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Title: Leslie J. Crofford, MD Gloria W. Singletary Professor of Womens Health Research Director, Center for

Leslie J. Crofford, MD Gloria W. Singletary
Professor of Womens Health Research Director,
Center for the Advancement of Womens Health
Health and the Kentucky Woman
Advancing womens health through
comprehensive medical care, education
and outreach, and research opportunities http
  • Create new knowledge towards the understanding
    and improvement of womens health through
    clinical and basic research initiatives
  • Train primary care practitioners in
    gender-specific medicine and sensitize all health
    practitioners to understand and respond to the
    health care concerns and needs of women
  • Provide gender-specific diagnostic, treatment and
    preventive health care services in a coordinated,
    comprehensive and compassionate manner
  • Share women's health resources and information
    with consumers, communities, health care
    professionals, educators, and policy makers
  • Enhance the professional development of women at
    all academic levels within the University
    of Kentucky Chandler Medical Center, and increase
    recruitment, retention, promotion and advancement
    of women faculty

Goals for this Presentation
  • Discuss determinants of health
  • Review recommendations on how to maintain good
    health and prevent disease
  • Review behaviors associated with health
  • Consider what we can do to promote good health in
    our families and our community
  • Introduce the Kentucky Womens Health Registry
  • http// www.kywomensregistry

  • Health
  • Chronic disease prevention
  • Longevity
  • Wellness

Live well, live long
  • Determinates of Health
  • Genes
  • Environment
  • Behavior
  • Attitude

Genes and Health
  • Single gene disorders
  • Cystic fibrosis, sickle-cell anemia, hemophilia,
  • Chromosomal abnormalities
  • Downs syndrome, etc
  • Complex traits
  • Heart disease, depression, etc
  • Diseases associated with gene mutation
  • Cancer

  • DNA is the building block for genes
  • Genes are inherited from parents as discreet
    units that come in pairs and are carried on
  • Simple genetics can be applied to single-gene
    traits that are either dominant or recessive
  • More complex traits and diseases are associated
    with some genes that are permissive and others
    that are protective

Gene/Environment Interactions
  • Most chronic diseases are attributable to both
    genes and environmental exposures
  • Some exposures cannot be avoided, others are the
    result of modifiable behaviors
  • What counts as environment?
  • Natural environment, e.g. sun
  • Infectious exposures
  • Chemical or toxin exposures
  • Trauma and other physical stressors
  • Psychological stressors
  • Dietary exposures

Gene/Environment Interactions
  • Cancer
  • Metabolic diseases and heart disease
  • Autoimmunity
  • Depression
  • Chronic pain and fatigue

Genes, Environment, and Health
  • Understand your genetic risk factors
  • Family history
  • Understand your environmental risk factors
  • Unavoidable exposures
  • Know what kinds of preventative steps may be
    important for you
  • Screening that works

Concept of Preventative Health
  • Prevention and early detection are essential to
    good health
  • Potentially infinite lists of advice and tests
  • Many have little scientific basis for widespread
  • Preventative strategies should be evaluated in
  • On what do you base recommendations for
  • Burden of suffering
  • Characteristics of screening tests
  • Effectiveness of early screening in
  • reducing morbidity and mortality

  • Only about 10 of cancer risk can be attributable
    to inherited genes while the other 90 of cancer
    is associated with mutations associated with
    environmental exposures
  • Genetic mutations accumulate with age and
    exposures, e.g.
  • Sun
  • Diet (saturated fat, fiber)
  • Chemicals and toxins (tobacco smoke)
  • Infections (human papillomavirus)

Cancer-Associated Genes
  • Cancer genes are involved in cell growth, and
    their ability to invade surrounding tissues or
  • Presence of genes which allow uncontrolled growth
  • Absence of cells which put the brakes on growth
  • Genes that help cancer cells avoid removal
  • Genes that assist cancer cells in spreading

Cancer in Women The Big 3
  • Lung Cancer
  • Breast Cancer
  • Colon Cancer

Lung Cancer in Women
  • Lung cancer will kill about 72,130 American women
    this year
  • Kentucky leads the nation in lung cancer deaths
  • With a given smoking exposure, women are more
    likely to get lung cancer
  • Women are more likely than men to die of lung
  • Kentucky leads the nation in adult smokers
  • 32.6 (2 is Alaska at 29.4)
  • About 90 of lung cancer deaths in women are
    related to smoking
  • Second hand smoke counts
  • A family history of lung cancer, but not other
    cancers, increases risk for lung cancer
  • The risk of inherited lung cancer is greater for
    women than men
  • The risk is most easily identified in non-smokers
  • Those with a family history of lung cancer could
    be considered high-risk

