Chronic Disease in Ontario and Canada: Determinants, Risk Factors ...

Chronic Disease in Ontario and Canada: Determinants, Risk Factors and Prevention Priorities

Emma Haydon, Michael Roerecke, Norman Giesbrecht, Jürgen Rehm & Marianne Kobus-Matthews

Prepared for the Ontario Chronic Disease Prevention Alliance and the Ontario Public Health Association

March 2006

Acknowledgements

The production of this document was made possible through the financial support of the Public Health Agency of Canada to the Ontario Public Health Association (OPHA). Special thanks to Emma Haydon, Michael Roerecke, Norman Giesbrecht, Jürgen Rehm, Marianne Kobus-Matthew and the Centre for Addiction and Mental Health for the preparation of this document. The Ontario Chronic Disease Prevention Alliance would also like to thank the following individuals for their comments and contributions: Sunny Ba, Elfreda Burkholder, Connie Clement, Erica Di Ruggiero, John Garcia, Dexter Harvey, Tracy Howson, Meera Jain, Marjorie Keast, Mary Lewis, Gregory Taylor and Connie Uetrecht. The views, opinions and policies expressed in this document are those of the authors and do not necessarily reflect the perspectives of the organizations that they are affiliated with nor the Public Health Agency of Canada or the Ontario Public Health Association.

Please address any correspondence to: Ontario Chronic Disease Prevention Association (OCDPA) c/o OPHA 700 Lawrence Ave. W., Ste. 310 Toronto ON M6A 3B4 Or email [email protected]

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TABLE OF CONTENTS FOREWORD............................................................................................................................. VII EXECUTIVE SUMMARY ........................................................................................................ IX 1. CHRONIC DISEASE IN CANADA: DEFINITIONS, EPIDEMIOLOGY AND DISEASE ....................................................................................................................................... 1 1.1 BURDEN OF ILLNESS ........................................................................................................ 1 1.2 ECONOMIC COSTS ............................................................................................................ 8 1.3 EPIDEMIOLOGY OF SELECTED CHRONIC CONDITIONS .................................................... 14 1.3.1 Cancer....................................................................................................................... 15 1.3.2 Cardiovascular Diseases .......................................................................................... 22 1.3.3 Respiratory Disease .................................................................................................. 29 1.3.4 Diabetes .................................................................................................................... 36 1.3.5 Mental Health ........................................................................................................... 42 2. THE SOCIOBEHAVIOURAL RISKS AND DETERMINANTS OF CHRONIC DISEASE ..................................................................................................................................... 47 2.1 DEFINING RISK .............................................................................................................. 47 2.1.1 Risk on the Individual Level and on the Population Level ....................................... 48 2.1.2 Conceptualization of the Sociobehavioural Risks of Chronic Disease..................... 50 2.2 PROXIMAL FACTORS IN CHRONIC DISEASE .................................................................... 53 2.2.1 Physical Inactivity..................................................................................................... 56 2.2.2 Unhealthy Eating ...................................................................................................... 58 2.2.3 Overweight and Obesity............................................................................................ 61 2.2.4 Tobacco Smoking ...................................................................................................... 65 2.2.5 High Blood Pressure................................................................................................. 69 2.2.6 Alcohol ...................................................................................................................... 73 2.2.7 Substance Use ........................................................................................................... 80 2.3 DISTAL FACTORS IN CHRONIC DISEASE: THE SOCIAL ENVIRONMENT ........................... 85 2.3.1 Sociodemographics ................................................................................................... 86 2.3.2 Socioeconomic Status................................................................................................ 87 2.3.3 Social Support Networks – Social Exclusion ............................................................ 97 2.3.4 Physical and Built Environments.............................................................................. 99 2.3.5 The Obesogenic Environment ................................................................................. 102 3.

FRAMEWORKS FOR HEALTH PROMOTION .................................................... 105 3.1 3.2

INDIVIDUAL LEVEL MODELS........................................................................................ 105 COMPREHENSIVE POPULATION LEVEL MODELS .......................................................... 107

4. CHRONIC DISEASE PREVENTION INITIATIVES: DO WE KNOW WHAT WORKS? ................................................................................................................................... 113 4.1 THE IMPLICATIONS OF ROSE’S WORK FOR PREVENTION .............................................. 113 4.2 THE CANADIAN SITUATION OF CHRONIC DISEASE PREVENTION ................................. 114 4.2.1 Canadian Chronic Disease Prevention Programs and Frameworks ..................... 114 4.2.2 The State of Program Evaluation in Canada.......................................................... 119

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4.3 4.4

LESSONS LEARNED FROM TOBACCO CONTROL ............................................................ 122 RECOMMENDED PRACTICES FOR PREVENTING CHRONIC DISEASE ............................... 125

5. RECOMMENDATIONS FOR A COMPREHENSIVE CHRONIC DISEASE PREVENTION FRAMEWORK ............................................................................................. 141 5.1 THE IMPORTANCE OF AN ECOLOGICAL MODEL – SMEDLEY & SYME’S (2000) RECOMMENDATIONS ................................................................................................................ 141 5.2 CHRONIC DISEASE PREVENTION POLICY AND SOCIAL JUSTICE .................................... 143 5.3 RECOMMENDATIONS FOR A COMPREHENSIVE CHRONIC DISEASE PREVENTION FRAMEWORK ........................................................................................................................... 144 6.

CONCLUSION ............................................................................................................. 151

7.

FUTURE CONSIDERATIONS................................................................................... 153

REFERENCES.......................................................................................................................... 155 APPENDIX I: DATA SOURCES AND DEFINITIONS....................................................... 184 NATIONAL POPULATION HOUSEHOLD SURVEY ........................................................................ 186 CANADIAN COMMUNITY HEALTH SURVEY .............................................................................. 186 AGE-STANDARDIZED MORTALITY RATE ................................................................................... 187 AIDS DEATHS .......................................................................................................................... 187 AIDS DEATHS POTENTIAL YEARS OF LIFE LOST (PYLL) ........................................................ 188 ALL DISEASES OF THE CIRCULATORY SYSTEM DEATHS............................................................. 188 ALL DISEASES OF THE RESPIRATORY SYSTEM DEATHS ............................................................. 188 ALL MALIGNANT NEOPLASMS (CANCER) DEATHS..................................................................... 189 ASTHMA................................................................................................................................... 189 BODY MASS INDEX (BMI) ........................................................................................................ 189 CANCER DEATHS POTENTIAL YEARS OF LIFE LOST (PYLL).................................................... 190 CANCER INCIDENCE ................................................................................................................. 190 CIRCULATORY DISEASE DEATHS POTENTIAL YEARS OF LIFE LOST (PYLL) ............................ 191 DEPRESSION ............................................................................................................................. 191 DIABETES................................................................................................................................. 192 DIETARY PRACTICES ................................................................................................................ 192 EXPOSURE TO SECOND-HAND SMOKE AT HOME ........................................................................ 192 FREQUENCY OF HEAVY DRINKING ............................................................................................ 192 HIGH BLOOD PRESSURE ............................................................................................................ 192 INJURIES................................................................................................................................... 193 LIFE EXPECTANCY.................................................................................................................... 193 MENTAL HEALTH AND WELL-BEING ......................................................................................... 193 PHYSICAL ACTIVITY ................................................................................................................. 195 POPULATION ATTRIBUTABLE FRACTION ................................................................................... 196 POTENTIAL YEARS OF LIFE LOST (PYLL) ............................................................................... 196 RESPIRATORY DISEASE DEATHS POTENTIAL YEARS OF LIFE LOST (PYLL) ............................. 197 SMOKING STATUS..................................................................................................................... 197 SUICIDE.................................................................................................................................... 198 SUICIDE POTENTIAL YEARS OF LIFE LOST (PYLL).................................................................. 198 TOTAL MORTALITY .................................................................................................................. 198

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TOTAL MORTALITY POTENTIAL YEARS OF LIFE LOST (PYLL) ................................................ 198 UNINTENTIONAL INJURY DEATHS ............................................................................................. 199 UNINTENTIONAL INJURY DEATHS POTENTIAL YEARS OF LIFE LOST (PYLL)........................... 199 APPENDIX II: CRUDE DATA TABLES .............................................................................. 200 APPENDIX III: TARGETS FOR CANCER 2020 – CANCER PREVENTION & CONTROL ................................................................................................................................ 209 APPENDIX IV: CANADA’S FOOD GUIDE AND CANADA’S GUIDE TO ACTIVE LIVING...................................................................................................................................... 210 APPENDIX V: CHRONIC DISEASE FRAMEWORK BY MILLS (2003) ....................... 212

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FOREWORD This report was commissioned by the Ontario Chronic Disease Prevention Alliance (OCDPA) in order to provide an epidemiological and conceptual context for current work of this group. The activities of OCDPA include, but are not limited to, developing an updated overview of partner activities and opportunities for inter-NGO collaborations, and developing a strategic plan. OCDPA and its members are also involved in on-going liaison and collaboration with provincial and national level government groups, and NGO committees focused on chronic disease prevention, healthy living initiatives and specific risk factors. The production of the report was funded by the Public Health Agency of Canada, via the Ontario Public Health Association. In kind support was received from the Centre for Addiction and Mental Health, which is the institute of primary affiliation of the authors when the draft was prepared. An earlier draft of our report was presented to members of the OCDPA Core Group, and feedback has been gratefully received by members of this group, as well as from other colleagues with expertise in chronic disease prevention, specific risk factors, and social determinants of health. The purpose of the report is multi-dimensional: •

A primary goal is to draw links between evidence, determinants, and risk factors of chronic disease in Canada, and consider options for health messages and action steps.

•

The report is also designed to inform “best practices” by providing an overview of available evidence.

•

The report is expected to provide a basis for communicating and marketing of OCDPA, as well as to be used as a resource by this group for internal purposes and external contacts.

•

The report is expected to help form an advocacy strategy for OCDPA and to serve as a resource to opening policy windows.

•

Finally, it is hoped that this document will provide a resource for other provincial, territorial and national alliances and groups focusing on chronic disease prevention. The scope of the report includes national and international research. We include

epidemiological data for Canada and the province of Ontario. While there would be clear

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benefits to include data for the other provinces and territories, this was beyond the scope and timetable of this project. The structure of the report is that it first provides an overview of the epidemiology of chronic disease. The second section details the sociobehavioural risks of chronic disease. Sections three and four examine frameworks for prevention and evaluations. The final sections offers several recommendations and outline future considerations. At this stage the recommendations should be seen as “open-ended”, serving as a basis for refinement, elaboration and discussion. One of the unique features of this report is that it also examines risk factors that are overlooked, neglected or downplayed in some recent analyses or promotional initiatives pertaining to chronic disease in Canada. Alcohol, other drugs and mental illness are considered in the following pages and their relative impact on chronic disease examined. This provides a resource for closing the disjunction between the “informally approved” and “popular” risk factors in many Canadian initiatives, and the more comprehensive approach to risk factors highlighted in the global burden of disease analysis by the World Health Organization (WHO) (http://www.who.int/whr/2002/en/). The report also outlines costs estimates and economic burden related to chronic disease in Canada. This document is intended for a wide audience. The original audience is the current members of OCDPA and also its potential members. It is hoped that the report will also be of interest to federal/provincial/territorial associations focusing on chronic disease prevention. It is expected that funders and policy makers might be interested in the themes and content provided. Last, but not least, partners in health care, industry, and other sectors are also an intended audience for this document.

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EXECUTIVE SUMMARY Chronic disease is a major concern in Canada and worldwide, accounting for substantial burden of illness related to both morbidity and mortality. Cancer, cardiovascular disease (CVD), respiratory illnesses, genitourinary diseases, and diabetes are the major non-communicable chronic diseases in Canada. Communicable chronic diseases, such as hepatitis C and HIV, have their impact on the burden of illness as well, while chronic mental illnesses are often neglected, even though they contribute as a major cause of morbidity in Canadian society. Both communicable and non-communicable chronic diseases result in substantial economic expenditures. This report examines the risk factors of chronic disease, the Canadian situation regarding chronic disease prevention, and recommended practices in chronic disease prevention, and makes a number of recommendations that may be useful for directing future initiatives in chronic disease. Chronic disease can no longer be explained only as an outcome based on engaging in the “wrong” health behaviours. There is a need to look beyond individual responsibility to understand the ways in which the social environment shapes the decisions we make and the behaviours we engage in. Chronic disease can be conceptualized within a web of causation, with proximal (direct) and distal (indirect) factors all playing a role. One chronic disease outcome can be the result of multiple risk factors interacting in a multitude of ways, and one particular risk factor can affect multiple chronic disease outcomes, and general susceptibility to negative health outcomes. While the causes of particular cases of chronic disease in individuals can be assessed in the clinical context – and are often linked to behavioural factors – the causes of incidence in the population at large may be different. It is within the social environment where the most promise for understanding how chronic disease develops may lie, and may provide the best opportunity for prevention interventions. The proximal risk factors of chronic disease development that are the main considerations in the current literature are physical inactivity, poor diet, and tobacco smoking. All of these risk factors contribute substantially to the disease burden of cancer, CVD, and respiratory illness, among others. In the report, we also draw attention to more neglected proximal risk factors, specifically alcohol use and other substance use.

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The research methodologies for studying the role of distal factors have been less consistent and less sophisticated (because of the difficulties in the application of “gold standard” research methodologies), and thus have not allowed for the evidence of these factors to be as strong as those considered proximal. This does not mean, however, that distal social environmental factors should be ignored. Rather, it points to the need to understand these factors more, especially due to their operation on the population level – thus affecting many Canadians. Sociodemographics, socioeconomic status, social relationships, and components of the physical and built environments have all been implicated in the development of chronic disease. As the understanding of the risk factors involved in chronic disease has focused on individual level factors, so too have the models of prevention. It is quite recent that the population health approach has been advocated in the Canadian context, and this approach now feeds the majority of strategic frameworks. However, there has been a disjuncture in the overarching direction of population health in guiding frameworks and strategies with the actual implementation of programs. The programs that have been implemented in Canada and abroad, and from which we can derive recommended practices, continue to be primarily focused on the individual level. While we acknowledge that individual behavioural change is the goal of chronic disease prevention, there is a need to change the “point of attack” and incorporate the rhetoric of population health into action in chronic disease prevention. The experiences in tobacco use prevention, and to some extent alcohol use prevention, through the comprehensive tactics of both clinical interventions and policy initiatives (involving regulation, taxation, point of decision interventions, and access limitations) can serve as important lessons to the development of larger comprehensive strategies to address chronic disease and health in general. Based on a review of the existing literature on chronic disease risk and current interventions, we propose a comprehensive model of chronic disease prevention which suggests that chronic disease prevention should occur within an ecological model, which takes account of both the individual and population. We argue for the incorporation of multiple determinants of health over the life course, social justice, integration, capacity-building, the use of best practices (but without automatically discounting those interventions that currently lack evidence), more research into the social environment, and flexibility in approach. Chronic disease prevention should involve multiple stakeholders, multiple levels of intervention, multiple media, multiple strategies, and ongoing development, research, surveillance, and capacity-building.

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1. CHRONIC DISEASE IN CANADA: DEFINITIONS, EPIDEMIOLOGY AND DISEASE There is a growing interest in chronic disease prevention in Canada and a number of other countries (e.g., Centre for Chronic Disease Prevention and Control and Public Health Agency of Canada, 2005). Chronic disease results in substantial burden of illness for the population of Canada overall, contributing to morbidity, mortality, and economic costs. This chapter provides the epidemiological context for the rest of the report. This information offers a context for evidence-based interventions and policies, informs best practices, and provides a baseline for tracking current and future initiatives. Understanding the prevalence and incidence of chronic disease and related risk factors is critical to contextualize the range of actions with the potential to reduce the health, economic, and social burdens that all Canadians bear. The burden of illness is examined for Canada and Ontario, using age-standardized mortality or prevalence rates where possible. Crude prevalence rates by sex can be found in the Appendix. A number of chronic conditions are considered, such as cardiovascular disease (CVD), cancers, respiratory disease, diabetes, genitourinary diseases, and mental illness. 1 Also, economic costs are examined in connection with the major chronic diseases. 1.1

Burden of Illness The leading causes of death in Canada are, like in most developed countries, chronic

diseases such as CVD, cancer, respiratory diseases, cancers, diabetes, and genitourinary diseases. The US Centers for Disease Control and Prevention (CDCP) define chronic disease broadly as “illnesses that are prolonged, do not resolve spontaneously and are rarely cured completely” (see http://www.cdc.gov). In this report, mortality and morbidity, as well as the age-standardized mortality or prevalence rate is reported. This gives the opportunity to separate population growth, aging of the population and changes in the rates a disease or risk factor (individual) or risk condition

1

This is not an exhaustive list. Other diseases that might be considered are arthritis, hypertension, osteoporosis, and obesity.

1

(societal) that occur in the population. For example, regarding cancer, the increase in total number of incidence and mortality is caused by a shift in the distribution of the population (more elderly and growing overall population), rather than an increase in age-standardized rates. By adjusting prevalence and incidence for age, the effect of differences in age composition of a population over time is minimized. When considering the burden of mortality and morbidity of a chronic disease in the future, one has to consider that without any intervention, the burden caused by any risk factor that is rising or has been increasing in the past will continue to increase. This is the case for obesity, alcohol consumption, and high blood pressure in particular. The most recent data 2 on causes of deaths in Canada are available for 2002, provided by Statistics Canada. In 2002, there were a total of 223,603 deaths in Canada, of which 113,266 (50.6%) were men and 110,337 (49.4%) were women (Statistics Canada, Mortality Files). According to the Death Database, of the total 223,603 deaths, CVDs account for 33.4% (74,626), 29.1% (65,102) were cancer deaths, 7.9% (17,761) were caused by respiratory diseases, 3.5% (7,868) by diabetes mellitus, and 2.0% (4,529) by genitourinary diseases. Figure 1 shows the increase in deaths from 1980 to 2004. The total number of deaths has increased steadily for both Canada and Ontario. The increase from 1980 to 2004 for Ontario was greater than the increase for Canada, with 41.4% and 36.8%, respectively. This steeper rise in part reflects a greater increase in total population for Ontario compared to Canada as a whole. In recent years, we saw an accelerated increase in deaths in Canada and Ontario. In 2001 the total number rose by 0.7% (1,476), then by 1.9% (4,065) in 2002, 1.6% (3,682) in 2003, and 3.2% (7,308) in 2004.

2

Please see Appendix I for more information about data and methods.

2

Figure 1: Total Number of Deaths, Canada and Ontario, 1980 – 2004

Canada Ontario

250,000

Deaths

200,000

150,000

100,000

50,000

04 20 03 20 02 20 01 20 00 20 9 9 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19 83 19 82 19 81 19 80 19

Year

Sources: Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada; Statistics Canada.

Although the number of deaths increased steadily over the last decades due to shifts in the distribution of the population, the age-standardized mortality rates for both men and women showed a decline over the same period (Figure 2). Figure 2: Age-Standardized Mortality Rate (Canada 1991) for All Causes, Canada, by Sex, 1984-2001 Sex

1,200

Both Males Females

Rate per 100,000

1,000

800

600

400

200

0

01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19

Year Sources: Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada; Statistics Canada.

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Figure 3 shows the age-standardized mortality rate for both sexes by disease category. As can be seen, CVDs showed a steady decline, whereas cancer and COPD remained steady over the same period. Diabetes shows an increase in recent years. In the following chapters these rates will be explained further, taking also into account sex differences, which is important for cancer and COPD in particular. Figure 3: Age-Standardized Mortality Rate (Canada 1991) For Selected Causes, Both Sexes, 1984-2001

Neoplasms Circulatory Disease Chronic Obstructive Lung Disease Diabetes

400

Rate per 100,000

300

200

100

0

01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19


CVD is the greatest single cause of death, disability, and illness in Canada (see Figure 4). The break-down of the CVD category for both sexes combined for all ages for 2002 shows ischaemic heart disease (IHD) accounted for 54.4% of all deaths attributable to CVD, followed by cerebrovascular disease 20.7%, heart failure 6.1%, and aortic aneurysm with 2.6%. All other CVD accounted for 16.2% of all CVD deaths in 2002. Cancers (malignant neoplasms) were responsible for 29.1% of all deaths. Among cancer deaths, lung cancer has been the largest contributor to total mortality caused by cancer for

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several years (26.4% of all cancer deaths in 2002), followed by female breast cancer (15.4%), colorectal cancer (10.8%), prostate cancer (5.9%), and pancreas cancer (4.9%). Respiratory diseases (non-lung cancer) accounted for 7.9% of all deaths in 2002. The majority (53.2%) of all respiratory disease deaths were related to chronic obstructive pulmonary disease (COPD). Influenza and pneumonia were the cause in 26.6% of all respiratory disease related deaths. Figure 4: Number of Deaths by Selected Causes, Canada, 2002

Cardiovascular Diseases

74,626

Cancers (malignant neoplasms)

65,102

Cause of Death

Respiratoy Diseases

17,761

Unintentional Injuries

9,050

Diabetes

7,868

Genito-urinary Diseases

4,529

Suicide

3,650

Other Causes

40,923

0

20,000

40,000

60,000

80,000

Number of Deaths

Note: Source:

Coded according to the International Classification of Diseases version 10 (ICD-10). Statistics Canada, Mortality Files.

Table 1 shows that cancer is the leading disease in terms of potential years of life lost (PYLL), followed by CVDs, unintentional injuries, and respiratory diseases. Among cancers, lung cancer is responsible for the majority of PYLL due to cancer, a fact that is also reflected also in prevalence and incidence rates. Lung and colorectal cancer show sex differences with more PYLL among men than women. Among gender specific cancers, breast cancer is more common and costs 334.5 PYLL per 100,000 population, while prostate cancer is responsible for 56.6 PYLL per 100,000 population. Also, CVDs cost more PYLL among men than women in all sub categories. The rate of ischaemic heart disease in men is more than three-fold of that for

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women. Respiratory disease rates show the same general pattern as in the other categories, but sex differences are not as pronounced. For men who were born in 2002 the life expectancy rose to 77.2 years (up 0.2 years from 2001) whereas the life expectancy for women remained stable at 82.1 years (unchanged compared to 2001). The life expectancy of men at age 65 was 17.2 years in 2002, while women aged 65 could expect to live an additional 20.6 years. Compared to 2001, only male seniors saw an increase of 0.1 years, while the life expectancy of female seniors did not rise.

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Table 1: Potential Years of Life Lost (PYLL,) Number and Rate per 100,000 Population, by Sex, Canada, 2001 PYLL Condition

All malignant neoplasms (cancers)

Total Rate per 100,000

Men Rate per 100,000

Number

Women Rate per 100,000

Number

Number

1,574.0

460,535

1,604.7

235,871

1543.0

224,664

Colorectal cancer

138.2

40,423

160.8

23,630

115.3

16,793

Lung cancer

403.5

118,061

453.0

66,588

353.5

51,473

Prostate cancer

-

-

56.6

8,323

-

-

Breast cancer

-

-

-

-

334.5

48,703

Circulatory diseases

853.7

249,773

1195.1

175,668

508.9

74,104

Ischaemic heart diseases

507.1

148,360

783.2

115,115

228.3

33,245

Cerebrovascular diseases

216.3

63,302

269.9

39,675

162.3

23,627

All other circulatory diseases

130.2

38,091

141.9

20,859

118.3

17,232

Respiratory diseases (excluding infectious and parasitic diseases)

162.0

47,408

185.4

27,248

138.5

20,161

Pneumonia and influenza

38.5

11,268

45.9

6,749

31.0

4,519

Bronchitis, emphysema and asthma

20.1

5,877

21.0

3,088

19.2

2,789

All other respiratory diseases

103.3

30,213

118.1

17,362

88.3

12,851

Unintentional injuries

639.9

187,216

942.7

138,562

334.1

48,654

Suicides and self-inflicted injuries

393.5

115,130

610.2

89,683

174.8

25,447

Human immunodeficiency virus (HIV) infection

46.4

13,572

76.7

11,279

15.7

2,293

5,101.5

1,492,644

6,328.5

930,201

3,862.8

562,443

Total, all causes of death Source:

Statistics Canada, Canadian Vital Statistics, Death Database, and Demography Division (population estimates)

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As indicated above, there has been an increase in deaths in Canada between 1980 and 2004, partly reflecting changes in the population. However, the age-standardized mortality rates show a decline for both sexes over this period. The greatest single cause of death among Canadians is CVD, followed by cancer. With regard to potential years of life lost cancer is the leading disease in Canada.

1.2

Economic Costs Costs can be measured in many ways and include direct health care costs, indirect health

care costs, and losses in productivity. Not all of these costs were included in the studies mentioned in this report and therefore comparability is limited. In 2002, Health Canada published a report containing estimates of economic costs of illness using an opportunity approach estimating the gain for society if the illness or disease would be eliminated in Canada for 1998 (Health Canada, 2002a). The overall costs of illness were estimated to be $159.4 billion in 1998, of which $83.9 billion were in direct costs, and $75.5 billion in indirect costs consisting of productivity losses due to premature mortality and losses due to disability (short-term and long-term). Direct costs included payments and resources used for treatment, care, and rehabilitation. Figure 5 shows the proportion of each cost component of the total costs. Hospital care contributed 17.3% to the total direct costs ($27.6 billion), drug expenditures 7.8% ($12.4 billion), and physician care 7.3% ($11.7 billion). Among the indirect costs, mortality costs were estimated at 33.5 billion (21.0% of indirect costs), long-term disability at $32.2 billion (20.2%), and short-term disability at $9.8 billion (6.2%). Mortality costs were estimated using an incidence-based human capital approach mostly used in cost-of-illness studies, where the future costs due to present deaths are incorporated in the estimates (Health Canada, 2002a). CVDs, mental disorders, digestive diseases, respiratory diseases, injuries, and nervous system and sense organ diseases were responsible for more than 50% of the direct costs of illness in Canada. Musculoskeletal diseases, cancer, CVDs, and injuries contributed over 60% to the indirect costs in 1998 (Figure 6 and Table 2). Figure 6 provides an overview of total economic costs by diagnosis category from 1986 to 1998 in 1998 dollars. The total economic costs rose from $135 billion in 1986 to $167 billion in 1993 and then declined to $159 billion in 1998.

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Table 2 gives an overview of direct and indirect costs of illness for selected chronic diseases in Canada. CVDs have one of the biggest shares of both direct and indirect costs. Mental disorders rank second among direct costs, but seventh among indirect costs. It should be noted that $41.7 million of psychiatric hospital costs (3.8% of the psychiatric hospital expenditures) were attributed to injuries and not mental disorders. Figure 5: Percentage of Total Economic Costs by Category, Canada, 1998 (Total $159.4 billion)

60

50

Percent

40

30

20

10

0 Direct Costs

Hospital Care

Drug

Physician Care

Care in Other Institutions

Indirect Costs

Mortality

Morbidity Morbidity (long-term) (short-term)

Cost Category

Note: Source:

Percentages of hospital care, drugs, physician care, care in other institutions were among all direct costs; mortality and morbidity costs (long – and short-term) were among all indirect costs. Health Canada, Economic Burden of Illness in Canada, 1998.

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Figure 6: Economic Costs for Selected Diagnosis Categories in Canada, 1986, 1993, 1998 (in 1998 $1,000,000) Diagnosis

25,000

Cancer CVD Mental Disorders Respiratory Diseases

Costs in $1,000,000

20,000

15,000

10,000

5,000

0 1986

1993

1998

Year Source:

Health Canada, Economic Burden of Illness in Canada, 1998.

Table 2: Direct and Indirect Costs by Diagnosis Category, 1998 Costs Direct

Diagnosis Category

Cancer Cardiovascular Diseases Digestive Diseases Genitourinary Diseases Injuries Mental Disorders Musculoskeletal Diseases Nervous System/Sense Organ Diseases Respiratory Diseases Source:

Indirect

% (direct costs)

Costs ($ million)

% (indirect costs)

Costs ($ million)

2.9

2,462

15.6

11,758

8.1

6,818

15.4

11,654

4.2

3,540

3.1

2,314

3.1

2,597

1.2

916

3.8 5.6

3,224 4,680

12.6 4.2

9,512 3,190

3.2

2,648

18.2

13,732

3.4

2,822

7.3

5,478

4.1

3,461

6.7

5,069


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On the other hand, the majority of indirect costs were attributed to only four disease categories, namely cancer, CVDs, injuries, and musculoskeletal diseases. The distribution of costs varies considerably by sex and age group. Men account for almost twice as much mortality costs as women. The population aged 65 and over account for 30% of total costs, whereas they make up 12.7% of the population. Among those 65 and over, hospital expenditures accounted for the highest amount of costs ($10.2 billion or 36.9%). Direct health care costs included hospital, physician care, and drug expenditures. Among hospital expenditures, CVDs were the category with the highest costs, followed by mental disorders, injuries, digestive diseases, and cancer. Mental disorders, genitourinary diseases and digestive diseases, as well as injuries, had much higher hospital costs in the 15 – 34 year age group than CVDs or cancer, which had more hospitalizations among people 35 years and older. CVDs lead the percentage of costs in every category. In terms of indirect costs, cancer (31.7%), CVDs (24.6%), and injuries (17.7%) had by far the greatest impact on economic costs of illness in Canada in 1998. In all categories of premature mortality, women had lower costs than men, with injuries and CVDs showing the largest differences. Tables 3 through 7 show the percentage and monetary expenditures by selected diagnosis category for 1998 (direct and indirect costs). Indirect costs constitute mortality and disability costs (long-term and short-term). CVDs are the major cause for indirect and direct costs in Canada, except for mortality costs, where cancer is the leading category, and short-term disability, where respiratory diseases lead among chronic diseases. The majority of economic costs of CVD come from hospitalization expenditures. CVD also leads the costs by diagnosis category among hospital expenditures and morbidity costs. Among hospitalization costs due to CVDs, hypertension accounts for almost half of the costs ($880.0 million) and ischaemic heart diseases for $512.7 million. Among mental disorders, depression has the largest share of drug costs with $252.7 million. Table 3 lists drug expenditures in Canada in 1998 by selected diagnosis category. Cancer has a share of only 1.7% of drug expenditures, while it is responsible for 31.7% of mortality costs in Canada. Though mental disorders account for 1.7% of mortality costs, they are responsible for 7.0% of long-term disability and 4.7% of short-term disability costs. They lead the physician care costs by category with 7.6%.

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Table 3: Drug Expenditures by Selected Diagnosis Categories, Canada, 1998 Drug Costs Diagnosis Category Cardiovascular Diseases

% (of drug costs)

Costs ($million)

14.3

1,773

Respiratory Diseases

8.9

1,110

Mental Disorders

8.8

1,093

Genito-urinary Diseases

2.6

323

Cancer

1.7

210

Source:


Table 4: Hospital Care Expenditures by Selected Diagnosis Categories, Canada, 1998 Hospital Care Costs Diagnosis Category Cardiovascular Diseases

% (of hospital care costs)

Costs ($million)

15.1

4,162

Mental Disorders

9.7

2,683

Cancer

6.7

1,839


5.6

1,561

Diabetes

0.7

204

Source:


Table 5: Physician Care Expenditures by Selected Diagnosis Categories, Canada, 1998 Physician Care Costs Diagnosis Category

% (of physician care costs)

Costs ($million)

Mental Disorders

7.6

885


7.0

822


6.6

777

Cancer

2.9

333

Source:


12

Table 6: Mortality Costs by Selected Diagnosis Categories, Canada, 1998 Mortality Costs Diagnosis Category

% (of mortality costs)

Costs ($million)

Cancer

31.7

10,622


24.6

8,250


4.9

1,647

Mental Disorders

1.4

480

Source:


Table 7: Morbidity Costs by Selected Diagnosis Categories, Canada, 1998 Morbidity Costs Long-term Diagnosis Category

Short-term

% (of morbidity costs)

Costs ($million)

% (of morbidity costs)

Costs ($million)


9.8

3,152

2.6

253

Mental Disorders

7.0

2,247

4.7

464


3.1

985

24.8

2,438

Cancer

3.0

962

1.8

174

Source:


Using prevalence data from the 2000/2001 CCHS cycle and population attributable fractions derived from a meta-analysis, Katzmarzyk and Janssen (2004) estimated the direct and indirect costs of physical inactivity and obesity for Canada. Cost estimates were derived using data from Health Canada’s 2002 report Economic Burden of Illness in Canada 1998. They estimated the total economic costs attributable to physical inactivity at $5,310 million, of which $1,619 million were for direct costs and $3,690 million for indirect costs. It has to be noted though, that these estimates do not include costs for mental illness, depression in particular. It has been suggested that sedentary Canadians are 60% more likely to suffer from depression than active Canadians (Chen & Millar, 1999). Regarding obesity, total economic costs were estimated to be $4,341 million, of which $2,743 million were indirect costs and $1,598 million were direct costs. In comparison, estimates for economic costs as a result of alcohol and tobacco consumption from 1992 were

13

$7,522 million total economic costs for alcohol use, $9,559 for tobacco use, and $1,371 million for illicit drug use. The estimates for alcohol and illicit drugs include $1,359 and $400 million, respectively for law enforcement (Single, Robson, Xie, & Rehm, 1998). In general, economic cost estimates should be handled with caution due to methodological differences across studies and availability of specific data. More detailed information on costs regarding risk factors and chronic diseases, where available, can be found in the respective sections on each risk factor or disease. It is difficult to pinpoint exact cost savings that might be gained from specific percent reductions in smoking, physical inactivity or body mass index units. The evidence presented, however, clearly indicates that there could be significant reductions in the burden of morbidity, mortality, and/or economic costs, as a result of changes in one or more of the risk behaviours. While there are number of costs estimates of illness, the picture is still far from complete. The 1998 estimate of about 160 billion for illness (direct and indirect costs) is now a significant under-estimation. CVDs contribute to a large share of both direct and indirect costs, followed by cancers, injuries and muskulosketal diseases. Generally, women have fewer costs than men do, with the largest differences with regard to injuries and CVDs. There have been some initiatives to assign and estimate costs by major risk factors.

