1. Stress and Disease Dr. Donald B. Giddon Harvard University, Fall 2013 Introduction and Overview 1

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3. The Four Core Questions 1.What factors are stressful for a given individual? (QI) 2.What direct and indirect neurohormonal or behavioral pathways are activated by stressors? (QII) 3. Why is a particular organ or system selected as the target of stress-related disorders? (QIII) 4. What are the cognitive, affective, and behavioral responses to disease? (QIV) 3

4. CHANGES IN HOW DISEASE IS VIEWED CHANGES IN HOW DISEASE IS VIEWED Time EtiologyDisease Pattern Provider Philosophy BCE DemonsPlagues (Black, cholera, typhus) Religion Purity- Poor lifestyle Trauma Exorcism Priests Hippocrates Shamans Isolation Sanitation Isolation Sanitation Hygiene Hygiene air, diet, sleep air, diet, sleep 1850 Biology InfectionMedicalization 1850 Biology InfectionMedicalization (Virchow)2/3 of deathsSocial Control 1900 to Biopsychological CVD Medical and Prevention 1950+ Degenerative Neoplasm Psychosocial (Cancer) 1970- CVD associated present Life Stylewith aging Wellness 4

5. 5 CHANGES IN HOW DISEASE IS VIEWED - continued CHANGES IN HOW DISEASE IS VIEWED - continued Time Acute Communicable BCE1850 1900 to 1950+ Chronic Noncommunicable 1970-present lifestyle (50-70%)

6. 6 Demographics Sex o Gender o Age Race National origin Ethnocultural BMI Occupation

7. Changes in Physical, Social, and Environmental Health Threats From 20,000 BCE to Modern Times 7

8. Food supplyFood supply o Starvation o Nutritional status Water supplyWater supply o Quality o Quantity PredatorsPredators 8

9. 9 New PathogensNew Pathogens o Microbes  Bacteria  Viruses  Fungi  Other o New allergens Environmental hazardsEnvironmental hazards

10. 10 Religious and social attitudes Health–related behaviors Sanitation measures Availability of trained health care providers Socio-economic factors

11. 11 Geographic factors o Climate o Location o Population density  Crowding  Psychological vs. physical o Transportation Other quality of life issues Communication o Mass o Interpersonal o Doctor-patient o Health literacy

12. 12 Resulting Common Health Problems in Modern Times Starvation Cancer Stroke Violence Accidents Suicide

13. 13 Resulting Common Health Problems in Modern Times – continued New infectious diseases Auto-immune diseases Allergies Acute mental illness – e.g. anxiety, depression, PTSD

14. 14 Obsession with physical attractiveness o Narcissism o Body dysmorphic disorder Pain Overuse of Medications o Prescriptions o Over the Counter Resulting Common Health Problems in Modern Times – continued

15. 15 Antibiotic-resistant micro- organisms Superinfection National disasters Changes in leisure activity Changes in provider behavior o Medical mistakes Resulting Common Health Problems in Modern Times – continued

16. 16 Chronic disease associated with lifestyle and longevity : o Lifestyle  Heart disease  HIV  Addiction o Computer  Obesity  Melanoma  Respiratory – COPD, etc. Resulting Common Health Problems in Modern Times – continued

17. 17 o Longevity  Alzheimer’s and dementia  Depression  Osteoporosis  Decreased sensory acuity  Eyes, Ears, Nose Resulting Common Health Problems in Modern Times – continued

18. o Longevity – continued  Decreased motor ability including balance  Skin problems  Diabetes Type 2  Disability 18

19. 19 Other Physical, Psychological and Sociocultural Variables

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25. 25 Race and Age Differences Women live 5.1 years longer than men. This is the first time that the data indicate U.S. black males have a life expectancy of 70 years.

26. Rachel Anderson [rachelmiyoko@gmail.com] 26

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29. Pathways linking SES and Health The solid lines indicate pathways studied by MacArthur Network on SES & Health; dashed lines indicate pathways of importance not studied. In: Adler and Stewart, 2010. 29

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32. Death rates correlate with income inequality across the 50 U.S. states and 10 Canadian provinces. (Adapted from Ross et al.) Death Rates and Income 32

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34. 34 Looking at the Causes of Major Chronic Diseases (Chronic refers to longterm responsibility) Heart disease Cancer Stroke

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42. The State of Cancer 42

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44. 44 BMI and Disease Risk

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46. Multivariate relative risk of death from cardiovascular disease, cancer and all other causes among men and women who had never smoked and who had no history of disease at enrollment, according to body-mass index. The reference category was made up of subjects with a body-mass index of 23.5 to 24.9. 46

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48. 48 Translocation

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51. 51 47.5 million U.S. Adults Report a Disability: Arthritis Remains Most Common Cause

52. 52 Reducing Disability is a Major Problem Increasing physical activity and reducing or preventing obesity and tobacco use can eliminate some of the underlying causes of disability and prevent secondary conditions in those already affected.

53. 53 Following arthritis, back, spine, and heart trouble are the top three causes of disability. Common identified limitations were: climbing stairs, walking three city blocks, accounting for 10% of adults. Disability increases with age. Women have a higher prevalence of disability than men.

54. Some Other Gender Differences 54

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56. 56 A large number of nurses reported seeing medical errors by physicians, but only a small number ever reported them

57. States with Greater Than 10% of Population Lacking Basic Literacy 57

58. Overuse of Antibiotics- An Additional Leading Cause of Death Enterocolitis due to Clostridium difficile (C. difficile), a bacterial inflammation of the intestines, is of growing public health concern because it is often acquired in hospitals or other health-care institutions with long-term patients or residents and accounts for an increasing number of deaths. In 2007, this cause was not among the 20 leading causes for the overall population. However, it ranked among the 20 leading causes of death for the population aged 65 years and older. Approximately 92% of deaths due to C. difficile occurred in persons aged 65 years and over in 2007. 58

59. Role of SES and Dietary Choices in Relation to Health and Disease 59

60. Diets 60

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63. Predisposing Variables Age, gender, SES, previous experiences: education, culture, race, religion, family Intervening Variables: Cognitive and Affective Knowledge, attitudes, beliefs, values (significance of health) Knowledge, attitudes, beliefs, values (significance of health) Objective need Perceptions Objective status of health care resources for health care (subjective) (facilities, finances, personnel) Need for Health CareHealth Care Resources - Therapeutic care (pain relief, appearance) - Availability - Therapeutic care (pain relief, appearance) - Availability treatment of disease) - Accessibility treatment of disease) - Accessibility - Preventive care (personal suseptibility, - Acceptability - Preventive care (personal suseptibility, - Acceptability seriousness of disease, preventability, seriousness of disease, preventability, salience relative to other needs salience relative to other needs self-efficacy) self-efficacy) 63

64. Evaluation & Training of Health Care Professionals Dr./Pt. Treatment Situation Situation Subjective Need Need Objective Need Objective Need 64 Biological Factors PSYCHOSOCIAL FACTORS Human Resources