Social and individual responsibilities for the prevention of chronic diseases

1. Social and individual responsibilities for the prevention of chronic diseases Philip James

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?

4. Some WHO background documents in addition to PAHO initiatives

5. National initiatives. UK: the current obesity challenge

6. The current obesity dilemma

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

9. Catering challenges: increases in hidden fat and sugary drinks evade appetite regulation and lead to weight gain

12. Chan JC, Cheung JC, Stehouwer CD, Emeis JJ, Tong PC, Ko GT, Yudkin JS. The central roles of obesity-associated dyslipidaemia, endothelial activation and cytokines in the Metabolic Syndrome-an analysis by structural equation modelling. Int J Obes Relat Metab Disord. 2002 Jul;26(7):994-1008.Chan JC, Cheung JC, Stehouwer CD, Emeis JJ, Tong PC, Ko GT, Yudkin JS. The central roles of obesity-associated dyslipidaemia, endothelial activation and cytokines in the Metabolic Syndrome-an analysis by structural equation modelling. Int J Obes Relat Metab Disord. 2002 Jul;26(7):994-1008.

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 >50s 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

17. The great benefit of diet and exercise for preventing the onset of type 2 diabetes in the elderly

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

23. Challenges for the Medical Profession - 1 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 >80% 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

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

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

34. Declining activity: age effects and recent trends in children

36. Few extracurricular sports in English children aged 7-11 years at primary school

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

38. The most cost-effective community (not national) interventions for Australian children

39. Obesity: time watching TV overwhelms leisure activity in Australia: community activities as a substitute crucial for both physical, mental and societal health

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

45. Consumer purchases in response to traffic light food labelling of principal nutrients as in healthy (green), reasonable (yellow), or unhealthy (red) amounts.

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!