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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
20
40
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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