1. State your health outcome of interest. Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention.
Health outcome of interest: type II diabetes.
Two key behaviors that are important factors leading to DMII are high fat/sugary diet (e.g. drinking soda and eating fast food), and inadequate physical activity. This example and behaviors are perhaps too obvious, with both unhealthy diet and inadequate physical activity being linked to metabolic disease, obesity and DMII, but given the rising prevalence and impact on health, it is of high interest to me as a family doctor. The behaviors can be highly influenced by social and economic factors; access to healthy food can be more difficult in low income/segregated neighborhoods that may have inadequate supermarkets (e.g. Bayview in SF, where the main supermarket closed in 2013 and a new one didn’t open until 2015), and there is commonly higher rates of corner markets/liquor stores and fast food restaurants. Neighborhoods without adequate sidewalks/play grounds, and/or with safety concerns, can limit residents’ ability to exercise and spend time outside, not to mention having to sometimes balance multiple jobs (often sedentary). Healthy food intake and exercise can both help prevent development of DMII. Interventions to increase healthy food options (e.g. through food vouchers/direct distribution of food, in addition to community and policy level interventions to improve access to healthy food) have been shown to help improve diabetes control. Interventions to improve green space, group fitness activities and free access to exercise/wellness events are also thought to improve diabetes outcomes.
2. Describe how you would study the role of one of the behaviors described for question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
To study the impact of unhealthy eating and limited exercise on diabetes control, with an interest in evaluating differences by stress, you could do a non-blinded randomized cluster analysis, wherein patients at a health center could be clustered by medical provider, and half of the providers could have their patients’ be randomized to weekly distribution of vegetables and fruits, and a structured exercise program, and the other half of medical providers' patients' receiving standard of care (providers could still promote healthy eating/exercise, but no structured programs). To look at the role of stress, all patients enrolled in the study could take a baseline stress questionnaire at the randomization visit, and at the last study visit. BaselineHgbA1c, and q3month blood draws could be used to track diabetes control.
Alternatively, you could do an observational study utilizing a questionnaire that asks about dietary intake/food security, exercise, and stress(e.g. questions from the National Academy of Medicine screener), and patient HgbA1could be included from the medical records, and data analyses utilized to look at the association between HgbA1c, diet, exercise and stress.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes? Why or why not?
Yes! Although we know that there is a strong influence, and studies have shown ways to influence and intervene, it is important to continue to evaluate interventions and impacts on health outcomes, such that we can improve funding streams and influence policy change, in addition to better understand differences in different communities and cultures, evaluate long-term outcomes, and ideally improve the sustainability of programs. Given how multifactorial the influence of health behaviors and social/economic factors, it is important to continue to monitor health outcomes and continue to search for best practices and ways to invoke policy change (to get the funding necessary to implement real, lasting change).