Disease prevention:How are we fairing?

9 November 2007

Roscoe TaylorDirector of Public Health

Director, Population Health

Well population Screen those at risk People with newly diagnosed Type 2

diabetes

People with controlled diabetes

Primary Prevention

Vulnerable/at risk Identified Conditions Managed Conditions

Keep people well: Prevent movement to the

“at risk” group

Prevent progression to established disease and hospitalisation

Prevent/delay progression to complications and prevent re-

admissions

Good diet Physical activity Maintain healthy

weight Alcohol in

moderation Social factors

Treatment & acute care Continuing care & maintenance Self-management Crisis intervention

Well population Secondary Prevention/ Early detection Management & Tertiary Prevention

Overweight & obese Age >55 (>35 Indigenous

Australians) Family history Pre-diabetes (IGT, IFG) Hypertension Women with previous

gestational diabetes

Action across the continuum of prevention & care: example of type 2 diabetes

GlobalisationIndustrialisation Modernisation

Sanitation (infra-structure)

Food safety: laws, regulations

Smoke control: zoning, fines

19001800 2000

Infectious diseases

Obesity

Urban air pollution

Road trauma

Energy use and greenhouse gas emissions: climate change health impacts

Burden of disease (indicative only, not to scale)

Seat belts, drink-driving, road design

Clean air laws

Preventable Environmental Health Hazards over Two Centuries (McMichael, 2006)

Death and its causes

Top 10 Causes of Death* in Tasmania, 2004

2.5%

2.6%

2.7%

3.6%

4.2%

4.8%

5.3%

6.6%

16.8%

30.1%Cancers(all types)

Ischaemic heart disease

Cerebrovascular disease

Chronic lower resp diseases

Accidents

Diseases of nervous system

Diabetes mellitus

Diseases of arteries etc

Intentional self-harm

Diseases of digestive system

Source: ABS, Causes of Death, 2004, cat. no. 3303.0, Table 1.9

* as a % of total age standardised deaths

Avoidable Mortality Rate for Tasmanians Aged < 75 Years

226.8 213.9 192.6

173.3

0

50

100

150

200

250

300

1999-01 2002-04 2010 2015

Rat

e p

er 1

00,0

00 P

op

ula

tio

n TT Targets

Potentially avoidable deaths by socioeconomic status quintiles in Tasmanians aged under 75 years, 1999-2004

0

50

100

150

200

250

300

1999 2000 2001 2002 2003 2004

Rat

e pe

r 100

,000

Low Rest High

Rates are age-standardised to the June 2001 Australian population.

Social gradient & health

Michael Marmot argues convincingly that:

Low control over life&Social disengagement

…are the most powerful explanatory factors

Attributable Burden of DALY's - Australia 2003

0.2

0.6

0.7

0.9

1.1

2

2

2.1

2.3

6.2

6.6

7.5

7.6

7.8

0 2 4 6 8 10

Osteporosis

Unsafe sex

Air pollution

Child sexual abuse

Partner violence

Illicit drugs

Occupational hazards

Low fruit & Veg

Alcohol

Cholesterol

Inactivity

Body mass

Blood pressure

Tobacco

%These 14 risk factors explain 32.2% of Burden of Disease

AIHW 2007

The SNAPPs approach we use to address common risk

factors for chronic conditions

• Smoking

• Nutrition

• Alcohol

• Physical Activity

• Psychosocial

The challenge:Prevention strategies that

WORK at the Psychosocial level

Without taking the “PS” and socio- economic factors into account, strategies that focus on individual behavioural change probably won’t work, and even environmental measures will be less effective

What are we

to do about SNAPPs, and what still needs to happen?

“S” is for…..

