11
Conclusion

As discussed throughout this report, human health is determined by the interaction of several factors, including the social environment, genetic inheritance, and personal behaviors. Socioeconomic status, race/ethnicity, social networks/social support, and the psychosocial work environment all have been shown to affect health outcomes (Chapter 2). These social determinants influence health at multiple levels throughout the life course. In addition to the vast array of social determinants that influence health, a person inherits a complete set of genes from each parent that contributes both directly and indirectly to the pathogenesis of disease. Genes have been identified for relatively uncommon, simple Mendelian patterns of disease inheritance, such as Tay-Sachs disease and cystic fibrosis, and recently research has begun to explore genetic susceptibility to disease as the consequence of the joint effects of many genes, each with small-to-moderate effects, often interacting among themselves and with the environment (Chapter 3). Behaviors also have been shown to affect health (Chapter 4). For example, tobacco use, obesity, and physical inactivity are the greatest preventable causes of morbidity and mortality in the United States (Mokdad et al., 2004). Furthermore, complex traits, such as sex/gender and race/ ethnicity, pose both a challenge and an opportunity in our search for a better understanding of environmental, genetic, and behavioral interactions as determinants of health (Chapter 5).

As this report demonstrates, research has documented associations between social factors and health, behaviors and health, and genetics and health. Yet, researchers are only now beginning to study in earnest the potential interactions between genetic and social environmental factors that



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11 Conclusion As discussed throughout this report, human health is determined by the interaction of several factors, including the social environment, genetic inheritance, and personal behaviors. Socioeconomic status, race/ethnicity, social networks/social support, and the psychosocial work environment all have been shown to affect health outcomes (Chapter 2). These social deter- minants influence health at multiple levels throughout the life course. In addition to the vast array of social determinants that influence health, a person inherits a complete set of genes from each parent that contributes both directly and indirectly to the pathogenesis of disease. Genes have been identified for relatively uncommon, simple Mendelian patterns of disease inheritance, such as Tay-Sachs disease and cystic fibrosis, and recently research has begun to explore genetic susceptibility to disease as the conse- quence of the joint effects of many genes, each with small-to-moderate effects, often interacting among themselves and with the environment (Chapter 3). Behaviors also have been shown to affect health (Chapter 4). For example, tobacco use, obesity, and physical inactivity are the greatest preventable causes of morbidity and mortality in the United States (Mokdad et al., 2004). Furthermore, complex traits, such as sex/gender and race/ ethnicity, pose both a challenge and an opportunity in our search for a better understanding of environmental, genetic, and behavioral interactions as determinants of health (Chapter 5). As this report demonstrates, research has documented associations be- tween social factors and health, behaviors and health, and genetics and health. Yet, researchers are only now beginning to study in earnest the potential interactions between genetic and social environmental factors that 219

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220 GENES, BEHAVIOR, AND THE SOCIAL ENVIRONMENT are likely to be contributing to a large fraction of disease in most popula- tions. Key to the success of research on these interactions is the conduct of such research in a collaborative and transdisciplinary manner, which “im- plies the conception of research questions that transcend the individual departments or specialized knowledge bases because they are intended to solve . . . research questions that are, by definition, beyond the purview of the individual disciplines” (IOM, 2003). Furthermore, more comprehen- sive, predictive models of etiologically heterogeneous disease are needed, and this requires the development and implementation of new modeling strategies and the use of profiling approaches. In order to ensure that findings are applicable beyond a small population, research must be con- ducted in diverse groups and settings (Chapter 6). Animal models, which are explored in Chapter 7, have a great deal to offer in understanding the effects of interactions of social, behavioral, and genetic factors on health. A clear formulation of the concept of interaction, and an understanding of research designs that can be used to test for it, are central to progress in assessing the impact on health of interactions among multiple factors. This report discusses several steps that are needed to advance the science of testing interactions (Chapter 8). These include new, accessible statistical software for implementing tests for interaction on an additive scale and research on developing study designs that are efficient at testing interac- tions, including variations in interactions over time and development. Transdisciplinary research on the impact on health of interactions among social, behavioral, and genetic factors places several demands on the research infrastructure, including the need for education and training of researchers, the enhancement and development of appropriate datasets, and the creation of incentives and rewards that will encourage investigators to move beyond the single discipline approach to research. Approaches that the National Institutes of Health can use to address these barriers include providing individual and senior fellowships, transdisciplinary institutional grants, short courses, and datasets that can be enhanced to provide the necessary information. The development of new datasets for topics that have high potential for showing interactions also would be valuable. Other incentives that foster the transdisciplinary research discussed in this report address hiring, promotion and tenure policies, peer review, and the alloca- tion of credit for collaborative research (Chapter 9). Finally, research that elucidates how social, behavioral, and genetic factors interact to influence health raises important ethical and legal issues, including those involving how individuals and groups understand and use complex scientific findings, as well as the potential impact such findings might have on policy development (Chapter 10). Furthermore, studying interactions among variations in social, behav- ioral, and genetic factors requires the collection of information that could

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221 CONCLUSION entail significant risk to research participants if it is inappropriately ac- cessed. This report offers recommendations for communicating with policymakers and the public, for expanding the research focus to include research on how best to encourage people to engage in health-promoting behaviors, for the establishment of data-sharing policies that ensure pri- vacy, and for improving the informed consent process. The intent of this report is to encourage and facilitate the growth of research on the impact of interactions among social, behavioral, and ge- netic factors on health that will further our understanding of disease risk and aid in the development of effective interventions to improve the health of individuals and populations. This report has resulted from collaboration that has occurred between scientists from the social and the biological worlds, and it provides a template for how their theories and methods can be integrated to advance knowledge. It is timely and important because it sets out an agenda for research that is needed to advance the science of gene-environment interactions in explaining individual and population health and health disparities. REFERENCES IOM (Institute of Medicine). 2003. Who Will Keep the Public Healthy? Educating Health Professionals for the 21st Century. Washington, DC: The National Academies Press. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. 2004. Actual causes of death in the United States, 2000. Journal of the American Medical Association 291(10):1238-1245.

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