Epidemiology of Chronic Disease II

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Epidemiology of Chronic Disease II
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Refocusing on Risk Factors

• Increased interest in shifting emphasis from
  single disease prevention approach
• Increased emphasis on the control of risk factors

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• Examples
• 2001 formation of Chronic Disease Prevention
  Alliance of Canada
• 25 member organizations
• Have submitted briefs to House of Commons
  Standing Committee on Finance

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• 2004 joint statement from the ACS, ADA and AHA
• 2005 report from Health Canada/Heart Stroke
  Foundation of Canada

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• Two or three modifiable risk factors play a
  significant role in the etiology of chronic
  disease
• Tobacco
• Obesity
• Diet
• Physical activity

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• All present complex challenges to those
  interested in prevention health promotion
• Not completely modifiable at the level of the
  individual
• Other factors have a major impact on the
  individuals capacity to deal with these risk
  factors

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Tobacco

• Tobacco is 2nd major cause of death globally
• Kills 1 in 10 adults
• In Canada, a leading cause of preventable death
• A Canadian dies of tobacco use every 11 min.

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• Health effects of tobacco use
• CVD
• Cancer
• Respiratory diseases
• COLD (chronic obstructive lung disease)
• Chronic bronchitis
• Emphysema
• Respiratory infections

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• Pregnancy
• LBW (low birth weight)
• Spontaneous abortion
• Placental anomalies/increased risk of bleeding
• SIDS (sudden infant death syndrome)
• Decreased milk supply
• Gastrointestinal effects
• Peptic ulcer
• Crohns disease

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• Periodontal disease
• Other
• Osteoporosis
• Sleep disturbance
• Cataracts
• Lower physical endurance
• Premature aging

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• Specific to women
• Cancer of cervix
• Early menopause
• Menstrual disorders
• Infertility
• Interactions with oral contraceptives
• Increased risk of CVD

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• Benefits of quitting are substantial
• Reduced risk of developing many diseases
  associated with tobacco use
• Quitting before age 50 reduces risk of dying in
  next 15 years in half

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• Patterns of Tobacco Use in Canada
• Canadian Tobacco Use Monitoring Survey (2004)
• Prevalence in Canadians aged 15 continues to
  decrease

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• 20 of Canadians smoke
• 22 of males
• 17 of females
• For 15-18 year olds, 11 smoke
• 18 of females
• Lowest recorded since monitoring began in 1965

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• For 20-24 year olds
• 28 smoke
• Lowest rate on record
• 30 of males
• 25 of females
• Canadians smoke fewer cigarettes/day
• Men smoke more than women

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• BC reports the fewest smokers (15)
• NB reports the most (24)
• NB reports highest number of cigarettes/day
• SK reports lowest number of cigarettes/day
• 28 of Canadians report exposure to environmental
  tobacco smoke

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• Prevalence of smokers higher in specific groups
• Aboriginal peoples
• Lower socio-economic groups
• Groups with lower educational attainment
• Nurses report the highest prevalence of smoking
  amongst health care professionals

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• In Canada, former smokers now outnumber smokers

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Strategies for Tobacco Reduction

• Individual Level
• 1. Health Education
• Evidence of success in convincing school aged
  children not to start smoking
• Constant ongoing battle with
• Developmental stage
• Advertising

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• 2. Effective smoking cessation programs
• No one-shot strategy here
• Most commonly reported strategies
• Gradual reduction of cigarettes smoked (56)
• Nicotine patch (use higher in older age groups)
• Quitting with a friend (24)
• Cold turkey

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• Current quit rates increasing
• Defined as percentage of daily smokers who
  stopped smoking for 2 years
• In mid 1990s 10
• In 2003 17

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• Some find it much harder
• Those who start smoking earlier
• Those with other addictions
• Heavy smokers
• Living with other smokers
• Dealing with other life stressors

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• Community Level
• 1. Participation of health care professionals
• Smoking cessation should be the concern of every
  nurse
• To assess readiness assist individual clients
• To initiate support community-wide tobacco
  control strategies

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• Does our own behaviour matter?
• 2. Increasing the cost of tobacco
• Most likely to discourage
• Young people
• Less committed smokers

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• Federal/provincial taxes account for 2/3 of
  purchase price of tobacco
• Taxation strategies have had their down side
• Unequal application of taxation strategy

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• 3. Curbs on tobacco advertising
• Tobacco companies responded by
• Increasing sponsorships
• Increasing retail promotions
• Additional legislation needed to deal with these
  issues

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• 4. Decreasing places where smoking is welcome
• 63 of Canadians now live where smoking
  restrictions are in place
• In 2004, 57 of Canadians stated that smoking
  should not be allowed in restaurants
• 37 believed it should not be allowed in bars

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• 71 worked in smoke-free environments
• Additional 20 worked in environments where
  smoking was restricted
• Two provinces ban smoking in the workplace
• Manitoba
• New Brunswick

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• 5. Warning labels on tobacco products
• Mandatory in Canada since 1989
• Resisted in courts by tobacco industry
• 50 of Canadians report it increased motivation
  to quit
• Habituation effect
• Need for more graphic warnings

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• Poverty Tobacco Use
• Poor people report higher rates of tobacco use
• May have different reasons for smoking
• May be less convinced by health education
  strategies

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• Identified as a major global issue by WHO
• Poor people spend higher percentage of budget on
  tobacco
• Increases risk for malnutrition
• Increases risk for disease
• Less likely to have health insurance

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• Tobacco production costs the world economy 200
  billion/year
• Diverts land from food production
• Tax revenues do not compensate for costs of
  illnesses caused by tobacco
• Profits from production not shared equitably
• Health risks associated with exposure to
  pesticides, etc.

