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Carol Worthman received her PhD at Harvard in 1978, after first attending Pomona College for her BA in Botany and biology, and subsequently the University of California at San Diego Medical School and Massachusetts Institute of Technology. Her interests include biological anthropology, human reproduction, human development, biocultural and life history theory, and developmental epidemiology. These interests are bioculturally focused. She also has worked with the University of Alabama's own Dr. Jason DeCaro on various projects concerning stress and developmental biology.

Brandon Kohrt is an assistant professor at Duke Global Health Institute and Department of Psychiatry and Behavioral Sciences. He conducts global mental health research focusing on populations affected by war-related trauma and chronic stressors of poverty, discrimination, and lack of access to healthcare and education. His research is conducted in Nepal, and he has worked closely with the Transcultural Psychosocial Organization (TPO) Nepal, the Carter Center Mental Health Liberia Program, and was a co-founder of the Atlanta Asylum Network for Torture Survivors. His interests include culture, health economics, health systems, and mental health.

Worthman and Kohrt are concerned with how our current approach to public health is dissonant with contemporary health concerns. They call this phenomenon a "paradox of success," which is characterized by historical accomplishments in public health perpetuating paradigms which cannot be applied globally or to recent emerging health concerns. Sometimes these paradigms result in negative effects on health, which I will explain below. According to multiple sources, only 2-60% of health outcome variation is explained by the models we currently use in public health (see Worthman & Kohrt 2005). In order to evaluate and adjust public health models, Worthman and Kohrt identify five paradoxes stimulating morbidity instead of expected success.

  1. Unmasking is characterized by changes in morbidity patterns. Advances in health care have created an epidemiologic transition from infectious disease to chronic degenerative and mental illnesses. Think cancer, Alzheimer's, etc... The example used in the article was depression, although the rise in mental illness could also be a result of historically unreliable data.
    What other examples of unmasking can you think of?

    Simplified model of epidemiological transition.


  2. Localization is an important paradox resulting from globalization of public health paradigms. It is becoming increasingly evident that biological function and regulation are heavily dependent on context. Vaccinations sometimes fail as a result of locally derived immunocompetence. Fetal/childhood development also play a role, as shown by the relationship between breastfeeding/birth spacing and infant survival/health.
    The article talked about fetal programming as a factor of localization. What about research in fetal programming is relevant here (in the article or outside)?

    Anti-vaccine propaganda. Success of vaccination can be affected by malnutrition, pathogen load, stress, and immune development of individual.


  3. Socialization in this context applies to the enhancement or diminishing of vulnerability to disease based on cultural factors. HIV/AIDS prevalence in African countries are exacerbated by cultural attitudes toward sex and the availability of sex education, as opposed to Western countries.
    What are some examples of cultural practices that perpetuate disease?

    Fast food culture... you can find these anywhere!

     

  4. Re/emerging disease is a resurgence of disease patterns, sometimes in more virulent forms. Tuberculosis is an important example, responsible for 3% of all mortality in 1999. Diabetes and asthma are other examples, although literature on  re-emergence of non-infectious disease is currently limited.
    What factors contribute to re/emergent diseases?

    Travel is just one factors contributing to re/emerging disease.
  5. Savage inequity adds fuel to the previously mentioned paradoxes. Poverty, inequality, and inequity are all included under this paradox. Global media especially perpetuates inequity and can be the cause of varying psychosocial factors that contribute to morbidity.
    What is the difference between inequality and inequity, and what are the health implications of each?

    Link between risk factors and income levels.

I thought about tuberculosis as an historical disease until I had to take my TB test before entering college. I wasn't positive, but the test indicated that I had been in contact with the disease at some point. I didn't realize that our health practices were, in a way, catalyzing the resurgence of antibiotic-resistant tuberculosis. Savage inequity is also a concept the resonates with me. Intuitively, I know that mental health is just as important as physical health, but this knowledge conflicts with what I've observed in medicine and health research. I only recently realized that this is a problem with the paradigm, not my understanding or health.

I also think it's important to note that, although socialization and local biology seem obvious contributing factors to health in our class, we are anthropology students. It appears to me that medical students are vastly under-educated regarding biocultural models of medicine. I won't pretend to know how to change education policies in medical school, but it is important to recognize that a global public health paradigm isn't going to satisfy our global health needs.

