NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 2: Determina nts of Health
OVERVIEW
The purpose of this module is to examine the determinants of health using
epidemiological, social and environmental data. The data are used to assess trends and
establish priorities for the purpose of improving the health status of populations.
O BJECTIVES
At the conclusion of this module, the learner will be able to:
 Identify the determinants of health
 Discuss the overall health status of the U.S.
 Interpret national health survey data: NHANES, BRFSS
 Assess modifiable lifestyle risk factors for heart disease, cancer and stroke
focusing on smoking, high blood pressure, elevated blood cholesterol, diet,
overweight, obesity and physical inactivity
R EQUIRED R EADINGS
 Bournhonesque, R. & Mosbaek, C. (2002). Upstream public health: An alternate
proactive view. Portland, OR: Upstream Public Health. Retrieved
from http://libmedia.willamette.edu/xmlui/bitstream/handle/10177/4523/F2Mos
baek7.pdf?
sequence=1&isAllowed=y
 National Research Council. (2003). Assuring America's health. In The Future of
the Public's Health in the 21st Century (pp. 19-45). Washington, DC: The National
Academies Press. Retrieved from http://www.nap.edu/openbook/030908704X/
html/19.html#pagetop
 National Research Council. (2003). Understanding population health and its
determinants. In The Future of the Public's Health in the 21st Century (pp. 46-95).
Washington, DC: The National Academies Press. Retrieved
from http://www.nap.edu/openbook.php?record_id=10548&page=46
 Puska, P. (2009) Fat and heart disease: Yes we can make a change—the case of
North Karelia (Finland).Annals of Nutrition & Metabolism, 54 (suppl1), 33-38.
Retrieved from https://www.karger.com/Article/Pdf/220825
D IRECTIONS
View the module and suggested readings within the module. Then participate in the
discussion board question for the module.
 NRSG 780 - HEALTH PROMOTION AND
POPULATION HEALTH
Module 2: Determina nts of Health
A SSESSING H EALTH S TATUS OF THE P OPULATION
The health status of a population is most commonly measured by indicators that
reflect disease and mortality, rather than health. Despite the inherent problems with
using mortality as a proxy for health, mortality data are often available and used
throughout the world to describe the health status of populations. Data on morbidity are
not as readily available but are also essential when assessing the health status of a
population.
M EASURES OF M ORTALITY
Life expectancy is the average number of years people born in a given year are
expected to live based on a set of age-specific death rates. When life expectancy in the
U.S. is compared to other nations in the world, we are not at the top, where we expect
to be, but trailing behind many other countries for both men and women. During the past
two decades life expectancy in the US has fallen to 49th as compared to other nations
and is expected to fall further behind in the next several years.
The leading causes of death in the U.S. are heart disease, cancer, chronic lower
respiratory diseases, accidents (unintentional injuries) and stroke, followed by
Alzheimer’s disease and diabetes. These are all heavily influenced by lifestyle risk
factors.
 Source: National Center for Health Statistics, 2016
When assessing mortality, it is also important to consider the leading causes of death
by age group in the U.S.
 From 1 year to the age of 45, accidents are the leading cause of death.
 From 45 to 65, cancer is the leading cause of death.
 After age 65, heart disease is the leading cause of death.
Click here to view the leading causes of death by age group in the U.S.
We can also measure mortality in the U.S. by examining the leading causes of death
by gender and in comparison with peer countries.
Another way of looking at mortality in the U.S. is to consider the toll of premature
mortality on our society. Death before the age of 75 is generally considered premature.
Families, work, and the society as a whole lose the valuable contributions of each
member who dies prematurely. When we consider premature mortality in relation to the
leading causes of death, we see a different profile of the tolls of the leading causes of
death.

Years of potential life lost (YPLL) is a measure of the years of potential life lost due to
premature death. It is an estimate of the average years a person would have lived if he
or she had not died prematurely. Here is an example of a calculation of YPLL before the
age of 75 for males & females of ethnic groups in the U.S. Note the differences in years
of potential life lost by category if the calculation is based on the age of 65 as shown in
the chart below.

