Transcript GPI Atlantic National Round Table on the Environment and

Genuine Progress Index for Atlantic Canada
Indice de progrès véritable - Atlantique
New Directions for Health
Policy in Nova Scotia:
The Genuine Progress Index
Health Law and Policy Seminar Series
Dalhousie University, 29 September, 2006
Pop. health context: Romanow and
the 3 burning health policy issues
1) How to treat the sick - supply side
2) How to prevent disease and improve
the health of Canadians
3) How to check spiralling health care
costs - demand side
The next Royal Commission......
The larger context – how to
create a healthier Canada?
Valuing a Healthy Population
– the importance of indicators
GPI population health reports include:
• Costs of chronic disease in Canada and NS
• Women’s health in Canada + Atlantic Canada
• Income, Equity and Health in Canada/Atl Can.
• Costs of tobacco, obesity, physical inactivity,
HIV
• Economic Impact of Smoke-Free Workplaces
• Value of care-giving
Economic Language:
- Chronic Disease as Cost,
- Prevention = Investment
• Costs of chronic disease are very high
• Indirect costs, particularly, are huge
• Large proportion of costs preventable
• Disease prevention (esp. dealing with
root causes) is cost-effective
¾ Canadians die from 4
types of chronic disease
= 5,800 deaths in NS (cf 1900)
• Cardiovascular: 2,800
36%
• Cancer
30%
2,400
• COPD
370
5%
• Diabetes
230+
3%+
NS: High Rate Chronic
Disease
• NS - highest rate of deaths from cancer
and respiratory disease
• Highest rate arthritis, rheumatism
• 2nd highest circulatory deaths, diabetes
• 2nd highest psychiatric hospitalization
+ Gap with Canada is growing....
Chronic Disease Disability
• 1/4 Nova Scotians have long-term
activity limitation - highest in country
• NS has highest use of disability days
• 20% have arthritis or rheumatism
• 16% have high blood pressure
• 14% have chronic back problems
Costs of 7 types non-infectious
chronic disease, NS, 1998
• 60% medical costs = $1.2 billion / year
• 76% disability costs = $900 million
• 78% premature death costs = $900 mill.
• 70% total burden of illness = $3 billion
= $3,200 per person per yr = 13% GDP
Cost of Chronic Illness in
Nova Scotia 1998 (2001$ million)
Circulatory
Cancer
Respiratory
Musculoskeletal
Endocrine
Nervous system
Mental
TOTAL:
Hosp.
Doctor
Drugs
Other
Total
Direct
Premat.
Death
DisTOTAL
ability
161.6
71.4
21.6
55.9
18.5
55.3
104.2
26.6
11.8
3.2
20.3
7.2
27.9
17.7
63.6
7.5
16.6
22.0
29.3
19.2
39.2
137.8
49.6
22.7
53.8
30.1
56.0
88.2
389.6
140.3
64.1
152.0
85.0
158.5
249.2
326.8
427.2
43.4
3.5
43.8
30.0
16.0
244.4
14.5
78.1
307.2
27.0
158.6
72.3
960.8
582.1
185.5
462.8
155.8
347.0
337.5
488.4
114.8
197.5
438.1
1,238.8
890.8
901.9
3,031.5
These are under-estimates
• Exclude diseases: Digestive, cirrhosis of
liver, congenital, perinatal/LBW, blood, skin,
genitourinary (chronic renal failure), etc.
• “Principal diagnosis”: e.g. injury/fall vs
osteoporosis; diabetes under-reported
(complications: blindness, kidney failure,
amputations, cardiovascular disease,
infections). Diabetes 2 afflicts 4% (38,000)
Nova Scotians, disables 3,300, kills 230 850
What portion is preventable?
Excess risk factors account for:
• 40% chronic disease incidence
• 50% chronic disease premature mortality
• Small number of risk factors account for
25% medical care costs = $500 mill./yr
(->Creation of OHP)
• 38% total burden of disease = $1.8 bill.
