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From:
Maria Inês Reinert Azambuja <[log in to unmask]>
Reply To:
Social Determinants of Health <[log in to unmask]>
Date:
Fri, 4 Aug 2006 09:39:57 -0300
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text/plain
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Yes Dr. Lynch, I believe that some intergenerational effect is a good 
possibility that should be better explored...
Regards,
Maria Inês

----- Original Message ----- 
From: "John Lynch, Dr." <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, August 03, 2006 7:30 PM
Subject: Re: [SDOH] Obesity as a "cause" of diabetes?


> Dear Maria
> Good point and I agree with you. Some argue that the obesity epidemic in 
> kids is also partly that we are paying the price of having kids who more 
> vulnerable to obesogenic environments and diets via intergenerational 
> effects.
> Regards
> John
>
>
> -----Original Message-----
> From: Social Determinants of Health on behalf of Maria Inês Reinert 
> Azambuja
> Sent: Thu 8/3/2006 12:04 PM
> To: [log in to unmask]
> Subject: Re: [SDOH] Obesity as a "cause" of diabetes?
>
> Dear Dr. Lynch
> I totally agree with your approach of individual versus population levels 
> of
> causation. But I have a slight criticism regarding the usual 
> interpretation
> of the equation exposureX vulnerability. Quoting you:  "As Rose said, if
> causes at the population level (ie the factors that cause most cases in 
> the
> population) can be removed then susceptibility to those factors ceases to
> matter. (ie only certain susceptible individuals get sick - not all
> individuals who are obese get diabetes)"
>
> What I want to discuss is that this would also work the other way around: 
> if
> average population vulnerability to an environmental risk fall, than
> exposure to that risk ceases to matter.  And if it raises, the exacly same
> ammount of exposure may result in a previously non-existing effect of it.
> Notwithstanding all the discussion going on about nature-nurture
> interaction, we still think of individual vulnerability as a purely
> inherited (meaning "non-modifiable") trait. This has prevented us to 
> explore
> alternative hypothesis to time-trends like the rise and fall in CHD
> mortality.
> I have suggested that it resulted from a window of vulnerability to CHD
> deaths opened among birth cohorts most affected by the 1918 Influenza
> Pandemic - those born around the turn to the 20th Century. Average
> population serum cholesterol fell and high-fat diets ceased to matter
> regarding CHD cases when those vulnerable cohorts left the population. As
> the CHD mortality declined, remaining CHD cases were more and more
> representative of a different source sub-population of cases, associated
> with "a second atherogenic phenotype"- hypersinsulinemia, diabetes,
> obesity - which, by the way, was also dominant among cases recognized 
> before
> the rise in CHD mortality in the 1920s.
> The lack of recognition of this CHD true epidemic and of its determinant,
> has even prevented a better assessment of the role of social inequalities 
> in
> mortality trends. The lack os association of temporal trends (as reported 
> in
> your paper   http://www.milbank.org/820204html ) may be explained by  non
> considering the change which happened in the mix of CHD cases during the
> 20th Century. -
> Again we may be going through a change in population vulnerability to diet
> that may be more important then the diet itself.
>
> Best regards,
> Maria Inês Azambuja, MD, PhD
> School Of Medicine
> Universidad Federal do Rio Grande do Sul
> Porto Alegre, RS
> Brazil
> About Rose, I believe that he left a possibility uncovered...
>
>
> ----- Original Message ----- 
> From: "John Lynch, Dr." <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Thursday, August 03, 2006 8:23 AM
> Subject: Re: [SDOH] Obesity as a "cause" of diabetes?
>
>
>> Actually, Dennis and Steve are both correct - but depends on your
>> perspective.
