Genuine Progress Index for Atlantic CanadaIndice 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 indicatorsGPI 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 2,400 30%

• 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) Hosp. Doctor Drugs Other

TotalDirect

Premat.Death

Dis-ability

TOTAL

Circulatory 161.6 26.6 63.6 137.8 389.6 326.8 244.4 960.8

Cancer 71.4 11.8 7.5 49.6 140.3 427.2 14.5 582.1

Respiratory 21.6 3.2 16.6 22.7 64.1 43.4 78.1 185.5

Musculoskeletal 55.9 20.3 22.0 53.8 152.0 3.5 307.2 462.8

Endocrine 18.5 7.2 29.3 30.1 85.0 43.8 27.0 155.8

Nervous system 55.3 27.9 19.2 56.0 158.5 30.0 158.6 347.0

Mental 104.2 17.7 39.2 88.2 249.2 16.0 72.3 337.5

TOTAL: 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

PhysicalInactivity 700 $107 $247 $354

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,

obesityPercent of Canadians who believe that low-fat foods are expensive, 1994-95

40

37

34

32

40

25

27

29

31

33

35

37

39

41

lowest low-middle middle upper middle highest

Pe

rce

nt

Overweight- by Education and Age (20-64), Canada, 1997

(%)

30 29

22

15

24

29

3639

36

0

5

10

15

20

25

30

35

40

45

Pe

rce

nt

Obesity Trends* Among U.S. Adults, 1985Source: 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%

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

Obesity Trends Among U.S. Adults2002

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%

1995

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1995, 2005

(*BMI 30, or about 30 lbs overweight for 5’4” person)

2005

1990

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

Overweight Canadians (BMI = >27),Canada and Provinces, Age 20-64,

(%)Overweight Adults

38.537 37.6

41

26.528.4

34.2 35.3

29.426.4

29

0

5

10

15

20

25

30

35

40

45

Per

cent

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 long-term 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, fat-rich 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 (dose-response 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

24.5

20.7

22.1

22.9

24.7

20.5 20.320.8

19.6

20.7

21.6

15

17

19

21

23

25

27

Canada Nfld PEI NS NB Que Ont Man Sask Alta BC

Ho

urs

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, work-

places 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, high-calorie, 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 : 1991-2000Single 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”. Full-time 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 = +49% than degree Lower income = +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

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%; 2011 = 16%; 2036 = 28%

• 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

InvestmentFor example:

• Workplace = 2:1

• WIC = 3:1

• “Smoke-Free for Life” = 15:1

• Pre-natal counselling = 10:1

Brief physician counselling • Highly effective and cost-

effective. 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 CanadaIndice de progrès véritable - Atlantique

www.gpiatlantic.org