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Environmental Drivers of Chronic Disease Based on the report Environmental Threats to Healthy Aging by Jill Stein MD, Ted Schettler MD, MPH, Maria Valenti and Ben Rohrer 2010. Greater Boston Physicians for Social Responsibility (www.psr.org/Boston) and

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slide1
Environmental Drivers

of

Chronic Disease

Based on the report

Environmental Threats to

Healthy Aging

by

Jill Stein MD, Ted Schettler MD, MPH,

Maria Valenti and Ben Rohrer

2010

Greater Boston Physicians for Social Responsibility (www.psr.org/Boston)

and

The Science and Environmental Health Network (www.sehn.org)

what we will cover
What We Will Cover

Environmental factors are key drivers of many common chronic diseases

Environmental factors alter key biological pathways leading to chronic disease

Important environmental determinants of health include:

Food system/nutrition and diet

Toxic chemicals

Built environment / physical activity

Psychological & socioeconomic stress

Examples of cross cutting solutions for healthy people & a healthy environment

scope context of the problem
Scope & Context of the Problem
  • A century of change in natural, built and social environments has causedmajor changes in the patterns and distribution of diseases.
  • We are seeing dramatic increases in chronic diseases, and at younger ages, many of which, such as diabetes, are themselves risk factors for dementia.
  • The over- 65 population will nearly double by 2030 to more than 71 million, sharply increasing the number of people at risk of chronic diseases of aging like Alzheimer’s and Parkinson’s diseases, among others.
  • Environmental factors play a key role in health across the lifespan. Thus they offer a major prevention opportunity.
the changing environment and disease patterns
The Changing Environment and Disease Patterns

During the past century, human activity has altered virtually all aspects of the world’s ecosystems:

Pervasive spread of synthetic chemicals; air and water pollution.

Industrialized food supply.

Destruction of critical natural habitats, stressing ecosystems.

Climate change.

How we live, eat, work, play and socialize have substantially changed:

Built environments have increased social

isolation for many people; reduced

physical activity.

Growing income gap increases disease risk.

Diseases of civilization - obesity, diabetes,

cardiovascular disease, hypertension.

slide5
Environment Drives Chronic Disease

Chronic Disease

Environmental Factors

Altered Pathways

  • Western Disease Cluster
  • Diabetes
  • Obesity
  • Abnormal Lipids
  • Metabolic Syndrome
  • Cardiovascular Disease
  • Inflammation
  • Disrupted Insulin
  • Signaling
  • Oxidative Stress
  • Food system/Diet
  • Fossil Fuels
  • Socioeconomic Stress
  • Chemicals
  • Built Environment/
  • Transportation

Parkinson’s

Alzheimer’s

slide6
Profound Public Health Impact Of Environmentally-Driven Western Disease Cluster
  • Obesity/overweight – 2/3 US adults, prevalence x2 in ~25 yrs http://www.cdc.gov/chronicdisease/resources/publications/AAG/obesity.htm
  • Pre/Diabetes – 40% US adults, prevalence DM ~x2 over 20 yrsCowie 09, http://apps.nccd.cdc.gov/DDTSTRS/default.aspx
  • Cardiovascular disease – still leading cause of death. Hypertension increasing. http://www.cdc.gov/nchs/FASTATS/lcod.htm, Hajjar 03
  • Metabolic syndrome = early signs of other cluster diseases; 35% adults, ~55%>60 yrs Ford ES 05
  • Alzheimer’s disease – ½ >84 yrs old, 5.3M Alzheimer’s Assoc.
alzheimer s disease dementia
Alzheimer’s Disease/dementia

Not an inevitable feature of normal aging.

Progressive impairment of memory and multiple other cognitive functions, severe enough to interfere with daily functioning.

Expected to triple by mid-century

to over 13 million.

Likely caused by varying

combinations of genetic and

environmental factors.

Annual costs in US over $150 billion.

parkinson s disease
Parkinson’s Disease

Progressive movement disorder that includes tremors, stiffness, and slow movement. May lead to severe disability.

Likely caused by variable combinations of genetic and environmental factors.

About 50,000 new cases

annually in US.*

Prevalence in US expected to

double by 2030.*

*Due to the lack of registries and baseline data on Parkinson’s Disease, the figures used here are estimates.

alzheimer s and parkinson s diseases
Alzheimer’s and Parkinson’s Diseases

Characterized by:

abnormal protein deposits

chronic inflammation

abnormal oxidative stress

Many neuroscientists are beginning to think of some neurodegenerative diseases along a continuum, without clearly distinct boundaries in clinical or pathological manifestations

environment drives chronic disease
Environment Drives Chronic Disease

Basic Principles

  • Early life experiences can influence later-life health

and disease.