Source: http://webappa.cdc.gov/cgi-bin/broker.exe
 Source: https://webappa.cdc.gov/cgi-bin/broker.exe
For more information on how YPLL is calculated, watch this video.
M EASURES OF M ORBIDITY
National Health and Nutrition Examination Surveys

To address the limitations of focusing on mortality data and existing

utilization databases that only include information on those who access services, in
1956 the National Health Survey Act was passed. This federal legislation authorized a
continuing national survey to provide measures of morbidity in terms of current
statistical information on the amount, distribution and effects of illness and
disability in the U.S. Now called the National Health and Nutrition Examination
Surveys or NHANES, the U.S. has a continuous stratified sampling system in place to
gather the data that provides an overview of the health status of the population. Watch
the video, CDC’s Dr. Frieden discusses Public Health Data and the NHANES
Program for a better understanding of public health data and the role of NHANES.
NHANES gathers household and family level information:
1. Demographic background/occupation
2. Food security
3. Health insurance
4. Housing characteristics
5. Income
6. Pesticide use
7. Smoking
 8. Tracking and tracing
NHANES includes comprehensive self-reported information on all individuals in the
household:

Acculturation Medical conditions

Audiometry Miscellaneous pain

Balance Physical activity and physical fitness

Blood Pressure Physical functioning

Cardiovascular Disease Occupation

Dermatology Oral health

Diabetes Osteoporosis

Dietary supplements and prescription medication Respiratory health and disease

Diet behavior and nutrition Smoking and tobacco use

Digital symbol substitution exercise Social support

Early childhood Tuberculosis

Hospital utilization and access to care Vision

Immunization Weight history

Introduction and Verification Dietary recall

Kidney conditions Medical conditions

NHANES augments its data with a series of laboratory tests on all individuals in the
household which confirm or question much or the self-reported information:
1. Blood and urine
2. Venipuncture
3. Urine collection
 4. Bone markers
5. Diabetes profile
6. Infectious disease profile
7. Markers of immunization status
8. Miscellaneous laboratory assays
9. Kidney disease profile
10. Hormone profile
11. Nutrition biochemistries and hematologies
12. Sexually transmitted disease profile
13. Tobacco use
14. Blood lipids
15. Environmental health profile
NHANES conducts examinations on all members as well.
1. Audiometry
2. Balance and vestibular testing
3. Body composition
4. Body Measurement
5. Cardiovascular Fitness
6. Dermatology
7. Lower extremity disease
8. Muscular strength
9. Oral health
10. Physician’s exam
11. Vision
Using these data, we are able to profile the health status of the nation as a whole.
B EHAVIORAL R ISK F ACTOR S URVEILLANCE S YSTEM

In the late 1970s and early 1980s, states begin to ask the federal
government for data that were specific to their population rather than the nation as a
whole. Resources to replicate the NHANES laboratory and examination data would
have been prohibitive on a state-by-state basis. However, telephone surveys were
beginning to show the capacity to gain the requested data in a cost-effective format.
In the 1980s the Behavioral Risk Factor Surveillance System (BRFSS) was piloted by
the CDC through state health departments and ultimately expanded to provide unique
data for each state. The BRFSS uses telephone surveys which take about a half hour to
complete. The BRFSS is conducted on an annual basis. In most states the samples are
designed to also provide county specific data.
All states gather the same core data including:
1. Health Status
2. Health Care Access
3. Asthma
4. Diabetes
5. Care Giving
6. Exercise
7. Tobacco Use
 8. Fruits and Vegetables
9. Weight Control
10. Demographics
11. Women Health
12. HIV/AIDS
States can add optional modules that include:

Diabetes Injury Control

Sexual Behavior Alcohol Consumption

Family Planning Cardiovascular Disease

Health Care Coverage and Utilization Arthritis

Health Care Satisfaction Quality of Life and Caregiving

Oral health Folic Acid

Hypertension Awareness Skin Cancer

Cholesterol Awareness Tobacco Use Prevention

Immunization Smokeless Tobacco

BRFSS data can be analyzed by a variety of demographic variables:

 Age
 Sex
 Education
 Income
 Occupation
 Racial and Ethnic backgrounds
EXERCISE:
 Go to the BRFSS website and determine how data have been used recently in your
state.
Take a few moments to use the BRFSS maps to visualize the states with the highest reported
rates of obesity by clicking on the link https://www.cdc.gov/obesity/data/prevalence-
maps.html and the highest rates of smoking by clicking on the
link http://www.cdc.gov/statesystem/cigaretteuseadult.html . How does your state
compare?
 Module 2: Determinants of Health
ADDRESSING THE CHALLENGE
U.S. I S F ALLING S HORT OF I TS P OTENTIAL IN H EALTH
The Institute of Medicine in its report on The Future of the Public Health in the 21st
Century identified the U.S. as falling short of its health potential.

