently re-experienced in recollections and dreams
Persistent avoidance of stimuli associated with the event
Persistent symptoms of increase arousal (insomnia, irritability etc.)
What are examples of traumatic events?
Childhood physical/emotional/sexual abuse
Violent attacks
Natural catastrophes
Rape, war or combat exposure (shell-shock)
What physical illnesses are linked to stress?
Cancer
Coronary Heart disease
Chronic Fatigue Syndrome
Infertility/Miscarriage
Peptic Ulcers (H pylori bacteria)
Irritable Bowel Syndrome & Inflammatory Bowel Disease
Karoshi (a death from overwork - commonly a heart attack or stroke)
What are methods of stress management?
Exercise
Meditation
Yoga, Tái Chi
Cognitive Behavioural Therapy
What are the key functions of NHS press releases in response to media?
Reactive: defending the NHS reputation (reporting achievements, improvements, justifications)
Proactive: improving and protecting population health i Social marketing messages (Five-a-day, Change for life) ii Early recognition and symptom awareness (act FAST)
What diseases are linked to obesity?
Type II diabetes
Hypertension
Cancer deaths amongst non-smokers (10% of which attributed to obesity)
Coronary heart disease and stroke (obesity is a contributing factor)
Reproductive function (6% of primary infertility in women due to obesity)
Respiratory effects (obstructive sleep apnoea, pulmonary hypertension)
Osteoarthritis
Angina pectoris, congestive heart failure
Hyperinsulinaemia, insulin resistance, glucose intolerance
High blood cholesterol, dyslipidemia
Bladder control problems, uric acid nephrolithiasis
Psychological disorders (depression, eating disorders, low self esteem)
What are the causes of obesity?
i “Americanization” of diet and society
ii Increasing dominance of car culture, less walking
iii Numerous technical advances minimising physical work
iv More commuting
v Longer working hours
vi Greater availability of energy dense food, cheaper, better promoted
vii Replacing water by sugary drinks
BIOLOGY AND BEHAVIOUR DEFINITION OF OBESITY (WHO) ?
Abnormal or excessive fat accumulation resulting from chronic imbalance between energy intake and energy expenditure that presents a risk to health. It is a state of positive energy balance
What are the diagnostic measures for obesity?
MRI Dual-Energy X-ray Absorptiometry Waist circumference WHR (waist to hip ratio) Skinfold thickness BMI (Body Mass Index)
What is the link between obesity and genetics?
- Prader Willi Syndrome (PWS)
i Short statue, almond shaped eyes, small hands and feet ii Intelectual impairment, hyperphagia (over-eating) iii Chromosome 15 deletion (paternal)
- Mutations of the leptin and melanocortin receptors
-
- Congenital Leptin Deficiency
i Extreme adiposity and uncontrollable appetite
ii Monogenic obesity is very rare!
Polygenic Obesity
-
What are the ASPECTS OF BEHAVIOUR ASSOCIATED WITH WEIGHT GAIN?
Employment
i Shift work, lack of sleep, upset circadian rhythm ii Reduced physical activity iii Cortisol, leptin, ghrelin
Dietary Patterns
Leisure and Activities
What are the development factors linked with obesity?
Rapid infant weight gain (in the first 2yrs of life = increased risk) Breast feeding (associated with protective mechanisms from obesity) Early introduction of solid foods ( indirect controls can override the direct controls
What is satiation?
what brings an eating episode to an end
What is satiety?
inter-meal period
What is the satiety cascade?
Sensory -> Cognitive -> Post-ingestive -> Post-absorptive
Fat has a relatively weak effect on satiation and satiety
High-fat foods often improve the sensory properties (palatable!)
What is energy density of food?
People tend to keep the volume of their meals constant, regardless richness of the food ingested
By reducing the energy density we can consume fewer kcal & keep satiety
Reduction of Energy density i Incorporation of water or air ii Fruits and vegetables iii Reducing fat (industry) iv Method of cooking (no frying)
What is energy compensation?
The adjustment of energy intake following the ingestion of a particular food
Energy compensation is lower with liquids than solids (except of soup!)
What is the role of alcohol in overeating?
Stimulates intake, gives almost no satiety
Efficiently oxidised
Adds to the total daily energy intake
What are food environment characteristics?
Variety (greater variety stimulates over-eating) Portion size (has increased significantly over the last century) Distraction (promoting increased food intake) i Watching TV ii Social facilitation – eating with the others
What are the psychological factors of obesity?
Dietary restrain (disinhibited eating behaviour) Stress (individual, but often promotes eating) Sleep (short sleep linked to over-eating) Reward sensitivity (neural responses) …in a nutshell…
What are the factors that promote over-eating?
Environmental factors
i Portion size ii Distractions: TV iii Social facilitation
Psychological factors
i Stress ii Sleep iii Dietary restrains iv Reward sensitivity
Food Characteristics Factors
i Macronutrient composition ii Energy density iii Liquids vs. Solids
What are Sexually Transmitted Diseases?
Caused by more than 30 different bacteria, viruses and parasites
Transmitted predominantly by sexual contact
The main 4 STIs 1. Chlamydia 2. Gonorrhoea (drug resistance!) 3. Syphilis 4. Trichomoniasis
The majority of STIs are present without symptoms
HIV Safety: the “ABC list”: i A = abstain ii B = be faithful iii C = condom use
What must sexual and reproductive health do?
