1. 1 Physical Activity & Tobacco Prevention as the Keys for Health Promotion Mohammad R. Torabi, PhD, MPH, CHES Interim Dean & Chancellor’s Professor School of Health, Physical Education, and Recreation Indiana University – Bloomington

2. 2 Leading Causes of Death Leading Causes of Death Paradigm Shift Paradigm Shift Economics of Prevention Economics of Prevention Actual Causes Actual Causes Opportunities Opportunities Conclusions Conclusions Outline

3. 3 Leading Causes of Death

4. 4 3 Leading Causes of Death, 1900 (Transmissible Diseases) Source: Centers for Disease Control Prevention, National Center for Health Statistics, National Vital Statistics System and unpublished Statistics, National Vital Statistics System and unpublished

5. 5 3 Leading Causes of Death, 2000 (Non-Transmissible Diseases) Source: Minino et al. Deaths: final data for 2000. Natl Vital Stat Rep. 2002; 50:1-120.

6. 6 Top 3 Actual Causes of Death, 2000 (Lifestyle Related) Source: JAMA, March 10, 2004; 291(10): 1238-1246 435,000 400,000 85,000 (Numbers of Death Shown in Red)

7. Mortality rates due to major causes of death, Thailand, 1967-2006

8. 8 Diseases and risk factors among Thai males, 2004 Source: Working Group on Burden of Disease and Risk Factors in Thailand, International Health Policy Programme, 2006.

9. 9 Diseases and risk factors among Thai females, 2006 Source: Working Group on Burden of Disease and Risk Factors in Thailand, International Health Policy Programme, 2006.

10. 10 Joseph A. Califano: (former secretary of the US Department of Health and Human Service) We are killing ourselves by... We are killing ourselves by... You, the individual, can do more for your own health and well being than any doctor, any hospital, any drug, or any exotic medical device. You, the individual, can do more for your own health and well being than any doctor, any hospital, any drug, or any exotic medical device.  our own careless habits,  carelessly polluting the environment, &  permitting harmful social conditions to persist – conditions like poverty, hunger, and ignorance which destroy health.

11. Paradigm Shift

12. Control of infectious disease paralleling the emergence of chronic disease

13. Percentage of causes of disability- adjusted life years (DALY) lost of Thai people by age group, 2004 13 Source: Working Group on Burden of Disease and Risk Factors, Thailand. International Health Policy Programme, 2006.

14. 14 Lifestyle + Health Education/ Promotion + Environment Paradigm Shift Treatment + Quarantine + Hygiene

15. 15 Economics of Prevention

16. 16 Annual Economic & Health Burden of Chronic Disease Disease/ Risk Factors Morbidity (Illness) Mortality (Death) Direct Cost/ Indirect Cost Diabetes 20.8 million200,000$174 billion Heart Disease & Stroke 80 million870,000$448 billion Cancer 1.3 million new cases /year 553,000$219 billion Tobacco 45.3 million adults 438,000$193 billion Obesity/ Physical Activity/ Nutrition 64% of adults are overweight or obese 400,000.$117 billion Source: http://www.cdc.gov/NCCdphp/press/index.htm

17. 17

18. 18 During the Past 30 Years the Percentage of the GDP Consumed by Health Care Doubled

19. 19 The Cost of Health Care Threatens the Ability of the U.S. to Compete Economically with Other Nations

20. 20 Is This a Rational Investment Strategy? Is This a Rational Investment Strategy? Proportion of health expenditure going to the population-wide core functions of public health vs. medical treatment Proportion of health expenditure going to the population-wide core functions of public health vs. medical treatment Proportion of early deaths that could be prevented by population – wide public health approaches vs. medical treatment Proportion of early deaths that could be prevented by population – wide public health approaches vs. medical treatment

21. 21 Actual Causes

22. 22 Major Causes of Morbidity & Mortality #1 Tobacco Use - Cigarette: the Gateway Drug -

23. 23 Dose-Response Relationship Between Cigarette Smoking and Other Drug Use By Indiana Students in Grades 5-12 Source: Torabi et al.

24. 24 Dose-Response Relationship Between Cigarette Smoking and Other Drug Use By Indiana Students in Grades 5-12 Source: Torabi et al.

25. 25 Cigarette Smoking Among US Men, Women, High School Students, and Mothers during Pregnancy, 1965 – 2003 Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group

26. 26 If you are a smoker, your life… Source: MMWR 1997;46:444-51 -13.2 yrs -14.5 yrs

27. 27 If smoking relaxes you, then don’t quit. Being dead is very relaxing.