1.3

Epidemiology of Selected Chronic Conditions Incidence, where available, and prevalence rates for major chronic diseases, namely

CVD, diabetes, respiratory diseases, and mental health status, come from national hospitalization reports and large population surveys, such as the National Population Health Survey (NPHS) until 1999 and the Canadian Community Health Survey (CCHS) since 2000. Caution must be exercised when looking at NPHS and CCHS data, as they are based on self-reported information. There are limitations also to information from national hospitalization reports, as the data reflect the number of episodes, (event-based), rather than the number of patients (person-based). However, both population surveys may result in a significant underestimation of the problem as they exclude certain parts of the Canadian population, such as people living on Native reserves, members of the Canadian Forces, and people living in institutions (e.g., prisons, hospitals). In

14

addition, because prevalence of CVD, diabetes and asthma are based on self-reports of physician diagnoses, they also likely represent underestimates. All of these chronic conditions have risk factors - proximal and distal - that can be changed through lifestyle, environmental, or societal modifications. Thus, many of these conditions are likely preventable and modifiable. Higher incidence and prevalence rates might be due to more people actually having a disease or condition, better diagnosis or treatment so people with a condition live longer, or due to earlier detection. Nevertheless, these rates give important information on health service demands, needed prevention efforts and treatment in a population. 1.3.1

Cancer Cancer is one of the leading causes of death in Canada, and estimates indicate that one-

third of Canadians will be directly affected by the disease at least once in their lifetime. Statistics Canada data show an increase in the number of new cases in the last decade accompanying an aging population, as half of all new cases of cancer occur after the age of sixtyfive. Age-standardized incidence rates have remained relatively stable. Estimates from the Canadian Cancer Statistics 2005 report (Canadian Cancer Society, 2005) show that in 2005, approximately 149,000 new cases of cancer will occur, 76,200 of these will be men, while 72,800 will be women. Men will therefore continue to outnumber women in both, incidence and deaths from cancer. Men will have a 4.7% higher incidence and an 11.9% higher mortality in 2005. These numbers are down from 2001, where the differences were 4.8% and 12.7%, respectively. Three types of cancer account for at least half of the new cases in each sex: prostate, lung and colorectal cancers in males; and breast, lung and colorectal cancers in females. The incidence of these sex-related cancers among women continues to rise. Estimates for 2005 show breast cancer incidence at 21,600 new cases, lung cancer at 10,200 new cases, and 9,000 new cases for colorectal cancer. The 2005 estimates for Canadian men indicate that prostate cancer will continue as the leading form of cancer incidence, with an estimated 20,500 newly diagnosed prostate cases as compared with 12,000 lung cancer cases. Deaths from lung cancer however, are predicted to exceed the deaths due to prostate cancer in men in 2005 (10,700 to 4,300

15

respectively). The number of lung cancer cases (both sexes combined) is greater than the number of either prostate or breast cancer. Personal risk factors for cancer include tobacco use, unhealthy eating, excess body weight, physical inactivity, over-exposure to UV-rays, and alcohol consumption (Table 8). Tobacco is estimated to be responsible for about 30% of mortality and incidence of all cancers. It increases the risk of several cancers, including bladder, cervix, colorectal, esophagus, kidney, larynx, lung, oral, and pancreas. Advances in tobacco control have reduced the burden of disease due to tobacco exposure over past years. Incidence and mortality rates for lung cancer in men have been declining (see Figures 8 & 10). For women, lung cancer rates for both incidence and mortality are still rising and have not yet peaked (see Figures 7 & 9). Table 8: Modifiable Risk Factors and Potential Cancer Risk Reductions Cancer Risk Reduction Benefit Bladder Breast Cervix Colorectal Esophagus Kidney Larynx Lung Oral Pancreas Prostate Skin Stomach Uterus (excluding cervix)

Risk Factor Modification Avoid Tobacco

Be Physically Active

Maintain a Healthy Weight

× × × × × × × × ×

×

×

×

× × ×

Eat Healthy Diet

Limit Alcohol

× ×

×

× ×

× ×

× × × × ×

× ×

Avoid Excess Sun Exposure

×

× ×

× ×

Note: Taken from Canadian Cancer Society/National Cancer Institute of Canada, Canadian Cancer Statistics 2005, Toronto, Canada, 2005. Adapted from Stein & Colditz (2004) and Curry, Byers, & Hewitt (2003)

It is estimated that incidence of between 20-30% of cancers of the breast, colon, esophagus, kidney, and uterus are attributable to excess body weight and physical inactivity

16

(Vainio & Bianchini, 2002). Healthy eating, physical activity and healthy body mass have an estimated potential to decrease cancer incidence by 30-40%. Unhealthy eating is primarily related to cancer of the bladder, lung, oral cavity, pancreas, prostate, and stomach, but other cancers such as breast, colorectal, and endometrial are also affected by diet. Daily diets high in vegetables and fruits are estimated to reduce incidence for all cancers by 20% (World Cancer Research Fund and the American Institute for Cancer Research, 1997). The estimates for reduction in burden of cancer of breast cancer range from 33% to 55%, for prostate cancer from 10% – 20%, and from 66% to 75% for colorectal cancer (Young & Le Leu, 2002). Age-standardized mortality and incidence rates are stable or declining for all major cancer sites since 1988, except for lung cancer in women (both incidence and mortality are rising) and for prostate cancer among men (incidence rate). In 2002, 178.2 cancer deaths per 100,000 population occurred in Canada. However, the actual number of deaths increased by 2.1% from 2001. The increase in number of deaths due to cancer is mostly due to an increasing and aging population in Canada. Table 9 shows incidence and mortality for selected cancers. The age-specific incidence and mortality rate remain low until the age of 40 and then increase rapidly after that age for both sexes, but more for men than for women (Canadian Cancer Society, 2005). In total, 44% of incidence and 60% of mortality is attributable to cancer among 70+ year olds. Based on current estimates, 24% of women and 29% of men alive today will die from cancer in Canada (Health Canada, 2005a).

17

Figure 7: Age-Standardized Mortality Rate (Canada 1991) for Selected Cancer Sites, Females, Canada 19842001 Colorectal Cancer Lung Cancer Breast Cancer

100

Rate per 100,000

80

60

40

20

0

01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19


Figure 8: Age-Standardized Mortality Rate (Canada 1991) for Selected Cancer Sites, Males, Canada, 19842001

Colorectal Cancer Lung Cancer Prostate Cancer

100

Rate per 100,000

80

60

40

20

0

01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19


18

Figure 9: Age-Standardized Incidence Rates for Selected Cancer Sites over Time, Females, Canada, 19922005 Cancer Site

150

Lung Colorectal Breast

Rate per 100,000

120

90

60

30

0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002** 2003* 2004* 2005*

Year

Note:

Rates exclude non-melanoma skin cancer (basal and squamous) and are standardized to the age distribution of the 1991 Canadian population. * Estimated rates ** For 2002 Quebec incidence is estimated. Source: Canadian Cancer Society/National Cancer Institute of Canada, Canadian Cancer Statistics 2005, Toronto, Canada, 2005.

Figure 10: Age-Standardized Incidence Rates for Selected Cancer Sites over Time, Males, Canada, 1992-2005 Cancer Site

150

Lung Colorectal Prostate

Rate per 100,000

120

90

60

30

0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002** 2003* 2004* 2005*

Year Note:

Source:

Rates exclude non-melanoma skin cancer (basal and squamous) and are standardized to the age distribution of the 1991 Canadian population. * Estimated rates ** For 2002 Quebec incidence is estimated. Canadian Cancer Society/National Cancer Institute of Canada, Canadian Cancer Statistics 2005, Toronto, Canada, 2005.

19

Table 9: Estimated Age-Standardized Mortality and Incidence Rates and Number of Deaths and New Cases for Selected Cancer Sites, by Sex, Canada, 2005 Mortality Rate per 100,000

Cancer site

M All Cancers

Incidence Rate per 100,00

Deaths

F

M

F

M

New Cases F

M

F

219.0

149.4

36,700

32,800

448.2

354.5

76,200

72,800

Lung

63.4

39.6

10,700

8,300

70.8

49.3

12,000

10,200

Colorectal

26.8

16.9

4,500

3,900

62.1

41.4

10,600

9,000

-

24.0

-

5,300

-

105.8

-

21,600

26.4

-

4,300

-

121.2

-

20,500

-

Breast Prostate Source:

Canadian Cancer Society/National Cancer Institute of Canada, Canadian Cancer Statistics 2005, Toronto, Canada, 2005.

For Ontario, the number of new cases of cancer is estimated to be 56,200 in total, of these 28,500 will be men, and 27,700 will be women. Death due to cancer shows the same pattern for Canada as a whole, with more men (13,300) compared to women (12,300) dying from cancer. Estimates for Ontario show that the leading cancer for incidence among men is prostate cancer at 8,300 new cases in 2005, followed by colorectal cancer at 4,000 new cases, and lung caner at 3,900 new cases. Among women, the leading cause is breast cancer at 8,200 new cases, followed by lung cancer at 3,600 new cases, and close behind, colorectal cancer at 3,500 new cases (Table 10).

20

Table 10: Estimated Age-Standardized Mortality and Incidence Rates and Number of Deaths and New Cases for Selected Cancer Sites by Sex, Ontario, 2005 Mortality Cancer site

Rate per 100,000 M

All Cancers

Incidence Deaths

F

M

Rate per 100,00 F

M

New Cases

F

M

F

210

148

13,300

12,300

442

356

28,500

27,700

Lung

55

38

3,500

3,000

61

46

3,900

3,600

Colorectal

26

17

1,600

1,450

61

42

4,000

3,500

-

24

-

2,000

-

105

-

8,200

26

-

1,600

-

129

-

8,300

-

Breast Prostate Source:

Canadian Cancer Society/National Cancer Institute of Canada, Canadian Cancer Statistics 2005, Toronto, Canada, 2005.

Cancer is responsible for 2.9% ($2,462 million) of direct costs and 15.6% ($11,758 million) of indirect costs in Canada in 1998 (Health Canada, 2002a). Losses in productivity due to premature mortality caused by cancer are estimated to be $10,622 million or 31.7% of all premature mortality costs, which makes it the leading cause for mortality costs. Lung cancer leads with a share of 26.1% of all cancer mortality costs, followed by breast cancer with 10.0%, colorectal cancer with 9.1%, and prostate cancer with 2.9%. Lung cancer also shows the greatest share of hospital costs in 1998 ($227.5 million or 12.4% of all cancer-related hospital costs). Colorectal cancer follows close by with an estimated 11.8% ($216.3 million), and breast cancer with 4.6% ($84.8 million). Morbidity costs (long- and short-term) due to cancer sum up to $1,135.9 million (3.0% of long-term, and 1.8% of short-term disability). Almost half of the new cases among males involve prostate, lung and colorectal cancers; and among females it is breast, lung and colorectal cancers. Data since 1998 indicate that agestandardized mortality and incidence rates show a stable or declining trend for cancer sites, with the exception of lung cancer for women and prostate cancer among men. While five risk factors (tobacco, physical inactivity, unhealthy weight, poor diet, high risk alcohol consumption and excessive sun exposure) are linked with a number of types of cancer, it is tobacco and poor diet that are associated with a wide range of types of cancer. Estimates from 1998 indicate that cancer is implicated for about 3% o direct costs and 16% of indirect costs.

21

1.3.2

Cardiovascular Diseases This report also identifies the major risk factors leading to CVD and in turn to the burden

of disease for Canadians. Data for CVD in Canada come from hospitalization and mortality data. Data on incidence are rare, because, unlike cancer, CVD is not mandatorily reported. For most of the population, modifiable lifestyle risk factors are the major determinant for CVD for most of the population as opposed to hereditary risk factors (McKeigue, Miller, & Marmot, 1989). Individually modifiable risk factors for CVD include, but are not limited to, smoking, alcohol consumption, physical inactivity, nutrition, obesity, high blood pressure, dietary fat intake, and blood glucose level. One-third of all CVD is attributable to one of the following risk factors: tobacco use/exposure, alcohol use, high blood pressure, high cholesterol, or obesity (World Health Organization, 2002). Almost 80% of the Canadian population has at least one of the most common risk factors for CVD, i.e. smoking, being physically inactive, being overweight, having high blood pressure or diabetes (Heart and Stroke Foundation of Canada, 2003). Although trend data show a promising decline in prevalence of some risk factors for CVD, for example, smoking and physical inactivity, others continue to rise, such as high blood pressure, diabetes, alcohol consumption, and being overweight. Obesity in particular, shows a steady increase in age-standardized prevalence of obese population in Canada for men and for women (24% from 1996 to 2003); as well as hypertension (54% from 1994 to 2003); and alcohol consumption in terms of heavy drinking pattern (defined as 5 drinks or more in one occasion at least once in the last 12 months) among current drinkers (56% from 1996 to 2003). The increase in prevalence of obese people is especially visible in men, rising from 12.5% (18 years and older) in 1994/1995 to 15.9% in 2003 (Statistics Canada, NPHS and CCHS data). Due to the growing proportion of older people in the overall population, and because CVD prevalence tends to be higher among older people (50+ years), the actual number of hospitalizations due to CVD will continue to rise. Prevalence increases more with age for men than for women. CVDs continue to be the leading cause of death, although both the number of deaths due to CVD, after a steady period in the 1990, and the age-standardized mortality rate show a steady decline in mortality over time. As can be seen in Table 11, the share of CVD among total deaths for both sexes in Canada declined from 42% in 1987 to 33% in 2002. Both women and men showed the same pattern. This decline is probably caused by a combined effort of primary and 22

secondary prevention, such as the reduction of smoking rates, especially among men, and earlier detection of risk factors such as hypertension, and advancements in treatment. Also, mortality rates (age-standardized) for the most common CVD, such as ischaemic heart disease and cerebrovascular disease, decreased for both men and women since 1984 (see Figures 11 and 12). More people die of ischaemic heart disease than cerebrovascular disease, and the decrease was stronger for ischaemic heart disease than for cerebrovascular disease. Between 1984 and 2001, the rate for ischaemic heart disease decreased for both sexes by 47.3%, for men the rate decreased by 47.8%, and for women by 47.4%. The combined mortality rate for cerebrovascular disease decreased by 34.9%. The mortality rate for men decreased by 34.8%, for women by 34.5%. Table 11: Percent of Total Deaths Due to Cardiovascular Diseases, by Sex, Canada, 1987-2002 %

Year Total

Men

Women

1987

42.1

40.5

44.0

1988

41.3

39.5

43.4

1989

40.7

39.1

42.6

1990

39.1

37.3

41.2

1991

38.9

37.1

41.0

1992

38.8

37.1

40.7

1993

38.5

37.0

40.2

1994

37.9

36.4

39.8

1995

37.5

36.0

39.3

1996

37.3

35.9

38.8

1997

37.3

36.0

38.6

1998

36.4

35.3

37.5

1999

36.0

35.0

37.0

2000

35.1

34.1

36.1

2001

34.1

33.1

35.1

2002

33.4

32.5

34.3

Sources: Heart and Stroke Foundation of Canada, The Growing Burden of Heart Disease and Stroke in Canada 2003 and Mortality Files, Statistics Canada.

23

Based on estimates from Statistics Canada using current trends in age-standardized mortality, the actual number of deaths due to CVD will increase for women until 2015 and then decrease, and will remain stable for men until 2025 (Heart and Stroke Foundation of Canada, 2003). For cerebrovascular diseases, the number of deaths is expected to increase until 2015 among women and until 2025 among men. Although higher now, the number of deaths due to acute myocardial infarction among men is expected to fall below that of women after 2015 while continuing a downward trend. Figure 11: Age-Standardized Mortality Rate (Canada 1991) for Selected Cardiovascular Diseases, Females, Canada 1984-2001 Ischaemic Heart Disease Cerebrovascular Disease

300

Rate per 100,000

250

200

150

100

50

0 20

20

01

98

96

97

94

95

92

93

90

91

88

89

86

87

84

85

00 99

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19


24

Figure 12: Age-Standardized Mortality Rate (Canada 1991) for Selected Cardiovascular Diseases, Males, Canada 1984-2001 Ischaemic Heart Disease Cerebrovascular Disease

300

Rate per 100,000

250

200

150

100

50

0 01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19

Year

Sources:

Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada; Statistics Canada.

CVD is the leading cause of death in the overall population, as well as in the 65 and older age group. When looking at the age distribution, the percentage of deaths due to CVD increases with age for both sexes. Among men the increase begins after the age of 40, for women after the age of 50 (Heart and Stroke Foundation of Canada, 2003). All main CVDs show similar patterns regarding age and sex distribution; they all occur mainly in older age groups beyond 50 years of age. Following the pattern of mortality, hospitalization rates also occur mainly in the 50+ age group and rise rapidly beyond that age (see Figure 13). Across all age groups, men have higher hospitalization rates than women

25

Figure 13: Hospitalization Rates for All Cardiovascular Diseases by Age Group and Sex, Canada 2000/01 Sex

15,000

Male Female

Rate per 100,000

12,000

9,000

6,000

3,000

0 30 - 39

40 - 49

50 - 59

60 - 69

70 - 79

80 - 89

90+

Age Group (years) Note: Source:

Using most responsible diagnosis only. The Heart and Stroke Foundation of Canada, The Growing Burden of Heart Disease and Stroke in Canada 2003, using data from Hospital Morbidity Database, CIHI, Health Canada.

Despite declining mortality rates, the number of deaths due to CVD will remain the major burden of disease in Canada for many years to come as the population grows and ages. The shift in distribution of the population will likely increase the number of deaths among women. The number of deaths from acute myocardial infarction will likely decrease until 2025, whereas the number of deaths due to congestive heart failure and cerebrovascular disease will likely rise over the next two decades (Heart and Stroke Foundation of Canada, 2003). The concentration of heart problems among seniors provides a difficult challenge for intervention in the coming years. Therefore it is necessary to have more and better data available for both incidence and prevalence of CVD in Canada. In comparison with other countries, ischaemic heart disease seems to be a challenge in Canada in particular. While having a low mortality rate due to cerebrovascular disease, death from ischaemic heart disease is more common in Canada (World Health Organization, 2002).

26

Figures 14 and 15 show crude actual and projected CVD deaths and hospitalizations due to CVDs in Canada until 2025. Although the number of CVDs is projected to be somewhat steady between now and 2025, Figure 14 shows that both actual and estimated hospitalizations for CVD for both sexes in Canada are expected to rise steadily until 2025. Hospitalization rates for CVDs have been increasing since 1986, and are projected to increase further over time, as the population ages. In 2000/2001, heart disease and stroke accounted for 18% of all hospitalizations in Canada (Heart and Stroke Foundation of Canada, 2003). Figure 14: Number of Cardiovascular Disease Deaths, Actual and Projected, by Sex, Canada, 1950-2025

Note: Source:

Taken from Heart and Stroke Foundation of Canada, The Growing Burden of Heart Disease and Stroke in Canada 2003. Statistics Canada.

27

Figure 15: Number of Hospitalizations for Cardiovascular Diseases*, Actual and Projected, by Sex, Canada, 1980-2025

Note: Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. * Using most responsible diagnosis only. Source: Statistics Canada, using data from the Hospital Morbidity Database, Canadian Institute for Health Information.

The economic burden attributable to CVDs is estimated at $18,472.9 million, a total of 11.6% of the total costs of all diseases in 1998. CVDs were estimated at 8.1% of total direct costs, and 15.4% of total indirect costs ($6,818 million and $11,654 million, respectively) by Health Canada in 1998 (Health Canada, 2002a). Disability costs (long- and short-term) account for $3,404.8 million (9.8% of long-term, and 2.6% of short-term morbidity). Regarding mortality caused by CVDs, of the total $8,250.0 million due to CVD, 33.5% were for acute myocardial infarction, 25.2% for ischaemic heart disease, and 2.9% for aortic aneurysm. Hospital costs for CVD and cerebrovascular diseases sum up to $4,161.8 million in 1998, of which $1,274.8 million were for ischaemic heart disease, $103.2 million for aortic aneurysm, and $873.2 million for cerebrovascular diseases. CVD is a leading cause of death, although age standardized mortality rates show a steady decline over time. Nevertheless, the number of deaths due to CVD will remain a major burden for Canada for a number of years as the population grows and ages. Estimates point to an increase in hospitalization rates for both sexes until 2025. There is a promising decline in some risk factors, whereas others are on the increase, such as high blood pressure, diabetes, alcohol

28

consumption, and unhealthy weights. This suggests that costs estimates of 8% direct and 15% of indirect costs in 1998 will likely need to be adjusted upward.

1.3.3

Respiratory Disease Respiratory diseases for the focus of this report include asthma and chronic obstructive

pulmonary disease (COPD). Asthma is a chronic disorder with symptoms of cough, shortness of breath, chest tightness and wheeze. Acute attacks are associated with inflammation of the airway wall and narrowing of airways and caused by allergens, viral respiratory infections, exercise or exposure to irritant fumes or gas (Health Canada, 2001a). COPD is a chronic disease with shortness of breath, cough and sputum production most commonly due to chronic bronchitis (inflammation of the airways causing irritation with increased production of mucous blocking the airways) and emphysema (air sacs are enlarged and damaged, impairing breathing). Definitions of COPD have changed over the years. Nowadays, the definition of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) has become the standard for clinicians and researchers worldwide: “COPD is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.” Generally, COPD affects people over the age of 60, more so among women than men. An estimated 15-20% of smokers will develop COPD (Canadian Lung Association, 1993), and smoking is an attributable factor in 80-90% of COPD cases (Health Canada, 2001a). Because of an aging and growing population, the number of Canadians with asthma and COPD will rise in the future. Risk factors for respiratory diseases include mainly tobacco smoking and environmental tobacco exposure (ETS), especially in children, occupational exposure to dusts, and outdoor air quality. Smoking and ETS not only increase the risk of developing lung cancer and CVD, but also the risk of developing asthma and COPD. Other risk factors include hazardous exposure at the workplace, repeated respiratory infections (Health Canada, 2001a), and obesity in females (Chen, Dales, Krewski, & Breithaupt, 1999). However, smoking is the most important preventable cause of respiratory diseases. Air pollution is not likely a primary cause of asthma, but can worsen the symptoms. Therefore, prevention should focus on reduction of tobacco smoke exposure, improvements in air quality, and also reduction in occupational exposure to

29

dust fumes and gases, both indoors and outdoors. These risk factors not only influence the occurrence of COPD, but are also related to symptoms and progression of COPD. The age-standardized mortality rate for asthma in Canada shows a steady decline for both sexes from 1984 (2.19 per 100,000 population) to 2001 (0.82 per 100,000 population) (Figure 16). Using National Population Health Survey (NPHS) and Canadian Community Health Survey (CCHS) data, the age-standardized prevalence rate of asthma among the population 15 years and older increased from 1994 (6,195 per 100,000 population) to 2001 (8,374 per 100,000 population) for both sexes – which equals an increase of 35% - and remained stable until 2003 with a slight decline in men. Prevalence of asthma is higher among women than men across all age groups (Figure 17 and Table 12). These rates may be under-represented, since many people do not recognize the early symptoms of the disease and hence do not seek treatment. Figure 16: Age-Standardized Mortality Rate (Canada 1991) for Asthma, by Sex, Canada 1984-2001 Sex

3.0

Both Males Females

Rate per 100,000

2.5

2.0

1.5

1.0

0.5

0.0 20

20

01

9

7

8

6

5

4

3

1

2

0

9

8

7

5

6

4

00

9 19

9 19

9 19

9 19

9 19

9 19

9 19

9 19

9 19

9 19

8 19

8 19

8 19

8 19

8 19

8 19

Year Sources: Surveillance and Risk Assessment Division, CCDPC, Health Canada; Statistics Canada.

In 2003 in Canada, an estimated total of 2,226,770 Canadians reported being diagnosed with asthma (Statistics Canada, CCHS data), and approximately 500,000 Canadians were affected by COPD in Canada in 1998/1999 (Health Canada, 2001a). Prevalence of asthma is

30

highest among the population 0-19 years old. In 1998/1999, one third of all prevalent cases occurred in this age group (Health Canada, 2001a). The contribution of asthma to hospitalization in Canada is substantial. Asthma is among the five top reasons for admission to a hospital. Between 5-7% of people with asthma required hospital admission in the previous year (Health Canada, 2001a). Figure 17: Age-Standardized Prevalence Rate (Canada 1991) 15 Years and Over for Asthma, by Sex, Canada 1994-2003 Sex

12,000

Both Females Males

Rate per 100,000

10,000

8,000

6,000

4,000

2,000

0 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year Source:

Statistics Canada, National Population Health Survey and Canadian Community Health Survey

Table 12: Percentage and Number of Canadians 12 Years and Over Who Have Asthma, by Sex, 2003 Total

Age Group %

Men n

%

Women n

%

N

12 – 34

10.4

1,003,470

9.4

456,153

11.5

547,325

35 – 64

7.1

936,438

5.5

361,815

8.7

574,621

65+

7.6

286,854

6.9

114,901

8.1

171,953

8.4

2,226,770

7.1

932,870

9.6

1,293,900

Total (12+) Source:

Statistics Canada, Canadian Community Health Survey

31

Figure 18 shows that among young children aged 0-4 years, hospitalization rates were far higher than in all other age groups, although rates rise again beyond 45 years. Among the youngest age group, asthma is one of the leading causes for admission, accounting for 12% of all admissions. Although hospitalization rates were declining in the past years, suggesting improving disease control, the actual number of admissions may still be a sign of poor disease management overall (Health Canada, 2001a). Figure 18: Asthma Hospitalization Rates (per 100,000), by Age Group and Sex, Canada, 2000/01

Note: Source:

Taken from Health Canada (2001): Respiratory Disease in Canada. Centre for Chronic Disease Prevention and Control, Health Canada, using data from Hospital Mortality File, Canadian Institute for Health Information.

Figures 17, 19, and 20 show that, although prevalence rates were rising across all age groups and sexes, hospital separations due to asthma declined from 1987 to 2000.

32

Figure 19: Age-standardized Rates (Canada 1991) for Asthma Hospitalization in the Younger Age Groups, by Age and Sex, Canada, 1987/88-2000/01

Note: Source:


Figure 20: Age-standardized Rates (Canada 1991) for Asthma Hospital Separation among Older Adults, by Age Group and Sex, Canada excluding Territories, 1987/88-2000/01

Note: Source:


33

The WHO predicts that COPD will become the fifth most common cause for disability worldwide in 2020. The underlying disease process is poorly understood thus far and clinical management has proven to be challenging. Diagnosed COPD or symptoms suggesting the disease result in significant disability and functioning in daily activities for affected patients. Figure 21 shows the age-standardized mortality rate for COPD in Canada. From 1984 to 2001, the mortality rate remained roughly stable for both sexes, caused by a decline in men, and a rise in women. More men were dying from COPD, but unfortunately the gender gap is closing, with women’s mortality almost doubling over this period. Contrary to mortality, hospitalization rates were higher for men than for women (Figures 19 and 20). When comparing the distribution of COPD hospitalizations by age and sex, one can see that hospitalization rates were lower for men until the age of 65, and greater beyond that age. Higher rates in 2000/01 are likely to be a result of a question change reflecting more accurate diagnosis. Not only is COPD likely to be greatly under diagnosed, but people with COPD or symptoms indicating COPD do not receive treatment in a great proportion (see also Figures 22 and 23). COPD is associated with a relatively high hospitalization rate, which in turn results in high economic costs largely driven by hospital expenditures because these hospitalizations tend to be care and cost intensive (Murray & Lopez, 1997). Recent evidence suggests that COPD also increases the risk for CVD as hospitalizations for COPD patients are largely due to cardiovascular events, even controlled for smoking, age, and gender (Sin & Man, 2005).

34

Figure 21: Age-Standardized Mortality Rate (Canada 1991) for COPD, by Sex, Canada 1984-2001 Sex

50

Both Males Females

Rate per 100,000

40

30

20

10

0

01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90

89

19

88

19

87

19

86

19

85

19

84

19

19


Figure 22: Prevalence of Physician-diagnosed COPD, Females, by Age Group, Canada, 1994-2001

Source:

Centre for Chronic Disease Prevention and Control, Health Canada, using data from National Population Health Survey, Statistics Canada. Taken from: http://www.phac-aspc.gc.ca/ccdpc-cpcmc/crd-mrc/facts_copd_e.html; accessed August, 2005.

35

Figure 23: Prevalence of Physician-diagnosed COPD, Males, by Age Group, Canada, 1994-2001

Source:

Centre for Chronic Disease Prevention and Control, Health Canada, using data from National Population Health Survey, Statistics Canada. Taken from: http://www.phac-aspc.gc.ca/ccdpc-cpcmc/crd-mrc/facts_copd_e.html; accessed August, 2005.

The age standardized mortality rates for asthma show a decline between 1984 and 2001, whereas prevalence has been increasing at least since 1994. Nevertheless hospitalizations have been generally declining, across all age groups, since 1987. However, the age-standardized mortality rates for COPD has remained fairly steady (both sexes combined), with an increase among women. COPD is considered to greatly underdiagnosed and most do not receive treatment. The risk factors for respiratory disease include tobacco use, occupational exposure to dusts, and outdoor air quality. WHO estimates indicate that COPD will become the fifth most common cause of disability worldwide by 2020. 1.3.4

Diabetes Diabetes is a disorder affecting the regulation of insulin in the human body. Insulin

regulates blood sugar level and is produced by the pancreas. The inability to produce enough insulin in the pancreas leads to elevated blood sugar levels and thus to the damage of blood vessels. People with Type 1 diabetes cannot produce any insulin and with type 2 diabetes the production is limited and not effective. For Type 1, insulin has to be injected; for Type 2 external insulin provision is not mandatory for many people. There are limitations in availability of data on diabetes in younger age groups. This concerns Type 1 diabetes in particular, as it

36

occurs mainly in these age groups. Type 2 diabetes usually affects people after the age of 40 and is the preventable form of diabetes and related to physical inactivity, excess food consumption, and obesity (World Health Organization, 2002). According to the WHO, lifestyle changes can be more effective than treating diabetes with medication. Risk factors for diabetes include physical inactivity, unhealthy diet, being overweight/obese, fat intake, and blood glucose level, and raised blood pressure. Moreover, diabetes is a risk factor for other chronic diseases, such as CVD and cerebrovascular disease. Type 2 diabetes, for example, is associated with a 70-80% chance of premature death due to CVD or stroke (Chobanian et al., 2003). Although Types 1 and 2 diabetes are not differentiated in the NPHS results, it is estimated that up to 90% of new cases are Type 2 diabetes (Centers for Disease Control and Prevention, 1999). Type 2 diabetes is one of the most rapidly increasing chronic diseases in the world. Poor nutrition in childhood and physical inactivity rates are mainly responsible for steeply increasing prevalence rates of diabetes in developed countries (World Health Organization, 2002). Prevalence of diabetes continues to rise in Canada. In 1997, deaths due to diabetes accounted for 2.6% of all deaths; in 2002, this proportion rose to 3.5%, an increase of 35% in only five years. The age-standardized mortality rate rose since the early 1990s and reached 20 per 100,000 for both sexes in 2001 (Figure 24). It should be noted though, that the actual mortality rate might be much higher because of insufficient reporting of diabetes as a potential underlying cause of death (Heart and Stroke Foundation of Canada, 2003). The rate for men is higher than that for women (23 and 17 per 100,000 in 2001, respectively). Figure 25 shows the development of age-standardized prevalence of diabetes (Types 1 and 2) from 1994/95 to 2003. Canada showed a steep increase in prevalence from 3,073 per 100,000 in 1994/95 to 4,377 per 100,000 in 2003. Due to the fact that NPHS and CCHS data are physician-diagnosed self-reported cases diagnosed by a physician, the true prevalence is likely to be much higher. It is estimated that 3544% of all diabetes cases are undiagnosed (Harris, Flegal, Cowie, & Eberhardt, 1998).