 

EDITED 12-9-2013

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will-leonard3

The Author of this chapter, William R. Leonard, is currently a professor of anthropology at Northwestern University. He holds the title at this university as the Abraham Harris Professor of Anthropology. He He received his PhD from the University of Michigan in 1987. His research interests include biological anthropology, adaptability, growth and development, and nutrition focusing on populations in South America, Asia, and the United States. His most recent publication was on the topic of precursors to over-nutrition and the effects of household market food expenditures on body composition among the Tsimane in Bolivia.

The ecological variation of available food has been an important factor throughout the history of human evolution and continues to shape the biology of traditional human populations today. The relationship that humans share with their environments (i.e., acquisition and expenditure of energy) has adaptive consequences for both survival and reproduction. Humans are similar to other primates in that we are omnivorous (i.e., we eat both plants and animals) and we have nutritional requirements (e.g., the inability to synthesize vitamin C) that has caused us to adapt diets that include large quantities of fruit and vegetable material. However, what is unique to humans is our highly diverse diet (i.e., dietary plasticity) that evolved because of cultural and technological innovations that developed for processing various resources. This has allowed humans to expand into the many different ecosystems that we inhabit today.

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In order tomaintain our health, humans require six classes of nutrients:

(1)   Carbohydrates are the largest source of dietary energy for most human groups. For example, carbs account for about 40-50% of the daily calories of U.S. adults. There are three type of carbohydrates including monosaccharides (i.e., simple sugars), disaccharides (i.e., sugars formed by two monosaccharides), and polysaccharides (i.e., complex sugars made up of three or more monosaccharides).

(2)   Fats are the most calorically dense source of dietary energy and provide the largest store of potential energy for the body to do biological work. Fats are divided into three groups. The first, simple fats, is mostly made up of triglycerides (i.e., glycerol and fatty acid). Fatty acids can be further divided into saturated (i.e., found in animal products) and unsaturated fats (i.e., monounsaturated and polyunsaturated mostly found in vegetable oil). Compound fats are the second type of fat that consist of a simple fat in combination with another type of chemical compound, such as a sugar or a protein. Compound fats are important for blood clotting and insulating nerve fibers. The third category of fats is known as derived fats, which are a combination of simple and compound fats (e.g., cholesterol). Cholesterol is important for normal development and function. It is also a precursor in the synthesis of vitamin D and hormones like estradiol, progesterone, and testosterone.

(3)   Proteins are an important energy source, but they are also crucial for the growth and replacement of living tissues. In order to get theadequate nutrition per day a person needs a sufficient quantity and quality of protein. The digestibility and amino acid composition determine the quality of a protein. Complete proteins have the necessary amino acids in the quantity and proportions that are needed to maintain healthy tissue repair and growth. Good sources of complete proteins come from animal foods including eggs, milk, meat, fish, and poultry. Incomplete proteins are those that lack one or more essential amino acids. Incomplete proteins are found inplant foods, such as grains, legumes, seeds, and nuts. So if you want to be a vegetarian it will require combining different sources of plant foods in order to get all of the essential amino acids you need.

(4)   Vitamins are not a source of energy, because they just help the body use energy and carry out other metabolic activities. There are two categories of vitamins: water-soluble vitamins (i.e., B vitamins and vitamins C are needed on a daily basis because they are not stored in the body) and fat-soluble vitamins (i.e., vitamins A, D, E, and K are stored in the body so they don’t have to be taken every day). Be careful because if you take too many fat-soluble vitamins over a long period of time it can be toxic.

(5)   Minerals, such as iron, are inorganic elements that are needed in many biological molecules (e.g., hemoglobin) and are vital formaintaining various physiological functions.  

(6)   Water makes up a large portion of our body weight at 40-60% for adults. Humans get water from liquid intake, food, and “metabolic water” that is produced as the result of energy-yielding reactions.