The National Research Council and the Institute of Medicine investigated potential
reasons for the U.S. health disadvantage. The findings are detailed in its report, U.S.
Health in International Perspective: Shorter Lives, Poorer Health.
H EALTHY P EOPLE 2020
To address the health challenges, the U.S. continues to refine it national health planning
priorities. With Healthy People 2020, the U.S. emphasizes health promotion as the
means to improve the health status of the population.

The overarching goals of Healthy People 2020 include:

 Attain high quality, longer lives free of preventable disease, disability, injury, and
premature death.
 Achieve health equity, eliminate disparities, and improve the health of all groups.
 Create social and physical environments that promote good health for all.
 Promote quality of life, healthy development and healthy behaviors across all life
stages.
Data from NHANES, BRFSS and other national surveys are used to target and evaluate
national, state, county and local health and research initiatives for public and private
organizations. The data addresses four Foundation Health Measures:
 General Health Status
 Health-Related Quality of Life and Well-Being
 Determinants of Health
 Disparities
The Foundation Health Measures are used to monitor the progress we are making
toward achieving the 1,200 objectives of Healthy People 2020 in each of the 42 topic
areas:
A smaller set of Healthy People 2020 objectives, composed of 26 indicators, organized
under 12 topic areas has been selected to communicate high-priority health issues and
actions that can be taken to address them. The indicators are grouped under the
following topics referred to as the Leading Health Indicators:
 access to health services
 clinical preventive services
 environmental quality
 injury and violence
 maternal, infant and child health
 mental health
 nutrition, physical activity and obesity
 oral health
 reproductive health
 social determinants
 substance abuse
 tobacco
Data from national surveys are used to monitor progress of the 26 indicators on a more
regular basis that the entire set of objectives to provide a snapshot of progress toward
reaching the goals of Healthy People 2020.
See more information on the Progress Update for the Leading Health indicators.

M ODIFIABLE L IFESTYLE R ISK F ACTORS

Healthy People emphasizes that improvements in the health of Americans will not be
achieved through increasing the number of medical services but through greater efforts
designed to change lifestyles to promote health, reduce risk and prevent
disease. When we begin to study modifiable lifestyle risk factors for the leading causes
of death, it is important to note that many are risk factors for more than one cause of
death. As a result, efforts aimed at reducing a single risk factor, such as smoking or
obesity, will have an impact on reducing the risk of heart disease, cancer and stroke.
This table shows that many of the major modifiable risk factors for the three leading
causes of death in the U.S. are identical.
The next five subtopics in this module will provide a snapshot of the major modifiable
lifestyle risk factors for the leading causes of death:
 Smoking
 High Blood Pressure
 Elevated Blood Cholesterol
 Diet, Overweight, Obesity and Physical Inactivity
 Impact of Multiple Risk Factors
Scientific evidence will be highlighted that shows reducing these risk factors reduces
premature morbidity and mortality and that we have known this for over fifty years.

MODIFIABLE LIFESTYLE RISK FACTORS: SMOKING

One modifiable lifestyle risk factor of the leading causes of death is smoking. This
subtopic will focus on some of the evidence available on the effects of smoking and
trends associated with it.
Ernst Wynder’s landmark studies date as far back as 1950, and described tobacco
smoking as a possible factor in lung cancer. One of the earliest studies of 684 cases
describes smoking as a possible etiologic factor in bronchiogenic carcinoma (1), and
another study describes tobacco as a cause of lung cancer with special reference to the
infrequency of lung cancer among non-smokers (2).
1. Wynder, E.L. & Graham E.A. (1950). Tobacco smoking as a possible etiologic
factor in bronchiogenic carcinoma: A study of 684 proved cases. Journal of the
American Medical Association, 143(4), 329-36.
2. Wynder, E.L. (1954). Tobacco as a cause of lung cancer with special reference
to the infrequency of lung cancer among non-smokers. Pennsylvania Medical
Journal, 57, 1073-1083.
The Surgeon General Office has been issuing reports on smoking since 1964. These
reports reaffirm that cigarette smoking is the leading risk factor for premature death in
our country.
 Source: http://www.surgeongeneral.gov/priorities/tobacco/
For more information review the executive summary of The Health Consequences of Smoking—50 Years
of Progress: A Report of the Surgeon General, 2014. Available
at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/exec-summary.pdf:

R ISKS OF S MOKING
Tobacco is responsible for over 20% of deaths in the U.S. and serves as a major
contributor to deaths from cancer, heart disease, stroke, diseases of the lung and
numerous other causes.
 Source: 2014 Surgeon General's Report, Table 12.4, page 660
http://www.cdc.gov/tobacco/data_statistics/tables/health/infographics/index.htm
Evidence-based studies implicate smoking as a major risk factor for cancers, including:
 Lung cancer
 Bladder cancer
 Laryngealcancer
 Oral cancer
 Cervical cancer
 Pancreatic cancer
 Esophageal cancer
 Stomach cancer
 Kidney cancer
 Leukemia
Smoking is recognized as a leading risk factor for cardiovascular diseases including
abdominal aortic aneurysm, atherosclerosis, cerebrovascular disease and coronary
heart disease.
Smoking is implicated in a series of respiratory diseases including COPD, pneumonia,
and respiratory effects in utero, childhood, adolescence and adulthood.
Smoking has been identified as a risk factor for reproductive problems including fetal
deaths and stillbirths, impaired fertility, low birthweight and complications of pregnancy.
Other risks of smoking now include cataracts, low bone density and peptic ulcer
disease. Smoking related illnesses in the U.S. cost more than $300 billion a year,
including nearly $170 billion in direct medical care for adults and $156 billion in lost
productivity.
Source: The Health Consequences of Smoking: A Report of the Surgeon General,
2004 and
https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-
united-states.html
T RENDS IN C IGARETTE S MOKING

Based on its well-documented negative health effects, information

on tobacco use is part of the Behavioral Risk Factor Surveillance System.

Current data from the BRFSS indicates that there has been a modest decline in
smoking during the past decade. In 2015, 15.1% of adults in the U.S. identified
themselves as current smokers.
, In 2015 13% of young adults (18-24) and 8.4% of persons over 65 years smoke. Half
of all adolescents that continue to smoke regularly will die eventually from a smoking-
related illness.
In the U.S. smoking rates peak from 25-44 and then begins to decline
Q UESTIONS :
Given the impact of smoking on health, should smoking cessation initiatives be a public
health priority?
Can you identify barriers to community-based tobacco initiatives geared toward not
starting or stopping smoking?
Should providers be more involved in trying to assist their patients stop smoking?
Can you identify barriers to providers addressing smoking cessation with their patients?

