Healthy Living A Matter of Perspective...Metrolinx 2009 GTHA School Travel Household Attitudinal...

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Healthy Living A Matter of Perspective

October 23rd, 2018

David Mowat

Causes of Death

Preventability

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Pervasiveness Common risk factors

4 image from: Chronic Disease Prevention Alliance of Canada

Current state ---Risk Factors, PEI, 2014

Eating vegetables once a day or more (gr.6-10): 40% Binge drinking (gr.9-12) (in last year/ once a month): 43%/26% Current smoker (gr.12, males) 13% Self-reported obesity (gr.6-10) 7% Meets recommendations for physical activity (gr. 6-10) 20% Exceeding screen time recommendations (preschool) 58%

Social Determinants of

Health

In-Utero and Early Childhood Experiences linked to later life.....

School failure Sexual behaviours and teen pregnancy Criminality Smoking, alcohol, drug use Employment difficulties Depression Heart disease, hypertension, obesity, liver disease, COPD.

Needed:

•Stable, responsive relationships •Safe, supportive environments

•Policies which support these

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Current Prevention Efforts Are Misdirected

Distinguishing…

“Population health is an approach to health that aims to improve the health of the entire population and to reduce health inequities among population groups. In order to reach these objectives, it looks at and acts upon the broad range of factors and conditions that have a strong influence on our health.” http://www.phac-aspc.gc.ca/ph-sp/approach-approche/index-eng.php “Clinical preventive services can prevent disease or detect disease early, when treatment is more effective. These services include screenings for chronic conditions, immunizations for diseases such as influenza and pneumonia, and counseling about personal health behaviors.” https://www.cdc.gov/aging/services/

We will not solve this problem one person at a time.

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Why Not?

• Assumes personal choices are the most important issue • Confuses risk and burden • Disregards reach • Inverse Care Law • Disregards cost • May not be sustainable • Often not equitable

The rational/cognitive model

Problem is lack of information Answer is education Assumption there may be character defect

Does not explain: • temporal or geographic differences • poor performance of direct behavioural interventions

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What really happens…

Make the healthy choice the easy choice

Choice-directing interventions

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Fig 1. Illustration of the intervention pathway in low- (top) and high-agency (bottom) population interventions.

Adams J, Mytton O, White M, Monsivais P (2016) Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency. PLOS Medicine 13(4): e1001990. https://doi.org/10.1371/journal.pmed.1001990 http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001990

Most chronic diseases and

conditions are a normal response by normal people to

an abnormal environment.

Sick Individuals and Sick Populations: Sir Geoffrey Rose

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Sick Individuals and Sick Populations: Sir Geoffrey Rose

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Diabetes Prevention Program Impact

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o $2052 over 3 years per person o $15 million/$2052 = 7310 participants

COST

o 7310 participants/2.28 million with IGT = 0.3%

REACH

o Number needed to treat = 6.9 o 7310/6.9 = 1059 cases of diabetes prevented o 1059/652784 = 0.16% of IGT progression to diabetes

cases prevented

IMPACT

Diabetes Prevention Program (DPP)

“Lifestyle modification is likely to have important effects on the morbidity and mortality of diabetes and should be recommended to all high-risk people. The program used in the DPP study may be too expensive for health plans or a national program to implement. Less expensive methods are needed to achieve the

degree of weight loss seen in the DPP.”

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Eddy, Schleissinger, Kahn. Annals Int Med 2005.

Obesity Intervention Comparison

21 Gortmaker et. Al. Health affairs 2015, 34: 1932-1939.

Eliminating tax deductibility for advertising unhealthy food to children

Sugar sweetened beverage tax (1¢/oz)

4X increase to adolescent bariatric surgery

$0.66 ($0.27 – $1.13)

$2.49 ($0.62 - $10.59)

$1,611 ($1,241 -$2,337)

What is policy?

• Course or principle of action • Reflects societal consensus • Level of generality • Consequences of non-compliance • Symbolic or effective • Requires understanding of status quo

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Ethical implications

Individual Autonomy Societal benefit

“Ladder” of Interventions

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Nuffield Council on Bioethics. (2007). Public health: ethical issues. London: Nuffield Council on Bioethics.

Eliminate choice

Restrict choice

Guide choices through disincentives

Guide choices through incentives

Guide choices through default policy

Enable choices

Provide information

Do nothing and monitor

What is Equity?

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Policy: Summing Up

POLICY is…

SCALABLE – can apply to whole populations

SUSTAINABLE – does not require continuing effort

EQUITABLE – reach, low agency, targeted universalism

eff26

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Access to Healthy Food

Societal Changes to Energy Intake •Ready availability of inexpensive, energy-dense, nutrient-poor foods

•Reduced food preparation skills •Perceived lack of time to prepare meals • Increased frequency of eating out • Increased portion sizes •Aggressive marketing of less healthy foods, beginning in early childhood

REGION OF PEEL: CALL TO ACTION EATING PATTERNS HAVE CHANGED

1938

20010

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60 193819692001

Unprocessed 34.3 to 25.6 % Culinary

Ingredients 37 to 12.7%

Processed 4.3 to 6.8%

Ultra-Processed 24.4 to 54.9%

Contribution of food items to total household energy availability in Canada

Processed and Ultra-Processed Food Products: Consumption Trends in Canada from 1938 to 2011 Can J Diet Pract Res. 2014; 75:15-21) 29

% contribution to total household energy availability

Fig 1 US and UK posters illustrating changes in portion, package, and tableware sizes since the 1950s.