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Recent research has focused on developing and refining energy and nutrient requirements for the various human populations around the world. Many factors must be considered in order to efficiently estimate a person’s daily energy needs including diet, daily activities and exercise, energy costs for reproduction, sex and age. According to the World Health Organization (WHO), women who are pregnant need an extra 85 kcal/day during the first trimester, an extra 285 kcal/day during the second trimester, and an extra 475 kcal/day during the final trimester. Children’s and adolescents’ energy requirements are measured differently from adults, because they have extra energy costs that are associated with growth. Pregnant women, children and adolescents also require more protein than the average adult.

The dietary patterns and metabolism of humans has been shaped by the energy demands of our relatively large brain. The energy demands of humans are usually divided into maintenance energy (i.e., needed for day-to-day survival) and productive energy (i.e., needed for growth and reproduction). Humans spend a larger portion of their daily energy budget on brain metabolism when compared to other organs in the body. We use 20-25% of our BMR (basal metabolic rate) on brain metabolism compared to the 8-10% used by primates and only 3-5% used by other mammals. It has been hypothesized that because of the high metabolic costs of our brains we require high-quality diets. Animal foods contribute to about 45-65% of the diet amonghunter-gatherers, which is much higher quality than expected for primates of our body size. Humans also have small gut volumes for our size, because most large-bodiedprimates have large intestines for digesting fibrous, low-quality diets. So, we probably evolved to have smaller intestines and a reduced colon because of our high-quality diets.  

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Throughout the evolution of the different hominin species there has been changes in brain and body size. The australopithecines had smaller brains relative to their body size, but with the emergence of the genus Homo there was a dramatic increase in brain size. The body size of Homo erectusalso increased, but the changes of the brain size were much larger than those that occurred with body mass. Homo erectus had a larger brain and body but smaller teeth, which suggests that this species relied on a different subsistence source than the australopithecines that was probably easier to digest (i.e., less fibrous plant foods) and richer in calories. The greater nutritional stability of the genus Homo provided the fuel for the energy demands of their larger brains.   

While Humans do have a diverse range of diets across the world, environmental pressures have contributed to adaptations such as lactose tolerance and the ability to digest starch. Some adaptations have become maladaptive in modern society, such as increased fat storage, which has lead to increasing rates of obesity. The amount of animal foods (meat, eggs, milk, etc.) varies across cultures and geographic location. Contemporary foraging groups consume animal foods for approximately 45-65% of their diets. However in the US our animal foods consumption is approximately 26% of our diet. Macronutrient consumption also varies across populations. Americans derive 15% from protein, 34% from fat, and a very high 51% of their energy from carbohydrates. This carbohydrate % is higher than every other population except for small-scale farmers. Another interesting statistic is the estimated consumption percentages estimated for modern foragers: 20-31% protein, 38-49% fat, and 31% carbohydrates. What do you think about these forager percentage estimates in comparison to American percentages?  

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Carbohydrates consumed in subsistence-level societies are typically more complex with a small percentage of their carb consumption coming from simple carbs. American carbohydrates however come mostly from simple carbs and processed grains. These simple and processed carbs are absorbed faster into the blood stream than more complex varieties. A high glycemic level in the blood stream may lead to insulin resistance, which may lead to obesity, type II diabetes, hypertension, hyperlipidemia, and coronary heart disease. In comparison to subsistence-level populations, industrialized men weigh approximately 26.5 lbs more and require 150-200 kcal less. Industrialized women weigh 17.7 lbs more and demand approximately 90kcals. The US Department of Health and Human Services has also released guidelines that adults do approximately 150min/week of moderate physical activity. Another recommendation by IOM set the bar higher at 1 hour/day.

Another interesting fact from later on in the chapter is associated with the enzyme amylase. Carbohydrate digestionbeings in the mouth with amylase (enzyme found in saliva). Populations with high-carb diets have more copies of the AMY1 gene and therefore more amylase. So differences in dietin recent human evolution have exerted strong selection at the AMY1 locus. Also humans have three times as many AMY1 genes as chimps and bonobos. This implies that there was strong evolutionary selection on this gene during the early divergence of hominins from apes.

Food processing techniques are developed to fit the needs of the subsistence-level society that grows that particular crop. Corn, a major crop in the Americas, is high in protein but low in the amino acids lysine and tryptophan as well as the B vitamin niacin. To solve this problem, corn is processed in the presence of alkaliproducts (e.g., ash, lime, and lye) adding back these key nutrients. Andean populations processed potatoes in a way that removes the hazardous glycoalkaloids. Also, Asian populations processed the antitrypsin factor out of soybeans.

