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1995-2005

Behavior is the Bridge Between Biology and Society. Transdisciplinary Systems Integration to Improve Health David B. Abrams, Ph.D. Director abramsd@od.nih.gov…http://obssr.od.nih.gov. 1995-2005. A Brief History of OBSSR. 1993: Congress establishes OBSSR within NIH OD

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1995-2005

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  1. Behavior is the Bridge Between Biology and Society.Transdisciplinary Systems Integration to Improve HealthDavid B. Abrams, Ph.D.Directorabramsd@od.nih.gov…http://obssr.od.nih.gov 1995-2005

  2. A Brief History of OBSSR 1993: Congress establishes OBSSR within NIH OD 1995: OBSSR officially opens Dr. Norman Anderson, Director 1997: First Strategic Plan 1. Enhance behavioral and social sciences research and training 2. Integrate a biobehavioral perspective into all NIH research areas 3. Improve communication among behavioral and social scientists and with public 2000: Dr. Raynard Kington named Director, OBSSR 2005: Dr. David Abrams named Director, OBSSR 2006: OBSSR finalizes new Strategic Prospectus

  3. OBSSR at NIH ? New OPASI Division

  4. Partnership across NIH

  5. Behavioral and Social Sciences Research (BSSR) • Given the rapidly changing scientific • landscape and societal demands • for accountability during • tough financial times and globalization…… • What has BSSR contributed • What is the current status • Where should we be headed • High Leverage opportunities

  6. Behavioral and Social Sciences Research (BSSR) • Three OPTIONS • - we are fundamentally OK but we need to communicate and market our science better • - we need some change around the edges - what ? • - we have a crisis building and • need radical re-invention • our sciences are being co-opted and left behind - what is our core identity ? The cheese has moved - our reaction is ?

  7. (Mis) Perceptions of BSSR Behavior is hard or impossible to change, have no “laws” Behavior is common sense = what grandma already knew, …. so why invest in BSSR BSSR is soft science, immature Self report is unreliable - biomarkers Poor self- and other- image- in a natural science, engineering, big-pharma, biomedical dominant culture in health and health care We must be open to self criticism and change

  8. Health as a continuum between biological, behavioral and social factors across the lifespan with sensitive periods. Adapted from Glass, McAtee (2006). Soc. Sci. Medicine, 62: 1650-1671

  9. Human Brain Development –Synapse Formation Language Sensing Pathways Higher (vision, hearing) Cognitive Function 9 -3 3 1 0 6 4 8 12 16 -6 Months Years Conception AGE C. Nelson, in From Neurons to Neighborhoods, 2000.

  10. The BRAIN -Stress Response and Development of Allostatic Load • Perceived and actual stress - Diathesis and coping • influenced by experiences, genetics, and behavior , social buffering, culture, economic adversity…… • initiates physiologic and behavioral responses leading to allostasis, adaptation • Allostatic load can accumulate over time -wear and tear along epigentic pathways • overexposure to mediators of neural, endocrine, and immune stress can have adverse effects MIND BRAIN BEHAVIOR PERIPHERY McEwen (1998) NEJM, 338: 171-179

  11. Healthy Public Policy Primary & Secondary Prevention / Treatment Primary & Secondary Prevention / Treatment Levels of Causation for Health Levels of Causation Interventions Environmental Influences Social Position Organization & Community Interventions Social & Cultural Processes Primary & Secondary Prevention Psychological Processes Biological & Genetic Factors from McKinlay & Marceau (2000). Public health matters. Am J Pub Hlth, 90, 25-33, p. 29.

  12. A New Integrative Causal Model • The Biomedical Model: • Causes of disease lie in genes, molecules, proteins The Ecological Model: Causes of disease are behavioral and social factors INTEGRATION OF BIOMEDICAL CAUSES & SOCIO-ECOLOGICAL “CAUSES OF CAUSES”

  13. Many Challenges Remain • Emerging public health threats: • Unsustainable cost of healthcare • Obesity, inactivity, poor diet • Natural & human-made disasters • Aging population - degeneration • Mental Illness- stress, depression • Persistent public health challenges: • Disparities,Inequality in health • Tobacco use, addictions, abuse • “Toxic” built environment • Chronic disease management……