Lung Cancer Screening?
  • At this time, there is insufficient evidence that
    screening of asymptomatic persons improves
  • High false negatives on chest X-ray
  • High false positives on CT Scan
  • Poor sensitivity when screening sputum for cancer
  • Prevention is Essential

Breast Cancer
  • Breast cancer is the second leading cause of
    cancer deaths in all women, and the leading cause
    in young women
  • 1 in 8.2 women will develop breast cancer in
    their lifetime
  • 1 in 30 women will die from breast cancer
  • Risks
  • Genes
  • Mutations in BRCA1 and BRCA2, cancer suppressing
    genes, are associated with breast, ovarian, and
    prostate cancer
  • Environmental Risks
  • Estrogen
  • Early menarche, late menopause, nulliparity
  • Hormone replacement therapy (2002 WHI study and
    2006 NHS)
  • 24 increased risk after 5 years for combination
  • Significant risk for estrogen only after 15-20
    years (42 after 20 years)
  • Especially significant risk for thin women
  • High-dose radiation, obesity, heavy alcohol use
  • Protection from risk
  • Exercise, diet

Breast Cancer Screening
  • Screening mammography should be performed every
    1-2 years for women aged 40 and older
  • Little evidence separating 12-33 month intervals
  • With or without clinical breast exam
  • Insufficient evidence for breast self-exam
  • Evidence that digital mammography superior to
    traditional mammography
  • Effectiveness of early detection
  • Strongest for women aged 50-69
  • Most, but not all studies, show reduction in
    mortality for women 40-49
  • One study demonstrating reduced mortality for
    women 65-74

Colon Cancer
  • Colorectal cancer effects women and men equally
    and is the 3rd leading cause of cancer death in
  • 60 of patients with colorectal cancer have
    regional or distant metastases at the time of
  • 5-year survival
  • 91 for localized disease
  • 60 for regional disease
  • 6 for distant metastatic disease

Risk Factors for Colon Cancer
  • Family history
  • Familial syndromes account for 6 of colorectal
  • Family history increases the risk by up to 4x in
    those 40-60
  • Prior diagnosis of endometrial, breast or ovarian
  • Personal history of polyps
  • Diets high in fat, low in fiber

Colon Cancer Screening
  • Should begin at age 50
  • Yearly test for blood in the stool
  • Flexible sigmoidoscopy
  • Colonoscopy
  • Especially important for women as cancers tend to
    be in the proximal colon 64.8 of the time
  • Screen earlier in high-risk patients

Diabetes, Hypertension, Hyperlipidemia, and Heart
  • Genes and exposures control risks for metabolic
  • Metabolic diseases (and smoking) are the most
    important risks for heart disease
  • Heart disease is the 1 killer of women
  • Preventing these chronic diseases is essential
    for health, wellness and longevity
  • Behavioral factors are critical for preventing
    these diseases

Preventing Metabolic and Heart Diseases
  • Know your family history
  • Maintain a normal body weight
  • Exercise regularly
  • Eat healthy foods
  • Control blood pressure, blood sugar and
  • Use medications if needed
  • Dont smoke
  • More than ½ of heart attacks in women under 50
    are related to smoking

Screening for Metabolic Diseases Associated with
Heart Disease
  • Diabetes
  • Screen for type 2 diabetes in adults with
    hypertension or hyperlipidemia
  • Yearly fasting glucose for all starting at 45
    years of age and younger for those with risk
  • Family history of type 2 diabetes, overweight,
    and hypertension
  • Hypertension
  • Screen in adults aged 18 or older
  • Weight reduction, exercise and reduced salt
    intake helpful
  • Early treatment and good follow-up reduces all
    cause mortality 17
  • Hyperlipidemia
  • Women should be screened starting at age 45 (men
    at age 30)
  • Screen earlier if other risk factors for heart
    disease present
  • Women age 20 or higher
  • Measure total cholesterol LDL (bad) and HDL
    (good) cholesterol
  • Diet can lower cholesterol, but drug treatment
    lowers risk of death
  • Treat to LDL
  • Routine screening for coronary artery disease in
    asymptomatic women is not recommended