>>
>> If your objective is to statistically explain individual variation in 
>> risk
>> of diabetes or CHD then its true that only 33% is 'explained' by risk
>> factors
>>
>> If your objective is to explain population levels of diabetes and CHD,
>> then obesity and the conventional physiological/behavioral risk factors
>> explain the vast majority of case load in the population. Actually I 
>> think
>> Steve's estimates of half diabetes case being obese is if anything, an
>> underestimate. We know that 90%+ of CHD cases have at least 1 
>> conventional
>> risk factor. Thats been shown in several large scale studies with 
>> reliable
>> data and exactly what you would see in studies like Whitehall as well. 
>> The
>> population attributable risk for conventional risk factors ~ 80%. See
>> Yusuf in Lancet (2004)
>>
>> The first objective is like Geoffrey Rose's explaining 'why individuals
>> get sick'; the 2nd is like his 'why do populations get sick'. These are
>> quite different questions and its important to keep them clear. As Rose
>> said, if causes at the population level (ie the factors that cause most
>> cases in the population) can be removed then susceptibility to those
>> factors ceases to matter. (ie only certain susceptible individuals get
>> sick - not all individuals who are obese get diabetes)
>>
>> Why a particular individual gets diabetes (a clinical focus) is NOT
>> necessarily the same question as why populations have high levels of
>> diabetes (a population level epidemiological question).
>>
>> Rose G. Sick individuals and sick populations. International Journal of
>> Epidemiology 1985;14(1):32-8 also reprinted and discussed in Int J
>> Epidemiol (2001)
>>
>> So, if you prefer the idea that only 33 % is explained by risk factors
>> then you prefer individual prediction over population and so it seems 
>> hard
>> to me, to then try to translate that into calls for population-wide
>> change.
>>
>> In some ways these are very basic ideas but they are a bit tricky
>> sometimes and I find not all that well understood by my students. Here's
>> some material I get my students to ponder on this issue:
>>
>> Our recent paper shows that conventional risk factors DO explain social
>> inequalities in CHD
>> Lynch J, Davey Smith G, Harper S, Bainbridge K. Explaining the social
>> gradient in coronary heart disease:  comparing relative and absolute risk
>> approaches. Journal of Epidemiology and Community Health 2006;60:436-441.
>>
>> Our paper is related to this interchange:
>> Emberson JR, Whincup PH, Morris RW, Walker M. Social class differences in
>> coronary heart disease in middle-aged British men: implications for
>> prevention. Int. J. Epidemiol. 2004;33(2):289-296.
>> Marmot M. Commentary: Risk factors or social causes? Int. J. Epidemiol.
>> 2004;33(2):297-298.
>> Emberson JR, Whincup PH, Morris RW, Walker M. Reducing social 
>> inequalities
>> and the prevention of coronary heart disease. Int. J. Epidemiol.
>> 2004;33(5):1152-1153.
>>
>> Other useful stuff on "explaining" disease
>> Coggon DIW, Martyn CN. Time and chance: the stochastic nature of disease
>> causation. Lancet 2005;365(9468):1434-1437.
>>
>> Rockhill B. Theorizing about causes at the individual level while
>> estimating effects at the population level - implications for prevention.
>> Epidemiology 2005;16(1):124-129.
>>
>> John Lynch
>> Dept. Epidemiology
>> McGill University
>>
>>
>>
>> -----Original Message-----
>> From: Social Determinants of Health on behalf of Dennis Raphael
>> Sent: Thu 8/3/2006 6:33 AM
>> To: [log in to unmask]
>> Subject: [SDOH] Obesity as a "cause" of diabetes?
>>
>> Actually, the evidence concerning obesity as a causal factor in type II
>> diabetes is rather equivocal.  This is another example of the dominant
>> behavioural paradigm distorting analyis and understanding of a health
>> issue
>> -- see below...