  • Multiple factors interact to influence health & disease.
  • Environmental factors can alter natural pathways which

in turn can lead to chronic disease.

  • An ecological health framework considers the individual

in the context of family, community, society and

ecosystem.

slide12
Early life experiences can influence later-life health, disease

Obesity, hypertension,

Cardiovascular disease, diabetes

Toxic exposures

oxidative

stress

Alzheimer’s, dementia, Parkinson’s

Low birth weight

Aging begins at conception

slide13
Multiple Factors Interact to Influence Health & Disease

nutrients

builtenvironment

disease

stress

chemicals

energy

slide14
An ecological health framework considers the individual in the context of family, community, society, and ecosystem.
slide15
Environment Drives Chronic Disease

Chronic Disease

Environmental Factors

Altered Pathways

Mechanisms of Action

  • Inflammation
  • Disrupted Insulin Signaling
  • Oxidative Stress
c lassical c oncept of i nflammation
CLASSICAL CONCEPTOF INFLAMMATION

Defined by appearance.

“Calor, dolor, rubor, tumor.”

Heat, pain, redness, swelling.

The New Concept of Inflammation

Defined by microscopiccharacteristics & laboratory test: inflammatory cells & mediators

“Atherosclerosis is an

inflammatory disease.”

(2) Ross, Russell. Atherosclerosis – An Inflammatory Disease. NEJM 1999, 340(2); 115-126.

insulin signaling normal metabolism
Insulin Signaling = Normal Metabolism

Insulin

signaling

  • ↓blood sugar
  • ↓artery disease
  • ↓triglycerides
slide19
Disrupted Insulin Signaling = Inflammatory Metabolism

Insulin

signaling

Inflammation

Oxidative

stress

  • ↑ blood sugar
  • ↑artery disease
  • ↑triglycerides
slide20
Environment Drives Chronic Disease

Chronic Disease

Environmental Factors

Altered Pathways

Food System/Diet

slide21
Novel Nutrients Are Pervasive,

Promote Inflammatory Metabolism

what s novel in the western diet
What’s “Novel” in the Western Diet?

mg/day

% of calories from fat

Years

“Hypothetical scheme of fat, fatty acid (ω6, ω3, trans and total) intake (as percentage of calories from fat) and intake of vitamins E and C (mg/d). Data were extrapolated from cross-sectional analyses of contemporary hunter-gatherer populations and from longitudinal observations and their putative changes during the preceding 100 years [75].” From AP Simopoulos, The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomedicine & Pharmacotherapy 56 (2002) 365-379.

high glycemic carbohydrates increase the risk of chronic disease
High Glycemic Carbohydrates Increase the Risk of Chronic Disease

High glycemic carbohydrates break down quickly during digestion, rapidly releasing glucose (sugar) into the bloodstream.

INSULINEMIC RESPONSE

Δ Plasma Insulin,mg/dl

Low glycemic food

High glycemic food

Time, mins

properties of fatty acids
Properties of Fatty Acids

Omega-3Omega-6Saturated

FoodPerishable Durable Increased in

SystemShort shelf life Processed foods factory farmedIncreased in Long shelf life animals

pasture- fed

animals

ImmuneAnti-inflammatoryInflammatory & Inflammatory

Properties Anti-inflammatory

EvolutionaryRecent markedRecent markedRecent marked

Contextdecline increaseincrease

novel nutrients disrupt insulin signaling drive inflammatory metabolism
Novel Nutrients Disrupt Insulin Signaling, Drive Inflammatory Metabolism

↓Omega-3,

(↑Omega-6)

Fructose

Insulin

signaling

Inflammation

Oxidative

stress

  • ↑ blood sugar
  • ↑artery disease
  • ↑triglycerides

Saturated fat

↓Antioxidants

High Glycemic Carbohydrates

slide27
Increase risks

saturated and trans fats

high glycemic carbohydrates

lack of fruits/vegetables/omega 3s

excess omega 6s?

Reduce risks

fruits, vegetables

omega 3s

low glycemic carbohydrates

Mediterranean diet

Influence of Nutritionon Chronic Disease

benefits of mediterranean type diet on chronic disease risk
Benefits of Mediterranean-Type Diet on Chronic Disease Risk

Clinical intervention studies

70% ↓ heart attacks, cardiac death & total mortality DeLogeril 94

60%↓ cardiac events in CVD patients* Ornish 98

~50% ↓ metabolic syndrome Esposito 04

39% ↓ in CRP Esposito 04

↓insulin resistance Esposito 04

↓ weight Esposito 04

Prospective observation studies

80% ↓ diabetes Martinez-Gonzalez 08

~31% ↓ all-cause & cardiovascular mortality, 22% ↓ cancer mortality**calculated from Sofi 0873% Alzheimer’s mortalityScarmeas 07

