Social and individual responsibilities for the prevention of chronic diseases

1
Social and individual responsibilities for the
prevention of chronic diseases

• Philip James

LSHTM and Chair of IOTF and the Presidential
Council of the Global Prevention Alliance
2
The range of issues to be considered

• All societal initiatives that are not the
  exclusive concern of government
• Previous effective action policy proposals used
• Development of coherent plans based on analyses
  experience in each domain
• Role of government in promoting these social and
  individual developments?
• When to initiate these developments and how
  should they be assessed?

3
WHO initiatives for action on chronic diseases
2002
2003
2004
First presentation of the major risk factors
explaining the burden of sickness and early death
across the world
The update on the evidence on diet and physical
activity in relation to chronic diseases
The Member State agreed WHO Global strategy on
diet and physical activity
4
Some WHO background documents in addition to PAHO
initiatives
5
National initiatives. UK the current obesity
challenge
UK Government report Oct. 2007
Obesity is a normal "passive" biological response
to our changed physical and food environment
Some children/adults are more susceptible for
genetic, social and economic reasons
Overwhelming environmental impact reflects
outcome of normal industrial development
Obesity reflects failure of the free market
6
The current obesity dilemma
Obesity similar to climate change 1. Numerous
forces involved societal and industrial
developments 2. Action essential now -
exceptionally difficult to reverse 3. No single
remedy will suffice 4. Co-ordinated central and
local government, industrial, societal and
individual changes necessary 5. Major changes
needed - not just individual advice to eat less
and walk more! 6. Immediate action necessary
although many logical remedies remain unproven
UK Government Report Oct. 2007
7
New Regional initiatives Trinidad summit
proposals of Prime Ministers with PAHO on
September 15th -17th 2007

• Collaboration between CARICOM, PAHO, WHO
  partners!
• Establish National Commissions
• Legislation - immediate implementation tobacco
  framework ban sale marketing etc to children,
  tax, limit
• Money from tobacco, alcohol and other product
  taxes into NCD prevention
• Ministers of Health by mid 2008 develop action
  plan with other Ministries
• Physical education in schools immediate
  reintroduction
• Trans fats eliminate progressively
• Nutritional labelling get regional system
  organised
• Work site and other areas new plans for physical
  activity for the entire community
• Extensive public education
• Surveillance
• CARICOM continue development of economic trade
  plans

8
Foci for action in relation to chronic diseases

• Alcohol
• Salt/preservation methods
• Some meats/processed
• Fats- esp. trans
• Sugars
• Veg/fruits/cereals (whole grain)
• Physical activity

Obesity
Energy Density
9
Catering challenges increases in hidden fat and
sugary drinks evade appetite regulation and lead
to weight gain
Stubbs et al. Am J Clin Nutr, 1995 62 316-329
Three groups offered the same food but with very
different amounts of fat show that the groups ate
the same volume of food so those on high fat
foods unconsciously stored energy and gained
weight
Sucrose
Weight changes (kg)
Those adults drinking sucrose containing soft
drinks gained weight progressively for 10 weeks
those on calorie free drinks lost weight
Sweetener
Raben et al., Am J Clin Nutr 2002 76 721-9
10
Individual responsibility
Complementary approaches to obesity chronic
disease prevention
e.g. Focus on Health Education but need
understandable food labelling campaigns
selectively help upper socio-economic groups
Change in the environment

• Nutritional standards for food in all government
  facilities/schools involve business/catering in
  Finnish scale fruit veg. within meal costs
• Selectively increase costs of high fat/sugary
  products soft drinks
• Social/medical policies for breast feeding as the
  norm
• Limit/abolish all marketing to children
• Progressively adapt all towns/cities to favour
  pedestrian/cycling as norm with car restrictions

Adapted from Puska P, 2001
11
Societal policies and processes influencing the
population prevalence of obesityand chronic
diseases NGOs/academics influence most sectors
Modified from Ritenbaugh C, Kumanyika S,
Morabia A, Jeffery R, Antipatis V. IOTF website
1999 http//www.iotf.org
12
Levels of prevention measures
Universal prevention (directed at everyone in a
community)
Selective prevention (directed at high-risk
individuals and groups)
Targeted prevention (directed at those with
existing weight problems)
Obesity Report, WHO 2000.
13
Social initiatives who to focus on?