28. 28 Major Causes of Morbidity & Mortality #2 Overweight/Obesity

29. 29 Obesity Trends Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC

30. 30 Obesity Trends Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC

31. 31 Obesity Trends Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC

32. 32 Obesity Trends Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% ≥20 Source: Behavioral Risk Factor Surveillance System, CDC

33. 33 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) Source: Behavioral Risk Factor Surveillance System, CDC Obesity Trends Among U.S. Adults BRFSS, 2005 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

34. 34 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) Source: Behavioral Risk Factor Surveillance System, CDC Obesity Trends Among U.S. Adults BRFSS, 2009 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

35. 35 Source: National Health and Nutrition Examination Survey, 2004

36. 36 Source: National Health and Nutrition Examination Survey, 2004

37. 37 Why Has Caloric Intake Increased? More food available More food available Cheaper Cheaper Greater variety Greater variety Easier to acquire Easier to acquire Heavily marketed by more effective media Heavily marketed by more effective media More calorie dense foods More calorie dense foods High-fructose corn syrup High-fructose corn syrup Super-sized Super-sized More people who model increased caloric intake More people who model increased caloric intake

38. 38 Why Has Caloric Output Decreased? Fewer occupations require physical labor Fewer occupations require physical labor Fewer physical household chores Fewer physical household chores Less need and opportunities for manual transportation (walking, biking) Less need and opportunities for manual transportation (walking, biking) More attractive sedentary leisure-time activities More attractive sedentary leisure-time activities Less physical education and other physical activity Less physical education and other physical activity More people who model decreased caloric output More people who model decreased caloric output

39. 39 Why does it take six weeks to lose five pounds, but only one day to gain it all back?

40. 40 Major Causes of Morbidity & Mortality #3 Lack of Physical Activity

41. 41 Benefits of Physical Activity Physical activity can lower the risk of: Coronary heart disease Coronary heart disease Stroke Stroke Type II diabetes mellitus Type II diabetes mellitus High blood pressure High blood pressure Colon cancer by 30–50% Colon cancer by 30–50% Active people have lower premature death rates than people who are the least active Active people have lower premature death rates than people who are the least active

42. 42 Adults with 30+ minutes of moderate physical activity 5 or more days per week Source: Behavioral Risk Factor Surveillance System, 2007

43. 43 Adults with 20+ minutes of vigorous physical activity 3 or more days per week Source: Behavioral Risk Factor Surveillance System, 2007

44. Age18-2425-3435-4445-6465+ Recommended59.053.249.646.639.3 Insufficient31.936.939.839.636.9 Inactive9.19.910.713.823.7 No Leisure-Time Physical Activity 18.420.822.324.832.7 2007 National Average: Recommended Physical Activity by Age Source: Centers for Disease Control and Prevention, 2007

45. 45 Opportunities

46. 46 Progress Slowly prevention getting attention of policy makers Slowly prevention getting attention of policy makers Funding for tobacco settlements Funding for tobacco settlements New funding for nutrition and physical activities New funding for nutrition and physical activities

47. 47 Smoking Prevention in Thailand

48. 48 What fits your busy schedule better, exercising one hour a day or being dead 24 hours a day?

49. 49 Conclusions

50. 50 What Does Prevention Do for Us? 10 to 20 years of extended life 10 to 20 years of extended life Improved quality of life Improved quality of life Reduced chronic disease Reduced chronic disease Less medications/hospital visit/surgery Less medications/hospital visit/surgery Postponed disability Postponed disability Save money Save money

51. 51 Recommendations Building infrastructure, Building infrastructure, academic units, academic units, service units, service units, community agencies, community agencies, pilot projects, pilot projects, Providing wellness services Providing wellness services Developing and offering a wellness course as a core course for all students Developing and offering a wellness course as a core course for all students Advancing research Advancing research Leading by examples Leading by examples

52. 52 Ultimately Do not start smoking Do not start smoking If you smoke, quit If you smoke, quit Adopt an active lifestyle Adopt an active lifestyle Limit time spent in front of TV & computer Limit time spent in front of TV & computer Stay intellectually active Stay intellectually active Sleep between 6 to 8 hours a day Sleep between 6 to 8 hours a day Have balanced variety of foods Have balanced variety of foods Reduce stress Reduce stress Count your blessings Count your blessings

53. 53 “It is health that is real wealth and not pieces of gold and silver.” - Mahatma Gandhi

54. 54 Thank You!