What about Body Weight?
Underweight is associated with smoking and
osteoporosis overweight with diabetes,
hypertension, and heart disease
N Engl J Med. 2006 Aug 24355(8)763-78
Obesity Trends Among U.S. Adults BRFSS, 1990,
1995, 2005
(BMI ?30, or about 30 lbs overweight for 54
No Data 1519 2024 2529
Why this Epidemic?
  • Overweight and obesity result from an energy
    imbalance. This involves eating too many calories
    and not getting enough physical activity. 
  • Body weight is the result of genes, metabolism,
    behavior, environment, culture, and socioeconomic
  • Behavior and environment play a large role
    causing people to be overweight and obese. These
    are the greatest areas for prevention and
    treatment actions.
  • Despite obesity having strong genetic
    determinants, the genetic composition of the
    population does not change rapidly. Therefore,
    the large increase in . . . obesity must
    reflect major changes in non-genetic factors.

Obesity in Kentucky
  • The epidemic in Kentucky
  • 63 of adults in Kentucky are obese or overweight
  • 30 of Kentucky high school children are
    overweight or at risk of becoming overweight
  • 35of lower-income children between the ages of 2
    and 5 are overweight or at risk of becoming
  • Kentucky nutrition and physical activity plan
  • New standards for nutrition and physical activity
    in schools through legislation (Senate Bill 172)
    passed in March 2005, the states first public
    policy created in direct response to the obesity

Impacting Obesity
  • Aspirin thins the blood to reduce blood clots
    that can cause heart attack and stroke
  • The benefits of low-dose aspirin differ in men
    and women
  • In women aged 40-65, aspirin did NOT reduce the
    risk of a first heart attack, but did reduce the
    risk of stroke (more common in women)
  • After age 65, aspirin use decreased the risk of
    heart attack by 34
  • Remember that aspirin can cause ulcers and
    bleeding, a side effect that increases with age
    and with the use of other non-steroidal drugs
    (ibuprofen, naproxen)

Other Issues of Preventative Health
  • Osteoporosis
  • Risk factors
  • Female, advanced age, Caucasian race, low-body
    weight, surgical removal of ovaries before
    menopause, smoking, alcohol use, glucocorticoid
  • 50 of post-menopausal women will develop a
    spontaneous fracture
  • 15 of women will sustain a hip fracture
  • Screening
  • All women aged 65 and older should be screened
  • Women with risk factors should be screened at age
  • Prevention
  • Calcium and vitamin D lifelong!!
  • Weight-bearing exercise
  • Estrogen increased bone density and reduces

Hormone Replacement Therapy
  • Benefits and Harms
  • Benefits
  • Reduced osteoporosis and fractures
  • Reduced colon cancer
  • Harms
  • Breast cancer
  • Contraindications
  • Absolute
  • Undiagnosed vaginal bleeding, breast or
    endometrial cancer, recent blood clot
  • Relative
  • Liver disease, melanoma, gallstones, increased
    triglycerides, endometriosis, fibroids, history
    of blood clots

Vitamins and Supplements
  • Eating a wide variety of foods, including fruits,
    vegetables, whole grains, legumes and lean meats
  • Vitamin and mineral supplements may be needed if
  • Poor dietary habits
  • Less than 1,200 calories a day
  • Problems with absorption
  • Folic Acid
  • All women during reproductive years
  • Multivitamin or breakfast cereal
  • Calcium and Vitamin D
  • Iron
  • If heavy menstrual bleeding
  • Pregnant or trying to become pregnant
  • Other vitamins, minerals or supplements?
  • Omega-3 Fatty Acids
  • Fish or supplements
  • Reduces inflammation and heart disease
  • Fiber
  • Promotes healthy bowel function, reduces colon
    cancer, and may decrease risk of health disease

  • Influenza A Yearly
  • For those at risk or who care for those at risk
  • Adverse effects rare
  • Pneumococcal Every 5 years
  • Elderly (65), chronically ill or
  • Tetanus and diptheria Every 10 years
  • Measles, mumps, rubella One time
  • Hepatitis B One time
  • All under 18 and high risk groups
  • Meningiococcal
  • High risk groups (including residents of
  • Human papilloma virus?
  • Example of policy issue
  • Detectable in 75-95 of cervical cancer

