Social and individual responsibilities for the prevention of chronic diseases

1. Social and individual responsibilities for the prevention of chronic diseases Philip James IPA WHF IDF IUNS IOTF 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. WHO/EU Ministers of Health meeting, Istanbul Nov.2006 WHO Euro Nutrition Action plan 2004 WHO Obesity Report 2000 Extensive set of proposals for prevention Proposals for new systems of care and societal change Details of intersectoral needs 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 • Collaborationbetween 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 Weight changes (kg) Sucrose 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. NATIONAL/ REGIONAL COMMUNITY LOCALITY INTERNATIONALFACTORS INDIVIDUAL POPULATION WORK/SCHOOL/HOME Leisure Activity/ Facilities Public Transport Transport Energy Expenditure Globalization of markets Urbanization Public Safety Labour % OBESEor withchronic disease Infections Health Care Health Development Worksite Food & Activity Social security Sanitation Food intake : Nutrient density Media & Culture Media programs & advertising Family & Home Manufactured/ Imported Food Education School Food & Activity Agriculture/ Gardens/ Local markets Food & Nutrition National perspective Societal policies and processes influencing thepopulation prevalenceof 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 • Diabetesmaximum 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 No Diabetes Diabetes Non - Smoker Smoker Non -Smoker Smoker Gaziano et al. Lancet 2008;371:923-931

17. The great benefit of diet and exercise for preventing the onset of type 2 diabetes in the elderly DPP study. NEJMed. 2002; 346:393-403

18. WHERE IS THE PRIORITY ?

19. Relative risk of adult disease 5.0 4.0 Adult metabolic syndrome Childhood obesity 3.0 2.0 1.0 -2 1 4 2 3 5 Birth weight (kg) 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. Ministry of Education Ministry of Information Ministry of Agriculture/Environment Ministry of Trade Ministry of Finance Ministry of Foreign Affairs 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 >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

25. Scotland's Physicians' Colleges SIGN Obesity Guideline No 8, 1995 Opportunisticscreening Practice audit Self-referral 1. RECRUITMENT & REFERRAL 2.BMI ASSESSMENT MeasureBMI 25-30 >30 <25 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 Patientrefuses Offer weight management 6.WEIGHT MANAGEMENT Accepts

26. Scotland's College of Physicians SIGN Guideline No 8, 1995 Patientrefuses Offer weight management 6.WEIGHT MANAGEMENT Accepts 3-month weight loss programme, including: • Exercise • Behavioural advice • Diet Unsuccessful outcome • Support scheme: • Family • Health Centre • Community Consider additional drug therapy if BMI >30 Successful outcome, e.g. >5 kg loss Drug therapy continues Unsuccessfuloutcome Consider specialist referral for surgery if BMI >35 with major risk factors Maintenance of weight loss achieved. Regular monitoring. Prevention of further weight gain Healthy eating advice Requires a reorganisation of primary health care practices

27. An integrated comprehensive model for school-based obesity/chronic disease prevention. Family and community linkages Nutrition environment of the school School-site health promotion for faculty and staff Physical education classes School foodservices School counselling and psychology programs School health services Health instruction (curriculum) 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. Roads within 500m Roads further than 500m Railways Canals & streams Shops * 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 >8 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 cyclingfor 1 houreach way= 480 kcal • Travel to work by busassuming each journey 50min Total cost = 316 kcal • Travel by carfor 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

33. 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 InterventionCost 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 Medical treatment with drugs, e.g. Orlistat 14,000 Victoria State Analyses: Sept 2006

39. Leisure time sport & activity 28 Increasing TV time 27 26 Average BMI for each group TV time 25 24 23 22 21 High Moderate Inactive Low Total daily physical activity 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;24:600-606

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 43:855-61

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. Simple Traffic Colour GDA Mono GDA Multiple Traffic 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. JS Ham and Pineapple Pizzeria 356 all 5GREENon WoH Wheel of Health (WoH) 'Be Good to Yourself' Chocolate sponge puddings 4Green, 1 amber 42% 55% 42% 89% JS Ham & Pineapple Thin & Crispy Pizza 335g 1 red, 2 amber, 2 green 'Taste the Difference' Melting Middle Chocolate puddings 4 red, 1 amber 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 foodin 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 availabilitywithin main costin 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!