RISK

Research Methods Dent 313

Risk
Risk is the probability of some untoward event Definition
The probability that people who are exposed to certain risk factors will subsequently develop the disease more often than similar unexposed people

Risk factors
factors associated with an increased risk of becoming diseased
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This lecture
The lecture describes how estimates of risk are obtained by observing the relationship between exposure to possible risk and the subsequent development of the disease
Looking forwards Looking backwards

Risk Factors
Physical environment factors

Toxin, infectious agents, gas, pollutants

Emotional illness, stress, loss of family members, culture Smoking, driving without seat belts, inactivity Diabetes, cholesterol, triglyceride
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Social environment factors

Behavioral factors

Inherited factors

Exposure to risk factors

The exposed person
Has come in contact with risk factor Or has manifested the factor in question Before becoming ill

Duration of exposure
At a single point in time
Example: nuclear bomb in Hiroshima

Over a period of time

Example: smoking
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Amount of exposure
Relevant questions
Ever been exposed Current dose Largest dose taken Total cumulative dose Years of exposure Years since first exposure

Measures of risk factor-disease relationship

Exposure dose-disease relationship may not exist with all risk factors
Relationship: cumulative doses of sun exposure & non-melanoma skin cancer No relationship: episodes of severe sunburn & melanoma

Thus, correct measure has to be chosen to confirm the association between risk factor and disease
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Choice of appropriate measures

Based on
Clinical and biological effects Pathophysiology of the disease Previous epidemiological studies

Recognizing risk
It is easy to recognize the association of acute disease and risk factors clinically
Examples: radiation, sunburn, acute poisoning

It is more difficult to establish association between risk factors and chronic conditions clinically
WHY
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Information about risk

Because
Long latency period between exposure and disease Frequent exposure to risk factors Low incidence of disease Small risk from exposure Common disease Multiple causes of a disease
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Long latency period between exposure and disease

Chronic diseases have long latency period between the exposure and the 1st manifestation of the disease It might be years later
E.g., Hypertension & heart disease

The original exposure might be forgotten The link between the disease and the risk factors is not readily clear
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Common exposure to risk factors

Common risk factors
Smoking, cholesterol in Heart disease

Comparing patterns of disease between

Those with the risk factors Those without the risk factors (certain population subgroups)
E.g., All Mormons (no smoking) E.g., Vegetarians (no fat diet)

Comparisons through cross-sectional studies Investigating subgroups with low exposure to risk factors gives more information about the true risk-disease association
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Low incidence of disease

The incidence of diseases is very low (even with common diseases)
Lung cancer in heavy smokers is 2/1000 Doctors might witness some rare disease once or few times in their practice

It is difficult to draw a conclusion about infrequent events

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Small risk
Chronic disease caused by several risk factors acting together The risk of a single factor alone is very small If the risk is small, then large number of cases is needed to demonstrate the association of disease and risk factors
Example: coffee and heart diseases

If the risk is high you can establish conclusion easily

Hepatitis B and hepatoma
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Common disease
If the disease is ordinary or commonly occurring and its risk factor is already known
There is no incentive to find new risk factors Examples: heart disease, cancer, stroke

If the disease is rare, careful investigation about risk factors are carried out

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Multiple causes and effects

There is no one-to-one relationship between a risk factor and a disease
E.g., Hypertension & CHD Some people with HT develop CHD while others dont Some people without HT develop CHD

Multiple risk factors for each particular disease Dental caries is a multifactorial disease
Bacterial Carbohydrate Host factor
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Uses of risk
Prediction of the occurrence of disease Search for cause Diagnosis Screening Prevention

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Prediction of the occurrence of disease

The quality of prediction depends on similarity of an individual patient with
A large number of patients Who have past experience of the condition With similar risk factors

On an individual level, presence of a strong risk factor does not mean that the person is very likely to get the disease Prediction is expressed as a probability No better way than to use probability to guide clinical decision making at the individual level
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Search for cause

Search for risk factor is search for cause Causes
Immediate. E.g., virus infection Distant. E.g., maternal education low birth wt

A risk factor predicting disease is not necessarily a causal factor Marker: non-causal risk factor
Risk factor may mark the disease outcome indirectly It is called marker because it marks the increase probability of the disease
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Diagnosis
The presence of a risk factor increase the probability that a disease is present
Therefore, knowledge of risk factor can be used in the diagnosis process

The absence of risk factor helps to rule out a disease

Absence of high fluoride intake rules out fluorosis and strengthens other possibilities

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Screening
Knowledge of risk factors improves the efficiency of screening programs
By selecting subgroups at high risk E.g., Risk of breast cancer is high among women with affected young women relatives

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Prevention
Removal of risk factor can prevent the disease regardless whether or not the mechanism of action of the risk factor in known
Stopping drinking of certain water (risk factor) prevents cholera infection in people Stopping water with F > 1 ppm prevents fluorosis

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Studies of risk
Conducting an experiment helps to determine whether exposure to a potential risk develops disease People without disease divided into 2 groups
One subjected to risk factor The other group is not Otherwise the 2 groups are treated the same
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When arent experiments possible

Unethical to impose hazardous risk factors on healthy people for the purpose of a scientific research People hate to have their behavior modified by others for long period of time Experiments can be expensive to run Therefore, the choice goes in these situations towards observational studies
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Observational studies
Are clinical studies in which the researcher gathers data by simply observing events as they happened Have more potential for bias than experimental studies Most studies of risk factor Types
Cohort studies Case-control studies
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Cohort studies
Cohort: a group of people with something in common in assembly who are observed for a period of time to see what happens to them Two condition to conduct cohort study They do not have the disease at the time they are
assembled They should be observed for a meaningful period of time in the nature history of the disease in question Enough time for the risk to be expressed All member of the cohort should be observed over the full period of time
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Cohort study
People assembled has not experienced the outcome but have equal susceptibility to develop the outcome People are then observed over a period of time Examine which people experience the outcome Other synonyms
Incidence studies Longitudinal studies Prospective studies
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Cohort study
Exposed to risk factor

Disease outcome

YES NO

People at risk

TIME

YES
Not exposed to risk factor No

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Types of cohort studies

Concurrent (prospective) Historical (retrospective)

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Concurrent cohort
The group of people (cohort) are assembled in the present and followed in the future The data are collected for the purpose of the study with full anticipation of what is needed
Bias can be avoided Accuracy can be increased
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Historical cohort studies

Cases are assembled in the past and followed forward to the present The data are collected from available past records of patients Data may not be of sufficient quality for rigorous research Example: study cohort using dental records
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Cohort studies
PAST PRESENT FUTURE

Cases assembled

been followed-up

HISTORICAL COHORT STUDY Cases assembled To be followed-up

CONCURENT COHORT STUDY

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Advantages of Cohort studies

The only way of establishing incidence directly

Can assess the relationship between exposure

and many diseases Best substitutes for true experimental studies when not possible Follow the same logic as a clinical trial
Allow measurement of exposure to a risk factor Avoid bias because the unknown but expected outcome develops after exposure to risk factor not vice versa
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Disadvantages of cohort studies

Need large number of people at risk The people must remain under the study for a

long period of time Can not be used for rare diseases Expensive to run
Subjects are free living and not under control as in experimental studies Expensive to keep track of them Need resources employed for a long time

Usually limited to life-threatening diseases to

justify the big budget

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