The Epidemiologic Transition and the role of women and plants

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The Epidemiologic Transition and the role of
women and plants

• Anna Herforth, M.S.
• PhD student - International Nutrition

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What is epidemiology??

• Its Greek to me!
• epi upon
• demos the people
• logos thought/study
• Studying (the distribution and determinants of
  health-related) events that happen upon the
  people.
• In practice, it involves
• surveillance of populations for births, deaths,
  morbidity, and anthropometric indicators.
• the use of statistics to find associations
  between hypothesized risk factors and health
  outcomes.

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The main point of epidemiology

• To describe patterns of health and disease.
• To look at associations to characterize risk.

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Association

• Correlation
• Example Use of the plant Momordica charantia
  (Cucurbitaceae) is associated with having
  diabetes.

• Caveat Correlation does not equal causation.
• Another example Ground beef consumption is
  associated with getting diabetes.

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Risk

• Two-by-two tables (or contingency tables)
• Relative risk risk in the exposed a/ab
• risk in the unexposed c/cd
• Relative risk of 1.0 no additional risk from
  exposure.

Disease Yes No
Exposure Yes No
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A realistic example

• Diabetes prevalence in the DR is about 5
• If we randomly sample 1000 people, we expect 50
  to have diabetes.
• Obesity prevalence in the DR is about 16
• If we randomly sample 1000 people, we expect 160
  to be obese.
• Relative risk risk in the exposed a/(ab)
  40/(40120)
• risk in the unexposed c/(cd)
  10/(10820)
• RR 0.25 25
• 0.01

Diabetes Yes No
Obese Yes No
160
50
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Colditz GA, et al. Weight gain as a risk factor
for clinical diabetes mellitus in women. Ann
Intern Med 1995122481-6.
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BMI, Overweight, Obesity - Definitions

• BMI body mass index (height in
  meters)/(squared weight in kg)
• BMI of 25-29.9 overweight
• Health risks of being overweight are
  controversial.
• BMI of 30 or greater obese
• Clear health risks shown by epidemiological data.

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• Type II diabetes follows obesity like night
  follows day.

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Why do we care about obesity?

• By far the strongest observable risk factor for
  type II diabetes.
• Very similar to smoking lung cancer
• By the way, attacking the cause (obesity,
  smoking) also prevents other serious diseases.
• Most important Heart disease

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The Epidemiologic Transition

• a.k.a. The nutrition transition
• Previous major public health problem in
  developing countries malnutrition and child
  stunting
• Now dual burden of disease
• Stunting and other problems of malnutrition are
  not eradicated.
• Obesity and associated non-communicable diseases
  (NCDs) are fast emerging.
• This is happening rapidly in Latin America
  (transition economy)

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NCDs in Mexico, 1980-1998
Rivera-Dommarco J, Shamah-Levy T,
Villalpando-Hernandez S, et al. Estado
Nutricional de Ninos y Mujeres en Mexico.
Encuesta Nacional de Nutricion 1999. Instituto
Nacional de Salud Publica. Mexico. 2001.
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Disparities

• Ethnic and racial disparities in the U.S. (NCHS
  data)
• Non-Hispanic White 30.7 obese
• Non-Hispanic Black 49 obese
• Mexican American 38.4 obese
• Gender disparities
• There is almost universally a higher prevalence
  of obesity among females than males.

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Obesity in the DR

• Total 16.4
• Men 12.7
• Women 18.3
• (WHO data from 1998)
• Overweight 34 (vs. 60 in U.S.)
• Child malnutrition 5.9 (vs. lt1 in U.S.)

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Source PAHO
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Diabetes in Dominicans

• Dominican Republic
• Diabetes prevalence 4-5 (WHO)
• Diabetes is a growing problem, representing 4.2
  of deaths in 1998. (PAHO)
• United States
• overall diabetes prevalence is about 7
• Non-Hispanic whites 5
• Hispanics 9.8
• This health disparity pattern has been
  substantiated for Dominicans specifically.
• ethnicity was found to be a stronger predictor of
  diabetes status and control than socioeconomic
  status or health behaviors!

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Conclusions about these data

• Dominicans living in Dominican Republic and in
  the U.S. have high risk of developing diabetes.
• To understand how Dominicans manage diabetes,
  cultural attitudes, beliefs, and practices need
  to be examined.

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Why is it important to consider gender in
ethnobotany?

• Womens knowledge is underrepresented in
  ethnobotanical literature.
• Men and women have different roles in healing and
  offer different perspectives on disease and
  healing.
• Some diseases are cured almost exclusively by
  women.
• In Peru yeast infections (Candida albicans)
• Diet-related diseases

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Lessons (unintentionally) Learned from Peru
ethnobotany concerning gender

• Women are responsible for a lot of knowledge
  about medicinal plants, and they know many cures
  that the shaman doesnt use.
• Both men and women are substantially involved in
  healing, but they have different
  culturally-defined roles.