37

Figure 24: Age-Standardized Mortality Rate (Canada 1991) for Diabetes, by Sex, Canada, 1984-2001 Sex

25

Both Males Females

Rate per 100,000

20

15

10

5

0

01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19


The crude prevalence of diabetes in Canada has been estimated to be 4.6% of the population 12 years and over (1,222,882 Canadians). This number is up from 3.0% (722,491) in 1994/95. Diabetes prevalence increases with age, with the prevalence rate for people 65 years and older more than double (13.2%) that of those aged 35-64 years (4.9%) (Table 13). 3 In relation to sex, the prevalence rate for men is significantly higher (4.9%) than for women (4.3%) (see Figure 25). In 1994/95, the overall rates were almost equal for both sexes (3.1% for men, compared to 3.0% for women), and differences in prevalence peaked in 1998/99 (3.9% for men, 3.0% for women).

3

The majority of diabetes occurs in the population 35 and older. In younger age groups, the estimates were too unstable to be reported.

38

Figure 25: Age-Standardized Prevalence Rate (Canada 1991) 15 Years and Over for Diabetes (Type 1 and 2), by Sex, Canada, 1994-2003 Sex

5,000

Both Females Males

Rate per 100,000

4,000

3,000

2,000

1,000

0 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year Source:


Table 13: Percentage and Number of Canadians 12 Years and Over Who Have Diabetes, by Sex, 2003 Total

Age Group

Men

Women

%

n

%

n

%

n

12 – 34

0.7

62,895

0.6

29,738

0.7

33,157

35 – 64

4.9

649,595

5.5

357,866

4.4

291,729

13.5

510,392

15.5

257,612

11.9

252,780

4.6

1,222,882

4.9

645,215

4.3

577,666

65+ Total (12+) Source:


Prevalence rates are slightly higher in Ontario than for Canada overall. In 2003, 4.6% (474,127) of Ontarians stated that they have diabetes. Of these, 242,094 (4.8%) were men, and 232,034 were female (4.4%). The burden of disease and health care costs due to diabetes will rise dramatically in coming years. The main two reasons for this rise are the aging population and the rising prevalence of diabetes, in older age groups in particular. Of special concern is the 39

rise of diabetes in the Aboriginal community. Figures 26 and 27 show projections for diabetes prevalence in Manitoba for the general population and for the Aboriginal population. Starting from a higher level in 1995, the projected prevalence among Aboriginal peoples will be about 15% for females and over 15% for males. The rate for the general population will rise from under 6% in 1995 to about 11% among the population 20 years and over. Data on economic costs and impact of diabetes in Canada is limited. Using a human capital approach, economic costs of diabetes (including undiagnosed cases) in Canada 1998 in terms of direct health care costs and productivity losses were estimated to be $4,756 million US, of which $3,478 million were for direct medical costs and $1,277 million for productivity losses due to premature mortality (Dawson, Gomes, & Gerstein, 1998). Diagnosed cases only accounted for $3,701 million in total. These cost estimates include costs for chronic complications, such as CVD, renal disease, neurological disease, and other chronic complications. When looking at the costs of diabetes without taking into account these complications, $573 million in direct medical costs and $455 million in mortality costs were attributable to diabetes (diagnosed and undiagnosed); not included in this analysis were indirect morbidity costs. Therefore, these numbers present conservative estimates and the actual costs might be significantly higher. Based on 1991 data from Saskatchewan, Ohnimaa and colleagues estimated the increase in health care costs due to diabetes in Canada (Ohnimaa, Jacobs, Simpson, & Johnson, 2004). They estimated that the health care costs in terms of hospitalizations, physician services, prescription drugs, day surgeries, and estimated outpatient dialysis will increase from $4,657.8 million in 2000 (all numbers in 1996 CAD) to $8,142.7 million in 2016, an increase by 74.8%. Health care costs related to diabetes in Ontario will rise by 78.3%, from $1,763.0 million to $3,143.6 million in 2016. The increase in costs is largely attributable to an increase in prevalence among the population 50 years and older.

40

Figure 26: Projected Age-specific Prevalence of Diabetes in Manitoba, 1995-2025

Note:

Taken from Blanchard J: Epidemiologic Projections of Diabetes and Its Complications: Forecasting the Coming Storm, 2000. Available at: www.gov.mb.ca/health/publichealth/epiunit/docs/storm.pdf. Accessed June 06, 2005

Figure 27: Projected Age-specific Prevalence of Diabetes in Manitoba, Status Indian, 1995-2025

Note:

Taken from Blanchard J: Epidemiologic Projections of Diabetes and Its Complications: Forecasting the Coming Storm, 2000. Available at: www.gov.mb.ca/health/publichealth/epiunit/docs/storm.pdf. Accessed June 06, 2005.

41

Type 1 diabetes is typically associated with younger age groups, and Type 2 usually impacts persons over age 40 and is a preventable form related to various risk behaviours. Deaths, while about 4%, have increased sharply in just five years, and prevalence is increasing dramatically in Canada, and tends to increase with age. There are particularly high rates of diabetes in Aboriginal communities. The major risk factors include physical inactivity, unhealthy diet, being overweight/obese, fat intake, blood glucose level and raised blood pressure. Significantly more effective interventions will need to be implemented if the rising prevalence and attendant costs is to be contained.

1.3.5

Mental Health A variety of mental illnesses cause alterations in mood or thinking that in turn cause

distress and impaired performance and functioning. Symptoms and disorders may occur in combination and at different levels of severity. This depends on many factors, including the social environment, family history and the individual him or herself. Mental illnesses include mood disorders, such as major depressive episodes, bipolar disorder, or dysthymia, schizophrenia, anxiety disorders, personality disorders, eating disorders, and suicidal behaviour. Because up to 20% of Canadians will experience a mental illness in their lifetime, mental illnesses will indirectly affect many Canadians, if not all, through their social environment; not restricted by age or social background (Health Canada, 2002b). Data availability in Canada is limited and shows a need for more detailed and comprehensive surveillance. The majority of mental illness hospitalizations occur in general hospitals (86% of mental illness hospitalization or 3.8% of all hospitalizations in 1999). A report recently published by the Canadian Institute for Health Information (CIHI) showed that in 2002-2003, 6% of all hospitalizations in Canada were attributable to mental illnesses. Taking into account that another 9% involved hospitalizations, where mental illness was not the primary diagnosis, mental illnesses accounted for 15% of hospital stays in Canada. Because these patients tend to stay in hospital twice as long as other patients, mental illnesses accounted for one-third of hospital days in Canada (Canadian Institute for Health Information, 2005). As the report notes, the majority of psychiatric hospital separations occurred in Ontario, as well as over one third of total general separations associated with mental illness. Age-

42

standardized hospital separation rates in Canada were highest in Newfoundland and Labrador regarding psychiatric hospital separations (246 per 100,000), and lowest in British Columbia (17 per 100,000 population). When looking at the proportion of total separations due to psychiatric hospital separations, Newfoundland stands out with 38%, with British Columbia on the other end of the scale with only 3%. It should be noted that availability of services and other structural differences across jurisdictions might explain portions of the results stated above. Unipolar depressive disorders account for 7.2% of overall burden of disease in developed countries, second only to ischaemic heart disease (World Health Organization, 2002). Depression is a complex mood disorder with a variety of symptoms and caused by factors such as genetic history, psychological or biological factors, and through other illnesses such as cancer, CVDs or COPD, directly or as a reaction. Symptoms of depression include, among others, a sad, despairing mood that is present most days and lasting most of the day, for a period of at least two weeks. Depression can impair performance at work, at school, and in social relationships. Depression is more common in women than in men with many hormonal factors that may contribute to the occurrence of depression through menstrual cycle changes, pregnancy, or menopause. In men, it is more difficult to diagnose as it may show symptoms of anger, irritation, or discouragement. It usually appears in adolescence or young adulthood and the female-to-male ratio is 2:1, while bipolar disorder is equally distributed across both sexes (Bland, 1997; Fogarty, Russell, Newman, & Bland, 1994). The age-standardized prevalence rate of depression (with a probability greater then 0.9) declined from 5300 per 100,000 population for both sexes to 4100 per 100,000 population in 1996/1997 and rose to 5000 per 100,000 population in 2000/2001 (Figure 28). The prevalence rate for women compared to men was higher at all times (88% in 2000/2001). Table 14 shows Canadian prevalence data from 2002. All mental health problems were more prevalent in women than in men, except for alcohol dependence which was twice as high in men. Data specifically regarding depression is shown in Table 15.

43

Figure 28: Age-standardized Prevalence Rate (Canada 1991) 12 Years and Over for Depression (Probability ≥ 0.9), by Sex, Canada, 1994-2001 Sex

15,000

Both Females Males

Rate per 100,000

12,000

9,000

6,000

3,000

0 1994-1995

1996-1997

1998-1999

2000-2001

Year

Note:

Source:

Caution is recommended when comparing depression data from NPHS/CCHS with the Mental Health and Well-being Survey (2002) conducted as a cycle 1.2 of CCHS (displayed in tables 10-13). The depression data reported from NPHS/CCHS are referring to the 'risk of depression' derived from a set of questions on mental health that involves thoughts and feelings about various subjects. The depression data reported from the mental health survey were based on a Composite International Diagnostic Interview instrument. Major depressive disorder defined for this survey requires at least one episode of 2 weeks or more with persistent depressed mood and loss of interest or pleasure in normal activities, accompanied by decreased energy, changes in sleep and appetite, impaired concentration, and feelings of guilt, hopelessness, or suicidal thoughts. Data from this survey are restricted to those aged 15 and over. Statistics Canada, National Population Health Survey and Canadian Community Health Survey

Table 14: Percentage and Number of Canadians 15 Years and Over Who Have a Mental Health Problem, by Sex, 2002 Total

Disorder %

Men n

%

Women n

%

n

Any Measured Disorder or Substance Dependence

10.6

2,658,581

9.9

1,215,393

11.4

1,443,187

Alcohol Dependence*

6.2

1,542,886

9.5

1,162,514

3.0

380,372

Panic Disorder

1.5

375,973

2.0

125,430

2.0

250,543

Major Depressive Episode

4.8

1,195,955

3.7

451,618

5.9

744,337

Manic Episode

1.0

239,350

1.0

116,757

1.0

122,593

Illicit Drug Dependence

0.8

193,643

1.1

134,819

0.5

58,824

Note: Source:

* Highly probable case as defined by Statistics Canada. Statistics Canada, Canadian Community Health Survey, Mental Health and Well-being, 2002 (updated in September 2004)

44

Table 15: Percentage and Number of Canadians 12 Years and Over with Depression* by Sex, 2002

Age Group

Total %

Men n

%

Women n

%

n

12 – 19

6.5

208,868

3.4

55,843

9.7

153,025

20 – 34

8.8

550,347

6.5

205,581

11.1

344,767

35 – 44

8.7

461,730

6.1

161,188

11.3

300,543

45 – 64

6.7

488,519

4.8

173,603

8.6

314,916

65+

3.2

117,088

2.3

35,869

4.0

81,219

7.1

1,826,55 2

5.0

632,083

9.2

1,194,46 9

Total (18+) Note: Source:

* Highly probable (≥ 0.9) case as defined by Statistics Canada. 4 Statistics Canada, Canadian Community Health Survey, Mental Health and Well-being, 2002 (updated in September 2004)

As noted above, it is estimated that about 20% of Canadians will experience a mental illness in their lifetime, and these illnesses also affect many other Canadians. It is also estimated that mental illnesses account for 15% of hospital stays in Canada, these patients stay on average about twice as long as others. Unipolar depressive disorders are considered to account for about 7% of overall burden of disease in developed countries.

4

Population aged 12 and over with the probability of 0.9 or greater of having experienced a major depressive episode in the past 12 months based on responses to the short-form Composite International Diagnostic Interview (CIDI). Respondents are classified according to the probability that they would have been diagnosed as having experienced a major depressive episode in the past 12 months, if they had completed the long-form CIDI.

45

46

2. THE SOCIOBEHAVIOURAL RISKS AND DETERMINANTS OF CHRONIC DISEASE In examinations of the risks of chronic disease, the primary focus has been on individual level factors, specifically termed “lifestyle” behaviours. The “Big Three” behaviours of highest importance in chronic disease research and interventions have been tobacco smoking, physical inactivity, and diet. It is thus these factors for which there is an overwhelming amount of evidence, particularly from using the research “gold standard” of the randomized controlled trial. However, there are many other factors beyond these individual level risks that have emerged. One of our main purposes in the production of this report is to move the discourse around the development of chronic disease away from the “victim-blaming” language of lifestyle factors. For this reason, we are terming the risk factors for chronic disease as sociobehavioural. First, we provide a discussion on what risk is and how it will be conceptualized for the purposes of this report. This discussion includes a diagrammatic representation of the interactions between risk factors for the development of chronic disease. We then review the available evidence for the sociobehavioural risk factors of chronic disease, with special attention paid to the interactions between all levels of risk with regards to health outcomes.

2.1

Defining Risk The WHO defines risk as the probability of an adverse outcome, or a factor that raises this

probability (World Health Organization, 2002). Risks do not occur in isolation for any health outcome or disease. Health outcomes have their roots in complex chains of environmental, behavioural, and biological events that have many causes and may have occurred over long periods of time. The chain of events that may lead to the development of chronic disease includes both proximal and distal factors. Proximal factors act directly or almost directly to cause health outcomes, while distal factors are further back in the causal chain and act mainly via intermediary causes. The conceptualizations of proximal/distal and direct/indirect, however, are not always concrete and unchanging, as will be evident in the discussion below. Because of the relationships between various risk factors, isolating the specific causes of chronic disease is a

47

difficult - if not impossible - task. Thus, we refer to risk factors throughout the report, not causes. Risk thus operates on multiple levels, encompassing both the individual and populations. Moving away from the more direct, proximal, and individual risks of chronic disease leads to decreases in causal certainty and consistency, and is often accompanied by increasing complexity in explanations and causal chains (World Health Organization, 2002). This is due in part to the amplifying effects of distal causes, in that they can affect many different sets of proximal causes, thus having the potential to make quite large differences in disease outcomes. The WHO (2002) suggests that more complex multilevel models of causal webs of interactions among risk factors may lead to more appropriate estimates of the contributions of risk factors. Rather than looking at binary categories of risk such as “exposed” versus “unexposed”, it makes more sense to conceptualize risk along a continuum.

2.1.1 Risk on the Individual Level and on the Population Level Geoffrey Rose (1985; 1992) provides the most detailed scrutiny of how we define risk. It is useful for our present discussion of the risks of chronic disease because of its consideration of risk on the individual and population levels, and what this means for prevention efforts. A number of authors have discussed Rose’s arguments (for instance, Hunt & Emslie, 2001; Ebrahim & Lau, 2001; McCormick, 2001, Schwartz & Diez-Roux, 2001) and these authors’ arguments are also drawn upon for the present examination of risk. In 1985, Rose’s seminal paper on the consequences of a focus on sick individuals contrasted with a focus on sick populations was published. Rose argued that the causes of incidence within populations are not necessarily the same as the causes of individual susceptibility (or individual cases). For example, the reasons why your father at the age of 65 experienced a heart attack may be different from the reasons why a certain population experiences incidence of heart attack at a higher level than another population. Some of the best evidence of causal relationships has come from the study of individuals (McCormick, 2001). However, Rose (1985) suggests that we need to look beyond the causes of cases in order to better understand disease and health outcomes and to better inform prevention efforts. Detailed analysis using case-control methods and the production of carefully adjusted

48

odds ratios does not help in terms of practical public health (Ebrahim & Lau, 2001). We have the most knowledge, however, about pathophysiological and behavioural causes of disease because of the greater scientific certainty and universality of causal attributions. These causes are more easily examined by the manipulation of clinical data in a laboratory environment and are more easily identified in within-population comparisons (Schwartz & Diez-Roux, 2001). Rose (1985, 1992) argues that distal causes (i.e., those tied to the social and physical environments) have a bigger role to play in the development of disease outcomes than proximal factors, and that these distal factors hold the greater potential for prevention strategies. Rose does not dismiss the individual level characteristics that lead to disease (which he refers to as “susceptibility factors”), and does recognize their participation in the disease process as primary causes of cases. His argument entails the understanding that people are born into a number of social constraints on their lives and behaviours over which they have limited control. While individual susceptibility is critical in understanding health outcomes, distal social factors interact with the individuals and manifest in their behaviours (Schwartz & Diez-Roux, 2001). These “social facts” (Schwartz & Diez-Roux, 2001) are distinct from behaviours and can be examined and manipulated at levels outside of the individual. They influence individual level factors without being reducible to them. Thus, disease outcomes are not only the manifestation of an individual’s characteristics, but an interaction between the characteristics of the individual and the environment to which he/she is exposed and helps create (Schwartz & Diez-Roux, 2001). This sentiment is captured in the previous discussion of risk put forth by the WHO (2002), indicating webs of causation. Social facts may be of most relevance in populations where certain behaviours are ubiquitous, and thus do not differentiate one case from another within the field of causality (Schwartz & Diez-Roux, 2001). Rose (1985, 1992) also considers the relationship between wholes and parts in reference to populations and individuals. Populations are comprised of individuals, but are more than simply the sum of those individuals. This is illustrated clearly when one considers that even though individuals may come and go from populations, the populations or groups themselves maintain some consistent characteristics over time. In understanding the causes of disease, the usual focus is on “high-risk individuals”. However, many individuals at moderate risk within a population may actually lead to more disease than a few individuals at high-risk. Thus, the focus must be broadened to give strong attention to the population level and address the larger number

49

of individuals at lesser risk on the continuum. The implications of Rose’s work for prevention efforts are discussed in the section below on “what works” for prevention.

2.1.2

Conceptualization of the Sociobehavioural Risks of Chronic Disease The factors that contribute to the development of chronic disease operate on multiple

levels and in both interdependent and independent ways. The factors that contribute to chronic disease, whether they be proximal or distal, can be in some cases controllable or modifiable by the individual, while other factors operate on the population or group level and may be modifiable on the larger scale. The whole of this “causal chain” needs to be recognized in order to lead to the most effective prevention strategies. While biological factors (including genetics and physiological factors) are also implicated in the development of chronic disease, a review of the evidence related to these is beyond the scope of the current report. We do, however, look at the specific roles of obesity/overweight and high blood pressure as proximal factors. What have generally been termed as “lifestyle” factors in the development of chronic disease can thus be better described as proximal risk factors in the larger chain of factors. At the population level, chronic disease prevalence and outcomes are related to distal social environmental factors and characteristics of the health system, as well as the organization of society and services in general. These factors together make the group of sociobehavioural risk factors for chronic disease. In many ways, underlying social factors shape lifestyle and behaviours, as well as exposure to environmental factors and access to the health care system (Adler & Newman, 2002). It has been shown in the literature that about 50% of premature mortality is related to behavioural factors, and 20% is related to environmental factors (Adler & Newman, 2002). Thus, we consider multiple levels of sociobehavioural risk factors in understanding the development of chronic disease. Health Canada (2001b) established what they consider to be the twelve determinants of health, and we have drawn upon these for our current report (see also Wilkinson & Marmot, 2003). These determinants have been taken up in other consequent reports as being reflective of the range of factors that can influence the health of individuals and populations (for example, Ontario Public Health Association, 2002). The factors are as follows:

50

1.

Income/social status: higher incomes and social status are associated with better health outcomes.

2.

Social support network: social support networks are associated with better health and lower premature death rates.

3.

Education: higher education is associated with health status.

4.

Employment/working conditions: employment status is related to health, sense of identity and purpose, social contacts, and personal growth opportunities.

5.

Social environments: social environments are associated with opportunities to share resources and develop attachments to others.

6.

Physical environments: physical environments are related to health and the types of environmental risks one is exposed to.

7.

Personal health practices and coping skills: individual actions can prevent disease, and promote self-care, coping strategies, self-reliance, problem solving, and healthy choices.

8.

Healthy child development: early developmental experiences and opportunities are related to health status.

9.

Biology and genetic endowment: these are fundamental to health, and genetic endowment predisposes some to disease or health problems.

10.

Health services: the availability of health services is related to the health of a population.

11.

Gender: many health issues are related to gender-based status or roles. Women live longer than men, but are more likely to suffer from some chronic conditions.

12.

Culture: some groups face greater health risks due to a dominant culture that may marginalize stigmatize and devalue a group, and not provide culturally appropriate and sensitive health services.

Figure 29 is a diagrammatic representation of how we see the sociobehavioural risks of chronic disease. This diagram draws upon the model of proximal and distal risk from the WHO (2002) as well as the social environmental perspective on health from Smedley and Syme (2000). The sociobehavioural risks of chronic disease operate on multiple levels, are influenced by

51

sociodemographic variables, and are fluid across time and across the life course of both individuals and populations. Figure 29: The Sociobehavioural Risks of Chronic Disease

Social and economic context/policy

Sociodemographic factors Race/ethnicity Gender Class Religion Sexuality

Community level (e.g., neighbourhood, school, work, health care availability/access)

DISTAL (indirect)

Social relationships Individual risk behaviours and psychological factors Biological factors (physiology, genetics) PROXIMAL (direct)

CHRONIC DISEASE OUTCOMES

Over time and over life course

Adapted from: Smedley & Syme (2000) and World Health Organization (2002)

52

2.2

Proximal Factors in Chronic Disease The discussion of proximal factors in relation to chronic disease is essential because of

the wealth of evidence and their primacy in the causes of cases. It is for this reason that they feature strongly in this discussion of the sociobehavioural risks of chronic disease. However, it is important that they are not given priority over the involvement of the social environmental factors discussed later. Figure 30 shows the interrelationships among proximal risks in relation to chronic diseases. Modification of one risk factor likely reduces the development of not only one chronic disease but several, as factors interact. This section of the report focuses on major individually modifiable risk factors and risk conditions, including behavioural factors such as poor diet, physical inactivity, tobacco smoking, alcohol consumption and other substance abuse, and physiological proximal factors such as obesity/overweight and high blood pressure. These relatively few risk factors cause the majority of the burden of disease in Canada, and other developed countries (World Health Organization, 2002).

53

Figure 30: Selected Proximal Behavioural Risk Factors for Selected Chronic Diseases – The Strength of the Evidence

54

There are a number of indicators for each proximal risk factor, with the ones here chosen by availability of data. Prevalence estimates usually come from large population surveys, such as the National Population Health Survey (NPHS) – a biennial household survey - and the Canadian Community Health Survey (CCHS) – a 2-year cycle household survey with health region and provincial components. Mortality data is usually provided by Statistics Canada, Mortality files. Since the age-standardized prevalence rates and also the number of citizens with a certain risk factor reported here are based on large population survey estimates derived from selfreported data, caution should be exercised when interpreting the findings. The reported estimates represent underestimates; the actual number and percentages are likely to be higher than stated in this report due to undiagnosed cases and underreported consumption/behaviours. It should be noted that many of the risk factors mentioned do not occur separately, but often accumulate in one individual. For example, the 2000 CCHS showed that 80.2% of the Canadian population aged 20-59 years had at least one proximal risk factor for CVD, 30.0% had two risk factors, and 11.1% had three or more risk factors (Statistics Canada, 2004). A combination of smoking and obesity reduces life expectancy by 14 years (World Health Organization, 2002). Another example is physical activity. The proportion of obesity is higher among physically inactive people in Canada. The population attributable fraction (PAF) measures what proportion of a disease could theoretically be prevented if the risk factor could completely eliminated within the population (Walter, 1976; Walter, 1980). Because of interrelationships among the risk factors, the population attributable fraction for a disease with multiple risk factors can add up to more than one (Rowe, Powell, & Flanders, 2004). The method of assessment of the level of a risk factor has an important impact on the estimate of mortality and morbidity for physical activity and unhealthy eating, as well as alcohol consumption. The proportion of mortality attributable to these factors in particular is still being discussed (Mokdad, Marks, Stroup, & Gerberding, 2004). Limitations in availability of data and precision of existing data have to be taken into account when interpreting estimates in this report. Furthermore, attributable fractions are country-specific and cannot necessarily be transferred from studies conducted in other countries. The proximal behavioural risk factors described below focus on disease specific relationships. However, it is important to note that proximal and distal factors can have an effect on general susceptibility to poor health outcomes, rather than being simply disease specific.

55

2.2.1

Physical Inactivity Physical inactivity is a major proximal risk factor for CVD (Heart and Stroke Foundation

of Canada, 2003). Physical inactivity increases risk of heart attack and of death following a heart attack (Kohl III, 2001). It is associated with high blood pressure (Thompson et al., 2001), abnormal plasma lipid profile (Leon & Sanchez, 2001), decreased clotting time (Rauramaa, Li, & Vaisanen, 2001), obesity (Ross & Janssen, 2001; Shephard, 2001), and Type 2 diabetes (Kelley & Goodpaster, 2001). Physical inactivity is also associated with breast and colon cancers (Marrett, Theis, & Ashbury, 2000; Thune & Furberg, 2001) and osteoporosis (Shephard, 2001). A US Surgeon General report (1996) stated that regular physical activity that is performed on most days of the week reduces the risk of premature death and dying prematurely from heart disease. Regular physical activity also reduces the development of diabetes, high blood pressure, developing colon cancer, reduces feelings of depression, and helps control weight. Studies have shown that increasing regular physical activity is a preventive action for CVD (Kohl III, 2001), blood pressure (Fagard, 2001), cholesterol control (Leon & Sanchez, 2001), certain cancers (Marrett et al., 2000; Thune & Furberg, 2001) and Type 2 diabetes (Kelley & Goodpaster, 2001). Health benefits for the elderly include improved physical functioning and independent living, and greater longevity (Spirduso & Cronin, 2001). Even moderate physical activity lowers mortality among all ages (US Surgeon General, 1996). The increase in life expectancy is independent of genetic factors (World Health Organization, 2002). Although related to obesity, physical inactivity poses an independent risk factor for chronic diseases and premature mortality. Controlled for adipositas, Katzmarzyk and Janssen reported a relative risk for all-cause mortality of approximately 0.80 for physically active persons (Katzmarzyk & Janssen, 2004). Despite high prevalence in the population, there has been far less research on physical inactivity in comparison to other risk factors, such as smoking. Prevention efforts can reduce the risk of CVD, diabetes, high blood pressure, obesity, depression, and blood lipids even among older people (World Health Organization, 2002). Duration and level of exercise are important in reducing the risk of negative health effects. Even 60 minutes of vigorous exercise per week – or 150 minutes of moderate physical activity – can reduce the risk of CVD by up to 30% (World Health Organization, 2002). 56

As with unhealthy eating, the level of physical activity in the population is difficult to measure. In the CCHS, physical activity is classified as active (≥3.0 kcal/kg/day), moderately active (1.5-2.9 kcal/kg/day), and inactive (≤1.5 kcal/kg/day). This classification is based on participants’ responses on questions about frequency, duration, and intensity of leisure-time physical activity over the last three months before the interview. Table 16 shows the proportion of physically inactive Canadians. Worldwide, physical inactivity is responsible for 20% of CVD deaths (World Health Organization, 2002). Fortunately, Canadian trend data show that physical inactivity decreased over the past decade from 79% in 1981 to 63% in 1995 and remained on this level until 1999 (Canadian Fitness and Lifestyle Research Institute, 2000). Physical inactivity generally increases with age (Table 16). Despite a decreasing trend in physical inactivity, many Canadians cannot recall any guidelines for physical activity (Canadian Fitness and Lifestyle Research Institute, 2005) Katzmarzyk and colleagues report that, in 1999 about 2.5%, or $2.1 billion of direct health care costs in Canada were attributable to physical inactivity. They estimate that a 10% reduction in the prevalence of physical inactivity could result in a saving of $150 million per year. Using 1995 data, they also found that if physical inactivity in Canada were totally eliminated it would increase life expectancy and save 21,340 lives lost prematurely each year, or 10.3% of total deaths among adults (Katzmarzyk, Gledhill, & Shephard, 2000). These estimates were updated to $5.3 billion total economic costs in 2001, this time including direct health care costs and indirect costs due to premature death and resulting productivity losses. Of these, $1.6 billion were due to direct health care costs and $3.7 billion in indirect costs (Katzmarzyk & Janssen, 2004). The share of physical inactivity of the total health care costs rose slightly to 2.6%.

57

Table 16: Percentage of Canadians 12 Years and Over Who are Physically Inactive, by Sex, 2003 Total

Age Group %

Men n

%

Women n

%

n

12 – 34

38.6

3,719,843

33.9

1,651,169

43.4

2,068,674

35 – 64

50.8

6,690,635

49.9

3,278,130

51.7

3,412,505

65+

54.2

2,053,318

45.9

761,124

60.8

1,292,194

46.9

12,463,796

43.5

5,690,422

50.2

6,773,374

Total (12+) Source:


The Conference Board of Canada, using 1993 data, calculated that a 1% increase in the number of Canadians who were physically active would result in an annual saving of $877,000 (Conference Board of Canada, 1996). Physical inactivity is a major risk factor for CVD, and is associated with high blood pressure, Type 2 diabetes, breast and colon cancers, and osteoporosis. While it is related to obesity, physical inactivity poses an independent risk factor for chronic diseases and premature mortality. Physical inactivity has decreased among Canadians in the last two decades and in 2003 the Canadian Community Health Survey found 47% to be inactive. It has been estimated that a 10% reduction in the prevalence of physical inactivity could lead to a saving of $150 million per year, and if physical inactivity were totally eliminated this would positively impact 10% of total deaths among adults.

2.2.2

Unhealthy Eating Nutritional habits in industrialized countries are characterized by high consumption of

saturated fat, salt and sugar, and, at the same time, by low consumption of fruits and vegetables (World Health Organization, 2002). Although healthy weight is primarily related to healthy eating, the issue of nutrition by itself is a significant factor for chronic disease prevention. Excessive saturated fat and salt intake increase the risk for high blood pressure, which is a major factor in cardiovascular and renal diseases (Logan, 2005). Hypercholesterolemia, dyslipidemia and elevated triglycerides are a factor in both heart disease and stroke incidence: Prevention strategies should include a reduced intake of total fat and salt, and an increase in consumption of fibre (Hunter, 1993, Lagiou, 2002).

58

The role of diet in cancer causation is complex and difficult to unravel, but ample evidence exists to support recommendations for healthy eating. Reducing meat and animal fat intake, increasing consumption of vegetables and fruits, and reducing alcohol intake have been shown to reduce the risk of cancer overall and more specifically breast and colorectal cancers (Hunter et al., 1993). Daily diets high in vegetables and fruits are estimated to reduce cancer incidence by 20% (World Cancer Research Fund and the American Institute for Cancer Research, 1997). The estimates for reduction in burden of breast cancer range from 33% to 55%, for prostate cancer from 10% – 20%, and from 66% to 75% for colorectal cancer (Young & Le Leu, 2002). A combined prevention effort targeting several risk factors, such as physical inactivity, obesity, and unhealthy diet, could lead to a reduction of cancer mortality by 29% in the next 20 years (Adami, Day, Trichopoulos, & Willett, 2001). In the past, the authors conclude, primary and, to a lesser extent, secondary prevention has reduced cancer mortality by 13%. To date, the impact of unhealthy eating on chronic disease mortality and morbidity remains difficult to measure. Diets change over time, also, PAFs are difficult to estimate due to confounding effects of other risk factors and measurement problems, where reported nutritional intake and actual intake can vary substantially, (see, for example, Kristal et al., 2000; Lock, Pomerleau, Causer, Altmann, & McKee, 2005; Pomerleau, Lock, McKee, & Altmann, 2004). Data on nutrition intake on a national and provincial level is limited, although some efforts have been made (Krueger & Associates, 2005a). For the purpose of this report we will focus on number of times per day that participants consumed fruits and vegetables as assessed in the CCHS in 2000/01 and 2003 (Statistics Canada, 2004). It should to be noted that the assessment of food intake in terms of 5 servings of fruits and vegetables tends to underestimate actual intake (Kristal et al., 2000). In 2004, CCHS data will contain a 24-hour recall section on nutritional intake and therefore provide a more precise measurement of food consumption among Canadians. Figures 31 and 32, and Table 17 show further information about the intake of fruits and vegetables by Canadians. From 2000/01 to 2003, the age-standardized prevalence of less than 5 servings of fruits and vegetables dropped from 62,086 per 100,000 to 55,789 per 100,000 for both sexes combined. Nevertheless, the rate remains on a high level and contributes significantly to the burden of disease in Canada.

59

Figure 31: Percentage of Canadians 12 Years and Over Who Eat Fruits and Vegetables Less Than Five Times Daily, by Age Group, Males, Canada, 2000-2003

Year

80

2000/2001 2003

Percent

60

40

20

0 Total

12-19

20-34

35-44

45-64

65+

Age Group (years) Source:


Figure 32: Percentage of Canadians 12 Years and Over Who Eat Fruits and Vegetables Less Than Five Times Daily, by Age Group, Females, Canada, 2000-2003

Year

80

2000/2001 2003

Percent

60

40

20

0 Total

12-19

20-34

35-44

45-64

Age Group (years) Source:


60

65+

Table 17: Percentage of Canadians 12 Years and Over Who Eat Fruits and Vegetables Less Than Five Times Daily, by Age Group and Sex, 2003 Total

Age Group %

Men n

%

Women n

%

n

12 - 34

55.8

5,374,146

60.1

2927,652

51.3

2,446,494

35 - 64

57.7

7,596,028

65.1

4273,883

50.4

3,322,145

65+

44.9

1,698,017

49.6

823,605

41.1

874,412

55.2

14,668,191

61.3

8,025,140

49.3

6,643,051

Total (12+) Source:


Nutritional habits are significant factors in chronic disease prevention. Reducing meat and animal fat intake, increasing consumption of vegetables and fruit and reducing alcohol intake have been shown to reduce the risk of cancer overall, and specifically breast and colorectal cancers. While data on nutritional intake are limited, there is an indication of a recent modest decline in the proportion of Canadians who eat fruit and vegetables less than 5 times daily.