Proportion of Tasmanians Currently Smoking

24.4%25.5% 25.4%

10%12%

15%

0

5

10

15

20

25

30

35

1995 2001 2004/5 2010 2015 2020

TT Targets

Source: National Health Surveys 1995, 2001, 2004/5; Tasmania Together (Revised) 2006

Australia: 1950-2000Smoking-attributed deaths: % of all deaths at ages

35-69

0

5

10

15

20

25

30

35

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

Perc

ent

Males

Females

Smoking in Pregnancy

• Tasmania (2005): 27.6%

• NSW: 14.8%

• Tasmanian Public patients: 35.7%

• Private patients: 8.3%

• RR for Low Birth Weight Baby = 2.55

Self-Reported Tobacco Smoking Status During Pregnancy by Age, Tasmania 2005

13.5%17.1%17.5%

26.4%

43.8%

54.0%

< 20 20 - 24 25 - 29 30 - 34 35 - 39 40 +

DHHS, P erinatal Database No = 5,918

Proportion of Tasmanian Secondary School Students Currently Smoking* 1984-2005

0

10

20

30

40

50

1984 1987 1990 1993 1996 1999 2002 2005

Per

cen

t

Females 12-15 Years Males 12-15 Years

Females 16-17 Years Males 16-17 Years

*smoked within last 7 days; Source: Cancer Council, ASSAD Surveys

Try this on your next date!

Do health providers always ask their clients how many cigs they smoke, and advise them to quit?

“N” is for nutrition

Tasmanians Aged 18 Years and Over who are Overweight or Obese, 1989/90-2004/5

28.8% 30.5% 31.8% 30.0%25.0%

20.0%

10%

12.5%14.5%

17.1%

7.7%14.7%

0

10

20

30

40

50

60

1989/90 2001 2004/5 2010 2015 2020

Overweight Obese TT Targets

Source: ABS, NHS 1989/90 – 2004/5; Tasmania Together (Revised) 2006

Number of obese older people 1980 - 2000 (AIHW, 2003)

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

1980 1983 1989 1995 2000

Year

Num

ber

65+

55-64

Prevalence of chronic conditions by weight status in men (AIHW, 2003)

0

5

10

15

20

25

30

35

Diabetes Heart/Circulatorycondition

High bloodpressure

High bloodcholesterol

Men

Pre

vale

nce

(%)

healthy weight

overweight but not obese

obese

“Obese people should perform hard work, eat only once a

day, take no baths, and walk naked as much as possible.”

Hippocrates

quoted in Diabetes Care (2003) 26;11:3172-78)

In the modern era we have better solutions …

…..Sanitised tape worms!

We have to create supportive environments

Cool Canteen Accreditation program

Aims to help school canteens increase the availability of and promote safe and healthy food

and drinks

(*)

Creating Supportive Environments

Breastfeeding promotion

Aims to increase community

acceptance of and support for breastfeeding

Creating Supportive Environments

Nutrition Promotion

Funding for the Eat Well Tasmania Campaign to

promote enjoyable healthy

eating

Strengthening Community Action

Family Food Patch (peer educators) advocate for healthy eating at a local level.

Prevalence and consequence of Malnutrition in older people

• Malnutrition is common among elderly

• Malnutrition may lead to :– Higher risks of infection– Slow wound healing – Longer hospital stays– Poorer longer term health outcomes– Poor quality of life

Capacity Building

Healthy Settings

Community Development

Quality Improvements

The Action Steps of Mature Tastes Step 1: Use planning tool to identify, prioritise and plan to address key nutrition issues.

Step 2: HACC services action priorities.

Staff training Health PromotionNutrition Policy

Nutrition Screening

Menu changes

Step 3: Evaluation and further planning.

Some questions

• How would your service identify whether older patients were malnourished or at risk of malnutrition?

• Do you know whether malnutrition in your service’s older patients will be prevented by the care they receive when you discharge them?

Standard serves 1955 & 2001 (courtesy of Dept Human Nutrition, University of Otago)

1955Fries 72gCoke 200ml

2001Fries 205gCoke 950ml

Average number of food advertisements

0 2 4 6 8 10 12 14

Australia

UK

Greece

Germany

Netherlands

Norway TV3

Sweden TV4

Co

un

try

Average number of food ads per hour

And now we come to “A”, for

Alcohol….