Climate may also have an effect on metabolic rates. Studies show that populations living in warmer climates have a lower metabolic rate than those living in colder environments. This attributes to a variation in dietary needs in different climates. It is being questioned whether these population differences are genetic or part of acclimatization.

lactose-intolerance

The ability to digest lactase disappears after weaning for most mammals, however some human populations have developed the ability to digest lactose and are thus lactose-tolerant. This change is a relatively recent evolutionary event occurring within the last 10,000 years. Genetic analysis shows that selection for the lactase persistence appeared about 7500 years ago. The allele spread across Europe in association with dairy/farming subsistence. It also appears to have evolved independently in some African populations approximately 6000-7000 years ago. However, some malabsorbers (genetically intolerant) people are able to digest lactose, and some genetically tolerant people are unable to digest milk. This suggests that dietary habits during development may contribute to lactose tolerance. In the malabsorbers this is due to an increased tolerance in the colon instead of an increase in lactase (enzyme that digests lactose. Life tip:If it ends in –ase it is an enzyme).

African-Americans have an increased risk of cardiovascular diseases. One model says that the problem is a consequence of genetic adaptation for efficient sodium (Na+) storage. Na+ is readily lost in sweat and was rare in many tropical societies. These groups have lower sweat rates and lower sodium concentrations in their sweat than European control groups. Now with salt being readily available to people who have genetically evolved to retain it, these people have higher bloodpressure. In relation to this model, the same scientist says that slaves brought over on slave ships would have been exposed to severe dehydration, and those with salt-retention would have been more likely to survive. So dependents of slaves have a high probability of having this recently selected for trait. (This study focuses on the West Indies and thereforemay not be representative of the US). Some argue that the slavery hypothesis is overly simplistic and a modern representation of racism in science. Still others argue that this increased risk is related to socioeconomic stress. Increased stress leads to increasedsympathic nervous system activity. The release of norepinephrine and adrenocorticotropic hormone elevate blood pressure by increasing sodium retention.  Do you think the slavery hypothesis is racist? Which of these models makes more sense to you?

sugar-consumption-graph

Type 2 diabetes is when your cells reduce the number of insulin receptors and then become insensitive to insulin (your insulin levels are not necessarily affected). “Thrifty Genotype” is the current hypothesis for why we evolved to be sensitive to insulin. Hunter gather societies were faced with seasonal and year-to-year fluctuations in availability of nutrients and therefore would have developed a “thrifty genotype” that would have allowed for a quick release of insulin and an increase in glucose storage during times of plenty. Nowadays we live in a constant state of plenty, and this “thrifty genotype” is now maladaptive and a contributor to diabetes and obesity. Native Americans have a very high rate of diabetes which could beassociated with the fact that they were part of a population with many “thrifty genotype” traits due to their old lifestyle, and due to the recent change in diet they are especially at risk. In addition to the ancestry view of “thrifty genotype”, recent studies also show that babies with poor nutritional conditions in early life select for “thrifty phenotype” which can also lead to increased rates of diabetes and obesity in adulthood. Could thrifty phenotype be epigenetic and passed on to offspring?

obesity_trends_20092

The obesity epidemic is a combination of all the above traits, and is associated with the transition from subsistence-level nutrition to modern-day industrial nutrition styles (processed foods, growth hormones, etc.). Thrifty genotype and phenotype are playing a huge role in populationsthat are just now gaining access to stable food supplies. Urbanization and rising incomes throughout the developing world have increased rates of overweight and obesity. Trends in US food use patterns the global trends. Energy consumed from soft drinks has increased 70% since the mid-1970’s. Available energy from vegetable oils has increased by 30% over that same time period. Other factors include the increase in eating away from home and snacking. Sugars, processed grains, and added fats are some of the cheapest food options, and with today’s bad economy poorer people are consuming more of these bad nutrients. Our modern environment has been characterized as “obseogenic”—that is, providing abundant food energy, while requiring little work or activity to produce that energy. What do you think about the obesity epidemic? Is genetics an excuse?

obesity-and-fastfood-nations