2.2.3

Overweight and Obesity Worldwide, the per capita kcal intake increased from 2,947 in 1964/66 to 3,380 kcal in

1997/99 and is projected to be 3,440 kcal in 2015 among industrialized countries (World Health Organization, 2002). Guidelines established by the World Health Organization and adopted by Health Canada and Statistics Canada categorize adults in three categories based on their weight and height or Body Mass Index (BMI) 5 . The classification is somewhat arbitrary and varies by population, ethnicity, and sex (World Health Organization, 2002). Table 18 shows the weight classification scheme for adults over 20 years old. With increasing BMI, the risk for developing health problems, such as premature death, CVDs, diabetes, high blood pressure, osteoarthritis, and some cancers increase as well (Paeratakul, Lovejoy, Ryan, & Bray, 2002).

5

Other agencies set higher limits of overweight (BMI ≥ 27.0). This report adopts the categorization of Health Canada and Statistics Canada. The BMI has limited accuracy for children and the elderly. For children, a slightly different classification is recommended. For persons 65 and older the normal range is slightly shifted upwards.

61

Table 18: BMI Classification and Corresponding Risk of Developing Health Problems Classification Underweight

BMI (kg/m2)

Risk of developing health problems

< 18.5

Increased

Normal weight

18.5 – 24.9

Least

Overweight

25.0 – 29.9

Increased

Obese class I

30.0 – 34.9

High

Obese class II

35.0 – 39.9

Very high

Obese class III Source:

≥ 40

Extremely high

Health Canada. Canadian Guidelines for Body Weight Classification in Adults. Ottawa: Minister of Public Works and Government Services Canada; 2003

Although related to nutrition and physical inactivity, obesity and overweight pose an independent risk factor for chronic diseases and premature mortality. Controlling for physical activity level, Katzmarzyk and colleagues reported an elevated relative risk for all-cause mortality of approximately 1.23 for overweight people (BMI ≥ 25.0) (Katzmarzyk, Janssen, & Ardern, 2003). Obesity is a risk factor for CVD, both directly as a risk factor, and indirectly through its relationship to hypercholesterolemia, hypertension, and diabetes (Heart and Stroke Foundation of Canada, 2003; Ledoux, Lambert, Reeder, & Despres, 1997; National Institutes of Health, National Heart, & National High Blood Pressure Education Program, 1997). The prevalence of obesity, both generally and abdomen-specific (waist-hip ratio) increases with age, and is accompanied by an increased prevalence of high blood pressure, elevated levels of low-density lipoproteins (LDL cholesterol) and triglycerides, and Type 2 diabetes (Katzmarzyk et al., 2003; Kelley & Goodpaster, 2001). The relationship between obesity and cancer is complex and not yet clearly understood. Obesity in women is related to cancers of the gallbladder, breast, cervix, endometrium, uterus and ovary. Women who are above 35% of their ideal body weight (normal BMI 18.5-24.9) have a 55% higher chance of developing these cancers than do leaner women. In men, obesity is most closely related to cancer of the colon and prostate. Men who are above 35% of their ideal body weight (normal BMI 18.5-24.9) have a 40% greater chance of developing these cancers than do leaner women (Colditz, DeJong, Hunter, Trichopoulos, & Willett, 1996). Due to the complex nature of interrelationships among chronic disease risk factors it is difficult to partial out the unique contribution of obesity to chronic disease prevalence. Using

62

self-report data, studies have shown that in comparison to normal-weight individuals, obesity alone is associated with an increase of 67% for chronic conditions, such as diabetes, hypertension, asthma, heart disease and cancer. This increase is higher than, for example, for poverty (58%), or smoking (25%) (Sturm & Wells, 2001; Sturm, 2002). Regardless of chronic conditions, obesity is also associated with less health-related quality of life, comparable to that of living in poverty (Sturm & Wells, 2001; Sturm, 2002). BMI prevalence is easy to estimate based on self-report data. However, it has to be noted that self-report data provide conservative estimates of prevalence of obesity and actual rate might be higher (Campagna et al., 2002). Based on data from the CCHS (2003), 3,547,995 people in Canada are obese (BMI ≥30) and therefore at greater risk for chronic diseases. Between 1985 and 2000, the proportion of deaths from all causes attributable to these risk factors increased from 5.1% to 9.3% for adults between 20 and 64 years of age. The total number of deaths associated with overweight and obesity in this period sums up to 57,000 (Katzmarzyk & Ardern, 2004). Studies in the US have shown that male and female non-smokers lose three years of life due to overweight, and obesity in 40 year old adults is associated with a loss of 5.8 years in males and 7.1 years in females (Peeters et al., 2003). Another study showed that PYLL increase with age in overweight people (Fontaine, Redden, Wang, Westfall, & Allison, 2003). In combination with smoking, obese smokers lost more than 13 years of life compared to normalweight smokers (Peeters et al., 2003). Based on data from the NPHS and CCHS, between 1994/95 and 2003, the agestandardized prevalence rate for unhealthy weight shows no clear pattern (Figure 33). While being overweight decreased between 1998/99 and 2000/01, it rose again slightly in 2003 to 33,108 per 100,000. Obesity shows a steady increase over time after 1996/97. In 2003, the prevalence (age-standardized) had increased to 14,832 per 100,000, up from 11,950 in 1996/97. This corresponds to an increase of 24.1%.

63

Figure 33: Age-Standardized Prevalence Rate (Canada 1991) 18 Years and Over for “Unhealthy Weight” (BMI ≤18.5 or ≥25), by Sex, Canada, 1994-2003 Sex

70,000

Both Females Males

Rate per 100,000

60,000

50,000

40,000

30,000 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year Source:


According to the 2003 CCHS cycle, the overall number and percentage of the Canadian adult population who are overweight or obese is 11,477,019 (48.2%), with 56.9% of the male population and 39.6% of the female population being overweight or obese (Statistics Canada, 2004). For overweight alone (BMI 25.0 – 29.9), the rate of overweight males is 1.5 times the rate of female overweight Canadians (41.0% and 25.7%, respectively). In 2003, a total of 3,547,995 Canadians over the age of 20 years were considered obese. Men showed higher rates across all age groups. Also, the BMI increases steadily with age, more so for being overweight than for obesity. Sex differences are more pronounced for overweight, with men having 1.5 times the rates of women, regardless of age. Combining overweight and obesity rates, a total of 11,477,019 Canadians 20 years and over, or 48.2%, exceeded the recommended body weight (BMI ≥ 25.0). Birmingham and colleagues examined the economic impact of obesity to the health care system using a cost-of-illness approach. With a slightly different definition of obesity (BMI ≥27), the direct costs included in their study involve hospital care, physician and other health professional services, drug expenditures, other health care, and costs of research. They 64

concluded that the direct costs to the Canadian health care system in 1997 were $1.8 billion (2.4% of total health care costs) (Birmingham, Muller, Palepu, Spinelli, & Anis, 1999). Katzmarzyk and Janssen reported overall economic costs of $4.3 billion in 2001, including direct health care costs $1.6 billion as well as indirect costs due to productivity losses $2.7 billion. These sum up to 2.2% of the total health care costs in Canada in 2001(Katzmarzyk & Janssen, 2004). Obesity is a risk factor for a number of chronic diseases, both directly and indirectly, as noted above. There is a complex relationship between obesity and cancers and for both women and men who are 35% above their ideal body weight. Studies based on self-report data indicate that in comparison to normal-weight individuals, obesity is associated with a 67% of chronic conditions, such as diabetes, hypertension, asthma, heart disease and cancer. It is estimated that the proportion of deaths from all causes attributable to these factors increased among adult Canadians from 5% to 9% between 1985 and 2000. Prevalence of these risk factors shows no clear pattern over the past 10 years. Nevertheless the 2003 Canadian Community Health Survey indicates that 48% of adult Canadians were overweight or obese. The direct and indirect costs to the Canadian health system from these risk factors are estimated to be in the billions.

2.2.4

Tobacco Smoking Smoking is responsible for about 30% of all cancer deaths in Canada (Ontario Tobacco

Research Unit., 1995), and accounts for about 85% of all new lung cancer cases (Doll, Peto, Wheatley, Gray, & Sutherland, 1994). Tobacco consumption is causally related to cancers of the lung, mouth, larynx, esophagus and stomach, bladder, kidney, leukemia and pancreas (US Department of Health and Human Services, 2004). Studies documenting these relationships go back more than 40 years. The most convincing evidence comes from prospective follow-up studies, such as the original British Doctors Study (Doll, Peto, Boreham, & Sutherland, 2004), and an American Cancer Society study of one million men and women (US Department of Health and Human Services, 1989). In addition to the above cancers, about 25% of colon cancer can be attributed to smoking for 30 or more years (Heinenman, Haor Zahm, McLaughlin, & Vaught, 1994). Besides causing lung cancer, smoking and the exposure to environmental tobacco smoke causes more than 80% of all COPD (Canadian Lung Association, 1993).

65

Regarding CVD, the evidence is sufficient that smoking causes abdominal aortic aneurysm, atherosclerosis, cerebrovascular disease, and CVD (US Department of Health and Human Services, 2004). Far more people are affected by tobacco-related CVD than by lung cancer (World Health Organization, 2002). Evidence for a causal relationship with breast cancer is inconclusive (Department of Health and Human Services, 2004). Smoking during childhood or youth also can have a non-reversible effect on the lung function in later adolescence and early adulthood. Smokers’ risk of heart attack and stroke is more than twice that of nonsmokers (Dawber, 1980; Shinton & Beevers, 1989). The risk can increase four-fold in combination with certain genetic predispositions (World Health Organization, 2002). Smoking acts with other risk factors to greatly increase the risk for CVD and influences several factors that may increase insulin resistance and interfere with insulin action (Faccini, Hollenbeck, Jeppsen, Chen, & Reaven, 1992). Smoking therefore may be associated with the development of type 2 diabetes, although the evidence is preliminary (Faccini et al., 1992). The increase in risk for chronic diseases and premature death due to tobacco smoking are partially reversible (US Department of Health and Human Services, 2004). After smoking cessation, the risk of developing lung cancer is reduced by 50% if smoking would be stopped before the age of 50, when smoking is stopped before 30 years, the risk attributable to tobacco is reduced by 90% compared to continuing smokers (Doll et al., 2004; Peto et al., 2000). In the United States, 22.1% of all adults are current smokers while 18.9% report being former smokers. Thus, about 46% of people who once were smokers have successfully stopped. Attributable fractions for mortality of other chronic diseases are 27% for all CVD deaths in 2002 (ischaemic heart disease = 14%), 22% for all respiratory diseases deaths (COPD = 19.9%), and approximately 2.2% of all deaths of the non-smoking population (Baliunas et al., manuscript in preparation). Smoking accounts for about 85% of all new cases of lung cancer (US Department of Health and Human Services, 1989). The elimination of smoking would have a major impact on cancer and myocardial infarction mortality rates. Baliunas and colleagues estimated tobacco-attributable deaths in Canada in 2002 at 37,207, of which 23,766 were among men and 13,441 among women. Smoking-attributable deaths accounted for 16.6% of all Canadian deaths in 2002 (Baliunas et al., manuscript in preparation).

66

Age-standardized prevalence rates of current smokers (daily and occasional) confirm the downward trend among Canadians (Figure 34). For both sexes combined the age-standardized prevalence rate fell from 30,702 per 100,000 population in 1994/95 to 24,268 per 100,000 in 2003. Figure 34: Age-Standardized Prevalence Rate (Canada 1991) 15 Years and Over for Current Smokers (Daily and Occasional), by Sex, Canada, 1994-2003 Sex 35,000

Both Females Males

30,000

Rate per 100,000

25,000

20,000

15,000

10,000

5,000

0 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year Source:


The percentage of young smokers (daily or occasionally) declined for both sexes in the same period from 20.9% in 1994 to 14.8% in 2003. Contrary to rates among the general population, among 12-19 year olds more females than males smoke daily or occasionally, although the difference became small in recent years (see also Table 19).

67

Table 19: Percentage And Number Of Canadians 12 Years And Over Who Are Current Smokers (Daily or Occasionally), by Sex, 2003 Total

Age Group %

Men n

%

Women n

%

n

12-19

14.8

490,404

14.4

244,134

15.2

246,270

20-34

29.9

1,886,990

33.4

1,057,101

26.3

829,890

35-44

28.2

1,495,339

31.1

830,499

25.3

664,840

45-64

22.9

1,802,696

24.3

946,405

21.6

856,290

65+

10.8

409,780

11.4

189,215

10.4

220,566

22.9

6,085,209

25.0

3,267,353

20.9

2,817,856

Total (12+) Source:


Exposure to second-hand smoke is another form of hazardous effect of tobacco smoking and also very common in Canada. The smoke from a cigarette inhaled by non-smokers contains more hazardous substances than inhaled smoke. In addition, it contains more tar (70%), more carbon monoxide and more nicotine. Environmental tobacco smoke (ETS) is linked to lung cancer, CVDs, respiratory diseases such as asthma and bronchitis, and cancer. There is sufficient evidence, based on human studies, to show that ETS is a human carcinogen, with a causal relationship between passive exposure to tobacco smoke and lung cancer in non-smokers (US Department of Health and Human Services, Public Health Service, & National Toxicology Program, 2001). Regular ETS exposure increases the risk of heart attack (Law, Morris, & Ward, 1997) and stroke (Bonita, Duncan, Trueisen, Jackson, & Beaglehole, 1999) in non-smokers. Results from epidemiological studies provide strong evidence that exposure of children to second-hand smoke is associated with increased rates of lower respiratory illness, and increased rates of middle ear effusion, asthma, and sudden infant death syndrome (American Academy of Pediatrics Committee on Environmental Health, 1997). The risk of lung cancer among non-smokers who are exposed to second-hand smoke increases by 20% compared to non-exposed non-smokers (Health Canada, 2005a). It is estimated that 62,000 people die each year from heart disease caused by passive smoking in the US (World Health Organization, 2002). Recent meta-analyses for the relative risk of dying from ETS estimated a relative risk of 1.21 for lung cancer (Richard, Robert, Alistair, & Megan, 2001) and 1.24 for ischaemic heart disease (de Groh & Morrison, 2002). In 2002 in Canada, ETSattributable deaths accounted for 2.2% of all deaths in that year (male: 831; female: 507). 68

Rates of exposure to second-hand smoke have been declining since 1965 and in 2003, a total of 10.5% of non-smokers over the age of 12 years in Canada were exposed to second-hand smoke at home (Table 20). The percentage of exposed varies by age and sex. Table 20: Percentage of Non-smoking Canadians 12 Years and Over Who are Exposed To Second-hand Smoke at Home, by Sex, 2003 Total

Age Group %

Men n

%

Women n

%

n

12 - 34

15.8

1,138,699

16.8

596,077

14.8

542,623

35 - 64

8.1

794,988

8.5

402,852

7.8

392,136

65+

6.4

214,524

7.3

106,840

5.7

107,684

10.5

2,148,211

11.3

1105,768

9.8

1,042,444

Total (12+) Source:

Statistics Canada, Canadian Community Health Survey.

Exposure to ETS is of special concern in children. In Canada in 2003, 14% of children aged 0-11 years were exposed regularly to second-hand smoke at home, 19% of children aged 12-17 years (Canadian Tobacco Use Monitoring Survey, Household component, February December 2003). The percentage of children aged 0-11 years declined to 12% in 2004 and remained stable for 12-17 year olds (Canadian Tobacco Use Monitoring Survey, Household component, February - December 2004). Tobacco use is associated with many cancers and is estimated to contribute to 30% of all cancer deaths and 85% of all new lung cancer cases. It is a causal factor in a number of CVDs and respiratory diseases, and interacts with other risk factors. It is estimated that 17% of all Canadian deaths in 2002 were attributable to tobacco smoking. Studies of ETS have shown a causal relationship between passive exposure to tobacco smoke and lung cancer in non-smokers, increased risk of heart attack, respiratory illness and stroke. In Canada, both rates of smoking (daily or occasionally) have been declining, as has reported exposure to second hand smoke.

2.2.5

High Blood Pressure High blood pressure is defined as a systolic blood pressure ≥140 mm Hg or a diastolic

blood pressure ≥ 90 mm Hg. The cut-off for treating high blood pressure might be even lower when other risk factors are present, such as diabetes or kidney disease. High blood pressure is a

69

major independent individual risk factor for CVD and is the most important factor in the development of CVD. An increase of only 10 points of diastolic blood pressure, or an increase of 20 points in systolic pressure doubles the risk of CVD (World Health Organization, 2002). Moreover, high blood pressure is common as an antecedent for end-stage renal disease, second only to diabetes (Chobanian et al., 2003). According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 30% of adults in the US are unaware of their hypertension and 40% with hypertension are not on treatment. Furthermore, two thirds of hypertensive patients are not being controlled to blood pressure levels less than 140/90 mm Hg. Incidence of ischaemic or hemorrhagic stroke is reduced substantially by controlled blood pressure. Because doubling of CVD risk already begins at levels of 115/75 mm Hg, health promoting lifestyle changes are indicated at systolic blood pressure above 120 mm Hg or above 80 mm Hg diastolic (Chobanian et al., 2003). High blood pressure is also associated with unhealthy diet, having diabetes, being physically inactive, excessive alcohol consumption, and being overweight or obese. Risk factors for hypertension include excess body weight, excess dietary sodium intake, reduced physical activity, inadequate intake of vegetables, fruits and potassium, and excess alcohol intake (Chobanian et al., 2003), which are also prevalent in the Canadian population. While the agestandardized prevalence of overweight (BMI 25-29.9) in Canada, as a risk factor for high blood pressure, decreased by 6.3% from 1994 to 2003, obesity (BMI ≥30) increased by 24%. A 5 mm Hg reduction in systolic blood pressure in the population would result in an overall reduction of stroke mortality by 14%, 9% for CVD mortality, and 7% in all cause mortality. Controlling high blood pressure would also reduce the incidence of stroke by 35-40%, and the incidence of heart attack by 20-25% (Chobanian et al., 2003). High blood pressure often goes undetected as it shows no early symptoms. A reduction of 4.5 kg in weight reduces and/or prevents hypertension in a large portion of the overweight population. The most effective lifestyle change remains quitting smoking (Chobanian et al., 2003). The risk of chronic diseases rises among people over the age of 50 years, as blood pressure usually rises with age (World Health Organization, 2002). In all age groups above 40, the death from heart disease or stroke increase linearly from blood pressure levels as low as 115 mm Hg systolic. For every increase by 20 mm Hg systolic, deaths from both stroke and ischaemic heart disease are doubling (Chobanian et al., 2003). Salt intake increases blood

70

pressure in people who already suffer from hypertension, in about 25% of people with normal blood pressure, and also in the overweight population (World Health Organization, 2002). People over 55 years who have normal blood pressure have a 90% lifetime risk of developing hypertension (Chobanian et al., 2003). Prevalence of hypertension among the Canadian population is high, but not as high as in the United States, where more than 65% of adults 65-74 years and 78% of adults over 75 are affected by hypertension (Fields et al., 2004); in Canada, the rates were 41% and 45%, respectively. Figure 35 shows the increase of age-standardized prevalence since 1994/95. The increase of the percentage of Canadians who have high blood pressure over the years cannot be fully explained by the shift in population as the population ages. The age-standardized prevalence rate increased from 8,856 per 100,000 in 1994/95 to 13,648 per 100,000 in 2003, this corresponds to an increase of 54.1%. The average systolic blood pressure of the Canadian population 30 years and over is even higher than in the comparable age group in the US (World Health Organization, 2002). As Table 21 shows that the proportion of the population who have high blood pressure increases rapidly with age, with a higher percentage of women (47.0%) affected than men (37.2%) in the 65+ years age group.

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Figure 35: Age-Standardized Prevalence Rate (Canada 1991) 15 Years and Over for High Blood Pressure, by Sex, Canada, 1994-2003 Sex

15,000

Both Females Males

Rate per 100,000

12,000

9,000

6,000

3,000

0 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year Source:


Table 21: Percentage of Canadians 12 Years and Over Who Have High Blood Pressure, by Sex, 2003 Total

Age Group

Men

Women

%

n

%

n

%

n

12-19

.6

20854

.6

10512

.6

10342

20-34

2.4

150916

2.7

86237

2.1

64680

35-44

6.4

341244

7.4

198292

5.4

142952

45-64

21.5

1692809

21.5

834821

21.6

857988

65-74

40.9

893207

37.3

383991

44.2

509215

75+

45.1

723137

37.0

232749

50.4

490388

14.4

3822166

13.3

1746602

15.4

2075564

Total (12+) Source:


High blood pressure is a major independent risk factor for CVD. It is associated with smoking, unhealthy diet, having diabetes, being physically inactive, excessive alcohol consumption, and being overweight and obese. It often goes undetected, as it shows no early 72

symptoms. There is a high prevalence of hypertension among older Canadians: 41% for those aged 65-74, and 45% for those over 75. Between 1994 and 2003 there has been an increase in age-standardized prevalence rate of high blood pressure for both male and female Canadians aged 15 and older. 2.2.6

Alcohol In the case of alcohol, despite of a vast array of scientific knowledge gained in the last 30

years, the importance of its contribution to overall burden of illness, and chronic diseases in particular, is still underestimated. Alcohol is related to over 60 medical conditions through various pathways. These include intoxication, resulting mostly in motor vehicle crashes, injuries and violence, and alcohol dependency, resulting mainly in, but not limited to, liver cirrhosis, and through direct biological effects, such as blood clot dissolution, pancreatic damage and risk for high blood pressure (Apte, Wilson, & Korsten, 1997). Alcohol-related harm includes liver cirrhosis, several types of cancer, CVDs, hypertension, and cerebrovascular disease (English et al., 1995). Because alcohol is widely available and consumed in Canada, the impact on society is enormous, not only due to chronic conditions, but also due to injuries and other acute consequences. Although heavy drinkers are at highest risk for negative health effects, the societal impact of moderate consumption is also high, in part also due to high prevalence rates (see below for definitions of drinkers by English et al. (1995). Alcohol consumption is related to cancer of the pharynx, esophagus, larynx, colon, rectum, liver, oral cavity, and breast cancer in women (even in low levels of consumption (Ridolfo & Stevenson, 2001; Smith-Warner et al., 1998). For breast cancer, consumption of 10g per day is associated with an increase in risk of breast cancer by 9%, 30-60g per day increase the risk by 41%. The relationship is linear and dose-related, meaning the risk increases with higher levels of consumption. Even low to moderate consumption is related to several cancers (Corrao, Bagnardi, Zambon, & Arico, 1999). The global burden of disease increased for both morbidity and mortality. From 1990 to 2000, the alcohol-related burden of disease and mortality increased from 1.5% to 3.2%, although these estimates are limited in their comparability due to methodological differences (World Health Organization, 2002).

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English and colleagues provided a widely used classification of alcohol consumption: among men, abstainers or very light drinkers drink 0-0.25g/day, low drinkers 0.25-40g/day, hazardous drinkers 40-60g/day, and harmful drinkers 60+g/day. Among women, abstainers or very light drinkers drink 0-0.25g/day, low drinkers 0.25-20g/day, hazardous drinkers 2040g/day, and harmful drinkers 40+g/day (English et al., 1995). Three dimensions have to be taken into account when examining harmful effects of alcohol consumption on an individual and a society as a whole. First, average volume of alcohol consumption (Bruun et al., 1975), second, patterns of drinking (Murray et al., 2002), and third, drinking that occurs outside of meals (Trevisan, Schisterman, Mennotti, Farchi, & Conti, 2001). The measure of drinking patterns has been less frequently included in epidemiological studies. Thus, there is a clear need for research into the influence of drinking patterns on conditions like cancers, liver cirrhosis, CVD, cerebrovascular diseases, and depression. Alcohol has been found to have a J-shaped relationship between average consumption and all-cause mortality. The protective effect of low and regular consumption applies only to certain CVDs in established market economies, mainly through an increase in high-density lipoproteins (HDL) (Rehm et al., 2003). There is also some evidence for a protective effect of moderate consumption on diabetes, (Ashley, Rehm, Bondy, Single, & Rankin, 2000). Among women and men 45 years and older alcohol consumption on a low level one standard drink (13.6 grams of alcohol) 6 for women and two standard drinks for men has a protective effect for ischaemic heart diseases compared to abstainers and higher and irregular consumption patterns. Episodic heavy drinking (5+ drinks on one occasion) increases the risk of heart diseases even when overall consumption is low to moderate. Therefore, although alcohol consumption also causes CVD deaths, the CVD net mortality is negative, meaning alcohol consumption prevents more CVD deaths than it causes (Holman, English, Milne, & Winter, 1996; Rehm & Bondy, 1998; Rehm, Gutjahr, & Gmel, 2001). The positive health effect is mediated through reduction of plaque deposits in arteries, and protection against blood clot dissolution (Zakhari, 1997). Irregular heavy drinking does not have a positive health effect. Although protective for some CVDs in parts of the population as pointed out above, drinking two standard drinks a day raises

6

This measurement comes from the Low-Risk Drinking Guidelines (Centre for Addiction and Mental Health).

74

the risk of cancer, and the risk increases with larger amounts (Ashley et al., 1997; Campbell, Ashley, Carruthers, Lacourciere, & McKay, 1999; Corrao et al., 1999). When comparing morbidity and mortality due to alcohol consumption, it becomes clear that for certain conditions, the proportion of morbidity is higher than the proportion of mortality due to alcohol. For example, neuropsychiatric conditions have a share of 38% of alcoholattributable Disability Adjusted Life Years (DALYs) and 6% of alcohol-attributable mortality (Rehm et al., 2003). Overall, the burden of disease caused by alcohol is far greater than the positive effects of alcohol. As scientific knowledge gained in the last years has shown, no pattern of drinking is risk-free. Recent evidence suggests a causal relationship of alcohol use to depressive disorders (Rehm et al., 2003). For western industrialized countries, attributable fractions for depressive disorders caused by alcohol were estimated at 9% for male and 2% for females (Rehm et al., 2003). Tjepkema, in an analysis of CCHS and NPHS data, examined the relationship between depression and alcohol use. As the author pointed out, heavy drinking more than once a week leads to episodes of depression and depression also leads to episodes of heavy drinking. In general, depression was more common among alcohol dependent drinkers (as per definition of Health Canada) with 15% of alcohol dependent drinkers having had a depressive episode in the past year in 2002 (Tjepkema, 2004). Table 22 gives an overview of attributable fractions in western societies with very low mortality rates. High levels are evident for liver cirrhosis, esophageal cancer, epilepsy, live cancer, and mouth cancers.

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Table 22: Population Attributable Fraction (PAF) for Alcohol-related Conditions in Western Developed Countries (WHO Region: The Americas A) PAF (%)

Condition Men

Women

Mouth and orophageal cancers

32

22

Oesophageal cancer

40

29

Liver cancer

34

22

Breast cancer

-

8

Unipolar major depression

9

2

43

26

100

100

29

17

Coronary heart disease

-13

-8

Stroke (hemorrhagic)

23

-13

2

-27

Diabetes

-6

-4

Liver cirrhosis

61

35

12.0

3.2

Epilepsy Alcohol disorder Hypertension

Stroke (ischaemic)

Total burden of disease Source:

Rehm et al., 2003.

A significant share of indirect economic costs of alcohol consumption comes from people who are not dependent. These costs are caused by occasional drinkers who face problems due to alcohol consumption, such as traffic accidents, Rehm and Gmel (1999) found that heavy drinking more so than average volume of drinking was associated with the occurrence of accidents. Their part of the costs is relatively high because their share of the population is high as well. Prevention measures and alcohol policies are a common theme in the literature, and for a discussion of these initiatives, including taxes and other control policies, please see Babor et al. (2003), Chisholm, Rehm, van Ommeren, and Monteiro (2003), Edwards et al. (1994), and Room, Graham, Rehm, Jernigan, and Monteiro (2003). The benefits of reduced overall consumption go beyond chronic diseases and include also a reduction of injuries (40% of alcohol-attributable morbidity, 46% of alcohol-attributable mortality in western industrialized countries). A vast majority of Canadians are classified as current drinkers (at least one drink in the past 12 months), and the age-standardized prevalence rate shows that this prevalence has

76

remained relatively stable over the last decade with a slight increase since 1996/97. The agestandardized prevalence rate for heavy drinkers, in this report classified as having had 5 or more drinks on one occasion more than 12 times over the course of the last 12 months prior to the interview, rose from 11,402 per 100,000 in 1996/97 to 17,795 per 100,000 in 2003 (Figure 36). This is of concern as the risk of negative health effects rises with the occurrence of heavy drinking patterns. Figure 36: Age-standardized Prevalence (Canada 1991) of Drinking Status among Canadians 15 Years and Over, by Sex, Canada, 1994-2003 Sex

100,000

Both Females Males

Rate per 100,000

90,000

80,000

70,000

60,000

50,000

40,000 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year Note: Source:

This figure presents the data in a different way then published on the website of Statistics Canada as it displays the rates of heavy drinkers among the total population, not among current drinkers. Statistics Canada, National Population Health Survey and Canadian Community Health Survey

In 2003, according to data from the CCHS, the vast majority across all age groups drinks alcohol. The percentage of current drinkers peaks among 20-34 year olds and declines at both ends. Slightly fewer women drink alcohol than men (Table 23). Heavy drinking prevalence is shown in Figure 37. Heavy drinking patterns show a peak among 20-24 year olds for both sexes, and declines to a total of 3.6% among those 65 years and older. Men, however, have more than double the rate compared to women. Almost half the male population 20-24 years old Canadians reported a heavy drinking pattern in 2003. A total of

77

4,274,481 or 16.9% of the Canadian population 15 years and older drink heavily (Table 24 and Figure 38). Figure 37: Age-standardized Prevalence (Canada 1991) of Heavy Drinkers (5+ Drinks on One Occasion 12 or More Times in The Past Year) 15 Years and Older, by Sex, Canada, 1994-2003 Sex

30,000

Both Females Males

Rate per 100,000

25,000

20,000

15,000

10,000

5,000

0 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year

Note: Source:

This figure presents the data in a different way then published on the website of Statistics Canada as it displays the rates of heavy drinkers among the total population, not among current drinkers. Statistics Canada, National Population Health Survey and Canadian Community Health Survey

Figure 38: Percentage of Heavy Drinkers (5+ Drinks at One Occasion 12 or More Times in the Past Year) among Current Drinkers, Canada, 1994-2003 Age group

35

12-19 years 20-34 years 35-44 years 45-64 years 65 years +

30

Percentage

25

20

15

10

5

0 1994-1995

1996-1997

1998-1999

2000-2001

2003

Year

Source:


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Table 23: Percentage of Canadians 15 Years and Over Who are Current Drinkers, by Sex and Age Group, 2003 Total

Age Group %

Men n

%

Women n

%

n

15 – 19

72.8

1,486,081

74.7

774,477

70.8

711,604

20 - 24

88.5

1,917,849

91.4

1,015,969

85.5

901,880

25 - 34

86.5

3,588,606

90.4

1,856,577

82.6

1,732,029

35 - 44

84.9

4,497,784

87.8

2,345,330

82.0

2,152,454

45 - 54

83.1

3,800,419

86.0

1,927,458

80.4

1,872,961

55 - 64

78.8

2,591,785

83.7

1,380,943

73.8

1,210,843

65+

68.2

2,581,251

76.4

1,267,769

61.8

1,313,482

80.9

20,463,776

85.1

10,568,522

76.8

9,895,253

Total (15+) Note: Source:

Current drinking is coded as having had at least one drink in the past 12 months. Statistics Canada, Canadian Community Health Survey

Table 24: Percentage of Canadians 15 Years and Over Who are Heavy Drinkers, by Sex and Age Group, 2003 Total

Age Group %

Men n

%

Women n

%

n

15 – 19

22.2

453,401

28.0

289,736

16.3

163,665

20 - 24

36.6

793,688

46.5

516,697

26.3

276,991

25 - 34

22.7

943,347

33.9

696,281

11.8

247,066

35 - 44

17.7

938,700

26.3

702,091

9.0

236,609

45 - 54

14.6

667,765

23.0

515,247

6.5

152,517

55 - 64

10.3

339,630

17.0

280,739

3.6

58,891

3.6

137,950

6.9

115,058

1.1

22,892

16.9

4,274,481

25.1

3,115,849

9.0

1,158,631

65+ Total (15+) Note: Source:

Heavy drinking is coded as having had more than 12 times 5+ drinks on one occasion in the past 12 months. Statistics Canada, Canadian Community Health Survey

A 2004 national survey found that 23% of past-year drinkers (15% of females and 30% of males) exceeded the low-risk drinking guidelines, with the highest proportion found among those aged 18 to 24. This study also reported that 17% (9% of females and 25% of males) were considered to drink hazardously – as indicated by the Alcohol Use Disorders Identification Test (AUDIT) (Adlaf, Begin, & Sawka, 2005).