Theresa M Marteau et al. BMJ 2015;351:bmj.h5863

©2015 by British Medical Journal Publishing Group

Eat Food

Not Too Much

Mostly Plants

Michael Pollan

Guidelines for Eating • Eat food

• Prepare it yourself • Limit processed,& especially ultra-processed foods

• Sit down, eat with others, eat slowly • Limit red meat and processed meat • Avoid sugar-sweetened beverages

• And artificially-sweetened beverages • Be wary of sugar and salt

• Eat this way when eating out, and avoid large portions • Be wary of advertising and marketing

• Help your children to develop food skills • Recognize that healthy eating has a value in time and money

• Demand action from all levels of government

“Healthy Foods”

•Fruit Juice

•Fruit Juice as a Sweetener

•Snack-size Yoghurt

Policies for a Healthy Food Environment local

• Food and beverage policies– schools, daycare, parks & rec.

• Zoning fast food away from schools

• Limit drive-thrus

• Menu labelling

• Water fountains

Children eat while they watch…. and eat what they watch

Policies for a Healthy Food Environment National/Provincial

•Stop advertising to children

•Front of package labelling, stop-lights

•Tax sugar-sweetened beverages

A Nod to Smoking

•A partial success story—thanks to policy actions

•Smoking in the movies •Marihuana

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Physical Activity

Societal Changes to Energy Consumption

• Decrease in and disincentives for the need to walk • Decline of manual occupations • Perceived safety concerns for children, leading to

reduced opportunities for outdoor play • More home appliances • Design of neighbourhoods to support the use of

cars • Increased availability of sedentary entertainment

options

The Problem

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Majority of Canadians, at all ages, do not achieve the recommended activity levels Sedentary activity is prevalent and increasing Increasing BMI Increasing waist circumference Flexibility, muscle strength in children is low and declining Active transportation rates low and unchanged

Recreation is not the Answer Recreation is not the Answer

t the Answer

SOURCE: DOWELL D, OLSON C, COREY C, HOLDER-HAYES E, KHEIRBEK I, CAFFARELLI A. HEALTH BENEFITS OF ACTIVE TRANSPORTATION IN NEW YORK CITY. NYC VITAL SIGNS SPECIAL REPORT 2011, 10(3); 1-4.

Average Daily Active Transportation and Recreational Activity Among New Yorkers Who Work Outside the Home

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WE HAVE ENGINEERED PHYSICAL ACTVITY OUT OF OUR LIVES

More of the same is not going to work…

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Obesity Relationships

Likelihood of Obesity

Each additional hour spent in car per day 6% increase

Each additional kilometer walked per day 5% reduction

Each quartile increase in land-use mix around home 12% reduction

Am J Prev Med 2004;27(2):87-96

Active Transportation

Active transportation is using human power to get from place to place

Walking, cycling, using a wheelchair, in-line skating

and skateboarding are all forms of active transportation that

link residents to their everyday destinations of work, school and recreation.

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Most Canadian Children have bicycles, but only one to two percent of them ride to school.

Only 28% of children in Canada walk to school.

In the Toronto-Hamilton region, 71% of parents

walked to school as a child. 39% of their children walk to school

Active Transportation

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Children’s mobility, Health and Happiness: A Canadian School Travel Planning Guide, 2012. Metrolinx 2009 GTHA School Travel Household Attitudinal Survey, 2010

• 91% of Canadian children have bicycles…

• 5% ride them to school !

• Only 33% of children and youth walk to school, yet 87%

live within 2 kms of their school. 71% of their parents walked to elementary school.

Active Transportation

Children’s Play

• Why it’s important • Managing risk • Preferences • Policy

Suburban design discourages walking and increases reliance on cars

• Large lot sizes (more sprawl)

• Less connected streets (longer blocks)

• Purely residential zoning

• Few walkable destinations

• Often no sidewalks

Less walkable neighbourhoods less walking, less physical activity and more obesity

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The Solution

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Features of walkable neighbourhoods

• More compact/dense

• Grid-like street pattern (shorter blocks)

• Mixed land use

• Destinations within walking distance

• Sidewalks

More walkable neighbourhoods more walking 54

…Healthy Communities by Design

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• Designed for all ages, abilities, and modes of travel

• On Complete Streets, safe and comfortable access for pedestrians, bicycles, transit users and the mobility-impaired is not an afterthought, but an integral planning feature

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Creating Supportive Environments

Aging

Active Transportation | Health Outcomes | Obesogenic Environment | Sustainable Communities

WALKING

• Walk and talk • Walk and watch • Walk and be watched • Browse • Shop • Explore • Be with someone

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•Environmental sustainability •Economic sustainability •Accessibility •Quality of life

Synergy With Other Goals

What We Know Attempts to change behaviour through education have largely failed Unhealthy behaviours are largely a normal reaction by normal people to an abnormal environment The problem of chronic disease will not be solved one person at a time Changing environments to make the healthy choice the easy choice is required

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Thank You

David Mowat davidlmowat@gmail.com