25-30% ↓ Parkinson’s disease Gao 07

78% ↓ childhood asthma maternal diet Chatzi 08

*10% low fat, vegetarian diet + exercise, stress reduction

**For every 2 point increase in adherence (on a 9 point scale), risk reductions were observed of 0.91 for all cause mortality, 0.91 for CV mortality, 0.94 for occurrence

and mortality from neoplasm. To convey the implications of these findings, we have applied the risk reductions across a 9 point adherence scale to yield a calculated

~31% ↓ all-cause & CV mortality and a 22% ↓ in cancer mortality.

benefits of sustainably produced food
Benefits of Sustainably-Produced Food
  • Nutritional benefits:
  • Generally higher levels of vitamins, minerals and phytochemicals (often dependent on soil quality)
  • Higher Omega-3 content
  • Organic samples contained higher concentrations of polyphenols and antioxidants in 75% of the matched pairs representing those nutrients
  • Benefits for farm workers and communities:
  • Reduced exposure to pesticides
slide30
Environment Drives Chronic Disease

Chronic Disease

Environmental Factors

Altered Pathways

Toxic Chemicals

Air pollution, Lead and other heavy metals, some Pesticides,

Bisphenol A and other Endocrine Disruptors

slide32
Cumulative occupational exposure

↑ cognitive impairment Shih 2007

2x risk Parkinson’s Coon 2006

Cumulative community exposure

↑cognitive impairment Shih 2006

Up to 15 years cognitive aging Weisskopf 2004

Animal studies of early life exposure

Late-life Alzheimer’s markers Basha 2005, Lahiri 2007

Lead

slide33
Parkinson’s Disease

Human studies - 24/31 studies show ↑ risks for PD. (OR 1.6-7) Brown 2006

Animals - Rotenone & paraquatdamage dopaminergic neurons in

striatal region of brain Uversky VN 2004

- Combinations of maneb and paraquat; prenatal

exposure “primes” the brain, increasing adult

susceptibility Cory-Slechta 2005

Cognitive decline/dementia

Low level fungicides in vineyards 3.5x poor attention, memory Baldi 2001

Occupational exposure in men associated with 2x risk of developing AD Baldi 2003

Insulin Resistance, metabolic syndromeLee 2006, 2007, 2007

Some persistent pesticides show strong

dose-response relation to insulin resistance

and metabolic syndrome.

Pesticides

slide34
Bisphenol A
  • Found in polycarbonate plastic, resins, sealants.
  • Exposures are nearly ubiquitous.
  • Endocrine disruptor, oxidative stress.
  • Causes fat accumulation & insulin resistance at low levels (animals). Alanso-Magdelena 2006, Wada 2007
  • 3-fold ↑ Cardiovascular disease. Lang 2008
  • 2-fold ↑ Insulin Resistance. Lang 2008

polycarbonate

environmental factors disrupt insulin signaling drive inflammatory metabolism
Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism

↓Omega-3

Fructose

Insulin

signaling

Inflammation

↓Antioxidants

Oxidative

stress

  • ↑ blood sugar
  • ↑artery disease
  • ↑triglycerides

Saturated fat

Lead, other

heavy metals

Some

Pesticides

Air Pollution

Endocrine

Disruptors -

BPA, dioxins, PCBs, some pesticides

High Glycemic Carbohydrates

slide36
Environment Drives Chronic Disease

Chronic Disease

Environmental Factors

Altered Pathways

Built Environment

Physical Activity

health benefits of physical activity
Health Benefits of Physical Activity

Reduced ongoing levels of oxidative

stress and inflammatory burden.

Brooks 2008, Attipoe 2008

Inversely associated with the

risks of Alzheimer’s/dementia and

cognitive decline. Rovio 2005

Subjects at risk for AD who walked 150 min. per week showed improvements in cognition while the control group showed no net change from baseline at 1.5 yrs. Lautenschlager 2008

Increasing physical activity at any age improves physical and emotional wellbeing.

livable communities enhance healthy aging
Walkable Cities Projects

Community Gardens

Farmer’s Markets

Rails to Trails

Livable Communities Enhance Healthy Aging
slide39
Sustainable Food & Transportation Solutions:The Cuba Example

Cuba- lost fossil fuels

↑biking, walking, local plant-based food

↑physical activity50%

↓obesity 50%

↓mortality: DM 51%, CVD 35%, stroke 20%, all cause 18%

Franco M et al. Impact of Energy Intake, Physical Activity, and Population-wide Weight Loss on Cardiovascular

Disease and Diabetes Mortality in Cuba, 1980-2005. AJE 166, 12; Sept. 19, 2007

slide40
Shortens post surgical recovery time, reduces need for pain medications.

Ulrich ‘84

Attention deficits improve after a walk in the park. Effect = methylphenidate.