MODIFIABLE LIFESTYLE RISK FACTORS: HIGH

BLOOD PRESSURE
Another modifiable lifestyle risk factor for the leading causes of death is high blood
pressure. This subtopic will focus on the effects, risks and trends associated with high
blood pressure.
Until the early 1960s blood pressure was thought to rise with age. The Framingham
Heart Study first identified hypertension as a risk factor in the development of coronary
heart disease in 1961(1).
 Kannel, W., Dawber, T.R., Kagan, A., Revotskie, N., & Stokes, J. (1961). Factors
of risk in the development of coronary heart disease—Six year follow-up
experience. Annals of Internal Medicine, 55(1), 33-50.
Research conducted by the Veterans Administration Cooperative Study Group on
Antihypertensive Agents beginning in 1963 also challenged this assumption and
showed that treatment dramatically reduced the risk of a morbid event from over a five
year period and that treatment also reduced the risk of heart failure and stroke. In part
two of the study, the differences between the participants in the treated and control
(taking placebos) groups were so dramatic that the trial was terminated early. (2, 3)
 VA Cooperative Study Group. (1967). Effects of treatment on morbidity in
hypertension, Journal of American Medical Association, 202(11), 1028-1034.
 VA Cooperative Study Group, (1970). Effects of treatment on morbidity in
hypertension II. Results in patients with diastolic blood pressure averaging 90
through114 mm Hg, Journal of the American Medical Association, 213(7), 1143-
1152.
The five-year findings of the Hypertension Detection and Follow-up Program (HDFP)
Cooperative Group of nearly 11,000 community-based participants from 30-69 showed
that a program of stepped care as compared to referred care achieved better control of
hypertension and significant reductions in mortality. The study concluded that
systematic effective management of hypertension has a great potential for reducing
mortality for the significant number of people with high blood pressure in the population,
including those with mild hypertension (4).
 HDFP Cooperative Study Group. (1979). Five-year findings of the hypertension
detection and follow-up program I. Reduction of mortality of persons with high
blood pressure, including mild hypertension, Journal of the American Medical
Association, 242(23), 2562-2577.
R ISKS OF H IGH B LOOD P RESSURE
High blood pressure significantly increases the risk of:
 Stroke
 Coronary heart disease
 Congestive heart failure
 Aneurysm
 Kidney failure
 Vision changes
T RENDS IN H IGH B LOOD P RESSURE
In the U.S. trends show that there has been a slight increase in high blood pressure
during the past decade with roughly a third of the population indicating that they have
blood pressure in excess of 140/90.
 Source: BRFSS Trend Data 2017 https://www.americashealthrankings.org/explore/2017-annual-
report/measure/Hypertension/state/ALL
In the U.S. blood pressure increases with age. Blood pressure is higher in men at
younger ages. It shifts to being higher in women 45 and over, when menopause occurs,
and stays higher than in men for their lifespan.
Nationwide (States and DC) - All available years Adults who have been told they have
high blood pressure
As blood pressure increases, the risk of developing blood pressure related diseases
increases. The relative risk of developing CHD is twice as high when systolic blood
pressure is in the 130-139 range as compared to below 110, and 4.5 times as great
when systolic blood pressure exceeds 160 (5).
Relative Risk of Developing CHD vs. Systolic Blood Pressure
Data from the NHANES surveys show that trends in adults in blood pressure
awareness, treatment and control are far from ideal. This is particularly noteworthy
given the risk of preventable disease, the toll of diseases such as stroke, and the well-
documented effectiveness of anti-hypertensive treatment.
Using 140/90 as the standard of the population that has high blood pressure, 83% are
aware, 76% are being treated and only 52% are under control.

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012. Retrieved
from http://www.cdc.gov/nchs/data/databriefs/db133.htm
When we consider the unacceptably low level of control and the fact that by the time
Americans reach age 74, over 60% of the adult population has high blood pressure, it is
clear that uncontrolled hypertension plays a significant role in the health status of the
US population as a whole.
Q UESTION :
Dr. Carolyn Clancy, former Director of the Agency for Healthcare Quality and Research
(AHRQ), gave The Dean’s Distinguished Virginia Lee Franklin Lecture at the School of
Nursing in 2011. She identified our inability to control high blood pressure, given our
arsenal of treatment options, as one of the greatest failures of our health care system.
Can you identify possible interventions at the community, provider and policy level that
may help to improve the level of control?

MODIFIABLE LIFESTYLE RISK FACTORS:

ELEVATED SERUM CHOLESTEROL
Another modifiable lifestyle risk factor for the leading causes of death is elevated serum
cholesterol. This subtopic will focus on the effects, risks, trends and cultural differences
associated with elevated serum cholesterol.
In 1961, the Framingham Heart Study also identified elevated serum cholesterol for the
first time as a risk factor in the development of coronary heart disease in 1961(1).
1. Kannel, W., Dawber, T.R., Kagan, A., Revotskie, N., & Stokes, J. (1961).
Factors of risk in the development of coronary heart disease—Six year follow-
up experience. Annals of Internal Medicine, 55(1), 33-50.
The Western Electric Study of the relationship between diet, serum cholesterol and
mortality followed nearly 2000 middle-aged men between 1960 and 1980. The study
concluded that the lipid composition of diet affects cholesterol levels and increases the
risk of coronary death (2).
2. Shekelle, R., Shyrock, A., Paul, O., Lepper, M., Stamler, J., Liu, S., & Raynor,
W. (1981). Diet, serum cholesterol and death from coronary heart disease “The
Western Electric Study”, New England Journal of Medicine, 304(2), 65-70.
The Lipid Research Clinics Coronary Primary Prevention Trial studied the efficacy of
cholesterol lowering in reducing risk of coronary heart disease in nearly 4000 middle-
aged men over an average of more than seven years. Results demonstrated that
reducing total cholesterol by lowering LDL-C levels can diminish coronary heart disease
morbidity and mortality. (3)
3. Lipid Research Clinics Program, The Lipid Research Clinics Coronary Primary
Prevention Trial results I. Reduction in incidence of coronary heart
disease, Journal of American Medical Association, 251(3), 351-364.
R ISK OF E LEVATED B LOOD C HOLESTEROL
Elevated blood cholesterol significantly increases the risk of coronary heart
disease and stroke.
As cholesterol levels increase, heart disease mortality rates increase.
D IFFERENCES IN C HOLESTEROL BY G ENDER AND A GE
NHANES data indicate that over the last several decades the average serum
cholesterol levels for men and women are declining.
Figure 5. Trends in age-adjusted high total cholesterol and low HDL cholesterol among
adults aged 20 and over: United States, 1999–2000 through 2013–2014.
Source: http://www.cdc.gov/nchs/data/databriefs/db226.htm
When you study the population over the age of forty, the differences between men and
women shift. Overall, the toll of this risk factor remains a significant contributor to heart
disease and stroke in the U.S., particularly for women over 60 who have significantly
higher levels than men and are further away from achieving targets.
C ULTURAL D IFFERENCES IN C HOLESTEROL
Cultural differences in serum cholesterol levels are significant. Notice how the average
serum cholesterol in Japan is under 150 and the curve is quite narrow. Compare these
data to Finland, where the mean is 250 and the population levels range from 150 to
350.

MODIFIABLE LIFESTYLE RISK FACTORS: DIET,

OVERWEIGHT, OBESITY AND PHYSICAL
INACTIVITY
Other modifiable lifestyle risk factors for the leading cause of death are diet, overweight,
obesity and physical inactivity. This subtopic will focus on each of these risk factors in
relation to their trends and the risks associated with them.
Research on diet, overweight, obesity and physical inactivity and their relationship to the
leading causes of death has been ongoing since the initiation of the Seven Countries
Study in 1947(1). The Framingham Study first noted the relationship between the risks
of physical inactivity and obesity to increase the risk of heart disease in 1967 (2,3).
1. Keys, A. et al. (1980). Seven countries. A multivariate analysis of death and
coronary heart disease. Cambridge, MA: Harvard University Press.
2. Kannel, W.B. (1967). Habitual level of physical activity and risk of coronary
heart disease: The Framingham Study. Canadian Medical Association Journal,
96(12), 811-812.
3. Thomas, H.E.J., Kannel, W.B., & McNamara, P.M. (1967). Obesity: A hazard to
health. Medical Times, 95, 1099-1106.
I NFLUENCE OF D IET ON C ANCER
When the influence of diet is studied in relation to cancer, approximately 40% of
cancers are attributable to diet and alcohol.

The evidence now shows that many cancers are associated with low levels of fruit and
vegetable consumption, including:

 lung  esophagus
 stomach  larynx
 breast  bladder
 colon  pancreas
 breast  endometrium
 prostate  cervix
 ovarian  ovary
 pharynx  pancreas
 oral cavity
Behavioral Risk Factor Surveillance System data indicate that nearly 75% of Americans
are consuming fewer than 5 fruits and vegetables a day.

Source: BRFSS Trend Data 2017 https://www.americashealthrankings.org/explore/2017-annual-

report/measure/Fruit/state/ALL
 Source:
BRFSS Trend Data 2017 https://www.americashealthrankings.org/explore/2017-annual-
report/measure/Veggie/state/ALL
International studies show that the higher the average dietary fat consumption of the
population, the higher the death rate from breast cancer. Notice how low the rates are in
the Philippines, Thailand and Japan as compared to the Netherlands, New Zealand,
Canada and the U.S. The same relationship is found between high dietary fat
consumption and death rates from intestinal and prostate cancer.
O BESITY AND O VERWEIGHT
Excess dietary fat, excess calories and sedentary lifestyles are major causes of the
epidemic of obesity that we are facing in the U.S.
R ISKS OF O BESITY
Obesity and overweight increase the risk of a variety of health problems, including
  type 2 diabetes
 gall bladder disease
 stroke
 asthma
 congestive heart failure
 high blood pressure
 elevated serum cholesterol
 sleep apnea and respiratory disorders
 coronary heart disease
 angina pectoris
 gout
 bladder control problems
 musculoskeletal disorders
 osteoarthritis
Watch this video developed by the CDC on the Obesity Epidemic.
Overweight and obesity increase the risk of poor female reproductive health–
pregnancy complications, menstrual irregularities, irregular ovulation and infertility.
Overweight and obesity also increase the risk of a variety of cancers, including:
 breast
 prostrate
 liver
 colon and rectum
 uterus
 kidney
  pancreas
 esophagus
T RENDS IN O VERWEIGHT AND O BESITY