• Different age groups elderly, middle aged,
  school children, babies, pregnant women, young
  adults
• Different settings
• Public sector facilities - hospitals, armed
  forces, police, schools, nurseries, prisons, old
  people's homes
• Private business workplaces
• Sports centres,
• Schools
• Nurseries
• Clubs women's, farmers', arts

14
Social initiatives who to focus on?

• Middle aged elderly because
• They have the highest incidence of chronic
  disease
• They show the greatest benefit from interventions
  on diet and physical activity
• They are the neglected groups as the focus is
  usually on children
• The elderly have a major opportunity to
  contribute to both their own wellbeing and that
  of their grandchildren
• Can be shown to learn completely new skills
• Are often highly motivated

15
Examples of benefits for older people of diet and
exercise changes

• Risk of cardiovascular disease - both coronary
  artery disease and strokes - highly dependent on
  risk factors with proven benefits from reversal.
  New risk charts suggest benefit from simple
  screening which all doctors can do very quickly
  and which individuals can understand
• Diabetes maximum incidence rate in gt50s with
  maximum marked proven reduction in the
  development in diabetes from defined changes in
  both diet and physical activity.
• Nutritional quality of diet critical because
  total energy intake lower so avoidance of anaemia
  and vitamin deficiencies provide major benefits
  including mental function.

16
Elderly few know the extent of their
vulnerability the benefits of intervention
No Diabetes
Diabetes
Non - Smoker
Smoker
Smoker
Non -Smoker
Gaziano et al. Lancet 2008371923-931
17
The great benefit of diet and exercise for
preventing the onset of type 2 diabetes in the
elderly
DPP study. NEJMed. 2002 346393-403
18
WHERE IS THE PRIORITY ?
19
Optimum birth weights in relation to adult risk
of diabetes, cardiovascular disease cancer
depends crucially on non-smoking, good nutrition
in pregnancy
20
Mobilising society focus on the most committed
then the most powerful effective groups

• Societal groups Women's organisations, business
  men's clubs, trade unions
• NGOs - consumer groups
• Academic medical, nurses, nutritional, dietetic,
  sports/physiotherapy, social science and
  economics
• Professional groups architects, urban planners,
  environmentalists, transport experts
• Food chain Farming, manufacturing, catering
  trade organisations, food writers, TV cooks
• Clubs e.g. walkers, cyclists, swimmers, dance
  groups

21
Strategies for engagement and promoting
prevention initiatives

• Involve key groups in developing not just
  implementing the plan
• Need a national body to drive public/private
  involvement
• Public transparency the key rarely do government
  initiatives of a cross sectoral nature work if
  the organisation remains within government only
  exceptions are national security or crisis
  management
• Set public goals which require societal and
  individual changes
• Media involve the best and accept bad publicity
  is often a useful stimulus in the long term

22
Government policies need to support the public
and private sectors in their promotion of chronic
disease prevention through a National Public
Institution
WHO/PAHO
FAO, UNICEF, UNESCO, WTO, World Bank etc.
Ministry of health actions
National Information
1. Professional training 2. Health
promotion national networks (NGO, voluntary
Orgs.) national campaign 3. Regional and
district food policy 4. Catering
establishments 5. Priorities, research and
surveillance
MINISTRY of HEALTH (HEALTH POLICY GROUP)
Health statistics Dietary risk
fact.surveys Nutritional surveillance Food
production Agricultural Food production
statistics Market structure Import/export
policies Food security measures Public
perception Economic evaluation of policy proposals
Actions
INDEPENDENT NATIONAL INSTITUTION

• school postgraduate education
• school meals

• coordinating educational materials

• re-evaluation of current policies

• controls on food industry
• licensing, cooperative trade arrangements

Private sector
Nongovernmental organizations and consumer
representatives

• tax, subsidy adjustments

• policy on import / export trade
• coordinating regional actions

23
Challenges for the Medical Profession - 1
Improve screening procedures and effective
treatment evidence shows doctors respond best
when

• Assess practices publicly on a regular basis
• Payment for effective treatment striking
  difference between the poor response of European
  Cardiologists in their usual practice and UK GPs'
  success when paid if gt80 of their patients are
  under proper hypertensive control
• Coherent public support demanded medical
  profession needs to be challenged to support
  local and national preventive initiatives

24
Challenges for the Medical Profession - 2 Primary
care physicians

• GPs need to develop a coherent strategy of
  opportunistic screening and audit of their
  practice / community as proposed by Scottish SIGN
  guidelines for obesity (see next 2 slides)
• Link with exercise facilities and local
  government initiatives for physical activity
• Play major new role in pregnancy care public
  scrutiny of the success of breast feeding rates
  of patients
• Take new approaches to reorganise their
  practices with nurse - or non - professional
  voluntary groups for obesity management
• Identify those vulnerable to illness