(includes direct and indirect costs)
A few risk factors cause many
types of chronic disease
• Tobacco - heart disease, cancers,
respiratory disease
• Obesity - hypertension, diabetes 2,
heart disease, stroke, some cancers
• Physical inactivity - heart disease,
stroke, hypertension, colon and breast
cancer, diabetes 2, osteoporosis
• Diet/fat - heart disease, cancer, stroke,
diabetes
Costs of Key Risk Factors,
Nova Scotia (2001 $ millions)
Deaths
Direct
Indirect
Total
Tobacco
1,700
$188
$300
$488
Obesity
1,000
$120
$140
$260
700
$107
$247
$354
Physical
Inactivity
Case Study:
Obesity-related illness
• Costs U.S. $118 billion / year (Colditz) now exceeds smoking; but doctor, drug,
hospital costs make economy grow
• More than 50% diabetes 2 due to obesity
• Type 2 diabetes grown 5-fold globally
since 1985 from 30 to 150 million (17
million in US). WHO predicts 300
million by 2025
Health Impacts
• BMI >30 = 4x diabetes; 3.3x high blood
pressure; 56% more likely have heart
disease; 2.6 times urinary incontinence;
50% less likely rate health positively (Statcan)
• Association with some cancers, gallbladder
disease, stroke, asthma, arthritis, thyroid
problems, back problems, sleep disorders,
impaired immunity, depression, etc.
A “Global Epidemic” (WHO)
• Obesity increased 400% in the western world
in the last 50 years.
• Underfed and Overfed: The Global
Epidemic of Malnutrition:
“ for the first time in human history the
number of overweight people in the world now
equals the number of underfed people, with 1.1
billion each.”
March, 2000, Worldwatch Institute, Washington D.C.
Underfed and Overfed
• The hungry and the overweight share high
levels of sickness and disability, shortened life
expectancies, and lower levels of productivity -all of which impede a country's development
• Among the overweight, "obesity often masks
nutrient starvation," as calorie-rich junk foods
squeeze healthy items from the diet. In Europe
and North America, fat and sugar now account
for more than half of total caloric intake
BUT few doctors give nutrition counselling
Low-income, poorly educated, elderly
= higher rates overweight, obesity
Percent of Canadians who believe that
low-fat foods are expensive, 1994-95
41
40
40
39
37
37
Percent
35
34
33
32
31
29
27
25
lowest
low-middle
middle
upper middle
highest
Overweight- by Education and
Age (20-64), Canada, 1997 (%)
45
39
40
36
36
35
30
29
Percent
30
29
25
24
22
20
15
15
10
5
<
-6
4
Ag
e
55
-5
4
Ag
e
45
-4
4
Ag
e
35
-3
4
25
Ag
e
Ag
e
20
-2
4
ity
rs
e
Un
iv
e
ol
le
g
C
ho
sc
Hi
gh
Hi
gh
sc
ho
ol
ol
0
Obesity Trends* Among U.S. Adults, 1985
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. Adults, 1986
Obesity Trends* Among U.S. Adults, 1987
Obesity Trends* Among U.S. Adults, 1988
Obesity Trends* Among U.S. Adults, 1989
Obesity Trends* Among U.S. Adults, 1991
Obesity Trends* Among U.S. Adults, 1990
Obesity Trends* Among U.S. Adults, 1991
Obesity Trends* Among U.S. Adults, 1992
Obesity Trends* Among U.S. Adults, 1993
Obesity Trends* Among U.S. Adults, 1994
Obesity Trends* Among U.S. Adults, 1995
Obesity Trends* Among U.S. Adults, 1996
Obesity Trends Among U.S. Adults, 1997
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends Among U.S. Adults, 1998
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends Among U.S. Adults, 1999
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends Among U.S. Adults 2000
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends Among U.S. Adults 2001
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends Among U.S. Adults
2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends Among U.S. Adults 2003
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends Among U.S. Adults 2004
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends Among U.S. Adults 2005
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1995, 2005
(*BMI 30, or about 30 lbs overweight for 5’4” person)
1995
1990
2005
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Overweight Canadians
(BMI = >27),Canada and Provinces, Age 20-64, (%)
Overweight Adults
45
41
38.5
40
37
37.6
34.2
35
29
29.4
28.4
26.5
26.4
25
20
15
10
5
BC
Al
ta
Sa
sk
an
M
nt
O
ue
Q
NB
NS
PE
I
Nf
ld
0
Ca
na
da
Percent
30
35.3
European studies: e.g.
• Netherlands: Obese individuals 40% more
likely visit doctors; 2.5 times more likely take
drugs for CVD = direct costs
• Sweden: Obesity accounts for 7% of lost
productivity due to sick leave, disability.