Data from the 2013-2014 NHANES shows that 32.7% of adults age 20 and over are
overweight, 37.9% are obese and 7.7% are extremely obese and the prevalence is
similar across all age groups.

NIH recently found that extreme obesity may shorten life expectancy up to 14 years. For
more information, please review https://www.nih.gov/news-events/news-
releases/nih-study-finds-extreme-obesity-may-shorten-life-expectancy-14-years.
The Congressional Budget Office indicates that rising obesity rates significantly effects
health care spending.
 Behavioral Risk Factor Surveillance System data indicate that the
percentage of the population that is neither overweight nor obese is dramatically
declining. CDC has used the BRFSS data to map the changes in obesity prevalence
since 1985.

Five years later, at least 10% of the population of the majority of states were obese. By
1999 20% were obese. Now obesity rates are greater than 30% for nearly half of the
U.S.
P HYSICAL I NACTIVITY
Another key to epidemic of obesity is sedentary lifestyle. Numerous studies have shown
the importance of regular physical activity for reducing the risk of chronic disease.
Morris’ work in England on the drivers and conductors of the double-decker busses in
the 1960s is a classic. Drivers and conductors were studied over a ten year period. Both
groups were virtually identical in terms of socioeconomic status, educational level and
environmental exposures. The single difference was that the drivers were sedentary
throughout the day and the conductors ran up and down the bust stairs during the day
collecting tickets. Because the bus company supplied the uniforms, accurate records
were available on the waist sizes of the men throughout the years.
Sudden death from ischemic heart disease showed distinct differences between the two
groups – the rate for drivers was substantially higher.

Average waist sizes between the two groups varied significantly over time, with drivers
gaining weight at a much higher rater than the conductors as they aged.
CHD rates in the busmen between the ages of 35 and 64 varied significantly with
drivers’ raters far exceeding the conductors.
 Data from 2014 indicate that only 22.7% of the population
participates in any physical activities and that only 20.5 % of the population participated
in enough aerobic and muscle strengthening exercises to meet guidelines.

Cholesterol levels in different countries vary even in young children ages 5 to 9 years.
Notice the differences between the mean levels in Mexico as compared to the U. S.
Data from the landmark Ni-Hon-San study show that cholesterol levels are not
genetically determined alone. Studies of Japanese natives who migrated to Hawaii
showed that their cholesterol levels eventually matched those of the Hawaiian islanders.
Cholesterol levels of those who migrated to the San Francisco area eventually reflected
the levels of the average American. Studies of each of the migrant populations showed
that they adopted the dies of their new homelands.
 Data from the Behavioral Risk Factor Surveillance System show
that in 2013 over 76.4% of Americans have had their cholesterol checked. Over 38%
were told it was high.

Source:
https://nccd.cdc.gov/BRFSSPrevalence/rdPage.aspx?rdReport=DPH_BRFSS.ExploreByTopic&isl
Class=CLASS02

Q UESTION :
Given the relationship between diet and cholesterol levels and mortality, can you
identify possible interventions at the community, provider and policy level that may help
to reduce the level of elevated serum cholesterol in the population?
MODIFIABLE LIFESTYLE RISK FACTORS: IMPACT
OF MULTIPLE RISK FACTORS
The impact of risk factors is cumulative; each factor adds to the long-term risk of
cardiovascular and noncardiovascular mortality and life expectancy. Findings from very
large population-based, prospective studies show that individuals with favorable levels
of blood pressure and cholesterol who do not smoke have much longer life spans. If
there is an increase in the proportion of the population at lifetime low risk, this could
contribute significantly to ending the coronary heart disease and cardiovascular disease
epidemics, reducing all-cause mortality, increasing life expectancy and improving the
health status of the U.S .