>> -------------------------------------------------------------------------
>> "Ninety percent of the variance in occurrence of metabolic syndrome
>> observed in the Whitehall studies cannot be accounted for by conventional
>> behavioural risk factors.33"
>>
>> "Virtually nothing is known about the causes of recent increases in
>> morbidity and mortality among the Canadian population in general, and the
>> low-income population in particular.28  The presence of the metabolic
>> syndrome has been identified as a significant indicator of a
>> predisposition
>> to diabetes (as well as CVD).29 30 Conventional thinking among health
>> care,
>> public health workers, and disease-oriented associations attributes
>> increases in the presence of the metabolic syndrome and increases in
>> morbidity and mortality to changes in dietary and activity patterns among
>> Canadians 31, similar to traditional thinking concerning CVD-related
>> issues.12,32 Yet, this dominant "health behaviours" paradigm takes little
>> account of the increasing literature concerning the importance of the
>> social determinants of health in population health in general and the
>> incidence and management of diseases such as diabetes in particular.
>> Ninety
>> percent of the variance in occurrence of metabolic syndrome observed in
>> the
>> Whitehall studies cannot be accounted for by conventional behavioural 
>> risk
>> factors.33 "
>>
>> "An extensive analysis of the determinants of adults' health-related
>> behaviours such as tobacco use, physical activity, and healthy diets,
>> found
>> these behaviours were predicted by poor childhood conditions, low levels
>> of
>> education, and low status employment.(37) The study also found that poor
>> socioeconomic conditions during early life make it less likely that 
>> people
>> feel they have control over their lives - a factor that can contribute to
>> illness Identifying some of the possible pathways to diabetes mellitus
>> such
>> as material deprivation, excessive psychosocial stress, and adoption of
>> health threatening behaviours suggests value in applying a societal
>> determinants of diabetes approach. Certainly, such an analysis would
>> contribute to our understanding of why and how diabetes mellitus is an
>> especially important issue for low income and other vulnerable
>> populations.
>> And considering the increasing numbers of low income families living in
>> urban Canada, such a focus seems especially important.(12)"
>>
>> Yu, V. & Raphael, D. (2004). Identifying and addressing the social
>> determinants of the incidence and successful management of type 2 
>> diabetes
>> mellitus in Canada. Canadian Journal of Public Health, 95, 366-368.
>>
>> http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/h_Library/083BA721B77F5BA485256F2E004EB029/?OpenDocument
>>
>> Raphael, D., Anstice, S., Raine, K., et al. (2003).  The social
>> determinants of the incidence and management of Type 2 Diabetes Mellitus:
>> Are we prepared to rethink our questions and redirect our research
>> activities? Leadership in Health Services, 16, 10-20.
>>
>> http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/h_Library/2F5A8832066E485F85256D86003EE54C/?OpenDocument
>>
>>
>>
>>
>>
>>
>> Steve Cummins <[log in to unmask]>@YORKU.CA> on 08/03/2006 05:49:06
>> AM
>>
>> Please respond to Social Determinants of Health <[log in to unmask]>
>>
>> Sent by:    Social Determinants of Health <[log in to unmask]>
>>
>>
>> To:    [log in to unmask]
>> cc:
>>
>> Subject:    Re: [SDOH] anti-obesity technology
>>
>> I find the view that obesity is an unreliable indicator of physical
>> health rather a strange and potentially dangerous one.
>>
>> It is true that how obesity is measured is contested and that
>> discrimination and weightism is rife. For example BMI is not as reliable
>> as Waist-Hip Ratio or Abdominal Fatness and that certain groups (such as
>> athletes for example) can be heavier and still be healthy. It is also
>> true that some people who are overweight are not unhealthy (in fact
>> being overweight in old age is protective). You can be 'fat' and 'fit'.
>>
>> However the evidence that being obese causes physical health problems at
>> the population level CANNOT be seriously contested at present. For
>> example there is strong evidence that being overweight is implicated in
>> half of all diabetes cases and reduces life expectancy by up to 7 years.