  14. The big picture Health care 10% Genetics 30% Behavior 40% Environment 5% Social 15% McGinnis , 2003

  15. OBSSR’s Vision at NIH To mobilize the biomedical, behavioral, and social science research communities as partners in interdisciplinary research to solve the most pressing health challenges faced by our society. Programmatic Directions to Achieve the Vision: • Transdiciplinary science • “Next generation”, vertically integrated, basic science • Problem-based, outcomes oriented research - strengthen the science of dissemination and dissemination of the science • Systems - thinking for population health improvement (impact)

  16. Exciting Opportunities for BSSR • Macro-Social Behavior (e.g., migration) • Social & Interpersonal Behavior (e.g., ethnic bias) • Perception, Learning, Emotion & Cognition (e.g., vigilance) • Early Development (e.g., temperament early life events) • Gene-Environment Interactions (e.g., bio-social stress) • Technology, measures, methods (e.g., sensors. EMA, biomarkers) • Cross-cutting research (e.g., health disparities, obesity, health services) Sources: IOM Report New Horizons in BSSR, National Academies, 2002. Research Opportunities in the Basic Behavioral and Social Sciences at NIH. Report of the Working Group of the NIH Advisory Committee to the Director, December 2, 2004.

  17. From Basic Science to Policy Source: Abrams, D.B. (1999). Transdisciplinary paradigms for tobacco prevention research. Nicotine & Tobacco Research, 1, S15-S23. Adapted from: Greenwald & Cullen, National Cancer Institute, 1986.

  18. With a Focus on Population Impact • A large number of people at small risk may give rise to more cases of disease than a small number of people at high risk. • A preventive measure that brings large benefits to the community affords little to each participating individual. • ~ Rose, 1992 Source: Rose, G. (1992). The Strategy of Preventive Medicine. Oxford, England, Oxford University Press.

  19. “Next Generation” Basic Science OBSSR will support and facilitate the next generation of basic behavioral and social science research informed by breakthroughs in complementary areas such as genetics, informatics, and multilevel analyses. SCIENCE RECS IN NEW HORIZONS AND Basic Science at NIH, ACD REPORT, 2004

  20. Decade of Discovery: 1995 - 2005 Human Genome Map - Completed 4/14/03 Total: 3 billion bases across 46 chromosomes Genes: approx 23,000 Genes in the brain: 16,000 Brain specific genes: 6,000 Genes with known function: less than 1%

  21. Measured Gene-Environment Interactions in Psychopathology: Concepts, Research Strategies, and Implications for Research, Intervention, and Public Understanding of Genetics Moffitt, Caspi, Rutter (2006) Perspectives on Psychological Science, 1(1): 5-27 • A gene-environment interaction occurs • When the effect of exposure to an environmental factor on health and behavior is conditional upon a person's genotype • Or conversely, when the genotype's effect is moderated by the environment.

  22. Science, 302: 386-388. 2003 1057 consecutive births in Dunedin, New Zealand followed for 26 years with evaluation every 2-3 years beginning in first year. At age 26, 17% met criteria for major depressive disorder. Neither life stress alone nor serotonin transporter genotype predicted depression.

  23. Serotonin Gene, Experience, & Depression Age 26 A. Caspi, Science, July 2003, Vol 301. Depression Risk .70 SS S = Short Allele L = Long Allele .50 SL LL .30 No Abuse Moderate Abuse Severe Abuse Early Childhood

  24. STRATEGIES FOR PROGRAMMATIC RESEARCH INTO MEASURED G × E Testing for an Interaction • Study Sampling Designs • Most informative design for testing G × E begins with cohort sample • Represents population variation in genotype, exposure to environmental pathogens, and variety of health outcomes • Ideal if cohort enlisted prospectively in early life and followed longitudinally • Repeated assessments obtain unbiased measures of cumulative exposure to environmental pathogens, and ascertain history relative to timing of exposure (Collins, 2004; Hunter, 2005) Environmental Risk In simple case of dichotomous genotype and environment variables, four cells of participants can be compared: GeneticRisk Moffitt, Caspi, Rutter (2006) Perspectives on Psychological Science, 1(1): 5-27

  25. The FDA acknowledges a large variation in response rates to treatments for a variety of conditions Frueh FW. (2006). Pharmacogenomics: Patient selection for clinical trial participation and enrichment strategies. Available at www.fda.gov/cder/genomics

  26. Hood (2003) Environmental Health Perspectives, 111(11) published by NIEHS, NIH NIH MedlinePlus Magazine, Winter 2007

  27. Graphical results of GWAS of nicotine dependence.MEASURING phenotype, endophen. and intermediate From: Bierut, Madden, Breslau,et al . (2006). Hum Mol Genet, Dec. 7.

