The key to your health could lie in your zip code

The key to your health could lie in your zip code

In January 2015, President Obama launched thisPrecision Medicine Initiativea plan to support research into treatment and prevention strategies that take differences into accountbetween people– especially genetics – must be taken into account.

However, precision medicine cannot only look genetically deep. Where we live – the air we breathe, the water we drink, the environment around us – has a huge impact on our health and even our DNA.

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As a professor of environmental health sciences, epidemiology and medicine and co-director of the Joint Geisinger-JHSPH Environmental Health Institute (EHI), I work with electronic health records to address environmental issues ranging from animal feeding operations, agricultural practices, unconventional natural gas production and the built environment to outcomes such as drug-resistant infections, Diabetes and asthma control, pregnancy outcomes and obesity. Together with Dr. Annemarie Hirsch, an epidemiologist at EHI, we want to find out how we can translate these findings into providing more precise clinical care.

A better understanding of how our environment and social conditions influence our health could lead to better treatments and prevention. Before we can do this, however, two problems stand in our way. The first is that this data is not collected. And if we started collecting them, healthcare providers wouldn't know how to use them.

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Biology isn't the only thing that makes us different

We know that our genetics can influence our health, but so can three other important factors. These are social determinants of health and the social and physical environment of the community.

The social determinants of health include income, poverty and inequality. The social environment includes things like crime rates and the wealth of your neighborhood. When we talk about the physical environment, it's about whether your neighborhood is walkable, has access to healthy foods, or has heavy industry.

These factors can have a direct and indirect impact on your health. For example, inhaling a poison from a factory can directly cause asthma or cancer. Living in a neighborhood with access to healthy foods within walking distance of your home can have an indirect positive impact on your health.

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In fact, many studies have documented that these three factors have a greater impact on health than individual biological differences between people. For example, income and education level are at least as strongly associated with hypoglycemia in patients with diabetes as known clinical risk factors. People who live in areas with limited opportunities for healthy eating and physical activity are at higher risk of developing type 2 diabetes.

Dr. Risa Lavizzo-Mourey, President of the Robert Wood Johnson Foundation, stated:
“We know that a child’s life expectancy depends more on their zip code than their genetic code.”

That's not an exaggeration. In the United States, there are dramatic differences in life expectancy depending on where people are born. The places with the highest life expectancy tend to be in the northeast and west, with the lowest in the south. While genetics and health care are crucial, others have argued that "zip code, race, and class are more important than genetics and health care as predictors of health."

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Cracking the ZNA code

Dr. Francis Collins, NIH Director, tweeted recently that our zip code at birth is our “CNA,” “the blueprint for our behavior and psychosocial makeup,” critical determinants of health.

Recent technological advances in geographic information systems (GIS), including digital software, maps, and longitudinal datasets on socioeconomic and environmental factors, can be used to describe multiple aspects of an individual's community and environment. Just as we can sequence a person's DNA, we could use this data to sequence our "ZNA" from birth to death.

With the increasing adoption of electronic health records (EHRs), it is possible to link newly collected environmental data to patients' medical records. And this connection is relevant to clinical care and research and, perhaps most importantly, allows for a greater focus on prevention.

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We spend more on treating diseases than preventing them

In the United States, healthcare spending accounts for 17% of gross domestic product, among the highest of any country in the world. But health outcomes in the USA are in the middle range of western industrialized countries. This discrepancy between health spending and outcomes has often been explained as a difference between clinical medicine and public health.

We spend far more on providing clinical services, often at the end of life for seriously ill patients, than on public health. Public health focuses on the health of the entire population and often on preventing disease in the first place. In attempting to achieve its goals, public health takes into account social determinants of health and the social and physical environment.

That's because the causes of disease often lie more heavily in factors outside the healthcare system - such as where we live, what we eat, the air we breathe. But the health care system and its providers are ignorant of these community, economic, environmental, behavioral and social causes of disease. As a rule, no information about them is currently collected or requested.

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This data is important, but we are not ready to collect it yet

Ensuring that this valuable information is collected and integrated into routine care could help resolve this discrepancy. However, there are many hurdles to proposals for using this information.

Currently, healthcare providers are not paid to collect, document, or use this data. And medical education and clinical care guidelines do not yet teach providers how to integrate these factors into care. Therefore, they would need instructions on how to deal with this new social, environmental and community information.

And most clinical risk models do not account for environmental, community, or social determinants of health. For example, researchers have found that the Framingham Risk Score, used to predict risk of coronary heart disease, leads to underdiagnosis of cardiovascular disease in low socioeconomic status (SES) populations because it does not take SES into account. However, integrating SES and other determinants of health into established risk calculators and clinical protocols requires investment from health systems.

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Policymakers and scientists are already meeting to develop a large-scale initiative in response to the Precision Medicine Initiative. We believe it is critical that community, economic, environmental, behavioral and social determinants of health be part of these discussions.

Brian S. Schwartz, Professor of Environmental Health Sciences, Johns Hopkins University and Annemarie Hirsch, Research Scientist, Joint Geisinger-JHSPH Environmental Health Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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