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Womens role in healing

• Women are the popular or lay healers often
  the first person contacted upon illness.
• They are important to the health and wellness of
  a family as mothers and grandmothers.
• Some women acquire renown for their healing
  abilities and are integral in caring for the
  health of many in the community
• midwives
• Tends to be non-ritual healing.

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Mens role in healing

• Tends to be ritualistic, sensational, shamanistic
  reserved for special cases and serious
  health/spiritual problems.

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Gender and medicinal plant knowledge a study

• Community members were asked to interview people
  from their community who were knowledgeable about
  medicinal plants.
• Interviewers asked the equal numbers of men and
  women to respond.
• Each respondent filled out as many medicinal
  plant data sheets as possible.

Kothari, B. 2003. The invisible queen in the
plant kingdom Gender perspectives in medical
ethnobotany. In Howard (ed.) Women and Plants
Gender Relations in Biodiversity Management and
Conservation. Zed Books, New York.
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Percent of total medicinal plant data sheets
filled out as a function of gender
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Women know more plants, and more plants per
illness
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Mother
Daughter
Grandmother
Midwife
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Importance of women in determining what is eaten

• Women are typically the meal-preparers
  (nutritional gatekeepers).
• Women are probably the main knowledge-keepers
  about diet-related medicinal plants.

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Hippocrates Let food be thy medicine

• You have to have good nutrition to be healthy and
  resist disease.
• Certain specific foods and food components can
  act as preventive or curative agents for specific
  diseases.
• Food is an important medicine to prevent and
  control diet-related chronic diseases.

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Food-based solutions to NCDs

• In situations of abundance, Less is more!
• Meal preparers have an influence on how big
  portions served are, how much fat is used, what
  kinds of foods are used.
• In U.S., health claims about certain foods and
  heart disease
• Soy
• Whole grains
• Olive oil
• Tea (not an official health claim)
• Medicinal plants

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Finding medicinal plants in the DR that are used
against diabetes

• Where do I start?
• Information given this weekend
• Ecological Observation
• Ethnobotany

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Ecological Interactions

• Sagebrush
• (Artemisia tridentata) Asteraceae

Photo courtesy University of Nevada, Reno
http//imageserver.library.unr.edu
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Observation
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Ethnobotany

• Speeds up the process greatly.
• Step 1 live with people and get to know them
  learn from them.
• You find out what diseases are most important to
  the community.
• As you learn more, focus on plant or family or
  disease of interest collect more detailed
  information through interviews.
• Youll probably be talking to a lot of women.
  (Make sure you do!)

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Your role

• Always remember that the information they share
  with you belongs to them.
• A list of plants cures is not enough, unless your
  goal is a publication by and for the community.
• Your contribution is
• Biochemistry identifying bioactivity in a
  laboratory setting, identifying compounds or a
  chemical profile.
• Anthropology Characterizing the knowledge,
  beliefs, attitudes, and practices about a
  disease.
• Foundations of epidemiology eg. observing
  associations between people who use anti-diabetes
  plants and those who dont.

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Why look at different sites?

• Sites
• Santo Domingo - Urban
• Cachote - Rural
• Punta Cana Tourist
• New York City major emigrant destination
• Urbanization influences obesity and diabetes
  prevalence
• Job/lifestyle influences food choices, physical
  activity, practices

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Main questions

• What are the knowledge, attitudes, beliefs and
  practices about diabetes among Dominicans in each
  of the sites? How are they similar or different
  between sites?
• How do people know they have diabetes/ why do
  they think they have it?
• Do they use plants to treat it? How prevalent
  (in general) is the use of anti-diabetes plants?
• Are the plants preventive or only curative?
• What does the plant do? (How do they describe
  its activity)
• Works on symptoms, or root causes of diabetes?

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Main questions, contd

• Who makes the decision eat the plant and who
  prepares it?
• Individual decisions, served up by mom, or bought
  in a market?
• Are only locally-grown plants used?
• Will be important particularly in looking at the
  pattern of anti-diabetes plants in Punta Cana
• Which plants are most commonly used?
• What is the biochemical composition and
  bioactivity of anti-diabetes plants?

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Questionnaire

• Short questionnaire for use in structured
  interviews.
• This is different from open-ended discussions,
  observation, and individual in-depth interviews
  in your area of interest.
• Diabetes group will design, and one or two
  students will carry out.

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The potential to improve public health

• Type 2 diabetes is primarily treated by
  behavioral change
• To use this treatment, we need to understand what
  peoples behaviors are in the first place.