>> To suggest otherwise is factually incorrect based upon current evidence
>> and detracts focus from what is a very real and pressing public health
>> problem
>>
>> A thorough evidence-based resource can be found here:
>>
>> http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
>>
>> Cochrane Reviews for obesity-related illnesses and interventions can
>> also be found here:
>>
>> http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME
>>
>> Best
>> Steve Cummins
>>
>>
>> Carrie Brown wrote:
>>> Thank you Graeme, I believe weight is an unreliable indicator of
>>> physical health.  I know many people within the "acceptable weight
>>> range" with high cholesterol, high blood pressure and who are not
>>> physically active or who don't eat well enough to achieve health
>>> benefits.  I also know many people who are above the "acceptable weight
>>> range" who are physically fit and extremely healthy.
>>>
>>> I think in the next couple of years we're going to find that obesity
>>> rates have decreased, but overall, people's physical health has not
>>> improved.   Because all those people who do not fall into the overweight
>>> or obese category do not get the message because they are not being
>>> targeted and don't feel that they are at risk.
>>>
>>> I'm afraid as a society we've created the situation where we look at
>>> each other and judge health and character based on appearance.  This is
>>> extremely disconcerting, especially in a world so desperately in need of
>>> acceptance, empathy and compassion.
>>>
>>> Carrie Brown
>>> Health Promotion Liaison
>>> Northern Lights Health Region
>>> 11202 - 100 Ave.
>>> High Level, A.B.   T0H 1Z0
>>> Phone:  (780) 841-3204
>>> Fax:  (780) 926-7375
>>> [log in to unmask]
>>>
>>> "Take care of ourselves and each other, spend time with loved ones, take
>>> breaks when necessary and enjoy each moment on this lovely green and
>>> blue planet."  ~Tooker Gomberg~
>>>
>>>
>>> -----Original Message-----
>>> From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of
>>> Graeme Bacque
>>> Sent: Wednesday, August 02, 2006 11:08 AM
>>> To: [log in to unmask]
>>> Subject: Re: [SDOH] anti-obesity technology
>>>
>>> One more serious issue to point out about this whole obesity obsession -
>>>
>>> this kind of excessive state and medical-sanctioned focus on impossible
>>> standards of physical appearance and performance is in fact a known
>>> aspect of fascism. It indicates a degree of social intolerance which is
>>> becoming extreme.
>>>
>>> These kind of 'standards' have been used deliberately and systematically
>>>
>>> to denigrate and oppress women, non-Europeans, religious minorities and
>>> persons with disabilities (among others) for centuries.
>>>
>>> The original history underlying this probably dates back to Biblical
>>> times, where a person's physical characteristics were routinely
>>> associated with either 'good' or 'evil'. This became highly evident in
>>> Europe during the Burning Times. The Nazis escalated this form of
>>> persecution to an extreme degree during their reign.
>>>
>>> This is a no-win situation and the worst form of victim-blaming -
>>> although the person affected may actually be  primarily a 'victim'  of
>>> society's scorn over physical attributes which are entirely beyond their
>>>
>>> control and which may  not even specifically be a health issue. In the
>>> end it boils down to other peoples' sense of aesthetics being offended
>>> as opposed to being a valid indicator of someone's  true state of
>>> physical well-being.
>>>
>>> I for one find this obsessive, narrow, judgmental, out of context
>>> official focus on certain physical characteristics (to the exclusion of
>>> most other personal attributes) to be highly alarming. People need to be
>>>
>>> valued in all their diversity, no matter what color, shape or size they
>>> may come in.
>>>
>>> Graeme
>>>
>>> Adam P. Coutts wrote:
>>>> an innovative individual protective mechanism for the impending
>>>> obesity epidemic! I think it's US based.
>>>>
>>>> http://www.harrietcarter.com/Detail.cfm?pth=13&Cat=111&prod=4594&sr=1
>>>>
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>> --
>> Steven Cummins MSc PhD
>> MRC Fellow
>> Department of Geography
>> Queen Mary, University of London
>> Mile End Road
>> London E1 4NS
>>
>> T: 44 020 7882 7653
>> F: 44 020 8981 6276
>> E: [log in to unmask]
>>
>> W: http://www.geog.qmul.ac.uk/staff/cummins.html
>>
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