25
Scotland's Physicians' Colleges SIGN Obesity
Guideline No 8, 1995
Opportunistic screening
Practice audit
Self-referral
1. RECRUITMENT REFERRAL
2. BMI ASSESSMENT
Measure BMI

25-30
gt30
lt25
Assess current disease and risk factors
low risk
3. PATIENT CRITERIA
high risk
4. HEALTH ASSESSMENT

• Waist measurement
• Risk factors, e.g. smoking
• Blood pressure
• Urine glucose

• Plasma ?-glutamyl transferase
• Total plasma cholesterol
• Thyroid stimulating hormone

5. RISK FACTOR MANAGEMENT
Smoking, excess alcohol, lipids, blood pressure
Patient refuses
Offer weight management
6. WEIGHT MANAGEMENT
Accepts
26
Scotland's College of Physicians SIGN Guideline
No 8, 1995
Requires a reorganisation of primary health care
practices
27
Goal enhancing healthy eating practices and
physical activity patterns and achieving healthy
weights in children and adolescents
28
Strategies for combating childhood obesity a
challenge for consumers

• Protecting children aged up to 18 yrs
• Breast feeding
• Proper weaning practices
• Regulated child minders food and play
• Legislate on all forms of marketing TV, radio,
  text messages, internet, food product labelling,
  games etc.
• School environment
• Supermarket practices
• Pricing policies affect school aged children
• Availability policies density of fast foods
  outlets

29
Strategies for childhood obesity School councils
with parental/ pupil/teacher/governors needed

• School environment
• No "choice" !
• No vending machines
• Activities and sports for all after school
  activities
• Defined high quality meals only
• Contracts with parents on food
• Food and activity committee with Governor,
  pupil, parental representation
• Nutrition education
• Walk/bike to school changing and storage
  facilities
• Traffic policies around school
• Parental policies on transport to school

30
Fundamental changes in physical activity
inevitable and optional changes

• Inevitable
• Rural to urban transition
• Labour changes
• Mechanisation/computerisation of standard work
  also home duties e.g. cooking, washing, cleaning
• Optional
• Urban building policies high intensity or US
  style sprawl?
• Road and community design
• Office supermarket location policies
• Car policies versus preference for
  cyclists/pedestrians
• Policies on free spaces for children's play
  lighting for safety e.g. for older people
• Park/leisure/sports facilities/school PA lessons
• Ease of transport of perishable foods into
  towns/cities

31
Town planning crucial in one UK town only a few
roads are within 500 m of one or more shops where
food is reasonably priced selling gt8 kinds of
fresh fruit and vegetables other roads require
motor transport to shops
Source Dowler, Blair et al 2001
32
Options for transport to work the fundamental
importance of physical exercise

• Energy imbalance if adults gain on average 0.5kg
  per year imbalance 3,500kcal
  10 kcal/d
• Travel to work cycling for 1 hour each way
  480 kcal
• Travel to work by bus assuming each journey 50min
  
• Total cost 316 kcal
• Travel by car for 30min Total
  cost 201 kcal

Conclusions policies favouring car use induce
average population fall in energy needs of
140-280 kcal/d Cycling/walking to work
automatically uses about 150kcals/day more than
public transport
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CAR-RELIANCE limits child development
Increase in traffic
Parent concern for child safety
Sedentary replaces active transport
Parents chauffeur children
Organised sport replaces play for children
PHYSICAL INACTIVITY
Sarah Hinde The car-reliant environment. In The
7 deadly sins of obesity. Univ. of NSW,
Australia. 2007.
34
Declining activity age effects and recent trends
in children
Adults achieving suggested 30 mins walking x 5 /
wk
US National Survey of children 5-15 yrs.
children walking to school
UK National Survey of adults
35
Marvellous opportunities for activity in the
Netherlands
36
Few extracurricular sports in English children
aged 7-11 years at primary school
Taken from Mason, 1995. Young people and Sport in
England, 1994. A National Survey
37
Prevalence of obesity in schoolchildren in
Singapore - immediate impact from huge effort led
by Prime Minister now abandoned because focus on
selective controls for overweight children became
socially politically sensitive
16 14 12 10 8 6 4 2
1976 1978 1980 1982 1984 1986
1988 1990 1992 1994 1996 1998 2000
New growth charts used since 1994. Source
Ministry of Health, Singapore
38
The most cost-effective community (not national)
interventions for Australian children
Intervention Cost in Australian for each
DALY saved Restrict TV advertising 4 Soft drink
intervention at school 3,000 Walking buses to
school 770,000 Cycling (travel SMART
schools) 260,000 After-school community
programmes. 90,000 Doctors targeting the
overweight children 32,000 School multiple
interventions, but no physical education 14,000
Add Physical Education 7,000 School
education to reduce TV viewing 3,000 Family-based
program for obese child 4,000 School program
targeting overweight obese children 3,000 Medica
l treatment with drugs, e.g. Orlistat 14,000
Victoria State Analyses Sept 2006
39
Obesity time watching TV overwhelms leisure
activity in Australia community activities as a
substitute crucial for both physical, mental and
societal health
Adapted from Salmon, Bauman et al. IJO 2000
24600-606
40
Potential mechanisms for combating distorted
urban environments