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• Challenges to Tobacco Reduction
• Tobacco is highly addictive
• Emphasis on individual rights freedoms
• Tobacco is big business

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Overweight/Obesity

• Increases risk of chronic illness
• CVD
• Type 2 diabetes
• Cancer
• Musculo-skeletal problems
• Diminished quality of life
• Activity/mobility limitations
• Lowered self-esteem

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Patterns of Body Weight in Canada

• 6 million Canadian adults are overweight
• 3 million are obese
• More males report being overweight or obese
• In children aged 12-19
• 6 of males 3 of females obese
• 17 of males 10 of females overweight

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• Obesity prevalence is increasing
• In all age groups
• In both sexes
• Obesity has significant health impacts
• Reduces life expectancy

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• Obesity costs the health care system 1.8
  billion/yr
• Represents 2.4 of health care spending
• Three largest contributors
• Hypertension
• Type 2 diabetes
• Coronary artery disease

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Dietary Patterns in Canada

• 1/3 of Canadians eat 5-10 servings of fruit
  vegetables/day
• Those with low incomes less likely to consume
  recommended daily intake

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• Overall reduction in fat intake
• Similar pattern in US
• Referred to as the American paradox
• Speculation that decreased physical activity may
  play more of a role in risk for overweight/obesity

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• Other population trends of note
• Per capita consumption of soft drinks rose
  steadily between 1976 1996
• Since then, has remained static
• Per capita consumption of fluid milk has declined
  since 1976

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• Consumption of fruit juices has increased
• Consumption of food outside of the home has risen
• 30 of food dollars spent outside of home
• 15 of these dollars spent in fast food
  restaurants
• Food portion sizes have increased
• Largest portions consumed at fast food
  restaurants

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• Marketing direct advertising of fast foods,
  snacks soft drinks has increased
• School fundraising
• Exclusive rights contracts
• Television

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Patterns of Physical Activity in Canada

• 44 of Canadian adults report low or moderate
  physical activity during leisure time
• Walking
• Gardening
• Home exercise
• Swimming
• Bicycling

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• 12-19 year old children are physically active
• 75 of males
• 61 of females
• 82 are not active enough to meet international
  standards for optimal growth development

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• Patterns of physical activity vary regionally
• Highest in BC, Alberta, Territories
• Lowest in NB, NLD, Quebec, PEI
• Lower income adults children are less active
• Time pressures reported as a major reason for
  inactivity

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• TV viewing is primary leisure activity amongst
  Canadian adults
• 16 of public schools provide phys. ed. on a
  daily basis
• 50 of parents believe their children are active
  enough at school

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• Most Canadians travel to work or school by car
• 25 of those living within 2.5 km. of their
  destination never choose to walk
• 72 of those living within 8 km of their
  destination never choose to walk
• Suburban development is associated with lower
  physical activity levels

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Strategies to Combat Obesity

• Individual Level

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Strategies to Combat Obesity

• Individual Level
• 1. Health Education
• Dietary modification
• Increased physical activity
• But it really isnt that simple
• Many barriers to these behaviours exist

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• Community Level
• 1. Action on economic barriers
• Poverty makes being healthy a challenge
• Nutritious food is expensive
• Participation in organized physical activity
  programs is expensive

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• Other issues related to poverty may make diet
  physical activity a low priority
• Studies have shown that low income areas have
• More fast food outlets
• Higher food costs
• Less access to recreational facilities (even
  parks)
• Higher crime rates

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• 2. Making schools a site for healthy living
• Healthy schools initiative
• Diet/physical activity a focus
• Legislation to enforce same
• Alberta

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• 3. City planning
• Urban sprawl
• Increases non-active travel
• Family car identified as a significant threat to
  health
• Decreases fresh food consumption
• Increases commuting time
• Less leisure physical activity
• More fast food

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• Neighbourhood planning
• Nice streets (for cars), but no sidewalks (for
  people)
• No bike paths
• Pedestrian-friendly infrastructure often included
  in plans for new neighbourhoods, but cut out to
  reduce taxes
• Schools on major traffic routes

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• 4. Geographic and climatic barriers
• Food costs higher in northern Canada
• No fruit/vegetable production in winter
• Need to import increases costs
• More difficult to be physically active in winter

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What can We Conclude

• Each individual will come to their own conclusion
  about what the best way to tackle risk factor
  reduction
• Some things seem clear
• There are significant individual, social,
  economic barriers to health
• A combination of individual and community
  approaches offer more strategies
• Theres no silver bullet

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The Last Word

• Roy Romanos Tips for Health
• Dont be poor
• Get a good start in life
• Graduate from high school
• Get a job
• Preferably not a low-paid, stressful, manual job
• Live in a good community
• Live in quality housing