79

Alcohol consumption is related to over 60 medical conditions through various pathways, these include traumatic incidents and events, but also chronic diseases, for example, liver cirrhosis, several types of cancer, CVDs, hypertension, cerebrovascular disease, and depressive disorders. For some types of cancer the relationship is linear and dose-related, with increased risk at higher levels of consumption. There is a protective effect from low and regular alcohol consumption for certain CVDs in developed countries. Nevertheless, WHO estimates of the disease, disability and death from alcohol (the net burden taking into account these protective effects) has indicated that its contribution to the burden of illness is just below that of tobacco in developed countries and higher than other risk factors. Both average consumption and drinking patterns have been linked with alcohol-related damage and death. Average consumption has been increasing in Canada since 1997, and survey data point to an increase in the proportion drinking in a high-risk manner (5+ drinks on one occasion at 12 or more times a year) between 1994 and 2003.

2.2.7

Substance Use According to Health Canada, the number of positive HIV tests has risen in the last five

years from 2,111 in 2000 to 2,529 in 2004 (Health Canada, 2005b). The percentage of women among positive tests has increased from levels of less than 10% before 1995 to 26% in 2004. Noteworthy, the largest increase in positive tests among females occurred in the population 1529 years (13% before 1995 and 42% in 2004). Overall, in 2004 in Canada, 26.6% of reported positive HIV tests occurred among women and 73.4% among men (Health Canada, 2005b). Populations at risk for HIV infection include injection drug users (IDUs), Aboriginal people, men who have sex with men (MSM), and women (Geduld, Gatali, Remis, & Archibald, 2003). The prevalence of HIV among IDUs varies between cities in Canada from 5.1% in Toronto in 2003 (Health Canada, 2004a; Health Canada, 2004b) to 25-30% in Vancouver (Bruneau et al., 1997; National Task for on HIV/AIDS and Injection Drug Use, 1997; Strathdee et al., 1997). Although the proportion of incidence of HIV infections among adults (≥15 years) attributable to injection drug use has declined from one third in 1999 (Office of the Auditor General of Canada, 2001) to 18.4% in 2003 (Health Canada, 2004a), injection drug use continues to be a major risk factor for the incidence of HIV infection. The HIV incidence attributable to

80

injection drug use was highest among the 40-49 age group (27.1%) and second highest among IDUs aged 30-39 years (25.8%) (Health Canada, 2004a). Because these figures were retrieved from surveillance data, they underestimate the number of people living with HIV because surveillance data report cases with detected and diagnosed infections and fail to capture unreported infections. Based on estimates from a Vancouver study (Patrick et al., 2001), the incidence rate of HIV was 16 per 100 person years. Because ethnicity data is not available for one third of all positive HIV tests and AIDS cases, exact prevalence rates among Aboriginals is unknown, though an increase of the percentage of Aboriginals among positive HIV tests has been observed in recent years (Health Canada, 2005b). Note that, because of availability of specific data, the total number of positive HIV tests on which the following figures are based differs from figure to figure. Figures 39 to 44 provide prevalence data on HIV in Canada. Figure 39: Number of Reported Positive HIV Tests in Canada, 1995-2004

3,000

Number of Positive HIV Tests*

2,500

2,000

1,500

1,000

500

0 1995

1996

1997

1998

1999

2000

2001

2002

2003

Year Note: Source:

* As reported to CICPC up to February 21, 2005 Centre for Infectious Disease Prevention and Control (CIDPC), Public Health Agency of Canada.

81

2004

Figure 40: Percentage of Reported Positive HIV Tests among Adults 15 years and Over, by Exposure Category, Canada, 1999-2004

50

Exposure Category MSM MSM_IDU IDU Hetero

40

Percent

30

20

10

0 1999

2000

2001

2002

2003

2004

Year Source:

Public Health Agency of Canada (2005). HIV and AIDS in Canada: Surveillance Report to December 31, 2004.

Figure 41: Crude Prevalence of HIV Infections in Canada, 1999 and 2002 Year

Exposure Category

MSM

2002 1999

MSM-IDU

IDU

Heterosexual

Other

Total

0

10000

20000

30000

40000

50000

60000

Prevalence Source: Note:

Geduld et al. (2003) MSM: men who have sex with men; IDU: injecting drug users; heterosexual: heterosexual contact with a person who is either HIVinfected or at risk of HIV, heterosexual contact as the only identified risk, or origin in a country where HIV is endemic; other: recipients of blood transfusion or clotting factor, perinatal and occupational transmission.

82

Figure 42: Crude Incidence of HIV Infections in Canada, 1999 and 2002

Year

Exposure Category

MSM

2002 1999

MSM-IDU

IDU

Heterosexual

Other

Total

0

1000

2000

3000

4000

5000

Incidence Source: Note:

Geduld et al. (2003) MSM: men who have sex with men; IDU: injecting drug users; heterosexual: heterosexual contact with a person who is either HIVinfected or at risk of HIV, heterosexual contact as the only identified risk, or origin in a country where HIV is endemic; other: recipients of blood transfusion or clotting factor, perinatal and occupational transmission.

Figure 43: Reported AIDS Cases in the Aboriginal Community in Canada, 1992-2002

Source:

Public Health Agency of Canada, HIV/AIDS Epi Update - May 2004

83

Figure 44: Positive HIV Tests Among Aboriginal and Non-Aboriginal Persons, by Sex and Exposure Category, Canada, 1998-1999

Source:

Laboratory Centre for Disease Control, Health Canada.

Injection drug use is the major risk factor for infection with hepatitis C virus (HCV) since transmission through infected blood transfusions has been nearly eliminated in the May 1990 (Canadian Liver Foundation, 2000; Laboratory Centre for Disease Control, 1999). About 10% of prevalent cases were caused by infected blood transfusions (Canadian Liver Foundation, 2000). The primary route of infection for HCV is through the sharing of equipment used for drug injection, such as needles, syringes, water, and cotton (Zou, Forrester, & Giulivi, 2003). The risk of getting infected rises with the length of injection practice. Other sources of infection with lower risk than injection drug use are sexual transmission (having multiple partners), mother-to-infant transmission, and tattooing (Alter et al., 1999; Laboratory Centre for Disease Control, 1999; Patrick, Buxton, Bigham, & Mathias, 2000). It is estimated that 0.8%-1.0% (250,000-300,000) of the Canadian population are infected with HCV. These are conservative estimates, because approximately 1/3 of all HCV cases have not been diagnosed. Of people infected with HCV, approximately 5,000-10,000 are also infected with HIV. Incidence is estimated at approximately 5,000 new cases of HCV each year. Prevalence peaks in the 30-39 years age group, and declines in younger and older age groups (Zou et al., 2003). It is estimated that up to 50% of prevalent cases and up to 75% of new infection of HCV are attributable to injection drug use in Canada (Remis, 2004; Zou et al.,

84

2003). The first six months of beginning with injection drug use are the critical period for infection with HCV. Other risks factors for HCV infection include HIV comorbidity, the sharing of needles and other drug paraphernalia, Aboriginal ethnicity, homelessness, and time in correctional facilities are other risk factors for HCV infection. Prevalence rates among IDUs are much higher than, for example, for HIV. Recent estimates range from 54.4% in Toronto (Health Canada, 2004b), 70% in Montreal, to 92% in Vancouver (Patrick et al., 2001). HCV is transmitted 10 to 15 times more likely than HIV. The burden of disease from HCV infections will continue to rise because the incubation period can be up to decades.

2.3

Distal Factors in Chronic Disease: The Social Environment The physical and social environments in which individuals and populations live are not

separate. Different groups and different individuals experience the environments and contexts in which they live in different ways (Raphael, 2004). For instance, environmental exposures are often related to social, economic and cultural factors such as employment, income, housing, race, ethnicity, types of food consumed, and how food is produced and processed. In order to engage in physical activity, and do so safely, an individual requires access to green spaces, clean water and protection from UV radiation. Diet and nutrition depend on the availability of safe and nutritious food. Healthy working environments and conditions require safe and secure workplaces. The poor are most likely to live in the polluted parts of cities, be malnourished, live in the poorest quality housing and work in dangerous or stressful jobs (if working at all) (Evans & Kantrowitz, 2002). While the idea that the physical and social environments in which we live have an effect on the decisions we make and the behaviours we engage in, the research evidence has not been as strong as for the proximal behaviours discussed above. Lack of sophistication in research and difficulties in establishing causality because of the complexity of models that take into account the social and physical environments has meant that there has been less convincing evidence of the role of the social environment (Yen & Syme, 1999; Smedley & Syme, 2000). While we generally conceptualize of the environmental factors discussed below as distal factors, the review of the evidence shows that in some cases these factors may actually operate directly (refer to Figure 29).

85

This section on distal factors is broken into smaller subsections. The first deals with the role of sociodemographic factors in relation to health, including geographic location, gender, race/ethnicity, and age. The second deals with the role of socioeconomic status (SES), which includes such factors as income, income inequality, employment, education and literacy, food security, and housing access. The third examines social relationships and their connections to health status. The fourth section details physical aspects of the environments in which individuals and populations live, including environmental exposures and aspects of the built environment. A final section discusses a specific example of environmental factors and how they shape behaviours: the obesogenic environment.

2.3.1

Sociodemographics Substantial research has been undertaken to examine the role of sociodemographic

factors. Sociodemographic factors have been considered mainly in terms of health inequities, which are avoidable and unjust differences in health and health access for certain groups (World Health Organization, 2002). Gender, age, culture, sexuality, ethnicity, race, and other social status variables are non-modifiable factors that are critical with regards to the socioeconomic environment. What is modifiable in order to address the inequities in health is the way in which different sociodemographic populations are responded to in policy and other areas. Gender in particular has emerged as a critical factor in understanding the role of the social determinants of health. We now know that, overall, women experience health very differently in comparison to men. Women have longer life expectancies than men, and experience different types of chronic conditions during their lifetimes (see Section 1). Both women’s and men’s health is detrimentally affected by their gender roles and statuses. Women experience not only disparities in health, but also in economic success, and have been culturally, sexually, physically, and historically marginalized (Spitzer, 2005). Women are particularly vulnerable also because of their multiple roles as workers and caregivers participating in both paid and domestic (unpaid) labour. Women tend to be more likely to occupy the lower income brackets than men (Vissandjee, Desmeules, Cao, & Abdool, 2004). Social determinants also appear to have greater influence among women in comparison to men in Canada and also operate with different dynamics depending on gender (Denton, Prus, & Walters, 2004; Prus & Gee,

86

2003). Thus there are three related issues with regard to gender and social determinants of health: differences in average incomes between men and women, income inequalities (for similar occupations or positions), and social/health gradients. The health status of racial/ethnic groups is also of particular concern. A recent special issue on health disparities in the Canadian Journal of Public Health included a review article of the health of Aboriginal peoples. Adelson (2005) found that Aboriginal populations experience a disproportionate burden of health and social suffering, and that this is linked to social, economic, cultural, and political inequities. Kaplan, Everson, and Lynch (2000) reviewed the contribution of social and behavioural research in understanding the distribution of disease. They found that, specifically in the U.S. context (as this was their research focus), there are substantial geographic variations in life expectancy and other health outcomes. There is no simple explanation for this heterogeneity. In their review, they found important effects between geographical location and race/ethnicity in relation to such chronic diseases as asthma and breast cancer. House and Williams (2000) reviewed the role of racial and ethnic factors in health disparities and found important links between race/ethnicity and socioeconomic status in both health outcomes and medical care. Further, they emphasize that one of the mechanisms through which racial/ethnic differences lead to disparities in health is through racism and discrimination, including access to health care. Discrimination and racial segregation have been shown to have negative effects on health (Jackson et al., 1996; Krieger & Sidney, 1996). Elderly populations are also of concern in Canada and may be distinctly more vulnerable to the social determinants of health. Specifically, a consideration of the role of age and life stage in the development of chronic disease emphasizes the need to develop prevention strategies with a life course perspective in mind.

2.3.2

Socioeconomic Status There have been a number of different measures of socioeconomic status utilized in the

literature. Some have been on the individual level (for instance, educational attainment, yearly income), and others on the population level (for instance, average neighbourhood income). The research below reviews the roles of income on the individual level and population level,

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education/literacy, and employment with regards to health, with a further consideration of housing access and food security. Associations between area or neighbourhood socioeconomic status and a number of health outcomes have been established in the literature, including all-cause mortality (Anderson, Sorlie, Backlund, Johnson, & Kaplan, 1997; Carstairs, 1981), CVD mortality (Logue & Jarjoura, 1990), chronic disease symptoms (Jones & Duncan, 1995; Payne, Coy, Milner, & Patterson, 1993), smoking (Kleinschmidt, Hills, & Elliott, 1995), and physical activity (Yen & Kaplan, 1998). Some of these studies also used measures of individual socioeconomic status in the analyses. A substantial literature has been built on the relationship between income and health inequalities. For the majority of health status indicators, there is an inverse relationship between diseases and socioeconomic position. The main conclusion of this literature is that people with higher incomes generally live longer, healthier lives than those with lower incomes. This relationship holds in a relative fashion (rather than an absolute relationship). Middle income individuals are less healthy than those in high income brackets, and low income individuals are less healthy than those in middle income and high income brackets. In 2001, 16.2% of the total Canadian population living in private households reported low-income (income level below the low-income cut-off line). The growth of income and wealth in Canada is seen mainly at the top of the ladder and is behind the growth of income inequalities (Morissette, Zhung, & Drolet, 2002). Evidence regarding income levels and health has emerged from large-scale survey data (Health Canada, 1999). Only 47% of the Canadians in the lowest income bracket rate their health as very good or excellent, compared with 73% of those in the highest income group (Health Canada, 1999). With each “rung” climbed in the “income ladder” (the income categories set out in the survey), Canadians were found to experience less sickness, longer life expectancies and improved health. In an analysis of census data for the provinces of Manitoba (N=8032) and Nova Scotia (N=2116), Roos, Magoon, Gupta, Chateau, and Veuglers (2004) found that mortality rates were lower for those individuals who were well-educated and earning higher incomes and that individual income had an increased importance relative to mortality in advantaged neighbourhoods. Recent evidence in Canada from an analysis of the National Population Health Survey (1994/95 and 2002/2003) indicated that among middle-aged adults

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aged 45 to 64, socioeconomic characteristics such as the education level and household income were more important determinants of healthy aging than lifestyle behaviours (Statistics Canada, 2005), though these findings are crude and require further investigation. The following figures (figures 45-48) show some of the relationships between proximal risks and income in Canada. 7 Figure 45: Percentage of the General Population Aged 15+ Years Who Were Daily Smokers, by Income Adequacy and Sex, Canada, 2001

Note: Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. * Interpret with caution: based on small sample. Source: Canadian Tobacco Use Monitoring Survey (CTUMS) Health Canada.

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Although we do not provide data in this report as for some other proximal risk factors, alcohol use shows a particular relationship. Individuals in higher income categories consume more alcohol than those in lower income categories, but those in lower income categories experience more negative consequences, possibly due to social exclusion, other proximal risk factors, and less protection from intervention by authorities.

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Figure 46: Percentage of Adults Aged 12+ Years in the General Population Who Were Physically Inactive*, by Income Adequacy and Sex, Canada, 2000

Note: Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. * Energy expenditure at or below the leisure time activity level (1.5 kilocalories/kilogram/day) Source: Canadian Community Health Survey.

Figure 47: Percentage of Adults Aged 20-59 Years in the General Population Who Were Overweight*, by Income Adequacy and Sex, Canada, 2000

Note: Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. * Overweight: self-reported BMI ≥ 25.0 Source: Canadian Community Health Survey.

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Figure 48: Percentage of the General Population Aged 12+ Years Who Consumed Less Than the Recommended Daily Amount of Fruits and Vegetables, by Income Adequacy and Sex, Canada, 2000

Note: Source:

Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. Canadian Community Health Survey.

In a community tracking study of 9585 U.S. adults, Sturm and Gresenz (2002) found a strong continuous association between health and family income as well as education. Those living in the poorest fifth of income were significantly more likely to report a depressive/anxiety disorder, high blood sugar or diabetes, hypertension or high blood pressure, and trouble breathing/emphysema/chronic lung disease. In a review of the risks of CVD, Raphael and Farrell (Raphael & Farrell, 2002) argue that the evidence indicates that CVD results primarily from material deprivation in combination with excessive psychosocial stress and the adoption of unhealthy coping behaviours. Similarly, diabetes in Canada appears to be a disease located within the poor and excluded (Raphael et al., 2003). Income appears to be linked to different lifestyle behaviours that contribute to chronic disease in Canada. For instance, Cragg and colleagues (1999) found a clear relationship between income and participation in physical activity for children and youth in a profile document of physical activity. Three quarters (75%) of children in high income families participated in organized sports at least weekly compared to 25% of low-income children and 82% of highincome vs. 65% of low-income children participated in unorganized sports.

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The income inequality hypothesis is not as strongly supported in Canada, even though we do have gaps between rich and poor (Ross et al., 2000; Statistics Canada, 1999a). In a study of income inequality and income measures (using data from NPHS and self-reported health status), McLeod et al. (2003) found that although low household income was consistently associated with poor health, the combination of low household income and residence in a metropolitan area with less income inequality was associated with poorer health status than residence in an area with more income inequality. In a review of income inequalities and health in Canada, Dunn (2002) concluded that tax and social safety net polices ameliorated the impacts of income inequality on health. Evidence from the U.S. also indicates that the relationship between income inequality and mortality/poor health is not consistently positive and that there are instances of no relationship between the two (Muller, 2002; Sturm & Gresenz, 2002). Being employed and feeling secure in your job are related to positive health outcomes for individuals in general. Employment has a significant effect on health by providing money, a sense of identity, social contacts, and opportunities for personal growth. Globalization, slow economic growth in the 1970s and recessions in 1980s and 1990s led to restructuring of work that has impacted the health of individuals. The workforce has been restructured to incorporate more temporary, part-time and contract positions rather than full-time permanent positions. Only about 50% of all working Canadians are in a full-time permanent job that they have had for more than 6 months (Tremblay, Ross, & Berthelot, 2002). Thus, half of Canadian workers are ‘precarious workers’ with limited job security and no employer-financed access to private health insurance. Precarious employment is a source of stress due to lack of income and meaningful work, uncertainty of the future, and its potential to undermine social support networks (World Health Organization, 1999). Working longer hours has been linked to high blood pressure and CVD, and moving to longer working hours can have negative impacts on certain proximal risk behaviours, including smoking, drinking, and poor diet (Statistics Canada, 1999b). Many Canadians, especially women, work numerous hours in unpaid work within the home, providing child and family care, and maintaining the household. More than one third of women aged 25-44 years who work full time and have children at home report that they are severely stressed (Jackson, 2002). Canadians with low literacy skills are more likely to be unemployed and poor and to suffer poorer health and die earlier than Canadians with high levels of literacy. Thus, the

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contribution of education to health outcomes can compound the other social determinants of health by limiting income and job access and heightening exclusion. In the NPHS (1996-1997) (Statistics Canada, 1997), 17% of Canadians fell into the lowest prose literacy category; this translates into about one in five Canadians. In 2001, 85.3% of individuals aged 25-29 were high school graduates and 55.7% of individuals aged 25-54 had graduated from post-secondary education. The links between health and education are relatively consistent. In the1996-1997 National Population Health Survey, 19% of respondents with less than a high school education rated their health as excellent, compared with 30% of university graduates. This result is consistent with what was found in the 1994 NPHS (Cott, Gignac, & Badley, 1999). Thus, the less education an individual had received, the lower likelihood of excellent self-ratings of health. In a study of Ontario adults aged 18-64, the Canadian Cancer Society (2005) reported that those with the least education constituted the greatest proportion of overweight/obese women (57%) and those with the lowest education were least likely to eat 5 servings of fruits and vegetables per day. The relationship between education and physical activity was also different between the genders. Men who were university graduates were less active than men with other levels of education, while women with post-secondary education were more likely to be active (Cancer Care Ontario: Insight on Cancer, 2003). In a study of high school graduates and nongraduates in Canada, it was found that high school graduates use preventative medical services 11% more frequently, make 2% fewer multiple visits to doctors, have 23% better knowledge of health behaviours, have 13% better general health status, and have 26% better family functioning (Federal, Provincial, Territorial Advisory Committee on Population Health, 1999). The following figures (figures 49-52) show the distribution of proximal risk behaviours by education.

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Figure 49: Percentage of the General Population Aged 15+ Years Who Were Daily Smokers, by Education and Sex, Canada, 2001

Note: Source:

Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. Canadian Community Health Survey

Figure 50: Percentage of Adults Aged 12+ Years in the General Population Who Were Physically Inactive*, by Education and Sex, Canada, 2000

Note: Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. *Energy expenditure at or below the leisure time activity level (1.5 kilocalories/kilogram/day) Source: Canadian Community Health Survey

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Figure 51: Percentage of Adults Aged 20-59 Years in the General Population Who Were Overweight*, by Education and Sex, Canada, 2000

Note: Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. * Overweight: self-reported BMI ≥ 25.0 Source: Canadian Community Health Survey.

Figure 52: Percentage of the General Population Aged 12+ Years Who Consumed Less Than the Recommended Daily Amount of Fruits and Vegetables, by Education and Sex, Canada, 2000

Note: Source:

Taken from Heart and Stroke Foundation of Canada: The Growing Burden of Heart Disease and Stroke in Canada 2003. Canadian Community Health Survey

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Income is a critical factor regarding access to adequate housing and healthy, nutritious food. Low-income Canadians have limited funds in order to access these basic requirements. The reduced expenditures on social housing and social assistance and the lack of replacement funds by the private sector in the provision of affordable rental housing have led to a housing crisis in Canada (Bryant, 2002). Many epidemiological studies have tended to focus on the isolated aspects of housing and health, such as the presence of mould and the development of respiratory infections or overcrowding and its impact on mental health. Focusing only on these material characteristics of housing fails to explain how people end up in poor housing (Bryant, 2002). Housing is a multi-dimensional concept. It includes the house, the physical structure and design characteristics, the home, the social and psychological characteristics, and the neighbourhood, the physical area around the house, local services, and social characteristics (Moloughney, 2004). Moloughney (2004) reviews the state of knowledge and finds numerous linkages between housing and health. Definitive evidence exists for the following biological, chemical, and physical housing exposures in relation to ill health: lead, radon, asbestos, house dust mites, cockroaches, home safety/stairs, heating system, smoke detectors, environmental tobacco smoke, and cold/heat. Possible evidence indicates that overcrowding, structure, housing tenure, and housing satisfaction may have health effects, but consensus has not yet been reached. Homeless populations experience a much greater incidence of a variety of negative health conditions, and a lack of adequate housing can aggravate other problems associated with low income (Bryant, 2002). A survey in Toronto of homeless people found that they had a much higher risk in comparison to the general population for many chronic conditions, including respiratory diseases, arthritis, rheumatism, high blood pressure, asthma, epilepsy, and diabetes (Ambrosio, Baker, Crowe, & Hardill, 1992). For those Canadians in the lowest income brackets over two-thirds of income is utilized to meet the basic needs of housing, transportation and food. People run out of money for food in many cases because the grocery budget is flexible, unlike rent (McIntyre, 2002). Food insecurity refers to lack of access to adequate, nutritious food through socially acceptable means (McIntyre et al., 2003). Vozoris and Tarasuk (2003) determined in analyses of the 1996/1997 National Population Health Survey that 4% of Canadian households were food insufficient (i.e., sometimes or often did not have enough food to eat). In a study of 141 low-income mothers with

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at least 2 children under the age of 14 in Atlantic Canada, McIntyre et al. (2003) found that food insecurity was reported by 78% during the month-long study period, with mothers’ dietary intakes consistently poorer than those of their children. Although 20%-35% of households that report hunger or food insecurity indicate that they have sought assistance through charitable food sources like food banks and children’s meal programs (Che & Chen, 2001; McIntyre, Connor, & Warren, 2000; Vozoris & Tarasuk, 2003), there is evidence to suggest that the food acquired does is not sufficient to address the food deprivation for these households (Tarasuk & Beaton, 1999). In Canada, household food insecurity has been shown to be correlated with CVD, high blood pressure and diabetes (Vozoris & Tarasuk, 2003). A study in Metropolitan Detroit found that the spatial accessibility of large “chain” supermarkets was related to neighbourhood composition. African Americans were located in more impoverished neighbourhoods and had consequently reduced access to supermarkets (Zenk et al., 2005). Thus, socioeconomic status can be measured by a number of factors, including income (individual and neighbourhood), employment and job conditions, and education. All of these factors in turn have effects on access to the basic necessities of food and housing. In general, low socioeconomic status is associated with poorer health outcomes and increased risk of chronic disease.

2.3.3

Social Support Networks – Social Exclusion Some groups in Canada experience social exclusion – poor social and economic

conditions and inequalities regarding access to resources, support and services, and low civic engagement in mainstream society. These groups include Aboriginal peoples, immigrants and refugees, racialized groups, people with disabilities, single parents, women, the elderly, and lesbian-gay-bisexual-transgendered (LGBT) persons (Galabuzi, 2004). Poverty is a key cause and product of social exclusion and its impacts on health status are well established (Kawachi, Kunz, Milan, & Schetagne, 2001; Wilkinson, 1996). In addition to the negative health effects of relative deprivation, the actual experience of inequality and the stress associated with dealing with exclusion tend to have psychological effects that impact negatively on health status (Wilkinson, 1996).

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There have been four types of social exclusion described in the literature (Galabuzi, 2004): (1) social exclusion from civil society through institutional mechanisms, (2) society’s denial of social goods to certain groups, (3) exclusion from social production (denial of active contribution to social and cultural activities), and (4) economic exclusion (unequal access to livelihood and economy). Social exclusion can occur on the individual and community level, and many of the characteristics are mutually reinforcing. For instance, individuals who live in low-income neighbourhoods may have unequal access to housing, employment, and social services, and experience isolation, disconnection and higher health risks (Galabuzi, 2004). Having a support network of friends, family and community has been shown to be associated with more positive health outcomes (Galabuzi, 2004). Social support appears to be important in helping individuals deal with health issues. Social support also provides a ‘buffer’ or sense of well-being that can improve health outcomes. Marchand, Demers, and Durand (2005) reported on analyses conducted in a sample of 9501 workers in Quebec, which indicated that support available from social networks outside work was associated with reductions in psychological distress, which may be an important factor in overall health. In an analysis of the National Population Health Survey (1994/95 and 2000/01 components), Shields (2004) found that stress levels were higher among those who were less educated and less affluent and that emotional and social support moderated the relationship of chronic conditions related to stress in some ways. Intervention programs based on the Population Health Promotion Model may serve to improve situations of social exclusion by providing social interaction and support for individuals participating in the programs, as seen in a collective kitchen program in Calgary (Fano, Tyminski, & Flynn, 2004). Social policy has the ability to mobilize civil society to instigate social change, thus contributing to active citizenship and social inclusion (Vaillancourt, 2002). Strong, positive social relationships and networks of individuals and populations can serve as important buffer to negative health outcomes. Understanding how exclusion and isolation affect health is critical to examinations of the development of chronic disease.

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2.3.4

Physical and Built Environments The physical environment in which Canadians live has an important role to play in the

development of chronic disease. Although the Canadian physical environment is generally healthier than many others within a global perspective, there is increasing concern regarding rising levels of contaminants in the air, water, food, soil, buildings and other structures, as well as the consequences of climate change and exposure to radiation in the environment (Health Canada, 1999). It is also important to remember that physical environmental exposures are not limited to national boundaries. Canada does not sit in isolation with regards to the influence of the physical environment on the health of its citizens. The WHO conceptualizes global environmental hazards in two broad classes (World Health Organization, 1997): 1) traditional hazards related to lack of development (e.g., inaccessible safe drinking water, inadequate sanitation), and 2) modern hazards related to development which lacks appropriate health and environmental safeguards (e.g., climate change, ozone depletion, urban air pollution). Of primary concern for Canada are the latter, where sustainability of the environment is critical (von Schirnding, 2002). The earth’s natural filter to ultraviolet (UV) radiation is stratospheric ozone. Ozonedepleting chemicals (chlorofluorocarbons or CFCs), commonly used in air conditioners, refrigerators, and pesticides, have contributed to this depletion. When the ozone’s protective layer dissipates, there is increased passage of UV radiation to the earth’s surface. This is especially critical in the summer months, where spending time outside (with resulting sun exposure) is more likely and lengthier. Increased exposure to UV radiation has been shown to be related to skin cancer (melanoma and non-melanoma) development (Colditz et al., 1996). Indeed, evidence in Canada indicates rising levels of melanoma (an often fatal type of skin cancer) over the past 35 years are related to intense and intermittent exposure to UV (Health Canada, 1999). In a developed country such as Canada, one of the primary concerns with regards to environmental health is the release of greenhouse gases into the atmosphere and the resulting changes to air quality and climate. Greenhouse gases (e.g., carbon dioxide, nitrogen dioxide, methane) come primarily from the use and burning of fossil fuels, with the greatest quantity of use in Canada related to industry and transportation. While rising global temperatures can have some positive effects for Canada, such as longer periods for agricultural growth, there is also the 99

possibility of increased heat-related disease and the prolongation of smog over urban areas (World Health Organization, 2003). Further, increases in global temperature could also lead to increases in pollens and allergens (e.g., insect and animal antigens, moulds), which are critical in the development of allergic asthma (Peden, 2000). Air pollution in Canada is also related to the use of fossil fuels. The concentration of air pollution occurs primarily in urban areas, due to the use of fossil fuels in transportation and industry. This concentration is referred to as ‘smog’: a combination of transportation and industry emissions that takes on a brownish or yellowish colour and hazes over urban areas, primarily in summer months. 8 Urban ambient air pollution has been shown to be related to increased mortality in Canada and other countries (Pengally, Campbell, Ennis, Ursitti, & LiMiller, 2000; Moolgazkar, 2000; Stieb, Judek, & Burnett, 2002). In a study of mortality rates in11 Canadian cities, 8% of nontraumatic deaths were related to combined effects of carbon monoxide, nitrogen dioxide, ground level ozone, and sulfur dioxide (Burnett, Cakmak, & Brook, 1998), which translates into about 5000 premature deaths annually (Abelsohn, Stieb, Sanborn, & Weir, 2002). The existence of carbon monoxide in the air has been shown to be related to the development of CVD (Brunekeef & Holgate, 2002; Leikin, 2000; Rosenman, 1990). Diesel engine exhaust has a strong relationship with the development of lung cancer (Haugen, 2000). Air pollution (specifically ground level ozone, diesel engine exhaust, nitrogen dioxide and sulfur dioxide) is also a critical factor in the development of non-cancer respiratory diseases including asthma and COPD (Brunekeef & Holgate, 2002; Leikauf, 2002; McConnell et al., 2002; Solomon, 2003). Stieb et al. (2002) conducted an analysis of the costs and benefits of reducing acute cardiorespiratory morbidity related to air pollution in Toronto. They determined that the decrease in particulate sulfur concentrations in Toronto between 1984 and 1999 led to annual benefits of $1.4 million with regards to reduced emergency department visits and hospital admissions for cardiorespiratory illnesses. Canadians in general have access to a clean water supply. However, not all individuals have access to clean water, particularly those in remote areas and Aboriginal communities on

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However, the absence of visible haze over urban areas, does not necessarily mean that the air quality is of low risk, since many air pollutants do not necessarily create visible smog, and there can be high risk days for pollution during any time of the year.

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reserves. In a survey of water supplies in British Columbia, van Netten and colleagues (2002) found that, of 73 communities who returned a survey questionnaire with regards to their water supply, 25 reported a lack of primary disinfection, leaving them vulnerable to preventable drinking water contamination. Thus, Canada is not ‘immune’ from some of the ‘traditional hazards’ linked to poor development. Some toxins from industry, including pesticides (PCBs and DDT) are water-soluble and individuals and communities may be exposed. Pesticide exposure (often through contaminated drinking water) has been shown to lead to certain cancers and gastrointestinal diseases (Aschengrau, Rogers, & Ozonoff, 2003; Leikin, 2000; Snedeker, 2001). While development and industrialization have been critical in contributing to pollution in air, water and soil and have been instrumental in climate change and ozone depletion, there are certain aspects of the built environment that pose particular risks for the development of chronic disease. Transportation in urban areas is increasingly reliant on vehicles that produce fossil fuel emissions. These emissions have been implicated in the development of chronic diseases such as CVD, cancers, asthma, and other respiratory diseases (see above). This increasing reliance on motor vehicle transportation in the built environment also has an impact on alternative methods of transportation. Since the built environment in most urban areas is ‘car-centric’, alternative options such as walking or biking may be limited, although they continue to be viable suggestions to improve both physical activity and limit air pollution. Indoor environmental health is a critical factor in respiratory health, with negative health effects labeled as ‘sick building syndrome’ (Bass et al., 2003). Exposures to asbestos and lead can occur, especially in older buildings. Changes in the social welfare system and the increases in poverty across the country, when considered in light of increases in rents, likely mean that individuals and families are increasingly living in poorer quality housing, particularly in urban areas. These residential buildings may have asbestos, which has been linked to the development of cancer (Browne & Gee, 2000), poor indoor air quality in general, lack of access to clean water, overcrowding, building defects, pests, and high levels of noise (Raphael, 2003). Recently, a workshop headed by Cancer Care Ontario, regarding environmental exposures and cancer, was held (Krieger, Ashbury, Purdue, & Marett, 2003). A number of areas where improvements are needed were discussed, including research, surveillance and prevention, indicating that we do not yet know the full extent of the role of environmental exposures in

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relation to chronic disease. The factors of interest included both aspects of the natural physical environment and the built environments in which Ontario residents live. There is thus work ongoing in the area of the environmental factors in relation to chronic disease, emphasizing that these are factors of concern.

