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

2. Communities Putting Prevention to Work Wayne H. Giles, MD, MS Director Division of Adult and Community Health National Center for Chronic Disease Prevention and Health Promotion June 8, 2010 CPPW Action Institute, St. Louis, MO

3. Overview Why focus on chronic disease and underlying risk factors? Why policy, systems, and environmental change strategies? Why now?

4. Leading Causes of Death United States, 2006 Percentage (of all deaths) Heart Disease Cancer Chronic lower respiratory diseases Unintentional Injuries Alzheimer’s disease Diabetes Pneumonia/influenza Kidney Disease Stroke National Center for Health Statistics. Deaths: Final Data for 2006. Hyattsville, MD: US Department of Health and Human Services; 2008.

5. Ten Great Public Health Achievements 1900 - 1999 Vaccination Motor-vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard

6. 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

7. “ 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

8. 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

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

10. Chronic Diseases and Related Risk Factors Leading Causes of Death* United States, 2000 Actual Causes of Death † United States, 2000 Kidney disease 05101520 Tobacco Poor diet/ Physical inactivity Alcohol 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) 05101520253035 * 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.

11. Growing Challenges

12. Healthy Food Has Gotten More Expensive, Junk Food Cheaper Fresh fruits and vegetables Consumer price index Sugar and sweets Carbonated drinks Price Index (1982-84 = 100) Data from Bureau of Labor Statistics; represent U.S. city averages for all urban consumers in January of each year

13. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

14. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19

15. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

16. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

20. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24%

21. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24%

22. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24%

23. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24%

24. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

25. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

26. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

27. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29%

28. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

29. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

30. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

31. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

32. Childhood Obesity is Also Epidemic Prevalence of Obesity Among U.S. Kids Tripled in a Generation (BMI ≥ 95th percentile) Source: CDC, NHANES

34. How to weigh yourself and get the most accurate result. I can’t believe I was doing it wrong all these years

35. Why policy, systems, and environmental change strategies?

36. Largest Impact Smallest Impact Factors that Affect Health Examples 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 Context to make individuals’ default decisions healthy Long-lasting Protective Interventions Clinical Interventions Counseling & Education

37. 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

38. Great Depression End of WW II First Medical reports linking 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 190019101920193019401950196019701980 Year Adult per Capita Cigarette Consumption Environmental and Policy Changes in the US 1900-1990 Nonsmoker’s rights movement begins 1990

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

40. Policy Change: Producing Results - New York City 18.9% 11% % of New York City Smokers 8% 10% 12% 14% 16% 18% 20% 22% 1993 19941995 19961997 19981999 200020012002 2003 200420052006 2007 Protect people from tobacco smoke 18.3% W arn about the dangers of smoking 17.5% 350,000 fewer adult smokers >100,000 fewer smoking-related deaths in future years 15% 19.2% R aise taxes on tobacco (City & State) Monitor adult smoking prevalence 21.5% 18% M onitor youth smoking 2008 8.5% 16.9% 15.8%

41. Changing the Places that Touch People’s Lives Los Angeles, CA Moratorium on fast food Pinellas County, FL Daycare licensing PE requirement; PE in schools 5x/week Pittsburgh, PA Healthy foods in after school care

42. 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

43. The root causes of poor health outcomes

44. 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.

45. Obesity burden inversely correlated with income Obesity Rates in Community X, 2010

46. Community X’s Draft Community Action Plan Goal: Establish 8 farm stands to increase community’s access to healthy vegetables and fruits

47. = Farm stand Farm Stands in Community X’s CAP

48. 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

49. = Farm stand Farm Stands in Community X’s Revised Community Action Plan

50. 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

51. 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

53. Why now? Communities Putting Prevention to Work

54. 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.”

55. Policy, Systems, and Environmental Change Strategies MAPPS Strategies Media Access Point of Purchase / Promotion Price Social Support & Services

56. Leadership Teams

57. Healthy Communities, Healthy Living: A National Movement

58. Within our grasp ……

59. Message from Thomas R. Frieden, MD, MPH Director, CDC Administrator, ATSDR