• Urban planning crucial to
• Minimise car use encourage public transport,
  cycling and pedestrian habits, e.g. London -
  congestion charging Copenhagen, Netherlands
• Community sports facilities in grouped flats
  e.g. Singapore
• School facility policies and environment - e.g.
  road systems
• Supermarket / shopping mall location policies
  (UK)
• Housing estate lay-out - a crucial determinant of
  transport choices (US)
• Urban storage refrigeration facilities and
  transport lines for rural products e.g. fruit,
  vegetables
• Fast food outlets control urban density

41
Approaches to reinforcing individual
responsibilities

• Choosing suitable foods demands understandable
  food labelling new concept of nutritional
  profiling crucial for food labelling to allow
  individuals to change
• Some UK health centres have weekly posters of
  best cheapest foods in local supermarkets
• Local councils transfer fruit/vegetables into
  urban slums and create new facilities
• Physical activity try pedometers community
  facilities for a variety of sports/leisure e.g.
  dancing
• Some UK health centres organise with local
  council special walks/outdoor exercises x3 per
  week for groups
• Individuals at risk can identify themselves of
  developing diabetes, e.g. a) high waist
  circumference, b) over 40 yrs c) diabetes in
  family intervention provide clear benefit

42
Salt sources in a Western diet dominated by salt
in purchased foods good food labelling crucial



Derived by the lithium technique James et
al., Lancet,1987 1 426-429. Edwards et al.
Eur J Clin Nutr 1989 43855-61
43
Food labelling schemes based on nutritional
profiling tested by the UK Consumers'
Organisation - "Which"
UK Food Standards Agency scheme
Tesco SupermarketGDA labelling with a different
colour for each nutrient
GDA system
Tesco GDA traffic lights
IOTF demand for EU action
44
Testing consumer responses incorrect
responses in all those who made use of the
signposting system
62
Across all age, geographic, socio-economic and
main ethnicity groups
Incorrect response
No Signposting
Conclusions using signposting produces
significantly lower levels of incorrect responses
with Multiple Traffic Light system and
nutritional profiling of GDA scheme.
45
Consumer purchases in response to traffic light
food labelling of principal nutrients as in
healthy (green), reasonable (yellow), or
unhealthy (red) amounts.
Sainsbury's Supermarket presentation to The
National Heart Forum, UK., 2006.
46
5 Practical Priorities local activism by
business and NGOs leads to major changes

• Major drive to increase/ sustain breast feeding
  facilities at work important maternal leave
  cultural change
• Marketing restrictions (not just TV advertising)
  - statutory for children adolescents rights of
  child extend to 18 yrs
• Control of food in nurseries, all school
  facilities and school environment avoid choice -
  all foods of high nutritional quality
  facilities to allow spontaneous play - not TV
• Fruit and vegetable availability within main cost
  in canteens and restaurants - government local
  action
• Transformation of physical facilities for
  spontaneous leisure time activity urban design
  changes with novel traffic policies pedestrian
  only areas immediately adjacent to
  houses/apartments

47
Conclusions

• Greater societal challenge with obesity cancer
  than cardiovascular diseases which can be limited
  by "readily" manipulated changes in food
  composition
• Toxic obesogenic environment needs major changes.
  To improve society's obesity levels need big
  external changes in food and activity
  opportunities to overcome biological buffering by
  appetite control mechanism
• Systematic multilevel changes need coherent 5-10
  yr adaptable plan led by Governments
• Industry can be helped by developing specified
  regulations set out over 5 years and with
  projected changes to allow innovation.
• External public health groups/body drive change,
  report to Parliament publicly transparent great
  help to Ministries of Health in driving political
  change
• Medical leaders should start working for the
  public Interest!