http://www.cdc.gov/chronicdisease/recovery/

Communities Putting Prevention to Work

Wayne H. Giles, MD, MSDirector

Division of Adult and Community HealthNational Center for Chronic Disease Prevention and Health Promotion

June 8, 2010CPPW Action Institute, St. Louis, MO

Overview

Why focus on chronic disease and underlying risk factors?

Why policy, systems, and environmental change strategies?

Why now?

Leading Causes of DeathUnited States, 2006

Percentage (of all deaths)

Heart Disease

Cancer

Chronic lower respiratory diseases

Unintentional Injuries

Alzheimer’s disease

Diabetes

Pneumonia/influenza

Kidney Disease

Stroke

1.92.333

55.15.7

23.126

0 5 10 15 20 25 30 35 40 45 50

National Center for Health Statistics. Deaths: Final Data for 2006. Hyattsville, MD: US Department of Health and Human Services; 2008.

Ten Great Public Health Achievements 1900 - 1999

VaccinationMotor-vehicle safetySafer workplacesControl of infectious diseasesDecline in deaths from coronary heart disease and strokeSafer and healthier foodsHealthier mothers and babiesFamily planningFluoridation of drinking waterRecognition of tobacco use as a health hazard

Alarming Health Disparities Heart disease death rates 30% higher for African-Americans than whites; stroke death rates 41% higher

Diabetes higher among American Indians and Alaska Natives (2.3 times), African Americans (1.6 times), and Hispanics (1.5 times)

About 30% of Hispanics and 20% of African Americans lack a usual source of health care compared with less than 16% of whites

“Disparities in health care are among the nation’s most serious health care problems. Research has extensively documented the pervasiveness of racial and ethnic disparities.”

Institute of Medicine, 2002

Economic Impact

Chronic conditions account for 75% of the $2 trillion in health care costs

Smoking costs $96 billion per year

Obesity-related costs $147 billion per year

Why Chronic Disease?Something Can Be Done- Preventable Risk Factors

Chronic Diseases and Related Risk FactorsLeading Causes of Death*

United States, 2000Actual Causes of Death†

United States, 2000

Kidney disease

0 5 10 15 20

TobaccoPoor diet/

Physical inactivityAlcohol consumption

Microbial agents

Toxic agents

Firearms

Sexual behavior

Motor vehicles

Illicit drug use

Percentage (of all deaths)

Heart Disease

Cancer

Chronic lower respiratory disease

Unintentional Injuries

Pneumonia/influenza

Diabetes

Alzheimer’s disease

Stroke

Percentage (of all deaths)0 5 10 15 20 25 30 35

* Miniño AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-120.† Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1246.

Growing Challenges

Healthy Food Has Gotten More Expensive, Junk Food Cheaper

Fresh fruits and vegetables

Consumer price index

Sugar and sweets

Carbonated drinks

Pric

e In

dex

(198

2-84

= 1

00)

Data from Bureau of Labor Statistics; represent U.S. city averages for all urban consumers in January of each year

Obesity Trends* Among U.S. AdultsBRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1991

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19

Obesity Trends* Among U.S. AdultsBRFSS, 1992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24%

Obesity Trends* Among U.S. AdultsBRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24%

Obesity Trends* Among U.S. AdultsBRFSS, 1999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24%

Obesity Trends* Among U.S. AdultsBRFSS, 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24%

Obesity Trends* Among U.S. AdultsBRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. AdultsBRFSS, 2002

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

Obesity Trends* Among U.S. AdultsBRFSS, 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

Obesity Trends* Among U.S. AdultsBRFSS, 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

Obesity Trends* Among U.S. AdultsBRFSS, 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. AdultsBRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)(*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. AdultsBRFSS, 2007

(*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. AdultsBRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Childhood Obesity is Also Epidemic

1976-80 1988-94 1999-2002

2003-06 2007-080%

5%

10%

15%

20%

25%

2 to 56 to 1112 to 19

Year

% O

bese

Prevalence of Obesity Among U.S. Kids Tripled in a Generation(BMI ≥ 95th percentile)

Source: CDC, NHANES

How to weigh yourself and get the most accurate result.

I can’t believe I was doing it wrong all these years

Why policy, systems, and environmental change

strategies?

