EXPOSURE DAN OUTCOME

GIZI-PTM

DODIK BRIAWAN

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 Basic Question in Analytic Epidemiology

Are exposure and disease linked?

Exposure Outcome
(dietary assessment) (Health/disease)biasanya
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biomarker
Epidemiologi Gizi dan PTM (Dodik) 2
 Exposure - Outcome:
ART UGM

In epidemiology, the term “exposure” (paparan) can be broadly applied to

1. Dose
any factor that may be associated with an outcome of interest
Istirlah yang sifanya lebih umum, berbagai factor yang berhubungan
2.
outcome tertentu.
Intensity
3. Duration
The outcome of a study is a broad term for any defined disease,
State of health, health-related event or death. In some studies,
there may be multiple outcomes misalnya orang sakit diabetes ada
penyertanya
 Exposure - Outcome:
ART UGM

1. Dose
2. Intensity
3. Duration
 Aspect
ART ofUGM
exposure:
Harus mempertimbangkan 3 hal ini

1. Dose( misalnya dosis ekstrak terlalu tinggi bias menyebabkan bleeding)

2. Intensity( apakah sehari 2 kali atau 3 kali)
3. Duration
Harus mengkaji dari beberapa previous study. Untuk menyesuaikan dosis,
intensitas dan durasi yang akan dilakukan)
Direct Methods of
Nutritional Assessment
• Anthropometric methods
• Biochemical, laboratory methods
• Clinical methods
• Dietary assessment methods

How do you implemented this ABCD methods into E-O parameters?

 What the parameters for NCDs?

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 What are common health consequences of overweight
and obesity?

Raised BMI is a major risk factor for noncommunicable diseases

such as:
 cardiovascular diseases (mainly heart disease and
stroke),
 Diabetes,
 musculoskeletal disorders (especially
osteoarthritis - a highly disabling degenerative
disease of the joints);
 some cancers (endometrial, breast, and colon).
 OUTCOME - OBESITY

• Overweight and obesity are defined as

abnormal or excessive fat accumulation that
may impair health.
• How to measure obesity?
Berbagai Penyakit terkait Obesitas:
 Cardiovascular Conditions  Orthopedic Conditions
• Hyperlipidemia • Blounts Disease
• Hypertension (HTN) • Hip Disorders (SCFE)

 Endocrine Conditions  Psychological Conditions

• Dysmetabolic Syndrome • Depression/Self-Esteem
• Type 2 Diabetes • Substance Abuse
• Impaired Glucose Tolerance • Disordered Eating
• Menstrual Irregularities • Discrimination
• Polycystic Ovarian Syndrome
• Accelerated Growth  Pulmonary Conditions
• Asthma
• Sleep Apnea
 Gastrointestinal Conditions
• Non-Alcoholic Fatty Liver Disease
(NAFLD)
• Gallstones
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Ex: Outcome parameters for abdominal obesity
and multiple cardiometabolic risk factors (USA)
Patients with abdominal obesity often present with one or more
additional cardiovascular
Cardiovascular risk factor risk factors (NCEP ATP III criteria)
Parameters

Increased waist Men ≥ 102 cm (40 in)

Women ≥ 88 cm (35 in)
circumference
Elevated LDL- Cholesterol > 2.6 mmol/L (> 70 mg/dL)

Elevated triglycerides  1.7 mmol/L (150 mg/dL)

Low HDL- Cholesterol Men < 1.03 mmol/L (<40 mg/dL)
Women < 1.30 mmol/L (<50 mg/dL)

Hypertension BP  130/80 mm Hg

Elevated fasting glucose  6.1 mmol/L (110 mg/dL)

National Cholesterol
HDL: high-density Education
lipoprotein; BP:Panel/
blood pressure
Adult Treatment Panel III, 2002
OUTCOME - DIABETES What is diabetes?
Diabetes mellitus (DM) is a group of diseases characterized
by high levels of blood glucose resulting from defects in
insulin production, insulin action, or both.
The term diabetes mellitus describes a metabolic disorder of
multiple aetiology characterized by chronic hyperglycaemia
with disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin secretion, insulin
action, or both.
The effects of diabetes mellitus include long–term damage,
dysfunction and failure of various organs.
 Diabetes Long-term Effects-OUTCOME

The long–term effects of diabetes mellitus include

progressive development of the specific complications of
retinopathy with potential blindness, nephropathy that may
lead to renal failure, and/or neuropathy with risk of foot
ulcers, amputation, Charcot joints, and features of
autonomic dysfunction, including sexual dysfunction.