Obese workers = 2x more likely to take longterm sick leave = indirect costs
NS, NB – highest # sick days in Canada
Solutions must address
causes of obesity epidemic
• Poor diet
• Physical inactivity
• Poverty, illiteracy
• Employment patterns
• Other underlying social causes (e.g.
work schedules)
Obesity is only one
consequence of poor diet
• Nutrient-poor, high-fat, high-sugar diets,
with low fibre and chemical additives
contribute to cancers of breast, colon,
mouth, stomach, pancreas, prostate
• 30% of cancers worldwide could be
prevented by switching to healthy diets
• USA: fat + sugar = 50%+ average caloric
intake; complex carbohydrates just 1/3
Dangers are out of sight
• Fats, oils, sugars, salt added to processed
and prepared foods
• 1909: 2/3 discretionary sugar added in
household. Today, more than 3/4 of sugar
consumed is added to processed and
prepared food, out of sight of consumer
• Whole grains largely replaced by refined
grains (lack vitamins, minerals). Only 2%
wheat flour in U.S.= unrefined
Fast food
• Single fast-food meal may exceed daily
fat, sugar, cholesterol, and sodium RDAs
• Marketing: “Supersize” meal for 79c =
42 fl.oz. Coke (vs 16) + free refills; more
than double weight of french fries =
increases calories of nutrient poor, fatrich meal from 680 to more than 1,340
• 1/5 “vegetables” consumed in U.S. =
french fries and potato chips
Ignorance re processed food
• Surveys show food labels widely
misunderstood, misinterpreted, esp.
ingredient lists, nutritional panels, validity
of food claims on labels
• $30 billion annual food advertising dwarfs
nutritional education budgets. Consumers
get their knowledge from industry.
New DHPP school program step in right
direction…..!
Physical activity
• U.S. Surgeon-General: Physical activity
promotes fat loss; weight loss (doseresponse a/c frequency, duration of
session and program)
• Sedentary = 44% higher rate of obesity
than physically active; 5x risk of heart
disease; 60% higher depression (see
GPI report on cost of physical inactivity)
Television Viewing,
Average Hours per Week; 1999
27
25
24.7
24.5
22.9
23
22.1
Hours
21.6
20.7
21
20.5
20.8
20.7
20.3
19.6
19
17
15
Canada
Nfld
PEI
NS
NB
Que
Ont
Man
Sask
Alta
BC
TV linked to child obesity
• American Academy of Pediatrics: “Increased
television use is documented to be a
significant factor leading to obesity.”
• Study in JAMA: Children lost weight if they
watched less television
• Add computer games. Childhood obesity rate
has doubled in 20 years
Value of physician and school
counselling…
Stress, health, and weight
• Women w. high levels of job strain 1.8 times
more likely experience unhealthy weight
gain vs low job strain. Reduced work hours
= 1/2 odds of weight gain cf standard hours
• Longer hours = 40% more likely decrease
physical activity; 2.2 times more likely
experience major depression; higher levels
smoking (stress-related) and drinking
(Statistics Canada)
Value of counselling on stress, lifestyle
Eating out has increased
sharply, but...
• Harvard study - 16,000 children- the
more families eat at home together, the
more fruits & vegetables are eaten, less
fried food + higher intake of important
nutrients (calcium, fiber, folate, iron,
vitamins B & E
• Healthy diets persist into adulthood
Counsel eating home-cooked meals,
breast-feeding
Promote Healthy Diets and
Nutritional Literacy
– Teachers can be trained to explain
nutritional labels in class
– Singapore “Trim and Fit” program cut
school children’s obesity 33%-50%
– Doctors, nurses given more explicit
diet and nutritional training, yet only
23% U.S. medical schools require
separate nutrition course
Practising what we preach
• Schools, universities, hospitals, workplaces can act alone to improve food
quality, nutritional content (vs
contract with fast food companies)
• Berkeley schools - vegetable gardens
to teach, supply school cafeteria.
1999 - organic lunches
• DHPP’s new school food guidelines
Case studies and models
• U.S. grade 3-5 “Child and Adolescent
Trial for Cardiovascular Health” found
lower fat, higher physical activity well
into adolescence - Behavioural changes at
young age have lasting effects
• Finland - nutrition media campaign,
strict food labelling (e.g. “heavily salted”),
education - helped cut heart disease
deaths 65% 1970-95
And in the future....?