We’ve come a long way…

Alcohol Related Harms

• Alcohol responsible for 4% of the global burden of disease (WHO)

• Alcohol causally related to 60 different medical conditions (Ridolfo & Stephenson)

• Alcohol causally related to a range of injuries, other social harms as well as hospital admissions

• As population consumption increases, harm also increases correspondingly

Tasmanian Population Response

• Under development – watch this space

• Establish a monitoring system allowing analysis of alcohol related trends

• Explore legislative change in support of safer drinking environments

• Focus on availability and marketing issues as a harm reduction measure

Tasmanian Targeted Response

• Focus on adult drinking as well as that of youth

• Strategies to build resilience in early childhood

• Strategies to address Foetal Alcohol Syndrome Disorder

• Explore introduction of workplace strategies

How does socio-economic status affect alcohol consumption?

“P” is for Physical Activity…

….the hardest of all

the risk factors,

to get moving?

Proportion of Population who do not Exercise Sufficiently* to Avoid Chronic Disease

69%71.5%69.6%

25%

45%

55%

0

20

40

60

80

100

1995 2001 2004/5 2010 2015 2020

TT Targets

*includes no exercise, sedentary, and low level exercise*includes no exercise, sedentary, and low level exercise

Source: ABS, NHS 1995, 2001, 2004/5; Tasmania Together, Revised, 2006Source: ABS, NHS 1995, 2001, 2004/5; Tasmania Together, Revised, 2006

Live Life Get Moving: Tasmanian Physical Activity Plan 2005 -2010

• Premier’s Physical Activity Council• Four action areas/goals:

– Participation– People– Policy– Places

• Coordinated action required across all 4 areas and across sectors

Some projects and strategies– Evidence-informed social marketing campaigns – Get Active program– Move Well Eat Well (Schools)– Good Fuel for Police (DHHS will be next!...)– ‘Healthy community framework’ for local

communities– Guideline development around land use planning

and the “Healthy By Design” Guidelines (PPAC and Heart Foundation)

– Monitoring and surveillance (major deficiency).

How do health services ensure that physical activity is seen as part of treatment?

Recent national events & Prevention

(weak) National Chronic Disease Strategy? Service Improvement Frameworks Abolition of NPHP (mod) Australian Better Health Initiative? COAG Human Capital Reform –

Diabetes± ANZ Food Regulation MinCo Resources diverted / wasted on

politically motivated mass media? Federal election

Summary

• To get good traction with prevention, strong Government intervention is needed….

…and bold interventions in the marketplace are called for…

Thank you for your time

What we don’t want DHHS to do for its clients?

The continuum of prevention and care

• Primary Prevention: protection of health by measures that eliminate or reduce the causes or determinants of departures from good health, control exposure to risk, and promote factors that are protective of health.

• Secondary Prevention: early detection of asymptomatic biological changes or asymptomatic disease, and prompt and effective intervention to address these departures from good health.

• Tertiary Prevention: measures to reduce or eliminate long-term impairments, disabilities and complications from established disease and prevent or delay subsequent events.

Supporting people with chronic conditions to change behaviour

• It is relatively easy to identify the risks that will increase a persons likelihood of developing a chronic disease, but working with people to change these risk factors is a challenge faced by all health practitioners.

• Easy to call it “Non compliance” … or are different tactics required?– Self management has been identified as an

essential key element in health systems that effectively address chronic disease

Self management

• Uses principles of both health promotion and risk reduction

• The person is at the centre of their own health care

• Builds skills and confidence

• Enhanced by supportive communities and health care providers

• Involves all levels of the health system

Supporting people to manage their own risk factors and chronic conditions

• Health Practitioners:– New skills to integrate into practice: Health coaching, Mentoring;

Flinders Partners in Health Tools to assess client’s self management skills

• For clients:– Community based programs: Stanford Chronic Disease Self

management Program; Condition specific education classes; peer led Diabetes cooking classes, exercise groups;

• For the System:– A coordinated model of care that supports clients to manage their

condition in partnership with health practitioners: i.e. the Chronic care Model

• Policy Level:– National Chronic Disease Strategy– Tasmanian Health Plan: Primary Health Care services

Prevention is not merely proactively applying a disease

model to what we do