2.3.5

The Obesogenic Environment The built environment as we experience it today has had specific influence in some of our

health behaviours, including the consumption of food and engagement in physical activity. The social trends that precipitated the development of the obesogenic environment are many, and include the escalation of reliance on cars, increases in “busy-ness” and lack of time, and the rising use of convenience and prepared foods (Banwell, Hinde, Dixon, & Sibthorpe, 2005). Economic factors, including technological advancements, have also been implicated (Finkelstein, Ruhm, & Kosa, 2005). Components of the built environment include urban design factors, land use, available public transportation, and physical activity options for those living in the space (Handy, Boarnet, Ewing, & Killingsworth, 2002). These features of the built environment can facilitate and hinder physical activity and healthy eating (Jackson & Kochtitzky, 2001; Giles-Corti, Macintyre, Clarkson, Pikora, & Donovan, 2003). In a review of the existing literature on the role of the built environment in the development of obesity, Booth and colleagues (2005) found promising data that link neighbourhood of residence with obesity risk. Changes in the average daily consumption of food have been propelled by a sociocultural environment where forces lead towards gaining weight (Chopra & Darnton-Hill, 2004). The expansion of fast food restaurants and proliferation of soft drink/snack food vending machines have encouraged eating outside the home (Hinkle & Wu, 2003). For instance, a recent survey of Americans found that only 38% of meals eaten were home-made and many people had never cooked a meal from basic ingredients (Gardner & Halweil 2000). Income also has a role to play in this relationship, with one study showing poorer neighbourhoods having three times fewer supermarkets than wealthier neighbourhoods, but containing more fast food restaurants and convenience stores (Morland, Wing, Diez-Roux, & Poole, 2002). In a study of food advertising and outlets near New Zealand schools, Maher and colleagues (2005) found that the majority

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(61.5%) of advertisements within a one kilometer radius of the schools studied were for food and that 70.2% of these food advertisements were for foods classified as “unhealthy”. Furthermore, out of those schools that did sell meals to students, the proportion of these with advertised salad options was significantly lower in low socioeconomic status neighbourhoods. There are thus important differences and restrictions on the food options available to individuals and populations in modern society. Corporations are contributing to the development and persistence of the obesogenic environment in several ways: convincing people to consume more, and more highly energy dense, foods through relentless advertising and ubiquity of outlets; by increasing serving size and adding price inducements to order larger sizes; by substitution (reduction of agricultural products to simple industrial outputs that allows replacement by increasingly non-agricultural components) (Chopra & Darnton-Hill, 2004). Food advertising also has a role to play in the development of overweight and obesity (Lobstein & Dibb, 2005). Thus, it is obvious that many factors are operating and interacting on multiple levels and consequently leading to the development of obesity. Studies of the obesogenic environment indicate that changing diet and increasing physical activity is not simply a matter of individual behaviour change, but also requires substantial change on the macro/societal level in order to make healthful choices easy choices.

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3. FRAMEWORKS FOR HEALTH PROMOTION This section summarizes two generic types of frameworks: those focusing on the individual level and those on the population level. The individual level interventions are in place to facilitate change in individual or small group behaviours (e.g., via health education, counseling, treatment). The population level refers to frameworks that seek to address the burden of illness on a general population level, thus affecting the proportion of population engaging in certain behaviours and reducing overall chronic disease prevalence/incidence (e.g., via taxation schemes, environmental changes). Individual and population level interventions can include targeting to particular sub-populations.

3.1

Individual Level Models Since the major focus on the development of chronic disease has been on individual level

lifestyle risk behaviours, it makes intuitive sense that the major prevention models that have been relied on in the past (and still remain central) have also been on an individual level. These individual level intervention strategies are founded on cognitive psychology as their backbone and conceive that thoughts and the way information is processed in an individual can have a great impact on that individual’s emotion, motivation, and behaviour. Bandura’s Social Cognitive Theory (1989), which includes the important construct of self-efficacy, Ajzen’s Theory of Planned Behavior (1991), and Prochaska’s (1994) Stages of Change Model are three prevalent models for understanding health-related behavioural changes. According to the Theory of Planned Behavior (TPB), an intended behaviour is dependent on an individual’s attitude (whether or not he/she desires to behave that way), the subjective norm (what he/she believes to be other people’s judgments of the behavior), and the individual’s perceived control (their sense of whether they are capable of performing the behaviour). Behaviour, then, results from combinations of these three factors (Ajzen, 1991). In a study of dieting and weight loss, for example, perceived control (confidence in the ability to stay on a diet) was a better predictor of weight loss than was either attitude (desire to lose weight) or the subjective norm (how sensitive the individual is to social pressures on weight loss) (Schifter & Ajzen, 1985). Interventions based on the TPB aim at generating positive intentions in an

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individual to perform a target behaviour who previously was reluctant to do so (Fishbein & Azjen, 2005). The Social Cognitive Theory (SCT) suggests that behaviour is a function of interactions between the person and his/her environment, the personal ability to perform the behaviour, his/her expectation of the outcome of such behaviour, and his/her level of self-efficacy (the confidence that one can perform the behaviour). A review of past literature shows that selfefficacy, in particular, is a powerful predictor of health-related behaviours including smoking cessation, eating disorders, and CVD risk (AbuSabha & Achterberg, 1997). In general, improved self-efficacy for a task predicts improvement in actual performance of the task such that self-efficacy creates an increased effort towards and persistence at the task, leading to greater success. Research in oncology shows that high self-efficacy predicts increased adherence to treatment, decreased physical and psychological symptoms, and better adjustment to cancer diagnosis (Lev, 1997). Similarly, a chronic disease self-management program in the U.S. teaches participants to achieve better self-care by improving self-efficacy (Farrell, Wicks, & Martin, 2004). Bandura (2004) further suggests that a comprehensive approach to health promotion requires changes in social systems since they have such an important impact on human health. The Stages of Change Model (or Transtheoretical Model) operates under the assumption that for most people, change in behaviours occurs gradually. The model thus incorporates six steps: (1) precontemplation (where there is little consideration of making behaviour change because the individual is unwilling, unaware or uninterested in change), (2) contemplation (considering making a behaviour change and weighing the costs and benefits of change), (3) preparation (preparing to make a change and attempting some small changes), (4) action (taking definitive action), (5) maintenance (maintaining the new behaviour for a certain period of time), and (6) relapse (a normal part of the change process, where the individual can learn triggers of behaviours and where relapse prevention can be developed and implemented). Evidence for the effectiveness of the Stages of Change Model for change in certain behaviours including diet, smoking and exercise behaviour is not consistent, with some studies indicating benefit (Prochaska et al., 1994), and others indicating few added benefits in comparison to control conditions (Riemsma et al., 2002). Furthermore these models locate the entire “source of the problem” within the individual. If only the individual can progress through the stages adequately

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and engage in appropriate relapse prevention strategies and can change personal attitudes and beliefs with regards to health behaviours, then the individual will engage in the effective health behaviours. This view does not adequately take into account how beliefs about health may differ socially and culturally, nor how there may be specific barriers to changing health beliefs and behaviours. Although these individual level concepts are clearly relevant to chronic disease prevention, they should not be the only part of prevention frameworks and should work within a multi-level context, in order to optimize opportunities for effective prevention.

3.2

Comprehensive Population Level Models In an attempt to move away from purely individual level behavioural change in order to

prevent chronic disease, and due to an appreciation of the social influences on health, there has been a move towards more population level interventions. The primary model of population health that has been utilized to inform a number of more context-specific social environmental models is Brofenbrenner’s ecological model (1979). Figure 53 provides a graphical representation of his model. Figure 53: Bronfenbrenner’s Ecological Model (1979)

Source: http://sesd.sk.ca/psychology/ ecological.htm

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This model was first developed to explain child development, but has since been adopted in the area of general health promotion to understand how the individual interacts with the environment. According to Bronfenbrenner, each person is significantly affected by interactions among a number of overlapping ecosystems. At the centre is the individual. Microsystems are the systems that directly shape human development. The primary microsystems for individuals include the family, peer group, and neighbourhood. Interactions among the microsystems take place through the mesosystem. Surrounding the microsystems and mesosystem is the exosystem, which includes community structures and local educational, medical, employment, and communications systems that influence the microsystems and their interactions. And influencing all other systems is the macrosystem, which includes cultural values, political philosophies, economic patterns, and social conditions. This model shows how the individual does not exist in a vacuum and that the context has important effects that may be useful in the development of prevention models. McLeroy and colleagues (2003) take the ecological perspective on health promotion programs. Their ecological model includes intrapersonal factors (characteristics of the individual, including knowledge, attitudes, behaviours, skills, and developmental history), interpersonal processes and primary groups (formal and informal social networks and support systems), institutional factors (social institutions with organizational characteristics), community factors (relationships among organizations, institutions, and informal networks), and public policy (local, state, and national laws and policies). A specific framework that has recently been developed is the Expanded Chronic Care Model (Barr et al., 2003), which takes lessons learned from the management of chronic disease (for those who have already developed certain conditions) and utilizes them in combination with health promotion on a population level. By combining these two approaches and the evidence base supporting them, the goal is to prevent the development of chronic disease. The Expanded Chronic Care Model is very clinically-based, and it has been critical in assisting healthcare professionals in the development of effective interventions for individuals with existing chronic disease. The Expanded Model allows for the integration of population health strategies in the larger community and the involvement of health systems teams outside of the clinical setting. This is a new model that has been developed in British Columbia (Robinson, 2005) and being taken up in other Canadian sites. In Ontario, a draft Chronic Disease Prevention

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and Management Framework (Ministry of Health and Long Term Care, 2005) builds on central aspects of the Expanded Chronic Care Model (Barr et al., 2003; Robinson, 2005). The Social Ecological Model of Health Promotion (Hamilton & Tariq, 1996) is a comprehensive health promotion model that is multifaceted, and is concerned with environmental change, behaviour, and policy that help individuals make healthy choices in their daily lives. The ecological model takes into account the physical environment and its relationship to people at individual, interpersonal, organization and community levels. The underlying concept of the model is that behaviour does not occur within a vacuum. The Public Health Agency of Canada supports the use of the social ecological model for health promotion through the funding and support of hundreds of community based projects aimed at enhancing the capacity of individuals to engage in and shape their social environments. Figure 54 (below) provides a visual description of a population health approach to health promotion. Figure 54: Population Health Promotion Model

Source: Hamilton & Tariq, 1996

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A final population health model described in this section is from a social ecological perspective and seeks to make environmental changes to address a specific chronic disease determinant, obesity. The ANGELO framework is an ecological model for the prevention of obesity that was developed to conceptualize obesogenic environments and identify potential interventions (Swinburn, Egger, & Raza, 1999; Swinburn, Caterson, Seidell, & James, 2004). It is a grid framework which comprises two sizes of environments (micro and macro) and four types of environments (physical, economic, political and sociocultural) (see Table 25). Individuals interact with the environment in multiple micro or local settings, including schools, workplaces, homes and neighbourhoods. These micro settings are also influenced by broader macro environments or sectors, including the education and health systems, government, the food industry and societal attitudes and beliefs. These macro environments are less amenable to individual control. The physical environment refers to ‘what is available’, the economic environment refers to the costs related to food and physical activity, the political environment refers to the rules related to food and physical activity (laws, regulations, policies and institutional rules), and the sociocultural environment refers to a community’s or society’s attitudes, beliefs and values related to food and physical activity. The authors argue that this model is most valuable at the needs analysis and problem identification/prioritization steps of planning health promotion interventions for reducing obesity at a population level. It is useful for deconstructing the obesogenic environment with the goal of searching for appropriate interventions. The model was applied in New Zealand island communities and allowed participants to gain a wider view of environmental determinants which could be modified.

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Table 25: Examples of Prioritized Projects for Further Investigation in Pacific Island Communities

Type Size Micro setting Festivities

Neighbourhood

Physical

Economic

Recreation and sports facilities; safe walking paths; canteens serving local food Policies on physical education; promotion of traditional activities Home gardens Church leaders as role models

Churches Markets Macro setting Transport

Sociocultural

Cultural importance of high fat food

Schools

Homes

Political

Availability of local food Availability of buses and bus stops Policies and standard on imported food quality/labelling

Health regulatory system Source: Swinburn et al., (1999)

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All of the population health models frame chronic disease within a matrix of multiple contributing factors, with the physical and social environments as critical. The models incorporate multiple levels of intervention with regards to health, including the individual and the larger community, as well as government (to build healthy public policy). Whatever model is used in planning and implementing chronic disease prevention initiatives, several considerations are particularly noteworthy: •

The model should relate to and build upon current structures, institutions and processes.

•

The model should be cognizant of those institutions and processes that are most relevant to effective prevention.

•

It should facilitate incorporation of effective interventions.

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4. CHRONIC DISEASE PREVENTION INITIATIVES: DO WE KNOW WHAT WORKS? This section will detail the theoretical and empirical evidence for what works in chronic disease prevention. First, we revisit Rose’s work on individuals and populations to understand the implications for prevention. Next, we offer a commentary on the Canadian situation regarding chronic disease prevention. Third, we look to the lessons learned from tobacco interventions and how they can inform prevention for other chronic disease. Finally, we discuss the evidence in the literature for recommended practices regarding chronic disease. We choose not to refer to the practices we outline as best practices, as we feel that research and evaluation is still direly needed in order to establish currently evidenced or recommended practices as “best”.

4.1

The Implications of Rose’s Work for Prevention The arguments of causation in Rose’s work discussed in Section 2 on the

sociobehavioural risks of chronic disease have distinct implications for prevention. Rose (1985, 1992) argues that prevention efforts on the individual and population levels have their own distinct advantages and disadvantages. The “high-risk” strategy is the traditional medical approach to prevention. It seeks to achieve a truncation of the risk distribution by enacting special preventive action in high-risk individuals. The advantages of this method, according to Rose (1985), are that it provides an intervention appropriate to the individual, subject and physician motivation are relatively high, it is a cost-effective use of resources, and the benefit:risk ratio is favourable. The disadvantages of this prevention method are the difficulties and costs of screening for high-risk individuals, the fact that such prevention is usually palliative and temporary, the limited potential for the individual and the population, and that the interventions are largely behaviourally inappropriate (difficulties in changing individual behaviours). Rose (1985; 1992) discusses the population strategy as the alternative to the high-risk strategy. In its traditional public health form, the population strategy involved mass environmental control methods (for example, the provision of improved sanitation and clean water to populations). In its modern form, the population strategy is attempting (albeit less

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successfully) to alter some of society’s norms of behaviour. The advantages of this are that it is a radical strategy, it has a large potential for the population, and it is behaviourally appropriate. The disadvantages of this method are that it results in only a small benefit to the individual (the “prevention paradox”, discussed below), subject and physician motivation is low, and the benefit:risk ratio is not favourable. The “prevention paradox” presents particular challenges for interventions that seek to operate on the population level (Rose 1985; 1992). Preventive measures that bring much benefit to the population on the whole offer very little, especially in the short term, to each participating individual. Thus, while these initiatives are of enormous potential importance to the population as a whole, such public health measures may lead to poor subject motivation because of small benefit to each individual. Since negative health outcomes can result from factors that occurred substantial amounts of time earlier in an individual’s life, the results of incorporating preventive measures on the individual level may not be seen for years to come. This is another contributing factor to poor subject motivation, and also draws attention to the need to look at prevention across the life course. The main conclusion we can draw from Rose’s work is that prevention efforts through public health must confront the primordial distal factors of disease and disability in more direct ways (Ebrahim & Lau, 2001). Rose (1985) sees the high-risk strategy of prevention as an interim expedient that can be used to protect susceptible individuals but only as long as the underlying causes of incidence remain unknown or uncontrollable. By learning more about how to modify the social and economic factors behind health outcomes, we become more able to control and modify them, thus leading us to be able to implement population strategies to benefit a large number.

4.2

The Canadian Situation of Chronic Disease Prevention

4.2.1

Canadian Chronic Disease Prevention Programs and Frameworks Efforts were made during the preparation of this report to fully assess the Canadian

situation with regards to chronic disease prevention. This included contact to members of the Provincial/Territorial Alliance of the Chronic Disease Prevention Alliance of Canada, asking them to report on programs in their region that fell under at least one of the following criteria: (1)

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the program was on a large-scale, (2) the program was innovative, (3) the program had had some kind of evaluation. Few representatives responded with specific programs, and others directed the authors of this report to their respective websites. It became apparent that creating a list of the chronic disease prevention efforts currently underway in Canada would be a long and difficult process. We were also concerned about the possibilities of inadvertently omitting certain programs because of the particular search strategies that we may have undertaken. We believe this is an important task, but beyond the scope of the current report. While we do discuss some larger Canadian frameworks in the context of this review of ‘what works’, this is not to say that we are unaware of or ignoring the other initiatives that may exist. There are innumerable small- and large-scale chronic disease prevention programs currently underway in Canada, with some easily accessible and well publicized, and others more specific and confined to their particular communities. In Ontario specifically, there are five core strategies that provide direction for work in chronic disease prevention. These are the Ontario Tobacco Strategy, the Ontario Diabetes Strategy, the Healthy Weights Strategy, Cancer 2020, and the Ministry of Health and Long Term Care Report on Healthy Weights, Healthy Lives (see www.opha.on.ca/projects/ocdpa.html). We consider some of these documents below in our discussion of chronic disease prevention practices in Canada. We acknowledge that the Ontario Chronic Disease Prevention Alliance recently completed an environmental scan of chronic disease prevention and management strategies in Ontario (Lyons & Kungl, 2005). This scan concluded with some of the following observations: •

there is a lack of prevention focus in some disease strategies

•

private sector industries positively and negatively affect healthy public policy

•

there is a consistent application of social marketing

•

there is an absence of planned and cross risk factor communications and issues management

•

there are competing research priorities

•

there is a lack of healthy public policy and determinants of health integration in chronic disease strategies and health promotion infrastructure

•

knowledge exchange is underdeveloped

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•

there is a lack of systematic health professional development and retraining

•

there are some potential inconsistencies among provincial indicators of outcomes In recent years, a number of Canadian provinces have developed large-scale policy

documents with regards to chronic disease prevention. The large majority of the programs currently in place in Canada focus on established lifestyle risk factors of physical activity, healthy eating, and tobacco use. Programs have been implemented in a number of contexts, including schools, communities at large, and worksites, and take into consideration factors that extend beyond the individual level. However, there appears to be a gap between the more comprehensive policies and the actually instituted programs, which have a comparatively narrower focus. One of the most detailed and specific plans for addressing chronic disease currently in Canada is the Cancer 2020 plan in Ontario (Canadian Cancer Society & Cancer Care Ontario, 2003a). The goals of this program have been consequently implemented into other provincewide frameworks. The guiding principles of the strategy are: •

optimism (through the establishment of deliberately aggressive targets)

•

accountability

•

population health focus

•

evidence-based interventions

•

the precautionary principle (i.e., if the consequences of an action are unknown but likely have a high risk of being negative, then it is best not to carry out the action)

•

integration and collaboration

•

strategic use of resources. It is through these guiding principles that that vision of the action plan will be carried out,

with the following goals: •

to increase public understanding of health beyond traditional medical models to include social, economic and (physical) environmental determinants;

•

to develop healthier public policy in all health and non-health sectors; and 116

•

to develop a strong stable government spending plan on disease prevention and screening, specifically around cancer. The strategy encompasses multiple determinants of cancer: tobacco use, diet and

nutrition, healthy body weight, physical activity, alcohol consumption, occupational/environmental carcinogens, UV exposure, viral infections, and screening services for early detection. The specific targets (by the year 2020) for the initiative are provided in Appendix III. The report also sets out a detailed plan for the early detection and screening of cancer, but it is unclear as to the role this plays in the primary prevention of cancer itself. The Cancer 2020 report includes a substantial cost element and it is found that with the estimates of average cost of $22,000 per cancer case, over $375 million could be saved in direct health care costs over the 17 years of the program and would justify an increase in investment in cancer prevention to $20 million per year. The report goes further to state that great benefits would be achieved through meeting the targets on three factors alone: tobacco, fruit/vegetable intake, and physical activity. Although the report details some possible steps for short term and long term action plans underneath the entire “umbrella” of the program, the details for programs and initiatives for meeting the targets are unfortunately missing in the background/action plan document (although there is great detail about the implementation of screening programs). More generally, a specific plan of the initiatives that will be implemented to meet targets of chronic disease prevention frameworks is missing not just from Cancer 2020, but from the vast majority of documents detailing chronic disease prevention plans. In addition to the Cancer 2020 framework, another national strategy has been established. The national population health framework in place currently in Canada is entitled “The Integrated Pan-Canadian Healthy Living Strategy”. This framework has the goal of healthy living, which is defined as practices that are consistent with improving or maintaining health (including both individual and environmental factors (Public Health Agency of Canada, 2003). The components essential to healthy living that are the focus of the strategy are making healthy choices for diets, and engaging in physical activity. As part of this strategy, there are two reference documents that have been widely disseminated, Canada’s Food Guide to Healthy Eating and Canada’s Physical Activity Guide to Healthy Active Living (see Appendix IV).

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The strategy is an integrated approach, focusing on multiple settings for health, and encouraging the use of best practices. There is also a component of shared responsibility that recognizes that healthy living is not just the responsibility of individuals. The strategic directions of this Pan-Canadian initiative are leadership and policy, knowledge development and transfer, community development and infrastructure, and public information. This federal strategy recently received funding support of $300 million to improve diet and levels of physical activity in Canadians. Other risk factors for chronic disease, as they feature only minimally in the overall strategy, are unfortunately receiving only limited attention under this funding agreement. Some provinces have emerged with their own specific frameworks regarding healthy living and the prevention of chronic disease. These include the British Columbia Health Living Targets for 2010 (2005), the Alberta Healthy Living Network (2003), and the Nova Scotia Chronic Disease Prevention Strategy (2003). The national and provincial documents all endorse both individual and population level interventions with regards to chronic disease prevention. There is recognition that the social context shapes the lives of individuals and populations, and that we need to move away from explanations focusing only on individual responsibility. The focus of chronic disease prevention, however, is primarily on diet and physical activity. The role of tobacco in chronic disease development and in relation to prevention strategies is left primarily to the multi-level and comprehensive tobacco strategies already in place in many provinces (for example, Alberta and Ontario). These frameworks tend to ignore or gloss over the role of alcohol and other drug use in relation to chronic disease. While we recognize that diet and physical activity (as well as tobacco) have been shown to be the primary factors implicated in the development of chronic disease, we argue that there needs to be more inclusion of alcohol and other drug use in discussions and frameworks of chronic disease prevention. This inclusion is needed particularly in light of recent WHO analyses indicating that, in developed countries such as Canada, the burden of disease, death, and disability from alcohol is similar to tobacco and higher than other risk factors (World Health Organization, 2002).

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4.2.2 The State of Program Evaluation in Canada Many of the chronic disease prevention initiatives in Canada appear to come from a pragmatic orientation, with minimal information available on the underpinnings of programs. This may be the result of the disjuncture between programming and evaluation in the Canadian context; evaluation is not a central component of programming funding. While the extensive framework documents and prevention initiatives coming from the provinces are well-researched and consider the available research evidence, it is difficult to see how the framework and promising practices are applied in actual programs and initiatives. There is also a lack of communication and dissemination of information for individuals and organizations involved in chronic disease prevention in Canada. There are some exceptions to this, however, and a few of these evaluated programs will be described below. The Ontario Tobacco Strategy (Ontario Tobacco Research Unit, 2005a): The Ontario Tobacco Strategy (with research and evaluation supported by the Ontario Tobacco Research Unit), funded by the Ministry of Health and Long-Term Care, has the goals of prevention, protection, and cessation of tobacco use in Ontario. A recent evaluation detailed that the most of the strategy’s effort is directed to cessation and prevention (two thirds of total effort), while industry denormalization receives hardly any effort at all. In 2003, the Ontario Tobacco Strategy led the change in pricing for tobacco, and increased the price of cigarette cartons by $2.50, thus making it more financially difficult to purchase cigarettes. They are also focused on making the entire province of Ontario smoke-free by 2006, through systematic banning of smoking in public and some private places. Since 1999, the program has involved continually funded province-wide projects as well as community-specific projects (that have not been consistently funded over the last 6 years). The multitude of the community-based programs is beyond the scope of the current report. The province-wide programs supported under this strategy fall under three major categories: public education, assistance to smokers, and infrastructure development. Public education campaigns have been targeted at the population at large through large mass media campaigns (specifically through the Heart and Stroke Foundation of Ontario), and also specifically at youth, through websites and youth initiatives within the Ontario Lung Association.

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The provision of assistance to smokers has been established on a general population level through the implementation of a telephone helpline for smokers and the “Leave the Pack Behind” program to support smokers in smoking cessation. Infrastructure development includes an Aboriginal Tobacco Strategy, identification of better practices, clinical tobacco interventions, “Lungs are for Life” classroom curriculum, a media network, the Ontario Tobacco-Free Network, and TeenNet. These infrastructure programs are targeted at the population at large and at specific at-risk groups, including Aboriginal peoples, youth, and school children. The evaluation of the provincial programs is generally positive, but in most cases with modest results. Support has increased for province-wide tobacco control measures through the implementation of programs. There is still a current need to investigate different messaging and media strategies, as well as implementing more programs for the development of infrastructure. The Ontario Tobacco Strategy’s comprehensive approach to curbing tobacco use has served as a model for other provinces, including Quebec, Nova Scotia and New Brunswick, thus indicating its utility in the development of best practices. Ontario’s Heart Health Programs (Riley, 2005): In Ontario, there are 37 heart health programs that have been established to improve health related to CVD. Evaluation by an independent provincial level evaluator (for 4 years) was just recently completed regarding these programs to monitor province-wide trends. Figure 55 shows the model of heart health promotion that is utilized by these programs, emphasizing a multi-level approach.

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Figure 55: The Ontario Heart Health Program Model for Heart Health Promotion

Source: Riley (2005)

It was determined that the programs made impacts at three levels: organization capacity, programming, and environmental change and that the evaluation evidence supports continuation of the programs. Some of the successes detailed were: the development of a viable local infrastructure for population-based primary prevention, the contribution to environmental impacts, investments and resources, the partnership model and public health leadership for healthy living and chronic disease prevention, and the contribution to multiple risk factor programming. Areas for improvement for the programs included: health unit capacity, improvements to local-provincial linkages, province-wide implementation of heart health, increasing implementation of environmental support and policy initiatives. Sixty-seven percent of activities were allocated to awareness and education, compared to 12% for environmental support and policy approaches.

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Ever Active Adults Program (Alberta) (2004): The Ever Active Adults Program is an evidence-based course and curriculum that provides physical activity training for practitioners working in Alberta seniors’ housing. The participants receive training on how to increase physical activity opportunities for older adult residents. An evaluation was conducted by the Alberta Centre for Active Living to assess effectiveness, but this evaluation rested primarily on participants’ impressions of the value of the program and self-report measures of change. The evaluation of the program indicated that: the course gave coordinators the tools and knowledge needed to increase physical activity opportunities, the course positively affected coordinators’ practices, coordinators perceived positive changes in their lodges’ social and physical environments, coordinators realized that residents’ well-being could be positively affected by physical activity programs, and coordinators identified receiving support from residents and managers as key in allowing the implementation of programs. Program evaluation should be a critical component, given the level of damage attributable to chronic disease and the need to create interventions that are successful in reducing the burden. The current situation is primarily to evaluate process rather than outcome in chronic disease prevention. There is a distinct need for rigorous outcome research with regards to the programs currently ongoing. In Canada, the common or typical responses to chronic disease appear to be pragmatic and specific to the communities they serve. While there is a role for this, there also needs to be an overarching systems perspective included. If Canada is to take population health stance on the prevention of chronic disease and is to implement strategies using this approach, there is a need to establish rigorous evaluation frameworks and programs to establish best practices. Canada could be in a strategic position to become a central force in the evaluation of population health and environmental approaches to the prevention of chronic disease, especially since a number of provinces currently have frameworks to be implemented.

4.3

Lessons Learned from Tobacco Control In the section above, the Ontario Tobacco Strategy was discussed, but it is important to

note that there is a federal strategy to reduce tobacco use in Canada and each province and territory (with the exception of Saskatchewan) has supplemented the national strategy with its own tobacco control strategy (Ontario Tobacco Research Unit, 2005b). These tobacco strategies

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have drawn in many ways from the Ontario Tobacco Strategy and have implemented many of the similar initiatives, focusing on the provision of individual clinical care, education, mass media, regulation, and policy/legislation changes. These comprehensive approaches to tobacco in Canada, as well as those internationally, can serve as important models for framing chronic disease prevention in general. Tobacco strategies are among the first initiatives to fully and successfully implement environmental and policy approaches in combination with individual level interventions in order to address prevent and reduce tobacco use. There are important lessons that can be learned from the tobacco experience in order to further the discussion of chronic disease prevention. These findings are discussed below. In a recent review, Chopra & Darnton-Hill (2005) examined the strategies that had worked against the tobacco industry in efforts to reduce and prevent tobacco use, and developed similar strategies to target the food industry in order to help individuals and populations have healthier diets. They argued that the attempts by public health agencies and officials to restrict the food industry’s efforts to increase demand and sales are being resisted fiercely. They find that the food industry is using some tactics similar to those that were used by the tobacco industry: first, the half true contention that there is no such thing as unhealthy food, only unhealthy diets; second, the contention that the problem is not excessive diet but reduction in physical activity; and third, the smoke screen of conflicting scientific data about sugars and different fats. They go on to detail suggestions for responses against the food industry that mirror those for the tobacco industry: •

Accumulate and publicize evidence of health effects (governmental and non-governmental publication of evidence)

•

Exposure of industry advertising tactics through the release and dissemination of marketing strategies (for example, strategies targeted at young people, and event sponsorship)

•

Litigation: suing companies aggressively targeting young children

•

Labelling: health warnings on high fat food and high sugar soft drinks

•

Taxing: taxes on soft drinks and perhaps high fat foods

•

Publicize the social, economic, environmental impact: consumer group campaigns, identification and naming of the effects of obesogenic environments

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•

Increase awareness of the role of industry in supporting researchers: vigilance by journals and media on noting industry links and possible conflicts of interest, increasing publication of articles addressing the issue

•

Expose foreign governments that are enforcing the introduction and marketing of new brands into a country Chopra and Darnton-Hill (2005) acknowledge that it will be much more difficult to

establish internationally binding instruments or conventions like those achieved in tobacco control, but they argue that this should not put a stop to such changes. Potential international standards might cover issues such as marketing restrictions for unhealthy food products, restrictions on the advertising and availability of unhealthy products in schools, standard packaging and labeling of food products, or potential price or tax measures to reduce demand. Public attention can generate political capital for legislation. In a recent article published in the British Medical Journal, Yach and colleagues (2005) summarized the lessons that had been learned in tobacco control that can be useful to “speed up progress in tackling [the] new public health threats” (p.898) of unhealthy diets and lack of physical activity. The lessons they offer would also apply to reducing alcohol-related threats to public health: •

Address the issue of individual responsibility versus collective or environmental action early and often: “Healthy choices need to be easy choices”; governments, private interests and other sectors should work together to support individuals in making health choices.

•

Evidence of harm is necessary, but is not sufficient to motivate policy change: some essential epidemiological gaps need to be closed in relation to diets and outcomes.

•

Decisions to act need not wait for evidence of the effectiveness of interventions: sound judgment vs. evidence based.

•

Fully implement interventions known to be effective.

•

Real and perceived needs and concerns of developing countries need to be addressed even if they involve going beyond the initial scope of the risk being addressed.

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•

The more comprehensive the package of measures considered, the greater the impact: comprehensive partnerships, address constellation of risks with constellations of interventions.

•

Broad-based, well-networked, vertical and horizontal coalitions are key: all levels of health services, move outside traditional boundaries of health care.

•

Change in support for tobacco control took decades of effort led by media savvy

•

and politically astute leaders.

•

Modest, well-spent funds can have a massive impact, but without clear goals, funding may not be sustainable: well-spent, planned funds

•

Complacency that past actions will serve well in future may suppress future progress: need to look at new ideas and continue innovation (do not get stuck in addressing only lifestyle behaviours).