  28. Summary: Modulation of Common ‘System’ Treatment-Specific Effects attention-cognition CBT pCg PF9 P40 - hippocampus mF9/10 mood state Emotion-cognition integration thal bg aCg24 oF11 a-ins Cg25 - bs am hth CBT SRI inverse vegetative-circadian SRI only drug CBT only

  29. Mental Health Care in the Pre-Genomic Era??

  30. Systems-thinking Approaches to Health OBSSR will stimulate research that integrates multiple levels of analysis – from cells to behavior to society – required to understand the ways in which individual and contextual factors interact to determine health status. International Network for Social Network Analysiswww.insna.org/INSNA/na_inf.html

  31. Systems Integration • Capitalize on new discoveries and new tools • Informatics, Computer technology • Gene-Environment Interaction • Predict, pre-empt, personalize • Conduct interdisciplinary science • Partner to solve problems whose • scope overwhelms single paradigms • Translation, Dissemination, Policy • Systems integration, problem-based • Population Outcomes focus “The idea of a sharp distinction between health and disease is a medical artifact for which nature, if consulted, provides no support.” Pickering (1937)

  32. STRESS, VIOLENCE EARLY LIFE In UTERO, CHILDREN ADOLESCENT RISK TOBACCO USE UNHEALTHY DIET PHYSICAL INACTIVITY ALCOHOL POVERTY, POOR ACCESS TO CARE……… MENTAL ILLNESS CVD DIABETES CANCER COPD MUSCULOSCELETAL PREMATURE AGING COGNITIVE DECLINE ORAL HEALTH …….. Common Interactive Factors 33

  33. Cover of "The Economist", Dec. 13-19, 2003.

  34. Obesity Diabetes: Systems Integration from cells to society

  35. Source: Jones, A.P., Homer, J.B., et al., (2006). American Journal of Public Health, Vol. 96, No. 3, 488-494

  36. Alternative Futures: Obesity in Pop (age 20-74) Obese fraction of Adults (Ages 20-74) 50% 40% 30% Fraction of popn 20-74 20% 10% 0% 1970 1980 1990 2000 2010 2020 2030 2040 2050 Base SchoolYouth AllYouth School+Parents All Adults All Ages All Ages+WtLoss

  37. C. J. L. Murray, et al., Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States. PLoS Medicine: Sept. 2006. Volume 3, Issue 1513 9, e260 www.plosmedicine.org

  38. Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties, U S.

  39. C. J. L. Murray, et al., Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States. PLoS Medicine: Sept. 2006. Vol. 3, Issue 1513 9, e260 www.plosmedicine.org

  40. Society's Health Response General Targeted Primary Secondary Tertiary protection protection prevention prevention prevention Becoming no longer vulnerable Afflicted Afflicted with Safer, Vulnerable without Complications Healthier Population Developing Complications Becoming Becoming Population Complications Vulnerable Afflicted Dying from Complications Adverse Living Conditions more inter-organizationally complex, slower rate of improvement organizationally complex, faster rate of improvement Public Work (organizing, governance, citizenship, mutual accountability) Professional Work (customers, products, services) FOR SELF INTEREST FOR OTHERS IN NEED Basic Dynamics in the Health System and Recap Why S/E/E Drivers are So Important From: Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.

  41. Healthy Public Policy Medical and Public Health Policy Society's Health Response General Targeted Primary Secondary Tertiary protection protection prevention prevention prevention Becoming no longer vulnerable Afflicted Afflicted with Safer, Vulnerable without Complications Healthier Population Developing Complications Becoming Becoming Population Complications Vulnerable Afflicted Dying from Complications Adverse Living Conditions • World of Transforming… • Deprivation • Dependency • Violence • Disconnection • Environmental decay • Stress • Insecurity • Etc… • By Strengthening… • Leaders • Institutions • The meaning of work • Mutual accountability • Plurality • Democracy • Freedom • Etc… • World of Providing… • Education • Screening • Disease management • Pharmaceuticals • Clinical services • Physical and financial access • Etc… A Rare Opportunity to Complement Downstream Health Care with Upstream Health Action BCBSMF Initiative

  42. 700 start of the North Karelia Project Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35-64 years from 1969 to 2002. 600 extension of the Project nationally 500 North Karelia 400 300 - 82 % All Finland 200 Mortality per 100 000 population - 75% 100 69 72 75 78 81 84 87 90 93 96 99 2002 Year 15

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