Involve young people as they are key decision-makers
Provide comprehensive, accurate information
Address barriers to accessing health services
Empower adolescents to make life choices that are best for them
What is complementary and alternative medicine?
A broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs
It is those healing resources other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period
What are the different types of complementary and alternative medicine?
Acupuncture:
involves inserting needles into the body at acupuncture points (pain relief mostly)
Osteopathy:
emphasizes the physical manipulation of the body’s muscle tissue and bones
Herbal Medicine:
use of plants for medical purposes
Chiropractic:
techniques involving manipulation of the spine, joints and soft tissues
Homeopathy:
simila simmilibus curentur, homeopathic dilutions in alcohol or distilled water
Traditional Chinese Medicine:
vital energy “qi” circulates through channels – meridians – that have branches connected to bodily organs – no histological or physiological evidence for the concept of meridians – based on prescientific culture
Reiki:
Japanese, palm healing – transferring universal energy through the palms of the practitioner
Hypnotherapy:
a brief therapy used to create subconscious change in a patient
Anthroposophical medicine:
based on occult notions and spiritual philosophy, employing a variety of treatment techniques, including ultra-diluted substances (homeopathy), eurythmy
Ayurvedic medicine:
a traditional Hindu medicine
Naturopathy:
employs natural treatments: herbalism, homeopathy, acupuncture
Alexander Technique:
avoiding unnecessary muscular and mental tension, alleviates breathing problems and hoarseness during public speaking
Aromatherapy:
using aromatic compounds for to alter one’s mood or physical wellbeing
Reflexology:
application of pressure to the feet and hands with specific thumb/hand techniques without the use of oil or lotion – based on system of zones and reflex areas that reflect the body imaga on the feet and hands
Shiatsu:
“finger pressure” – massages with fingers and palms, pulse diagnosis
Iridology:
patterns, colours and other iris characteristics can be examined to assess patient’s systemic health
Applied Kinesiology:
testing muscles for strength and movement for “diagnosis”
T’ai Chi:
health training, relieving the physical effects of stress on body and mind
Qi Gong:
a practice to cultivate “qi”, life energy. A holistic system of coordinated body posture and movement, breathing and mediation, spirituality and martial arts training
What are the CLASSIFICATIONs BASED ON THERAPEUTIC SIMILARITY?
Manual Therapies:
chiropractic, osteopathy, massage, reflexology, cranial osteopathy, aromatherapy
Ethnic Medical Systems:
traditional Chinese medicine, acupuncture, herbal medicine, ayurvedic medicine, t’ai chi, yoga
Mind-body/energy medicine:
Mind-body/energy medicine: hypnotherapy, healing, reiki
Non-allopathic Systems:
homeopathy, iridology, kinesiology, naturopathy,…
What the House of Lords groupings for CAM?
Group 1
there is some scientific evidence of efficacy (acupuncture, chiropractic, homeopathy, osteopathy, herbal medicine)
Group 2
modalities working in a supportive capacity alongside conventional medicine, not offering independent diagnosis (massage, aromatherapy, reflexology, hypnotherapy)
Group 3
Traditional systems of medicine backed by historical practice only/ with little evidence (traditional Chinese medicine, iridology, kinesiology)
Who uses CAM?
age group, mainly women
higher income, higher education levels
poor health status, 60% have a chronic disease
geographical variation in the UK (mostly in the South & Southwest of England)
autism spectrum disorders WHY?
There are effectiveness gaps for commonly encountered problems (depression, eczema, chronic pain, IBS)
What are the expected outcomes of CAM?
Reduction of symptoms & disability
Avoidance of medication
Gaining control and improving coping skills
What are push factors for new CAM patients?
Lack of effective conventional treatment for problem
Concern about unpleasant side-effects
Experience of poor communication with doctors, rejection of science
Disease is not serious enough (e.g. life threatening)
Gullibility and naivety
High patient satisfaction rates (60-80%)
What are the major concerns with CAM?
Unrealistic expectations
Delayed conventional care
General safety (unregulated practitioners and treatments, drug interactions)
What are the big five CAM from the NHS Perspective?
- Acupuncture
- Chiropractic therapy
- Homeopathy
- Herbal medicine
- Osteopathy
What is the basic economic problem of healthcare?
The resources are finite (scarcity)
The desire for good and services is infinite (insatiable)
No country treats all treatable ill health (no capacity to do so)
Choice cannot be avoided (decision making)
What is opportunity cost in healthcare?
The opportunity cost of an activity is the sacrifice in terms of the benefits forgone from not allocating resources to next best activity
Loewy ignores this displaced activity
What is economic efficiency with healthcare?
Economic efficiency is achieved when resources are allocated between activities in such a ways as to maximise benefit
What is economic evaluation and what are the types of economic evaluation in healthcare?
The method used to assess whether benefit is maximised – the assessment of efficiency
Costs and effects are analysed in terms of their differences (increments)
Asking: Are the incremental benefits of a new treatment worth the incremental costs?
Types:
Cost-effectiveness analysis (outcomes measured in natural units: incremental cost per life year gained)
Cost-utility analysis (outcomes measured in quality adjusted life years: incremental cost per QALY gained)
Cost-benefit analysis (outcomes are measured in monetary units: net monetary benefit)
What is equity and what is equality?
Equity: fair distribution of goods and services based on individual need
Equality: fair distribution of goods and services