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Risk Behaviors are Established Early in Life
  • Smoking
  • More than 1 in 5 high school students are current
  • Unhealthy dietary behaviors
  • Almost 80 of high school students do not eat the
    recommended 5 servings of fruits and vegetables
  • Inadequate physical activity
  • Nearly 1 and 3 children and adolescents are
    overweight or at risk of becoming overweight
  • Alcohol an other drug use
  • Sexual behaviors that may results in HIV
    infection, other sexually transmitted diseases,
    unintended pregnancy
  • Every year, more than 870,000 adolescents become
    pregnant and over 3 million become infected with
    a sexually transmitted disease
  • Behaviors that contribute to unintentional
    injuries and violence
  • Not wearing seat belts, riding with a driver
    drinking alcohol, carrying a weapon

Concept of Wellness in Health
  • Incorporates concepts of being physically and
    mentally healthy
  • Exclusive of specific disease
  • Includes some components of functional capacity
    or activity
  • Adds positive psychological constructs of
    happiness and life satisfaction

Health-Related Quality of Life
  • Americans said they feel unhealthy (physically or
    mentally) about 6 days per month
  • Americans said they feel "healthy and full of
    energy" about 19 days per month
  • Nearly one-third of Americans say they suffer
    from some mental or emotional problem every
    monthincluding 10 percent who said their mental
    health was not good for 14 or more days a month
  • Younger American adults, aged 1824 years,
    suffered the most mental health distress
  • Older adults suffered the most poor physical
    health and activity limitation
  • Adults with the lowest income or education
  • more unhealthy days than did those with
  • income or education
  • Americans with chronic diseases or disabilities
  • reported high levels of unhealthy days

Mean Number of Unhealthy Days by State Kentucky
Leads the Nation
Main Factors Associated with Health and Activity
  • Depression/anxiety/
  • emotional problems
  • Cancer
  • Diabetes
  • Stoke
  • High blood pressure
  • Back or neck problems
  • Heart problems
  • Lung/breathing problems
  • Walking problem
  • Fracture/joint injury
  • Arthritis/rheumatism
  • Eye/vision problem
  • Hearing problem

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What Kinds of Things Cause Stress?
And Now
  • Deadlines
  • Too much to do to little time
  • Conflicts at home
  • Divorce
  • Illness
  • Worries about children
  • Discord at work
  • Interpersonal conflicts
  • Lack of respect/control
  • Money worries
  • Daily hassles
  • Traffic, rude behavior
  • Predators
  • Escaping
  • Surviving attack
  • Weather extremes
  • Drought
  • Heat
  • Cold
  • Starvation
  • Parasites

Stress and Adaptation
Individual Response
Determinants of the Stress Response
Circadian Rhythm
  • Genetics
  • Early life experiences
  • Childhood maltreatment
  • Deprivation
  • Family stress
  • Chronic stress
  • Social hierarchy
  • Instability
  • Coping
  • Glass half full/empty Optimism
  • Locus of control
  • Learned helplessness

Adrenal Cortex
Cortisol mg/dL
700 1300 1900 100 700
  • Exposure to violence is an important cause of
    physical and mental health problems
  • 12-14 prevalence in Emergency Rooms
  • 21-37 prevalence in primary care settings
  • Associated with stress-associated disorders
  • Continues during pregnancy
  • Important cause of injury and death during and
    after pregnancy
  • Mental health conditions associated with
    interpersonal victimization
  • Depression, anxiety, post-traumatic stress
    disorder, suicidality, hopelessness and low

Exposure to Intimate Partner Violence in Kentucky
  • 75 reported multiple forms of IVP
  • 74 injured and 69 more than one type of injury
  • 44 report children present during abuse
  • 40 of perpetrators use children to threaten
  • 39 abuse increased throughout relationship
  • 20 abused during pregnancy
  • 15 perpetrator harmed a pet
  • 5 perpetrator killed a pet

Healthy Aging
  • Myth
  • Health inevitably declines as we get older
  • Reality
  • People of any age can improve their health by
    adopting healthy behaviors