People with diabetes are at increased risk of cardiovascular,

peripheral vascular and cerebrovascular disease.
Values of Diagnosis of Diabetes Mellitus
 OUTCOME – VDs Cardiovascular Diseases (CVDs)

CVDs are a group of disorders of the heart and blood vessels

and they include:

 coronary heart disease – dis. of the blood vessels supplying

the heart muscle;
 cerebrovascular disease – dis. of the blood vessels supplying
the brain;
 peripheral arterial disease – dis. of blood vessels supplying
the arms and legs;
 rheumatic heart disease – damage to the heart muscle and
Ex: Potential Components of a “Multimarker” Approach

Daniels LB. Curr CV Risk Rep 2009.

 Risk factors of CVDs – Exposure

 The most important behavioural risk factors of heart

disease and stroke are unhealthy diet, physical
inactivity, tobacco use and harmful use of alcohol.
 The effects of behavioural risk factors may show up in
individuals as raised blood pressure, raised blood
glucose, raised blood lipids, and overweight and
obesity.
 These “intermediate risks factors” can be measured in
primary care facilities and indicate an increased risk of
developing a heart attack, stroke, heart failure and other
 OUTCOME - CANCER

 Cancer is a generic term for a large group of diseases that

can affect any part of the body. Other terms used are
malignant tumours and neoplasms.
 One defining feature of cancer is the rapid creation of
abnormal cells that grow beyond their usual boundaries,
and which can then invade adjoining parts of the body and
spread to other organs, the latter process is referred to as
metastasizing.
 Metastases are the major cause of death from cancer.
 Serum Protein Biomarkers for
Oral Cancer

Interleukin-6 [IL-6]
Interleukin-8 [IL-8]
Vascular Endothelial Growth Factor
[VEGF]
Vascular Endothelial Growth Factor C
[VEGF-C]

Trikha, M.; Corringham, R.; Klein, B.; Rossi, J. Clin. Cancer Res. 2003, 9, 4653-4665
Hebert, C. A.; Baker, J. B. Cancer Invest. 1993, 11, 743-750
O-charoenrat, O.; Rhys-Evans, P.; Eccles, S. A. Cancer 2001, 92, 556-568
 Risk factors of Cancer-
Expsore

 Tobacco use, alcohol use, unhealthy diet and

physical inactivity are the main cancer risk factors
worldwide.
 Some chronic infections are risk factors for cancer
such as
Hepatitis B (HBV), hepatitis C virus (HCV) and
some types of Human Papilloma Virus (HPV)
increase the risk for liver and cervical cancer
 OUTCOME -COPD

• Chronic obstructive pulmonary disease (COPD) is a life-threatening lung

disease that interferes with normal breathing – it is more than a “smoker’s
cough”.
• The primary cause of COPD is tobacco smoke (through tobacco use or
second-hand smoke).
• The disease now affects men and women almost equally, due in part to
increased tobacco use among women in high-income countries.
• COPD is not curable, but treatment can slow the progress of the disease.
• Total deaths from COPD are projected to increase by more than 30% in the
next 10 years without interventions to cut risks, particularly exposure to
tobacco smoke.
 MEASURING RELATIVE RISK

RR = 1, there is no association between E and O

RR > 1, an increased risk among those expose
(positive association)
RR < 1, an inverse association or decrease risk
among those expose
(negative association)

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Meta-analysis

PETO GRAPH
Outcome A
Study

A
B
C
D
E

Total

Placebo 0 Drug
Bradford Hill’s Criteria for Causal Inference (1971)

1. Consistency of findings
2. Strength of association
3. Dose-response effect (biological
gradient)
4. Temporal sequence
5. Biological plausibility
6. Coherence with established facts
7. Specificity of association