Taylor ’08

Access to green space reduces the effect of poverty on mortality by ~50%. Mitchell ‘08

Green Space

Reduces Stress, Mortality, Improves Cognitive Function

environmental factors disrupt insulin signaling drive inflammatory metabolism1
Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism

↓Omega-3

Fructose

Insulin

signaling

Inflammation

Oxidative

stress

  • ↑ blood sugar
  • ↑artery disease
  • ↑triglycerides

Saturated fat

Obesity

↓Antioxidants

Inactivity

Lead, other

heavy metals

Air Pollution

Some

Pesticides

Endocrine

Disruptors -

BPA, dioxins,

PCBs, some pesticides

High Glycemic Carbohydrates

slide42
Environment Drives Chronic Disease

Chronic Disease

Environmental Factors

Altered Pathways

Socio-Economic Stress

Depression, poverty, violence, inadequate health care

slide43
Socioeconomic, Psychosocial Stressors
  • Stress, depression risk for

CVD, ADSesso, Kario, Ownby

  • People with lower SE status are at risk for exposure to multiple environmental hazards ↑damage.
    • Lead + stress ↑cognitive impairment

Glass 2009

    • Lead + air pollution ↑CV autonomic dysfunction Park 2008
slide44
People who live in neighborhoods that lack social cohesion, sidewalks, or safety limit their exercise and have an increased risk of depression and possibly obesity.

Berke EM 07, Molnar BE 04

Effects of the Built Environment on Health

environmental factors disrupt insulin signaling drive inflammatory metabolism2
Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism

Fructose

↓Omega-3

Insulin

signaling

Inflammation

Oxidative

stress

  • ↑ blood sugar
  • ↑artery disease
  • ↑triglycerides

Stress

Saturated fat

Obesity

↓Antioxidants

Inactivity

Lead, other

heavy metals

Air Pollution

Some

Pesticides

Endocrine

Disruptors -

BPA, dioxins,

PCBs, some pesticides

High Glycemic Carbohydrates

environmental factors
Environmental Factors

Environmental Factors Drive Chronic Disease and the Climate Crisis

Climate Crisis

Heat, drought, storms,

fires, ice sheet instability, sea level rise,

loss of glacial irrigation, refugees, food insecurity/starvation,

tropical diseases

↑ Greenhouse

Gases

Altered Biological Pathways

Chronic Disease

major illnesses are preventable personal actions to profoundly reduce risks
Major Illnesses Are PreventablePersonal Actions to Profoundly Reduce Risks

Personal Level – “Approaches to Healthy Living”

  • Eat healthy – whole, fresh, unprocessed, plant based

foods

  • Avoid toxicants whenever possible
  • Exercise
  • Be socially engaged
slide50
Localized, diversified and sustainable food production

Clean, renewable energy↓air pollution, chemical exposures

Mass transit that connects with bike paths and sidewalkscan reduceair pollution & obesity

Chemical regulatory reform

“Safer substitute” programs and green product design  ↓ toxic exposures, ecosystem, wildlife contamination; job creation

Universal health care disease prevention & equitable health care.

Major Illnesses Are Preventable

Policy Initiatives to Profoundly Reduce Risks

slide51
Major Illnesses Are Preventable

Policy Initiatives to Profoundly Reduce Risks

Examples of Specific Initiatives:

Nutrition – Reform agricultural subsidies to be directed toward programs and practices that provide sufficient nutritious, sustainably produced food and restore ecosystems that have been degraded by agricultural activities.

Toxic Chemicals – Reform the national Toxic Substances Control Act to include phase out of persistent, bioaccumulative, or highly toxic chemicals.

Activity/Nature – Incorporate indoor and outdoor green spaces and exercise areas into designs of nursing homes and assisted living facilities

acknowledgements
Acknowledgements

Based on the Report by Greater Boston Physicians for Social Responsibility (www.psr.org/boston) and the Science and Environmental Health Network (www.sehn.org) authored by Jill Stein MD, Ted Schettler MD, MPH, Maria Valenti & Ben Rohrer

Primary authors of this presentation: Jill Stein MD, Ted Schettler MD, MPH

Contributing Authors: Maye Thompson RN, PhD, Marybeth Palmigiano MPH, Maria Valenti.

Illustrations by: Stephen Burdick Design

Permission is granted to use this presentation or individual slides with proper acknowledgement and cited as from Environmental Threats to Healthy Aging by Stein, Schettler et al. The authors of the presentation do not authorize changes, and are not responsible for the accuracy of material if changes have been made.

slide53
For more information contact:

Greater Boston

Physicians for Social Responsibility

www.psr.org/Boston

[email protected]

slide54
Additional References

For Mediterranean Diet Slide28

slide55
Additional Notes

What’s Novel in the Western Diet?

Slide 22

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