Insights from Centenarians the older you get,
the healthier youve beenThomas Perls, MD, MPH
  • Genetics is important
  • Absence of disease-causing genes and presence of
    longevity-enabling genes
  • Siblings live longer
  • Children have lower mortality
  • Lower prevalence of age-related chronic disease
  • Lower body mass index
  • Healthy cognitive functioning is a better
    predictor of independence than physical health
  • Some people markedly delay or escape
    age-associated brain diseases
  • Impact of chronic diseases important
  • Diabetes, heart disease, cancer, etc
  • 20 completely escape chronic disease
  • 40 have marked delay until after age 85
  • 40 develop diseases before 65, but survive long
    after diagnosis

Longevity Frailty
  • Longevity
  • Genes are important BUT….
  • Healthy lifestyle is also essential
  • Living long AND healthy is the goal
  • Frailty is characterized by
  • Exhaustion, weakness, weight loss, loss of muscle
    mass strength
  • Increases with age
  • 9.5 age 75-79
  • 16 age 80-84
  • 25 age 85-89
  • Preventing frailty
  • Exercise
  • Reduce cardiovascular disease
  • Positive mental outlook regarding aging

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Brain-Body Medicine Attitude and Health
  • How strongly do you believe good (or bad) things
    will happen to you in your future?
  • Almost 80 of people are somewhat to very
  • Optimism is associated with extroversion,
    persistence, and positive mood while pessimism
    is associated with neuroticism and negative mood
  • Optimism is associated with being engaged with
    lifes goals
  • Optimism is often associated with better health
    and better outcomes when confronting illness
  • Although optimism is likely to be related to
    genes, family, culture, the power to define
    personality may also be related to behaviors

Suzanne Segerstrom Breaking Murphys Law, 2006
The Guilford Press, NY
Health as an Advocacy and Policy Concern
Health Related Activism and Advocacy
  • Education
  • Reduce socioeconomic deprivation
  • Social position and its attendant assets are the
    most powerful determinants of health
  • Modify risk behaviors
  • Nutrition and physical activity in schools
  • Train health care providers
  • Biomedical Research
  • Support health care related research
  • National Institutes of Health (NIH)
  • Preventative Health Care and Epidemiology
  • Centers for Disease Control and Prevention (CDC)
  • Health Resource Services Administration (HRSA)
  • Environmental Concerns
  • Pollution
  • Global warming
  • Health Care Policy
  • Access to preventative services and chronic
    disease care
  • Mental health services

Education and Health
  • Better educated people are healthier (and more
    poorly educated people are less healthy)
  • Is it education, occupation or income?
  • Strongly interdependent
  • Why?
  • Influences work and economic conditions
  • Enhances social and psychological resources
  • Making judgments increasing self-control,
    self-efficacy, and resilience positive effects
    of social support
  • Enables lifestyle and health behaviors
  • Education is strongly associated with reduced
    risk behaviors and vice versa
  • Direct effect by unknown mechanisms
  • Genetic endowment
  • Inclination to postpone gratification
  • Public policy to promote early childhood
    development can protect children from the
    negative effects of low socioeconomic status and
    low parental education

Why do some diseases affect women more than men?
Why do women respond to some drugs and treatment
differently than men? What environmental factors
and behaviors most influence womens health? We
dont know. But we want to find out. And we need
your help. The Kentucky Womens Health Registry
Survey is now available on-line!
Registry Participants and Data Collected
  • Female residents of the Commonwealth of Kentucky
    between the ages of 18 and 89
  • Information collected
  • Self-report
  • Demographic
  • Socioeconomic
  • Education, work status
  • Personal and family resources
  • General health and symptoms
  • Focus on chronic pain, fatigue, stress
  • Health behaviors
  • Exercise, food behavior, smoking, alcohol, drugs
    of abuse
  • Medical diagnoses
  • Psychiatric symptoms and exposure to violence

  • Mission
  • To improve the understanding of diseases or
    illnesses affecting the women of Kentucky
  • Objectives
  • To increase understanding of variables and
    exposures that contribute to health problems at a
    local level
  • To learn where to target programs and assess the
    effectiveness of programs
  • To provide women with accurate information and
    educational opportunities about volunteering for
    medical research
  • To facilitate comfortable, convenient initial
    contact between the investigator and interested
    research participants

Thank you!
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