•

Rules of engagement with the tobacco and food industries need to be different and continually under review.

•

Risk factor envy is harmful – a joint approach is needed: focus on all risk factors rather than singling certain ones out at certain times. By drawing on what we have learned from the tobacco experience, it will be possible to

enact change with regards to chronic disease and health in general. The lessons from tobacco strategies reinforce the need to incorporate environmental components into frameworks and approaches to chronic disease. While the target still remains changing the behaviour of individuals, the point of attack no longer centres only on the individual, but on the population level.

4.4

Recommended Practices for Preventing Chronic Disease The goal overall of chronic disease prevention is to change behaviours, although the

“point of attack” does not necessarily have to be the individual. Thus, the presentation of recommended practices below considers the proximal behavioural factors that are implicated in chronic disease and the ways in which prevention can work, on both the individual and population levels. We consider the practices discussed below as “recommended” rather than

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“best” practices as we feel that the research and evaluation evidence is still needed. Our document can help to inform best practices in chronic disease prevention. Although we discuss in this section the evidence for recommended practices (“evidencebased” approaches to chronic disease prevention), we acknowledge the utility of interventions that have yet to receive full scientific and research “endorsement”. We refer, thus, to the precautionary principle. The precautionary principle states that “when an activity poses potential harm to human health or to the environment, precautionary measures to reduce exposure should be taken even if some cause-and-effect relationships are not fully established scientifically” (Canadian Cancer Society and Cancer Care Ontario, 2003a, p. 4 – based on initiatives by the Toronto Cancer Prevention Coalition). This is of particular importance for initiatives that operate on the population level or address the social environmental factors of chronic disease, as these areas have experienced less research concentration and less sophistication in methodology. In a broader context, the evaluation research for chronic disease interventions beyond tobacco and alcohol is, for the most part, glaringly missing. In a review of dietary change strategies, Bowen and Beresford (2002) found that individual level strategies (including sessions with nutritionists and educational/behavioural interventions) were the most researched and that the research for community approaches was very limited and, when available, largely inconsistent findings. In searching for evaluation studies regarding chronic disease prevention for this current project, this conclusion was very evident. It is, however, difficult to evaluate projects that do not fit within the medically-driven gold standard of the randomized controlled trial, as many do. Reviews of interventions for obesity, specifically around physical activity and improvements to diets show that there is a lack of high quality data on the effectiveness of obesity prevention, with minimal amounts of studies meeting criteria for evaluation and methodologies generally weak (Campbell, Waters, O'Meara, Kelly, & Summerbell, 2002; Ciliska et al., 2005; Joyal, 2004). Without this information, the establishment of best practices is not yet possible. More evaluation research on how to achieve healthy weights, through the implementation of effective policy and initiatives regarding healthy eating and physical activity is needed. Even in some cases where the environment is considered as playing a considerable role in the development of chronic disease, individual level models are still relied upon for the discussion of prevention interventions. For instance, Costain and Croker (2005) refer to the obesogenic environment in their review of issues surrounding obesity, yet recommend individual

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level interventions. They note that it has been argued that the modern obesogenic environment has taken body weight control from an instinctive survival process to one that require substantial and sustained cognitive and skill-based control, and that individuals need to make sustainable lifestyle changes supported by health professionals. Thus, while they succeed in noting the contribution of the environment in the development of obesity, they fail to include it in their presentation of prevention interventions. Tobacco control and alcohol use prevention are the areas in which established and reliable recommended practices on both the individual and environmental levels have been evaluated through systematic study. While there is recognition that healthy eating and physical activity are critical factors in determining chronic disease, comprehensive evaluted practices surrounding these determinants remain to be concretely established. There is a plan in place to develop a Canadian best practices system for chronic disease prevention and control (Public Health Agency of Canada, 2005). This process involves understanding the current state of knowledge, making decisions about the information based on priorities, implementing practices that address chronic disease and determinants of health and having a system in place to support and facilitate the decision-making process. This undertaking will allow for integration and expansion of the recommended practices that we detail below. Table 26 provides examples of evidence-based recommended practices for the main determinants of chronic disease, drawing on relevant literature. Alcohol and tobacco prevention practices are thoroughly documented and the evaluations have been relatively rigorous. For interventions regarding physical inactivity, unhealthy eating, and obesity, the evaluations are less consistent and, in many cases, lacking. Evaluations of interventions for illicit drug use focus on the individual still, and are mainly within populations of schoolchildren. Many of these practice recommendations fail to take into account the role of distal social and environmental factors. In the review of the Stanford Five-City, Stanford Three-Community, North Karelia, Pawtucket Heart Health and Minnesota Heart Health projects, Harvey and colleagues (Harvey, Hook, Kozyniak, & Selvanathan, 2002) indicated that mass media, program specific prevention initiatives (education and/or skill-building in multiple settings) and environmental action through policy and site development were the most important components for the reduction of CVD and

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related lifestyle risk behaviours. These findings are considered with regards to the different determinants listed below 9 . Table 26: Summary of Recommended Practices

Determinant (target) Physical activity GOAL: Increase physical activity

Limited evaluation research on effective strategies to increase physical activity

9

Recommended practice

Rationale/evidence

School-based multicomponent interventions (including physical education programs)

Programs designed to decrease sedentary behaviour in studies for reducing obesity in adolescent girls were effective in increasing physical activity (Matson-Koffman, Brownstein, Neiner, & Greaney, 2005; Raine, 2004)

Exercise referral schemes (interventions providing access to exercise activities/facilities)

Increase physical activity in certain populations (individuals who are already slightly active, older adults and those who are overweight) (Morgan, 2005). Targeted behaviour programs have been found to increase walking and cycling as an alternative to using cars (Foster & Hillsdon, 2004; Ogilvie, Egan, Hamilton, & Petticrew, 2004)

Prompts to increase stair use

(Matson-Koffman et al., 2005)

Access to places and opportunities for physical activity


Comprehensive worksite strategies

(Matson-Koffman et al., 2005; Raine, 2004)

Mass media campaigns

Should be seen as a part of comprehensive strategies (Foster et al., 2004)

Please note that these recommended practices are not presented in a priority order.

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Diet/nutrition GOAL: Improve diet, increase consumption of fruits and vegetables (Bowen & Beresford, 2002) Limited evaluation research on effective strategies to improve diet

Individual strategies: sessions with nutritionists, educational interventions, behavioural approaches (coupons)

Targeting individuals with interest in making large changes and larger population groups (for more modest changes). These were the most common type of intervention (individual/group counselling) and were successful in large changes

Family-based interventions

Interventions can come through individual providers and through community channels (religious organizations and education)

Point-of-purchase interventions

Public service announcements in grocery stores regarding fruits and vegetables leading to attitude change (Matson-Koffman et al., 2005; Raine, 2004)

School programs: comprehensive school health, school food policies

(Raine, 2004)

Availability of nutritious foods


Reminders and training to health care providers to give nutritional counseling


Pricing strategies

(Raine, 2004)

Food security programs and policies

(Raine, 2004)

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Healthy body weight

Low-fat diets

Low-fat diets are no better than calorie restricted diets for long-term weight loss (Pirozzo, Summerbell, Cameron, & Glasziou, 2002); lack of clarity regarding appropriate healthy diet for weight loss

School-based multicomponent interventions

Programs designed to decrease sedentary behaviour for reducing obesity in adolescent girls were effective in increasing physical activity (Clemmens & Hayman, 2004)

Dietary education and clinical interventions

Incorporate multi-media strategies (education, health promotion and/or psychological/family/behavioural/therapy/ counseling/management interventions) (Campbell et al., 2002)

Macro level interventions: community-wide and schoolbased campaigns, mass media strategies, laws and regulations, providing reminder systems, reducing costs to patients, home visits

(Institute of Medicine, 2004)

“Quit and Win” contests

Population-based smoking cessation interventions. While quit rates are above baseline community rates, the population impact is low because of program uptake. (Hey & Perera, 2005)

Workplace smoking cessation interventions: bans, social support, environmental support, individual level (therapy, counseling, nicotine replacement)

Individual level interventions for smokers increase likelihood of quitting. Consistent evidence that tobacco policies and bans decrease consumption during workday but conflicting evidence of overall cessation. Limited evidence of competitions and incentives (Moher, Hey, & Lancaster, 2005). Worksite tobacco control programs found 5% quit rates (Janer, Sala, & Kogevinas, 2002)

GOAL: Reduce body weight, maintain healthy weight

Tobacco use GOAL: Cessation of tobacco use

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Preventing tobacco sales to minors through active enforcement and multicomponent education strategies

Active enforcement more effective than giving retailers information. (Stead & Lancaster, 2005)

Tobacco taxation

Increasing prices on tobacco through taxation decreases purchase/use (Yach, McKee, Lopez, & Novotny, 2005)

School-based programs: Combine social influences and social classroom programs competence approaches (Thomas, 2002) (including family/community components) Prevention of smoking in public places through comprehensive multicomponent approaches

Policies banning smoking within institutions are more effective than posted warnings and educational material (Serra, Cabezas, Bonfill, & Pladevall-Vila, 2000). Comprehensive statewide tobacco control programs are effective and can produce dramatic declines in per capita cigarette consumption (Kelley & McCrory, 2003; Siegel, 2002)

Assistance to smokers (e.g., telephone helpline)

Ontario Tobacco Strategy uses specific targeted programs to support smokers in quitting (Ontario Tobacco Research Unit, 2005a)

Infrastructure development

Building sector linkages and developing programs/frameworks to address at-risk populations (Ontario Tobacco Research Unit, 2005a)

Public education and mass media campaigns

Increased support for tobacco-control measures through this method (Kelley & McCrory, 2003; Ontario Tobacco Research Unit, 2005a)

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Alcohol use GOAL: Reduce alcohol use and/or damage from alcohol use

Pricing and taxation increases

Higher alcohol prices reduce consumption. Although increased alcohol prices and taxes may increase illegal smuggling/sales, the net effect is a reduction in alcohol use and related problems.

Regulation of the physical availability of alcohol (total prohibition, reductions in hours/days of sale and number of outlets, regulations toward commercial vendors for sales to minors, making low alcohol beverages available)

There is evidence that total banning can lower drinking and reduce alcohol problems. Reductions in hours/days of sale, number of outlets and restrictions on alcohol access are associated with reductions in alcohol use and related problems. Costs of restricting availability are cheap relative to costs of the healthy consequences. Monopoly government systems for alcohol sales limit alcohol consumption.

Best practices from Babor et al. (2003) Reduce, but do not eliminate: protective effects of alcohol (Cordova, Jackson, BerkeSchlessel, & Sumpio, 2005)

Establishment of government-owned outlets Modifying the drinking context (Responsible Beverage Service Programs, limiting drinking, community mobilization, general safety measures)

Limiting drinking in contexts where alcohol is sold and consumed, including service regulations and implementing legal liability for bar staff and owners can reduce heavy consumption and high risk drinking. Community mobilization to raise awareness of problems associated with drinking are successful at reducing aggression. General safety measures for intoxicated people and modifying the behaviour of bystanders/victims is associated with lower levels of intoxication and problems

Drinking-driving countermeasures (punishment and increased visibility of enforcement, laws, treatment programs)

Although there is limited evidence supporting positive impact of punishment, celerity of punishment (proximity to crime) improves effects. Increasing the visibility of enforcement checkpoints leads to reductions in alcohol consumption and national/local laws for blood alcohol limits.

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Regulating alcohol promotion (advertising bans and legislation)

Advertising promotes and reinforces perceptions of drinking as positive and riskfree and legislations restricting alcohol advertising is a well-established precaution used by government. Self-regulation of advertising by industry does not work.

Education and persuasion strategies (school- and community-based)

School-based alcohol education programs have been found to increase knowledge and change attitudes, but actual substance use or damage from use remains unaffected. Activities inconsistent with alcohol use and building social skills important. Public service announcements are a useful supplement to effective interventions.

Multiple components

Directed at individuals, families, peers, schools, communities, media and the workplace (Skiba, Monroe, & Wodarski, 2004)

Current efforts focus on children and the individual (clinical, education)

Media

Prevention strategies to educated community, raise public awareness, develop community support, maintain momentum of established prevention efforts (Skiba et al., 2004)

Environmental approaches to substance use prevention are in theoretical stages only

Psychosocial strategies

Resistance skills, personal and social skills training (although need more information on how to implement programs that take into account gender, culture and socioeconomic status). Implementation of programs (particularly for at-risk groups of young people) that involve increased adaptation to social interaction demands and behavioural self-regulation (August et al., 2004; Skiba et al., 2004)

Illicit drug use GOAL: reduce and prevent illicit drug use and related harms

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Policy

Current national policies on drug use shape prevention efforts and dissemination of prevention programs and policies can impact drug use prevention (Pentz, Mares, Schinke, & Rohrbach, 2004)

School- and family-based programs for children and adolescents

Important to target children before they start using drugs. Skills based programs, classroom interventions (e.g., Early Risers Skills for Success), and programs with a family component are important (e.g., Strengthening Families Program) (Faggiano et al., 2005; Kumpfer, Alvarado, & Whiteside, 2003; McBride, 2003)

Above, we spoke about the lessons learned from tobacco strategies and how they might be utilized to address the food industry and other chronic disease. We discuss below two specific documents that detail comprehensive multi-level approaches to weight, which include some concrete recommendations and action steps that can and should be implemented. A document prepared by McLaren et al. (2004) at the Centre for Health and Policy Studies in Calgary explored the implementation of integrated approaches to promote healthy weights. They concluded that integration is mainly conceptual or theoretical, as opposed to taking the form of specific action plans. This makes it difficult to understand the feasibility and impact of an integrated strategy for obesity prevention. They also found that upstream factors (e.g., social, economic, political and cultural circumstances) are rarely incorporated into intervention strategies and interventions that target these influences are virtually absent in the literature. It is thus difficult to determine the best practices regarding obesity prevention, specifically those that target the environment rather than the individual. The recommendations from the report are presented in the table 27.

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Table 27: Recommendations for Reducing and Preventing Obesity

Regulation of advertising and promotion of foods to children (strong evidence linking television and obesity in children; especially explained by exposure to poor food items) Improvement of walkability of neighbourhoods (association between walkability and lower BMI/higher levels of walking) Fiscal policies to facilitate healthy lifestyle (price has implications for food purchasing) Whole school and whole worksite interventions to facilitate health Investigation into ‘non-health’ literatures to understand the impact on health of policies and practices in other sectors (social policy and private sector practices) Investigations into incentives for diet and physical activity (food taxation, subsidized facilities and services) Sufficient funding to ensure proper evaluation of health promotion interventions and social policy interventions; requirement that evaluation includes an assessment of distribution of impact (aim for equitable impact) Continued funding for synthesis research with greater clarity regarding dissemination Establishment and maintenance of continuous, long-term population-level surveillance for key variables Funding for research-policy placements Source: McLaren et al. (2004)

In the recent report from Ontario’s Chief Medical Officer, Dr. Sheela Basrur (2004), overweight and obesity are argued to be the “new tobacco”. Healthy Weights, Healthy Lives focuses on the multiple different determinants of body weight, including individual biological factors; social, economic and cultural factors (income, education, cultural norms, family life, acceptability of overeating); lifestyle, behavioural and health factors; environmental factors (community environment, geographic difference, transport, school environment, food costs and industry influences, food labelling, proliferation of high energy food available). The primary focus is on addressing and modifying the obesogenic environments in which we live. “The environment has a direct impact on what we eat, our food preferences, and how much we eat. The environment also affects how active we are. Mechanization, industrialization, and urbanization have had a major impact on physical activity, both by choice and by necessity. 135

The advent of remote controls for household devices, escalators, elevators, drive-through restaurants and banks, and pay-at-the-pump services have a cumulative effect on the amount people move. According to physical activity experts, we have engineered physical activity out of our lives.”(p.39f). These concepts come from Lobstein et al. (2004) which discusses how the obesogenic environment affects more ‘energy in’ through the increasing availability/variety and active promotion/marketing of energy dense foods, more frequent opportunities to purchase food, greater use of restaurants, larger food portions, increase in number/frequency of eating occasions, as well as less ‘energy out’ through the lack of public transportation, increase in car use (urban sprawl), urban design features, building design, increase in sedentary recreation activities and costs associated with healthy eating and physical activity. The report by Basrur (2004) indicates a number of strategies and initiatives that need to be explored in order to make environments more healthy for the promotion of healthy body weights, although because of the lack of evaluative research, these strategies remain as recommendations, rather than best practices (see Table 28 below).

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Table 28: Recommendations: Reducing and Preventing Obesity

Government of Ontario should: •

develop innovative, comprehensive, multisectoral plan to address healthy weights

•

develop mass media campaign to increase awareness of health benefits of healthy weights

•

promote eating and physical activity (using Canada’s Food Guide and Physical Activity Guide to Healthy Active Living)

•

promote energy balance; develop policies and programs that promote healthy eating (including controls on food advertising, food pricing)

•

develop policies that promote physical activity (investigate extent to which costs are a barrier to physical activity, support public and active transportation, establish Canada as leader in physical activity with Active 2010 plan)

•

conduct ongoing surveillance for chronic disease risk factors; partner with private sector

Health Canada should: •

invest in resources in a long-term multi-level strategy to promote healthy weight, eating and activity

•

fund applied public health research to investigate effective interventions

•

phase out trans fat from processed foods and broaden labelling; funding national fruit and vegetable promotional campaign

•

fund national physical activity promotion program (ParticipACTION model)

Local and regional governments should: •

examine community planning processes to identify how local communities can promote physical activity and reduce barriers

•

provide education on ‘active living by design’

•

provide more opportunities for physical activity (parks, safe walking/cycling routes, culturally appropriate and accessible recreational programs, designing neighbourhoods with components in walking distance)

•

ensure children in daycare have healthy food choices and daily physical activity

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•

identify people in leadership positions to act as role models

•

organize specific physical activity components into new and existing community programs

The health system should: •

update Mandatory Health Programs and Services Guidelines for healthy eating and physical activity promotion

•

support Boards of Health

•

encourage primary healthcare providers to discuss healthy eating and refer patients to weight management programs if required

•

encourage development of comprehensive and specialized weight management clinical services

•

give Ontarians better access to information and counseling

The food industry should: •

phase out use of trans fats

•

decrease serving sizes

•

develop healthier prepared foods

•

increase user-friendly food labeling

•

partner with governments and communities to promote and provide healthy food choices

Schools and school boards should: •

assess school environments and develop plans to create healthy school environment

•

promote healthy eating by developing guidelines for food available in cafeterias and providing nutrition curriculum

•

establish foundation for lifelong physical activity; allow community groups to use school facilities

•

encourage parents to support healthy eating and physical activity at home

•

include school features that support physical activity and healthy eating (bike racks, safe routes to school, kitchen facilities, indoor facilities, space for eating lunch)

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Individuals, parents and caregivers should: •

follow Canada’s Food Guide and Physical Activity Guide

•

monitor body weight

•

set personal goals to improve eating habits and increase physical activity

•

read labels on food products

•

help children be more physically active and eat healthy

Source: Basrur (2004)

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5. RECOMMENDATIONS FOR A COMPREHENSIVE CHRONIC DISEASE PREVENTION FRAMEWORK “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.” (Rose, 1992, p.129)

5.1

The Importance of an Ecological Model – Smedley & Syme’s (2000)

Recommendations Our review of the sociobehavioural risks and determinants implicates the central role of environmental and population level factors in the development of chronic disease. The research continues to build on how the environment affects health, and how this knowledge can inform prevention initiatives. While there are several existing documents in the Canadian prevention landscape that encourage a comprehensive and multi-level approach to chronic disease prevention, the actual translation of this perspective into programs is lagging behind. It has been previously argued that research and intervention efforts to address health and disease should be based on an ecological model, a social environmental approach to health and health interventions (Smedley & Syme, 2000). This population approach makes sense and has worked before in the context of population health, specifically in the previous movements towards improving hygiene and standards of living (Smedley & Syme, 2000). Through this report we have established the importance of understanding the role of distal social and economic factors in the development of chronic disease, as well as the more proximal behavioural factors that have been the primary focus in existing prevention interventions. The lessons learned from tobacco strategies provide even more support for a multi-level ecological model for the prevention of chronic disease and the promotion of health. The ecological model assumes that the differences seen in levels of health and well-being are affected by dynamic interactions between biology, behaviour, and the environment, and that these interactions unfold over the life course of individuals, groups, and communities (Smedley & Syme, 2000). Within this model there is also the assumption that age, gender, race, ethnicity, socioeconomic differences, and other sociodemographic and social status factors shape the

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contexts within which individuals and groups function, thus directly and indirectly influencing health risks and resources. The ecological model not only focuses on “downstream” individuallevel phenomena, as the majority of chronic disease interventions have, nor does it include only “mainstream” factors such as general population-based strategies focused on education and larger-scale clinical intervention. An ecological approach also emphasizes addressing “upstream” societal-level phenomena, such as public policies, in order to provide a fully comprehensive model of health intervention (Smedley & Syme, 2000). The ecological approach supports interventions that focus on the social and behavioural determinants of health. This orientation also uses multiple approaches, takes into account of special needs of particular groups, take the “long view” of health outcomes, and involve a variety of sectors, even those traditionally not associated with health promotion. It is beneficial to briefly describe Smedley and Syme’s (2000) recommendations for health interventions, as they were an important resource for the development of our chronic disease prevention framework. Their overarching recommendations for health interventions are: (1) balance the clinical approach and interventions that address social and behavioural determinants of health and disease, and (2) interventions should link multiple levels of influence (individual, interpersonal, institutional, community, and policy). They also detail more specific recommendations for intervention strategies: •

Make modifications to social capital: attending to the aspects of the social context that may hinder or promote efforts of health risk reduction

•

Develop policies that take account of and enhance positive health outcomes among subgroups (based on sociodemographics), with the knowledge that socioeconomic status can exert multiple effects

•

Make improvements in reproductive outcomes

•

Develop high-quality, centre-based early education programs

•

Address adolescents’ social environments

•

Develop community and worksite interventions and evaluations

•

Develop interventions to improve the health of older adults

They make further specific recommendations for research and funding:

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•

Psychosocial and biobehavioural mechanisms that influence health

•

Behavioural and social effects on pregnancy outcomes and women’s health over the lifespan

•

Early childhood interventions

•

Sources of health strengths and resilience

•

Pathways: social context to disease and outcomes

•

Evaluation of legal and regulatory interventions

•

Expansion of research methodologies

•

Cost-effectiveness

•

Working with communities

•

Reimbursement structure experimentation

•

Promotion of interdisciplinary and collaborative research and training by funding agencies

•

5.2

Funding of research on the social determinants of health

Chronic Disease Prevention Policy and Social Justice Although lifestyle behaviours (specifically physical inactivity, poor diet,

obesity/overweight, tobacco use, and alcohol/substance use) continue to be the best understood major risk factors responsible in the development of chronic disease, there is increasing literature supporting the argument that these behaviours do not occur in a vacuum and that environmental and other political sectors have an important contribution. Because of these environmental and contextual factors, there are distinct inequalities in health that need to be addressed and reduced (Evans et al., 1994). There is, however, a gap between the knowledge of the contribution of environmental and contextual factors to chronic disease and the explicit implementation of concrete interventions to target these factors (Stronks, 2002). There are increasing calls for public health to move out of a reactive position (Krasnik & Rasmussen, 2002) and to take on a more active role in reducing health inequalities and inequities (Oldenburg, 2002). Just as tobacco policy and interventions were instrumental in shaping norms regarding smoking, so too can policies around other aspects of health be critical in changing perspectives.

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Health equity should not stand alone; it should be embedded in the pursuit of social justice generally (Peter, 2001). Thus, we need to look beyond health policies and look at the implementation of other policies and practices in sectors other than health. Changes in these areas could also lead to health benefits related to chronic disease. There are a number of multilevel actions that can be employed to reduce health inequalities that go beyond individual health behaviours and direct population health promotion. The WHO devised a three-pronged approach to achieve health for all and address health inequalities (Zollner, 2002), which included the provision to all people of a “decent minimum” of assets and resources, targeted additional support for disadvantaged groups with dignity and human rights central, and appropriate policies, actions and investments to secure opportunities and support at all levels of society. Other ‘nonhealth’ specific actions to reduce health inequalities can be changes to macrolevel social and economic policies, improved living and working conditions and individual empowerment (Oldenburg, 2002). Policy approaches are needed to address poverty in Canada. Although it is widely recognized that poverty and health are connected, the narrow focus in programs has reduced the impact on the negative effects of poverty on health (Ross, 2003). Upstream strategies, specifically income support through the provision of social assistance, as well as downstream strategies focused on employment, self-sufficiency, community support, and neighbourhood improvement are needed to address poverty (Ross, 2003).

5.3

Recommendations for a Comprehensive Chronic Disease Prevention Framework In Canada currently, we appear to be at a stage where the general political climate is

ready to implement population health approaches to deal with the prevention of chronic disease and to save money for the public health and health care sectors. Individual approaches to chronic disease prevention still have an important place in programs, but should not be the primary focus or the sole approach. Different strategies have shown different levels of effectiveness for targeting populations and leading to large-scale behaviour change. However, policies must extend even further in order to change the environments in which we live everyday, as well as the factors that shape these environments. Changes need to be made so that healthy choices are easy choices (Yach et al., 2005), but in such a way that there is equilibrium

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in impact and cultural and social sensitivity is maintained. Healthy public policy should encompass policies implemented directly within the health care sector, as well as policies beyond the health care sector. The responsibility of the government and other stakeholders in chronic disease prevention is to ensure equal access for all citizens of Canada to lead healthy lives. Chronic disease prevention initiatives must also be flexible. Based in part on the lessons learned from tobacco and alcohol control, there are recommendations that can be made currently for ways to address and modify the risk factors of chronic disease, including obesity/overweight, physical inactivity, poor diet, and alcohol, tobacco, and illicit drug use. The following 14 recommendations are generic, i.e. they are not specifically oriented to a particular chronic disease or risk factor, nor do they pinpoint which organization or institution should take the lead. This is for local, provincial/territorial, and national groups to decide. However, they clearly imply that various levels of government (and multiple departments within each level), as well as a wide range of non-government organizations, need to be actively involved in a coordinated way in these initiatives. Nevertheless, there are some common experiences, themes and challenges that cut across chronic diseases and their prevention. They draw from publications and reports with multi-risk factor foci (Harvey et al., 2002; Mills, 2003; Yach et al., 2005) as well as recent work focusing on nutrition and healthy eating (Connolly, 2005; McLaren et al., 2004) or obesity (Basrur, 2004). The proceedings of a recent workshop on best practices for chronic disease prevention (Centre for Chronic Disease Prevention and Control & Public Health Agency of Canada, 2005) were also a useful resource. Recently, the WHO published a report on chronic disease prevention, detailing critical planning steps, including the estimation of population need and advocacy for action, the formulation and adopting of policy, and the identification of policy implementation steps (World Health Organization, 2005). This framework also emphasizes the inclusion of population wide and individual level interventions. All of these documents have been utilized in the development of our recommendations and framework. Initiatives are ongoing with regard a number of these recommendations, but further work will require attention to a number of topics, for example: •

What is the status of current work pertaining to a recommendation?

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•

Who should be the lead agency and which partners are essential in moving forward with implementation?

•

What are relevant action steps and messages? There may also be one set of suggestions for a comprehensive or cross-cutting approach,

and another set of responses if the focus is on implementing these recommendations in order to reduce a particular risk factor or facilitate the prevention of a specific chronic disease. There may be variability by the level or jurisdiction of the intervention, be it local, regional or national. Finally, there are some specific considerations relevant to the implementation of chronic disease prevention that need to be taken into account and that feature prominently in our model (Figure 56): •

Goal setting: Are there clear goals and are the resources accessible to achieve them?

•

Policy development: Are the most effective policies in place, implemented and enforced, and at all relevant levels?

•

Programs: Are the most effective best practices the most common? Are there mechanisms in place to facilitate coordination & avoid a duplication of effort?

•

Research: Is there a good mix of multidisciplinary initiatives to assess causation of chronic diseases, and inform and evaluate interventions?

•

Monitoring and surveillance: Is it adequate to capture inter-regional differences and sensitive to special populations?

•

Coordination: Are there adequate resources for infrastructure development, training, dissemination of best practices, etc.? Is there a clear understanding of who is responsible for what, how?

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Table 29: Recommendations for a Comprehensive Chronic Disease Prevention Framework 10

Recommendation 11 1. Multiple determinants of health should be incorporated into interventions, with the “points of attack” being both individuals and populations.

Explanation/ Rationale Chronic disease is not caused by a singular factor (not in a ‘vacuum’); rather, there are multiple factors with linkages and interactions between that need to be considered

2. Health inequalities as well as health inequities should be addressed, with an understanding of social and cultural influences on behaviour.

Ensure equitable and equal effects of prevention efforts. Do not ‘punish’ those individuals or populations who engage in personal cultural or social practices that may ‘go against’ established policies. Share responsibility.

3. Healthy public policy within health and non-health sectors should be developed.

Policies in other areas (social, economic) have been shown to have effects on health behaviours (e.g. tobacco and alcohol use). Focus on changing environments and institutions as well as behaviours by individuals. For example, Lipski & Ignagni (2001), Kumanyika (2001), and Raine (2004) point to the importance of policy interventions in facilitating population level improvements in healthy eating (see Connolly, 2005, pp. 42-44).

4. Communicable and noncommunicable chronic disease, as well as mental illness should be included in prevention initiatives.

Lifestyle factors are related to communicable disease and mental illness as well as to noncommunicable chronic disease. In the vast majority of the literature on chronic disease prevention, mental illness and chronic communicable diseases (e.g., HIV, HCV) have largely been excluded.

5. All relevant risk factors should be included in prevention and management strategies addressing chronic disease (comprehensive strategies).

Risk factors analyses and designation should be based on epidemiology and other research and not be unduly influenced by what is currently popular, topical, or politically “safe”. For, example, in a number of Canadianbased prevention initiatives, alcohol, other drugs and mental health issues do not appear to be acknowledged as risk factors for chronic disease. This is in sharp contrast to evidence from WHO as well as research conducted here.

10

A diagrammatic representation of our prevention framework is presented following this chart (Figure 52). Appendix V shows a diagrammatic representation of the chronic disease framework by Mills et al. (2003), which we also find follows our recommendations. 11 These are organized thematically, but the order does not necessarily indicate priority or importance.

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6. Strategies and frameworks should move beyond theoretical and conceptual levels into concrete and explicit initiatives and action steps.

Concrete implementation of evidence-based practices is needed as is promotion of practice-based evidence. This is especially needed to address the environmental determinants of health.

7. Where possible, strategies should rely on evidencebased practices, but can also include promising practices and demonstrated successes.

There needs to be a balance between innovative, but unproven, prevention strategies and those with a proven track record.

8. Support for programs and interventions that have not shown any impact (or may actually increase risky behaviour or worsen living conditions) should be phased out.

Prevention resources – human, financial and institutional -are limited. For example, if high profile and flashy programs, that are ineffective, continue to attract resources there is less available for those that are effective. Continued support for ineffective initiatives also gives the false impression that something worthwhile is happening.

9. Funding for programming should explicitly require evaluation and monitoring components.

There is typically a disjunction between program funding and evaluation resourcing. Programs with an evaluation component should receive priority in order to increase our knowledge base for best practices and to provide appropriate and timely feedback and support to those carrying out prevention programs at the national, regional or local levels.

10. Strategies should minimize risk factors and maximize protective factors (making healthful choices easy choices).

In addition to the important goals of institutional maintenance, the most important goals of reducing chronic disease might be downplayed or overlooked. Mills (2003, pg. 4, Fig. 1) refers to three purpose elements for an integrated chronic disease prevention approach: (1) improve population health, (2) reduce health inequities, and (3) prevent new cases of chronic diseases.

11. Options should be pursued for standardized criteria for chronic disease prevention programs in Canada (for example, for evaluation and comparison).

A number of models might be explored. These criteria should be based on principles of effective interventions. The arrangement would facilitate sharing of best practices and increase the number of effective interventions focusing on a risk factor and across risk factors.

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12. Sustainability of prevention programs should be improved over time through the provision of committed, long-term funding.

Yach et al. (2005) indicate that interventions known to be effective should be fully implemented. Those meeting these criteria should receive sustained support.

13. Empowerment and ownership within communities should be a critical component of community-based initiatives.

It is important that locally based interventions address both real and perceived needs (Yach et al. 2005). Addressing both may be essential to developing the social support for population level changes.

14. Capacity should be built through the vertical and horizontal integration and comprehensive institutional organization. Knowledge transfer, linkages, maximization of resources, minimization of duplication of effort, and harmonization of efforts should be central.