LargestImpact

SmallestImpact

Factors that Affect HealthExamples

Eat healthy, be physically active

Rx for high blood pressure, high cholesterol, diabetes

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Socioeconomic Factors

Changing the Contextto make individuals’ default

decisions healthy

Long-lasting Protective Interventions

ClinicalInterventions

Counseling & Education

Focusing on Dose

DOSE = REACH x INTENSITY

Intensity Deconstructed:• Exposure• Potency

What It Looks Like:

50% healthy vending slots ban on unhealthy foods whole school reform school + corner stores

Walk to school day walk to school year complete streets complete streets + school physical activity

Source: Kaiser Permanente

Great Depression

End ofWW II

First Medical reportslinking smoking and

cancer

Thousands per year

US Surgeon General’s first

report

Broadcast advertising

ban

Federal cigarette

tax doubles

Fairness Doctrine messages on radio and

television

1900 1910 1920 1930 1940 1950 1960 1970 1980

Year

Adult per Capita Cigarette Consumption Environmental and Policy Changes in the US 1900-1990

0

1

2

3

4

5Nonsmoker’s rights movement begins

1990

$1.25

$1.75

$2.25

$2.75

$3.25

$3.75

$4.25

19

23

27

31

35

1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006

Pric

e (2

/09

dolla

rs)

Prev

alen

ce

Year

Cigarette Prices and Adult Smoking Prevalence, United States, 1970-2008

Prevalence Price

Source: NHIS, Tax Burden on Tobacco, 2009, and author’s calculationsNote: green data points for prevalence are interpolated assuming linear trend

Policy Change:Producing Results - New York City

18.9%

11%

% o

f New

Yor

k C

ity S

mok

ers

8%

10%

12%

14%

16%

18%

20%

22%

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Protect people from tobacco smoke

18.3%

Warn about the dangers of smoking

17.5%

• 350,000 fewer adult smokers• >100,000 fewer smoking-related deaths

in future years

15%

19.2%Raise taxes on tobacco (City & State)

Monitor adult smoking prevalence

21.5%

18%

Monitor youth smoking

2008

8.5%

16.9%

15.8%

Changing the Places that Touch People’s Lives

Los Angeles, CA Moratorium on fast food

Pinellas County, FLDaycare licensing PE requirement;

PE in schools 5x/week

Pittsburgh, PA Healthy foods in after school care

Addressing health equity through policy, systems, and environmental change

• “We must endeavor to eliminate, so far as possible, the problem elements which make a difference in health among people”

W.E.B Dubois, 1899 The Philadelphia Negro

The root causes of poor health outcomes

Health Care Services are Only One Piece of the Picture ….

Reference: Institute of Medicine. (2003). The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press.Original source: Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies.

Obesity burden inverselycorrelated with income

Obesity Rates in Community X, 2010

Community X’s Draft Community Action Plan

Goal:Establish 8 farm stands toincrease community’s accessto healthy vegetables andfruits

= Farm stand

Farm Stands in Community X’s CAP

Community X’s Revised Community Action Plan

Goal:Establish 15 farm stands

--At least 7 farm stands in low income neighborhoods where obesity burden is greatest

= Farm stand

Farm Stands in Community X’s Revised Community Action Plan

Community X: Ensuring Effectiveness of Revised Community Action Plan

• ADDED ACTIVITIES:

– Enable farm stands to accept food stamp vouchers

– Build community buy-in through targeted media approaches

– Incorporate tracking of program impact of populations with disproportionate burden to monitor and evaluate program success

Prevention Can Be Good for Business Too!Austin, TX

The community leaders helped Capital Metro establish a comprehensive worksite wellness program.

Employee absences decreased 44%

Rising health care costs were rolled back from 27% per year increase to 9% per year

Why now?Communities Putting Prevention to Work

American Recovery and Reinvestment Act February 19, 2009

Congressional Charge:“carry out evidence-based clinical and community-based prevention and wellness strategies that deliver specific, measurable health outcomes that address chronic disease rates.”

Policy, Systems, and Environmental Change Strategies

MAPPS Strategies

Media

Access

Point of Purchase / Promotion

Price

Social Support & Services

Leadership Teams

Healthy Communities, Healthy Living:A National Movement

Within our grasp ……

Message fromThomas R. Frieden, MD, MPH

Director, CDC Administrator, ATSDR