HEALTH SYSTEMS RESEARCH UNIT

1. HEALTH SYSTEMS RESEARCH UNIT Report Back from Cardiovascular Disease Working Group Western Cape Burden of Disease Western Cape Burden of Disease Volume 6 of 7

2. Operational process of CVD work group: • Develop a conceptual frameworkbased upon a literature review to identify the causal factors associated with poor diet and lack of physical activity. • 2. Review the epidemiological dataof the distribution of these risk factors across the province. • 3. Systematicaly review interventionsthat have sought to address these risk factors. • 4. Further planned that the working group will systematically identify the most appropriate and feasible interventionsthat could be considered in the Province. • 5. Finally an analysis of the context of policy-makingin regard to these interventions will be undertaken to include a stakeholder analysis.

3. Top twenty leading causes of death across the Western Cape,2000(Bradshaw et al.2004)

4. Projected percentage increase in CVD deaths 2000-2040 Taken from Leeder et al 2005

5. Triple burden of disease in the Western Province

6. NCD rates similar across the various communities

7. Increasing numbers of middle age workers

8. Evidence that this epidemic can be reversed…

9. Aetiology of chronic non-communicable diseases …from…Preventing Chronic Diseases: a vital investment. Geneva, World Health Organization, 2005.

10. NCD Risk factors in the Western Cape: epidemiological diagnosis

11. Source: Youth Risk Behavior Survey, 2002 Behavioural diagnosis: national risk factor survey in adolescents:

12. Smoking • Important interventions have already been put in place • Surveys suggest that there has been a reversal of upward prevalence of smoking especially amongst African men • Important sub-groups still have high levels • Systematic review of interventions in pregnancy • Interventions with pregnant women being evaluated presently

13. (Temple et al., 2006) Western Cape school “tuck shop” survey

14. The potential future of nutritional risks

15. Systematic Review • Systematic approaches designed to increase levels of participation in physical activity, • Approaches above may have included interventions targeting changes in awareness, knowledge and/or attitudes toward nutrition and physical activity, improving self-efficacy, skill or competency concerning these behaviors; • Interventions may also have included programs or strategies targeting changes in social norms, policy and physical environment, health services or consumer behavior etc, leading to, for example, increased consumption of fruits and vegetables, reduced dietary fat intake, reduced obesity prevalence and increased levels of health-enhancing physical activity.

16. Various levels of intervention for prevention & health promotion based on McKinlay, 1995 (extracted from Rowland, 2006) Community/ecological interventions target all levels; structural interventions target either or both midstream (2) & upstream levels (3)

17. Results from review A review of more than 300 interventions have shown • that very few studies are from developing countries • and none published were from sub-Saharan Africa. • Despite this, there have been numerous successful interventions which have been sustainable and cost-effective and have the potential to be used in the South African context.

18. Summary of best practice review by setting (1):

19. Summary of best practice review by setting (2):

20. Summary of best practice review by setting (3):

21. Summary of best practice review by setting (4):

22. Summary of best practice review by setting (5):

23. Summary of best practice review by setting (6):

24. Summary of best practice review by setting (7):

25. School Setting • * Multi-component school programs which include; • a nutrition-based curriculum offered by trained teachers, a physical activity component; • a healthy school environment and parental involvement. • The curriculum should preferably run over 3 years in grade 4-6 children. • Two excellent examples in this regard are the PATHWAYS study which was developed for American Indians and the Know Your Body Program offered to primary school children in Crete. • Both of these studies were adapted to local culture, values and norms and showed positive outcomes in behavior, clinically and in psycho-social aspects.

26. Worksite Setting The successful studies were characterized by the following: • nutrition and physical activity advice/group sessions; • a physical activity program; • changes in the food service canteens; • use of printed materials and use of multi-media to promote health messages. • One of the most important factors in promoting successful outcomes was the use of an employee committee who participated in planning and managing a worksite program. • A good example of this is the Treatwell -5-a Day program.

27. Primary Health Care Setting • Interventions in primary health care and in the community with successful outcomes at the lowest level of cost. • These include using physicians to endorse healthy programs, dietitians or nurses to do group counseling. • The use of self-help materials for patients to use on their own. • Brief cholesterol screening programs with a minimum time spent on counseling were also effective in some studies. • The use of the media as a means of conveying healthy lifestyle messages was also shown to be effective in many studies.

28. Modification to improve diet • * Ban advertising of foods during children’s programs on radio & TV or reduce the market pressure on children by regulating advertising and obtaining cooperation from the mass media and Internet providers • * Introduce advertising and educational campaigns (multi-media) to promote increased consumption of fruit and vegetables and decreased consumption of fat, saturated fats, sugar and salt. Includes developing and building-on to the food-based dietary guidelines of the DOH. • * Ensure that communities have access to healthy and safe foods (food security) – such as food gardens, food outlets • * Develop and implement a policy for schools on foods which are allowed to be sold/provided at the schools-including feeding schemes and tuckshops

29. Further Recommendations • Introduce a nutrition & healthy lifestyle curriculum aimed at schoolchildren for the prevention of CVD • Ensure that all state facilities provide healthy foods (high in fruit and vegetables, low in salt, sugar and fats to inmates and patients • Develop a system of incentives for companies who introduce healthy canteens and physical activity facilities for their staff • trans fat: getting rid of partially hydrogenated oils is one of the simplest ways to prevent CVD. • Cut the sodium content of packaged and restaurant foods could make a huge dent in CVD. • "1% Or Less": switch people in several communities from high-fat to low-fat or fat-free milk.

30. Modification methods to improve physical activity • * Ensure that urban development includes access to areas for physical activity • * Introduce advertising campaigns (multi-media) to promote physical activity • * Introduce a physical activity curriculum aimed at schoolchildren for the prevention of CVD • * Ensure that all schools have adequate space and facilities for physical activity • * Ensure that all communities have access to safe areas where they can be physically active

31. Modification methods to reduce tobacco use and alcohol • * Increase the price of alcohol and cigarettes • * Ban advertising of alcohol • * Introduce a school policy of a smoke free environment

32. Members of the Working Group Authors • Prof Mickey Chopra (HSRU, MRC) • Dr Nelia Steyn (CDL, MRC) • Prof Vicky Lambert (UCT) Expert Committee • Prof. Thandi Puoane (SOPH, UWC) • Prof. Krisela Steyn (University of Cape Town) • Prof Dinky Levitt (University of Cape Town) • Dr Yusuf Saloojee (National Council Against Smoking) • Dr Emmanual Deviaud (Health Economist, MRC) • Dr Sue Parnell (University of Cape Town) • Prof Vanessa Watson (Planning, UCT) • Dr Lesley Bourne (Health and Development, MRC)