• Restrictions on advertising (cf tobacco)
• Tax on foods inversely proportion to
nutrient value per calorie (Kelly
Brownell, Yale). Fatty, sugary, highcalorie, low nutrition = highest taxes, ;
fruits, vegetables, whole grains exempt
• Tax revenues to nutritional education
just as portion of cigarette, gambling
revenues fund anti-smoking, counselling
Socio-economic
Determinants of Health
• Education, income, employment,
stress, social networks are key health
determinants. These too are
modifiable
• Lifestyle interventions effective for
higher income/education groups, not
lower - can widen inequity, health gap
The need for health promotion
personnel to be political……
Health Costs of Poverty
• Most reliable predictor of poor health,
premature death, disability: 4x more
likely report fair or poor health = costly
• e.g. Increased hospitalization:
Men 15-39 = +46%; 40-64 = +57%
Women 15-39 = +62%; 40-64 = +92%
Heart Health Costs of
Poverty
• Low income groups have higher risk of
smoking, obesity, physical inactivity,
cardiovascular risk = costly
• NS could avoid 200 deaths, $124
million/year if all Nova Scotians were
as heart healthy as higher income
groups
…delayed child development
• 31 indicators - as family income falls,
children have more health problems,
(NLSCY, NPHS, Statistics Canada)
• Child poverty -> higher rates
respiratory illness, obesity, high
blood lead, iron deficiency, FAS,
LBW, SIDS, delayed vocabulary
development, injury+….
Highest Risk Groups
• Single mothers & their children
• Homeless: longer hospital stay cf low income
• Unemployed, Aboriginals, migrants,
minorities, disabled
= Clustered disadvantages (poverty, illiteracy,
unemployment, ill-health): “Social
exclusion”
……health of single mothers
• Worse health status than married
(NPHS); higher rates chronic illness,
disability days, activity restrictions
• 3x health care practitioner use for
mental, emotional reasons = costly
• Longer-term single mothers have
particularly bad health (Statcan)
Employment of Female Lone
Parents 1976-2001
Low Incomes :
1991-2000
Single mothers w/out paying jobs
The Economics of
Single-Parenting
• Single mothers with pre-school children
spend 12% income on child care cf 4% in
2-parent families. In one pocket .........
• CPI for child care, restaurant good rises
faster than wages
• Robin Douthitt: “time poverty”. Fulltime single mothers = 75 hour week
Health Cost of Inequality
• British Medical Journal: “What matters
in determining mortality and health
is less the overall wealth of the
society and more how evenly wealth
is distributed. The more equally
wealth is distributed, the better the
health of that society.”
• e.g. Sweden, Japan vs USA
Costs of Inequality in NS
• Excess physician use (Kephart)
(Small fraction of total costs):
– No high school
Lower income
= +49% than degree
= +43% than higher
– Educational inequality = $42.2 million
Income inequality
= $27.5 million
= costs avoided if all Nova Scotians
were as healthy as higher income / BA
If Equality->Health, What are Trends?
Average Disposable H’hold Income Ratios, 1980-98
Canada
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Richest 20% : Poorest 20%
1980
1990
1998
8.2
7.1
8.5
7.6
5.8
7.3
7.4
6.2
6.7
7.1
6.2
8.5
6.7
6.1
7.0
7.6
6.9
7.9
7.8
7.1
8.3
8.8
6.7
7.6
8.1
7.3
7.4
9.1
7.4
10.4
9.3
7.6
8.0
Social Supports
• Health Canada: “...as important as
established risk factors” in contributing
to health and medical outcomes, and
reducing premature death, depression,
mental illness, stress, chronic disability,
aiding recovery from illness
• Family, friends, communities, volunteers
DHPP actions to strengthen social
support networks….
The economic case for
prevention: Aging - Delay
vs Cure Saves $
• NS 65+: 2001 = 14%;
2036 = 28%
2011 = 16%;
• 5-year delay in onset cardiovascular
disease could save NS $200 million / yr
• Physically active - lower lifetime illness
• Nutritional intervention - reduce
hospital use 25-45% among elderly
“Compression of
Morbidity”
• Fries: “The amount of disability can
decrease as morbidity is compressed
into the shorter span between the
increasing age at onset of disability
and the fixed occurrence of death.”
(= about 85: analysis of 1900s data)
• “Successful aging” can preserve
independence into old age
Disease Prevention is
Cost-Effective Investment
For example:
• Workplace = 2:1
• WIC = 3:1
• “Smoke-Free for Life”
= 15:1
• Pre-natal counselling
= 10:1
Brief physician counselling
• Highly effective and costeffective. Start with adding
lifestyle, work hours and other
questions to intake surveys
• Be aware of cultural factors –
WHOM we are counselling
Next Steps....A Chronic Disease
Prevention Strategy for Nova Scotia is
the responsibility of all sectors
Can it be
done?...1900s/1980s...
New measures of progress
are needed to help create a
healthier Nova Scotia for
our children –
Genuine Progress Index for Atlantic Canada
Indice de progrès véritable - Atlantique
www.gpiatlantic.org