This is an ongoing challenge and a cornerstone of sustained and innovative prevention efforts. Mills (2003) describes system capacity along three dimensions: governance (linkages, roles and responsibilities, mechanisms for courses correction), infrastructure (physical, organizational, financial, human and informational) and political and institutional commitment. (see Appendix V)

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Figure 56: Comprehensive Chronic Disease Prevention Framework (this model represents an amalgamation of a number of sources utilized in the report)

Goal setting Coordination and capacity Strategies

Multiple stakeholders Government NGOs Health care Industry Advertising Community groups Interest groups Public health Individuals

Programs

Multiple intervention contexts Schools Workplaces Communities Religious sites Neighbourhoods Families Households Clinical

Policies

Multiple target groups (over time and life course) Individuals Risk groups General population Sociodemographic groups

Multiple levels of intervention Individual Community City Province Nation

Multiple media Clinical/ counselling Education Multi/mass media Regulation Taxation Legislation Policy (health, social, economic)

Research, evaluation and surveillance

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Health outcomes Chronic disease prevention Health equity

6. CONCLUSION The comprehensive framework for chronic disease prevention thus links multiple levels of risk factors, multiple stakeholders, and multiple strategies. This ensures flexibility for the interventions that can be developed. The inclusion of multiple determinants of health and multiple stakeholders implies the understanding of multiple levels of responsibility for the development and prevention of chronic disease. Our framework is explicit in its incorporation of the ecological model, including individual and population level areas for intervention. Ongoing research, surveillance, program and policy development, and coordination and infrastructure are critical to the sustainability of a comprehensive chronic disease prevention strategy. There needs to be ongoing dialogue between all stakeholders involved in chronic disease prevention regarding current best practices and future directions, in order to set realistic goals and to have the resources and knowledge in place to fulfill these goals. The full report here has detailed the epidemiology of chronic disease in Canada, and this is task that needs to be continually updated in order to inform chronic disease prevention activities that lead to the most benefit for high-risk groups and individuals and the population at large. We also discussed the sociobehavioural risk factors relevant to health and chronic disease and argued for increased development in the research field regarding the contribution of social environmental factors. Research activities also need to be ongoing in the area of program evaluation and the development of best practices, in order to best use the financial resources available for chronic disease prevention in Canada. Programs can also be documented through health care surveillance and ongoing environmental scans. Research and surveillance are thus critical parts of a framework for chronic disease prevention in Canada. These research and surveillance activities will be able to feed into the process of developing effective programs and policies. We need to look beyond what has been traditionally done and look to the expansion of policy into multiple domains. Policy and programs should be developed in conjunction with and be headed by multiple groups, thus ensuring ownership and empowerment in chronic disease prevention. Our review of the current Canadian situation indicated a disjuncture between the overarching frameworks that emphasize the population health model, and the actuality of program implementation. Program evaluation is also currently

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not a required component of programming, thus further contributing to the lack of firm knowledge of which programs are currently underway and which are effective. However, research, surveillance, and program and policy development need at their root an effective infrastructure. Communications between stakeholders are essential to the effective implementation of a comprehensive and overarching strategy as well as to the implementation of actual individual programs and research projects. Infrastructure must thus be considered on a macro and micro level in order to work effectively. There are specific challenges that arise when a strategic framework is created and implemented, and these should be considered specifically with regards to the chronic disease framework and recommendations that we have put forth: •

Multiple determinants of health: Are disease or risk specific organizations a good match to address these issues? These are the institutions currently in place.

•

Health inequalities and health inequities: Is the significant expertise in knowledge exchange and transfer, education and persuasion the right response to these challenges?

•

Policies and strategies: The tobacco experience -- Is there a shortcut to developing effective policies for other risk factors?

•

Training: Is there adequate training in population-based perspectives and interventions?

•

Evidence-based practice: Are the protocols and resources in place for linking programming with monitoring and research on a routine basis?

•

Criteria for chronic disease prevention program: Are there mechanisms to phase out ineffective programs and encourage implementation of effective interventions?

These questions and more need to be continually addressed and revisited. The framework and recommendations presented in this report are intended to inform the direction of chronic disease prevention in Canada. We look forward to the implementation of the recommendations and to ongoing dialogue to prevent the burden of illness caused by chronic disease.

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7. FUTURE CONSIDERATIONS In consideration of the time and scope limitations placed on this project, we have presented only a small proportion of what is available in Canada regarding chronic disease prevention. There are some possibilities for future inquiry that we are proposing in this section so that different directions can be taken and a fuller understanding of the Canadian context can be had. The following are some suggested future directions related to chronic disease prevention in Canada. They focus on collecting and organizing background information on risk factors and chronic diseases, evaluations of programs, common policy elements and best practices: • Establish arrangements to regularly (e.g., every three years) update and disseminate the data-based analysis on risk factors and chronic diseases: This might be along the lines of sections 1 and 2 of this report (see above) and might include, where resources are available, similar information for all other provinces and territories, as is provided here for Ontario. This would appear to be a useful tool for prevention and policy planning at the national and regional levels of Canada. • An environmental scan of programs, initiatives, and interventions in Canada regarding chronic disease prevention: This suggestion is proposed with some ambivalence, since it would be a very time- and funds- consuming task. The results and their utility may not warrant the expenditure. Also, there are other options, listed below, that might have greater benefit in facilitating effective prevention of chronic disease. Therefore, clear goals and applications of the information should be carefully articulated before it is sponsored and undertaken. It may be more viable on a provincial basis. It would be useful, however, to have an understanding of what is happening in Canada regarding chronic disease prevention, if there is overlap in effort, what approaches programs and interventions are taking (individual vs. population), if there is ongoing evaluation, and if programs and interventions are working. This would also be valuable to set up in a database format for access by all individuals and organizations working in chronic disease prevention as a resource-sharing device (organizations/individuals can search other programs and

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interventions and update the progress for their respective interventions). However, given the large scale of such an undertaking, a more useful starting point would be to initially collect basic information on programs with an evaluative component. For example, the following core information might be considered: purpose of the program, infra-structure and source of support/funding; focus population, disease and risk factors, underlying model or conceptual framework, intervention strategy and components, evaluation protocol, findings (outcome and process) and dissemination. • A detailed historical progression of policies and programming related to chronic disease in Canada: This would be an invaluable task to understand the changes in policy and social/political norms regarding chronic disease. It would also be useful in understanding the best practices from the past. • Examine and analyze common policy and program elements, opportunities and challenges across risk factors: The emerging initiatives on improved diet, healthy eating, increased exercise and reducing obesity have a number elements in common with tobacco control experiences and initiatives to reduce the harm to health and society from certain aspects of alcohol consumption. There are differences, of course, but the central and effective roles that policies have played, as well as the key function of coordinated and comprehensive approaches (Babor et al., 2003; Yach et al. 2005), are lessons that should not be lost in tackling these other risk factors for chronic disease. • Conduct a detailed analysis and review of the available evaluation research: This would facilitate developing a comprehensive list of best practices, with evaluation and analysis of each of the details of chronic disease prevention and policy (similar to that done in Babor et al. 2003 regarding alcohol use). From this analysis, an evaluation framework could be developed and used across Canada to evaluate of chronic disease prevention. • Conduct an in-depth examination of the impact of environmental and lifestyle factors in relation to chronic disease and assess the quality of the evidence: This could occur as either a quantitative or qualitative assessment of the relative rank of the currently known risk factors and determinants of chronic disease in Canada.

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APPENDICES

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APPENDIX I: DATA SOURCES AND DEFINITIONS Table 1: ICD Codes Used for the Calculation of Total Number of Deaths in 2002

Condition Malignant neoplasms

ICD-10 C00-C97

Lung cancer

C33-C34

Prostate cancer

C61

Breast cancer

C50

Colorectal cancer

C18-C21

Urinary tract cancer

C64-C68

Pancreas cancer

C25

Diabetes mellitus

E10 - E14

Respiratory diseases

J00-J99

Pneumonia and Influenza

J10-J18

Bronchitis/Emphysema/Asthma

J40-J43, J45-J46

COPD

J40-J41

Cardiovascular diseases

I00-I99

Heart failure

I50

Ischemic heart disease

I20 - I25

Aortic Aneurysm

I71

Cerebrovascular disease

I60 - I69

Genito-urinary diseases

N00-N99

Unintentional injuries

V00-V99, W00 – W99, X00 – X59, Y85, Y86

Suicide

X60-X84, Y87.0

184

Table 2: Impact of Change of ICD Version

Cause

ICD-9

ICD-10

Impact of ICD-10

Colorectal cancer

153-154

C18-C21

-

Lung cancer

162

C33-C34

2% decrease

Breast cancer

174

C50 (and specify sex=F)

-

Prostate cancer

185

C61

3.3% increase

Acute myocardial infarction

410

I21-I22

2.7% decrease

Cerebrovascular disease

430-438

I60-I69 *

6.9% increase

Selected 430-432, 434, 436 I60-I66 ? cerebrovascular diseases ** Note: * I60-I69 does not include a category comparable to ICD-9 code 435, transient cerebral ischemia (ICD-10 G45) ** PIRC refers to "all stroke" for this subset which is not an accurate description. The STC Vital Statistics classification experts would refer to this unconventional grouping as "selected cerebrovascular diseases". Source: Statistics Canada, Vital Statistics, and Demography Division; ISQ. References: Statistics Canada Vital Statistics Death Databases. Available at: http://www.statcan.ca/english/freepub/82-401XIE/2002000/considerations/hlt/45hlt.htm.

Refer to: http://www.statcan.ca/english/freepub/82-221-XIE/2004002/quality.htm#2 for data definitions (see below).

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National Population Household Survey The National Population Health Survey (NPHS), which began in 1994/95, collects information about the health of the Canadian population every two years. It covers household and institutional residents in all provinces and territories, except persons living on Indian reserves, Canadian Forces bases, and in some remote areas. The NPHS has both a longitudinal and a cross-sectional component. Respondents who are part of the longitudinal component will be followed for up to 20 years. The Health Indicators data are based on both the longitudinal and cross-sectional components for household residents (institutional excluded) living in the provinces (territories excluded). Data are available for the first three cycles (1994/95, 1996/97 and 1998/99). The 1994/95 and 1996/97 cross-sectional samples are made up of longitudinal respondents and their household members and individuals who were selected as part of supplemental samples, or "buy-ins", in some provinces. The 1998/99 cross-sectional sample is made up mostly of longitudinal respondents and their cohabitants. No buy-ins were added to 1998/99 data. However, to keep the sample representative, infants born in 1995 and thereafter and immigrants who entered Canada since the beginning of 1995 were randomly selected and added to the NPHS sample. The 1994/95 provincial, non-institutional cross-sectional sample consisted of 27,263 households, of which 88.7% agreed to participate in the survey. After application of a screening rule to maintain the representativeness of the sample, 20,725 households remained in scope. In 18,342 of these households, the selected person was aged 12 or older. Their response rate to the in-depth health questions was 96.1% or 17,626 respondents. In 1996/97, the overall response rate at the household level was 82.6%. The response rate for the randomly selected individuals aged 2 or older in these households was 95.6%. A total of 81,804 respondents answered the in depth health questions in 1996/97. In 1998/99, the overall response rate was 88.2% at the household level. The response rate for the randomly selected respondents 0 or older in these households was 98.5%. A total of 17,244 respondents answered the in depth health questions in 1998/99. The 1994/95 provincial, non-institutional longitudinal sample consisted of 17,276 respondents. A response rate of 93.6% was achieved in 1996/97, and a response rate of 88.9% was achieved in 1998/99.

Canadian Community Health Survey Starting with data year 2000/01, the Canadian Community Health Survey (CCHS) replaces the cross-sectional aspect of the NPHS. The primary objective of the CCHS is to provide timely cross-sectional estimates of health determinants, health status and health system utilization at a sub-provincial level (health region or combination of health regions). The CCHS collects information from individuals aged 12 or older who are living in private dwellings. People living on Indian reserves or Crown lands, residents of institutions, full-time members of the Canadian Armed Forces, and residents of certain remote regions are excluded. The CCHS covers approximately 98% of the Canadian population aged 12 or older. Each two-year collection cycle is comprised of two distinct surveys: a health region-level survey in the first year with a total sample of 130,000 and a provincial-level survey in the second year with a total sample of 30,000. Sample sizes in any particular month or year may increase due to provincial or health region-level sample buy-ins.

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The response rate for the first cycle of the CCHS at the national level was 84.7% (131,535 respondents). The response rate for the second cycle of the CCHS at the national level was 80.6% (135,573 respondents). For more information about the CCHS, see: http://www.statcan.ca/english/concepts/hs/index.htm

Age-standardized mortality rate Definition: Age-standardized rate of death for selected causes per 100,000 population. From 1979 to 1999, causes of death were classified according to the International Classification of Disease, Ninth Revision (ICD-9). The year 2000 and subsequent years available are classified according to the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Selected causes are defined as follows: Colorectal cancer (ICD-10 C18-C21 or ICD-9 153-154), lung cancer (ICD-10 C33-C34 or ICD-9 162), female breast cancer (ICD-10 C50 females specified or ICD-9 174), prostate cancer (ICD-10 C61 or ICD-9 185), acute myocardial infarction (AMI) (ICD-10 I21-I22 or ICD-9 410), cerebrovascular diseases (ICD-10 I60-I69 or ICD-9 430-438), all stroke (selected cerebrovascular diseases) (ICD-10 I60-I66 or ICD-9 430432, 434, 436). Indicates the overall health of the population and is similar to what is measured by life expectancy. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) The age-standardized death rate for each cancer site (colon/rectum, female breast, and prostate) and for acute myocardial infarction and cerebrovascular disease is calculated by multiplying each observed age-specific death rate by the standard population in the corresponding age-group, summing the results, multiplying the sum by 100,000 and then dividing the product by the total standard population. The 1991 Canadian Census population is used as the standard population. Causes of death are classified according to the ICD-9 from 1979 to 1999. The year 2000 and subsequent years available are coded to ICD-10. The selected causes are presented here with corresponding codes from each ICD revision. AIDS deaths Definition: Crude rate and age-standardized rate of deaths due to AIDS and HIV infections (ICD-10 B20-B24) per 100,000 population. Measures success in preventing and treating AIDS and HIV (Human Immunodeficiency Virus, the agent that causes AIDS). Information on deaths can be used to estimate the number of persons living with HIV/AIDS, as well as the impact of treatment.

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Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) AIDS deaths Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) for human immunodeficiency virus (HIV) infection deaths (ICD-10 B20-B24) is the number of years of life "lost" when a person dies "prematurely" from AIDS/HIV – before age 75. A person dying at age 25, for example, has lost 50 years of life. Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) All diseases of the circulatory system deaths Definition: Crude rate and age-standardized rate of death from diseases of the circulatory system per 100,000 population:for all diseases of the circulatory system (ICD-10 I00-I99), ischaemic heart disease (ICD-10 I20-I25), cerebrovascular diseases (ICD-10 I60-I69) and all other circulatory diseases (ICD-10 I00-I02, I05-I09, I10-I15, I26-I28, I30-I52, I70-I79, I80-I89, I95-I99). Measures long-term success in reducing deaths due to circulatory disease, compared with other regions, provinces, and countries. Lower death rates indicate success in circulatory disease prevention, detection, and treatment. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) All diseases of the respiratory system deaths Definition: Crude rate and age-standardized rate of death from diseases of the respiratory system per 100,000 population:, for all respiratory diseases (ICD-10 J00-J99), pneumonia and influenza (ICD-10 J10-J18), bronchitis/ emphysema/asthma (ICD-10 J40-J43, J45-J46) and all other diseases of the respiratory system (ICD-10 J00-J06, J20-J22, J30- J39, J44, J47, J60-J70, J80-J84, J85-J86, J90-J94, J95-J99). Measures long-term success in reducing deaths due to respiratory disease, compared with other regions, provinces, and countries. Lower death rates indicate success in respiratory disease prevention, detection, and treatment.

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Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) All malignant neoplasms (cancer) deaths Definition: Crude rate and age-standardized rate of death from cancer per 100,000 population: for all cancers (ICD-10 C00-C97) and for specific sites: colorectal (ICD-10 C18-C21), lung (ICD-10 C33-C34), female breast (ICD-10 C50) female specified (ICD-9 174), and prostate cancer (ICD-10 C61). Measures long-term success in reducing deaths due to cancer, compared with other regions, provinces, and countries. Lower death rates indicate success in cancer prevention, detection, and treatment. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Asthma Definition: Population aged 4 and over (or aged 12 and over for data from the Canadian Community Health Survey and National Population Health Survey, North component) who report that they have been diagnosed by a health professional as having asthma. Sources: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file; Statistics Canada, National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file and North component; Statistics Canada, National Longitudinal Survey of Children and Youth (asthma for 4 to 11 years of age), 1994/95 Body mass index (BMI) Note: Definition change implemented in 2004 to conform with Health Canada guidelines for body weight classification. Definition: Population aged 18 and over, excluding pregnant women and persons less than 3 feet (0.914 metres) tall or greater than 6 feet 11 inches (2.108 metres). A definition change was implemented in 2004 to conform with Health Canada guidelines for body weight classification. Body mass index (BMI) is calculated by dividing the respondent's body weight (in kilograms) by their height (in metres) squared. The index is: less than 18.5 (underweight); 18.5-24.9 (normal weight), 25.0-29.9 (overweight); 30.0-34.9 (obese - class I); 35.0-39.9 (obese - class II); 40 or greater (obese - class III). Body mass index (BMI) is a method of classifying body weight according to health risk. According to the World Health Organization (WHO) and Health Canada guidelines, health

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risk levels are associated with each of the following BMI categories: normal weight = least health risk; underweight and overweight = increased health risk; obese - class I = high health risk; obese - class II = very high health risk; obese - class III = extremely high health risk. Rates are age-standardized using the direct method and the 1991 Canadian Census population structure. The use of a standard population results in more meaningful comparisons because it adjusts for variations in population age distributions over time and across geographic areas. Exclusions: Everyone less than 18 years of age, persons living on First Nation Reserves and on Crown lands, residents of institutions, full-time member of Canadian Armed Forces and residents of certain remote regions are excluded from the sample. Also excluded are pregnant women, and persons measuring less than 914 centimetres (3 feet) or greater than 210.8 centimetres (6 feet 11 inches) in height. Sources: Statistics Canada, Canadian Community Health Survey, 2000/01 and 2003; National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file (household component); National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file (North component) Cancer deaths Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) for all malignant neoplasms ( ICD-10 C00C97) and for specific sites: colorectal (ICD-10 C18-C21), lung (ICD-10 C33-C34), female breast (ICD-10 C50), and prostate cancer (ICD-10 C61). PYLL is the number of years of life "lost" when a person dies "prematurely" from any cancer – before age 75. A person dying at age 25, for example, has lost 50 years of life. Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Cancer incidence Definition: Age-standardized rate of new primary sites of cancer (malignant neoplasms) per 100,000 population, for all cancers. Specific site codes: colon/rectum (ICD-0-3 C18.0-C18.9, C19.9, C20.9, C26.0), lung (ICD0-3 C34.0-C34.9), female breast (ICD-0-3 C50.0-C50.9), and prostate (ICD-0-3 C61.9).

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Sources: Statistics Canada , Vital Statistics, Cancer Database, Canadian Cancer Registry, and Demography Division (population estimates), Health Canada (2001 - 2004 estimates) Circulatory disease deaths Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) for all circulatory disease deaths (ICD-10 I00-I99) and specific causes: ischaemic heart disease (ICD-10 I20-I25), cerebrovascular diseases (stroke) (ICD-10 I60-I69) and all other circulatory diseases (ICD-10 I00-I02, I05I09, I10-I15, I26-I28, I30-I52, I70-I79, I80-I89, I95-I99). PYLL is the number of years of life "lost" when a person dies "prematurely" from any circulatory disease – before age 75. A person dying at age 25, for example, has lost 50 years of life. Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Depression Definition: Population aged 12 and over with a probability of 0.9 or greater of having experienced a major depressive episode in the past 12 months. Based on responses to the short-form Composite International Diagnostic Interview (CIDI). Respondents are classified according to the probability that they would have been diagnosed as having experienced a major depressive episode in the past 12 months, if they had completed the long-form CIDI. Rates are age-standardized using the direct method and the 1991 Canadian Census population structure. The use of a standard population results in more meaningful comparisons because it adjusts for variations in population age distributions over time and across geographic areas. Exclusions: The survey excludes from its target population those living in the three territories, individuals living on Indian Reserves and on Crown Lands, residents of institutions, full-time members of the Canadian Armed Forces, and residents of certain remote regions. Persons less than 12 years of age are not surveyed. Sources: Statistics Canada, Canadian Community Health Survey, 2000/01 and 2003; National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file (household component); National Population Health Survey, 1994/95 and 1996/97, cross sectional sample, health file (North component).

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Diabetes Definition: Population aged 12 and over who report that they have been diagnosed by a health professional as having diabetes. Sources: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file; Statistics Canada, National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file and North component Dietary practices Definition: Population aged 12 and over, by the average number of times per day that they consume fruits and vegetables. Source: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file Exposure to second-hand smoke at home Definition: Non-smoking population aged 12 and over who reported that at least one person smokes inside their home every day or almost every day. Data source: Statistics Canada, Canadian Community Health Survey, 2003 Frequency of heavy drinking Definition: Population aged 12 and over who are current drinkers and who reported drinking 5 or more drinks on at least one occasion in the past 12 months. 'Heavy drinking' is defined as current drinkers who reported drinking 5 or more drinks on one occasion, 12 or more times a year. Sources: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file; Statistics Canada, National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file; Statistics Canada, National Population Health Survey, 1996/97 and 1998/99, North component High blood pressure Definition: Population aged 12 and over who report that they have been diagnosed by a health professional as having high blood pressure. Sources: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file; Statistics Canada, National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file and North component 192

Injuries Definition: Population aged 12 and over who sustained injuries in the past 12 months. Includes all injuries serious enough to limit one’s normal activities, but does not include repetitive strain injury. For those with more than one injury in the past 12 months, refers to “the most serious injury” as identified by the respondent. Sources: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file; Statistics Canada, National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file and North component Life expectancy Definition: Life expectancy is the number of years a person would be expected to live, starting from birth (for life expectancy at birth) and similarly for other age groups, on the basis of the mortality statistics for a given observation period. A widely used indicator of the health of a population. Life expectancy measures quantity rather than quality of life. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Mental health and well-being Data source: Statistics Canada, Canadian Community Health Survey, Mental Health and Well-being, 2002 (updated in September 2004) 2. The survey excludes from its target population those living in the three territories, individuals living on Indian Reserves and on Crown Lands, residents of institutions, full-time members of the Canadian Armed Forces, and residents of certain remote regions. The Mental Health and Well-being Survey is partially based on a modified World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI). The WMH-CIDI is a standardized instrument for assessment of mental disorders and conditions according to an operationalization of the definitions and criteria of DSM. DSM refers to the Diagnostic and Statistical Manual of Mental Disorders used by the American Psychiatric Association. It is an internationally recognized classification of mental disorders with several versions. Mental conditions or problems found in the CCHS 1.2 are partially coded either to DSM-IV or DSM-IIIR. Mental conditions or problems are derived from a set of questions pertaining to the feelings, the symptoms, severity, the intensity, and the impact relative to each of the measured disorders. Major depressive episode

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Major depressive episode is defined as a period of 2 weeks or more with persistent depressed mood and loss of interest or pleasure in normal activities, accompanied by symptoms such as decreased energy, changes in sleep and appetite, impaired concentration, and feelings of guilt, hopelessness, or suicidal thoughts. Population aged 15 and over are classified as meeting or failing to meet the CCHS 1.2/WMH-CIDI criteria for major depressive episode in the 12 months prior to the interview. Respondents who meet the criteria reported (1) meeting the criteria for lifetime major depressive episode*; (2) having a depressive episode in the 12 months prior to the interview; and (3) clinically significant distress or impairment in social, occupational or other important areas of functioning. *Population aged 15 and over who meet or fail to meet the CCHS 1.2/WMH-CIDI criteria for lifetime major depressive episode. Respondents who meet the criteria reported (1) 2 weeks or longer of depressed mood or loss of interest or pleasure and at least five symptoms associated with depression which represent a change in functioning; (2) that symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning; and (3) that symptoms are not better accounted for by bereavement or symptoms last more than 2 months or the symptoms are characterised by a marked functional impairment, preoccupation with worthlessness, suicidal ideation, or psychomotor retardation . The questions and calculation of the final derived variable are based on the WMH-CIDI (World Mental Health - Composite International Diagnostic Interview Instrument). The WMH-CIDI is a lay-administered psychiatric interview that generates a profile of those with a disorder according to the definitions of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The WMH-CIDI questions and algorithms were operationalised to meet the needs of CCHS 1.2. Any measured disorder or substance dependence Respondents aged 15 and over are classified as meeting or failing to meet criteria for any of the measured disorders (major depressive episode, manic episode, panic disorder, social phobia, agoraphobia) or substance dependencies (alcohol dependence, illicit drug dependence) in the 12 months prior to interview. Panic disorder Panic disorder is characterised by repeated and unexpected attacks of intense fear and anxiety accompanied by physiological manifestations such as palpitations, chest pain, smothering or choking, dizziness, sweating, nausea or abdominal distress, trembling or hot flushes or chills. Population aged 15 and over are classified as meeting or failing to meet the CCHS 1.2/WMH-CIDI criteria for panic disorder in the 12 months prior to interview. Respondents who meet the criteria reported (1) meeting the criteria for lifetime panic

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disorder*; (2) having a panic attack in the 12 months prior to interview; and (3) significant emotional distress during a panic attack in the 12 months prior to interview. *Respondents who meet the lifetime criteria report (A) recurrent unexpected panic where at least one of the attacks has been followed by one month of concern about having additional attacks or their implications or a change in behaviour related to attacks. The questions and calculation of the final derived variable are based on the WMH-CIDI (World Mental Health - Composite International Diagnostic Interview Instrument). The WMH-CIDI is a lay-administered psychiatric interview that generates a profile of those with a disorder according to the definitions of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The WMH-CIDI questions and algorithms were operationalised to meet the needs of CCHS 1.2 . Manic episode (mania) Mania is characterised by a period of a week or days with exaggerated feelings of wellbeing, energy, and confidence in which a person can lose touch with reality. Symptoms of mania include: flight of ideas or racing thoughts; inflated self-esteem; decreased need for sleep; talkativeness; and irritability. Population aged 15 and over are classified as meeting or failing to meet the CCHS 1.2/WMH-CIDI criteria for mania in the 12 months prior to the interview. Respondents who meet the criteria report (1) meeting the criteria for lifetime mania*; (2) having a manic episode in the 12 months prior to the interview; and (3) clinically significant distress or impairment in social, occupational or other important areas of functioning. *Respondents who meet the lifetime criteria report (A) a distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week; (B) 3 or more of 7 symptoms (or 4 or more if mood is only irritable); and (C) marked impairment in occupational or social functioning, or psychotic features, or hospitalisation was required. The questions and calculation of the final derived variable are based on the WMH-CIDI (World Mental Health - Composite International Diagnostic Interview Instrument). The WMH-CIDI is a lay-administered psychiatric interview that generates a profile of those with a disorder according to the definitions of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The WMH-CIDI questions and algorithms were operationalised to meet the needs of CCHS 1.2. Physical activity Sources: Statistics Canada, Canadian Community Health Survey, 2000/01 and 2003; National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file (household component); National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file (North component).

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Definition: Population aged 12 and over reporting level of physical activity, based on their responses to questions about the frequency, duration and intensity of their participation in leisure-time physical activity. Respondents are classified as active, moderately active or inactive based on an index of average daily physical activity over the past 3 months. For each leisure time physical activity engaged in by the respondent, an average daily energy expenditure is calculated by multiplying the number of times the activity was performed by the average duration of the activity by the energy cost (kilocalories per kilogram of body weight per hour) of the activity. The index is calculated as the sum of the average daily energy expenditures of all activities. Respondents are classified as follows: 3.0 kcal/kg/day or more = physically active; 1.5 - 2.9 kcal/kg/day = moderately active; less than 1.5 kcal per day = inactive. Rates are age-standardized using the direct method and the 1991 Canadian Census population structure. The use of a standard population results in more meaningful comparisons because it adjusts for variations in population age distributions over time and across geographic areas. Population attributable fraction The population attributable fraction (PAF) combines prevalence data and relative risks for risk factors and can be expressed as a percentage of a certain disease attributable to a certain risk factor, i.e. the percent of the disease that would have been prevented if the risk factor would have been completely eliminated. The fraction can vary by level of, for example, alcohol consumption, and also by sex and age. Other terms used for population attributable fraction is etiologic fraction. The PAF is based on pooled estimates of relative risks, preferably taken from systematic meta-analysis. The formula varies slightly in different studies, Single, Rehm, Robson, and Van Truong (2000) provide the following formula:

PAF =

P0 + P1 ( RR1 ) − 1 P0 + P1 ( RR1 )

where P0 and P1 are the prevalence rates for the population without the risk factor and the population with the risk factor respectively, and RR1 is the relative risk for the population with the risk factor relative to the population without the risk factor. PAF is different for mortality and morbidity and can be expressed in absolute numbers or net figures where the risk factor also has a protective effect, as in the case for alcohol consumption and CVD. Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) is the number of years of life "lost" when a person dies "prematurely" from any cause - before age 75. A person dying at age 25, for example, has lost 50 years of life.

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Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a standardized rate per 100,000 population. Causes of death are classified according to the International Classification of Disease (ICD-9) from 1979 to 1999. The year 2000 and subsequent years available are classified according to the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Provincial level PYLL was calculated only for suicide and unintentional injuries for the years 2000 and 2001 only. Selected causes are defined as follows: C olorectal cancer (ICD-9 153-154), lung cancer (ICD-9 162), female breast cancer (ICD-9 174), prostate cancer (ICD-9 185), acute myocardial infarction (AMI) (ICD-9 410), cerebrovascular diseases (ICD-9 430-438), all stroke (ICD-9 430-432, 434, 436), unintentional injuries (ICD-10 V01-X59, Y85-Y86 or ICD-9 E800-E929 excluding E870-E879), suicides (ICD-10 X60-X84, Y87 or ICD-9 E950-E959) Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Respiratory disease deaths Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) for all respiratory disease deaths (ICD-10 J00-J99) and for specific causes: pneumonia and influenza (ICD-10 J10-J18), bronchitis/emphysema/asthma (ICD-10 J40-J43, J45-J46) and all other respiratory diseases (ICD-10 J00-J06, J20-J22, J30-J39, J44, J47, J60-J70, J80- J84, J85-J86, J90-J94, J95J99). PYLL is the number of years of life "lost" when a person dies "prematurely" from any respiratory disease – before age 75. A person dying at age 25, for example, has lost 50 years of life.

Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Smoking status Definition: Population aged 12 and over who reported being either a current smoker (daily or occasional) or a non-smoker (former or never smoked). Sources: Statistics Canada, Canadian Community Health Survey, 2003, 2000/01, health file; Statistics Canada, National Population Health Survey, 1994/95, 1996/97 and 1998/99, cross sectional sample, health file and North component

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Suicide Definition: Crude rate and age-standardized rate of suicide death (ICD-10 X60-X84, Y87.0) per 100,000 population.

Measures long-term success in reducing suicide, a social as well as a major public health concern. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Suicide Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) for suicides (ICD-10 X60-X84, Y87.0) is the number of years of life "lost" when a person dies "prematurely" from suicide – before age 75. A person dying at age 25, for example, has lost 50 years of life.

Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Total mortality Definition: Crude rate and age-standardized rate of death from all causes per 100,000 population.

Indicates the overall health of the population and is similar to what is measured by life expectancy. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Total mortality Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) (total mortality) is the number of years of life "lost" when a person dies "prematurely" from any cause - before age 75. A person dying at age 25, for example, has lost 50 years of life.

Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group

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disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Unintentional injury deaths Definition: Crude rate and age-standardized rate of death from unintentional injuries per 100,000 population. Unintentional (“accidental”) injuries includes injuries due to causes such as motor vehicle collisions, falls, drowning, burns, and poisoning, but not medical misadventures/complications(ICD-10 V01-X59, Y85-Y86).

Measures long-term success in reducing deaths due to unintentional injuries, compared with other regions, provinces, and countries. Measures the adequacy and effectiveness of injury prevention efforts, including public education, community and road design, prevention, emergency care, and treatment resources. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates) Unintentional injury deaths Potential Years of Life Lost (PYLL) Definition: Potential years of life lost (PYLL) for unintentional injuries (ICD-10 V01X59, Y85-Y86) is the number of years of life "lost" when a person dies "prematurely" from unintentional injuries – before age 75. A person dying at age 25, for example, has lost 50 years of life.

Potential years of life lost are calculated by taking the median age in each age group, subtracting from 75, and multiplying by the number of deaths in that age group disaggregated by sex and cause of death. These data are presented as a count (total PYLL) and as a rate per 100,000 population. Sources: Statistics Canada, Vital Statistics, Death Database, and Demography Division (population estimates)

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APPENDIX II: CRUDE DATA TABLES

Figure 1: Prevalence of Asthma, Canada, 1994 – 2003

Sex Both Male Female

14

Percent

12

10

8

6 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:

Crude rate, not age-standardized Statistics Canada, National Population Health Survey and Canadian Community Health Survey

Figure 2: Prevalence of Asthma, Ontario, 1994 – 2003


14

Percent

12

10

8

6 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


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Figure 3: Prevalence of Diabetes, Canada, 1994 – 2003

Sex

10

Both Male Female

Percent

8

6

4

2 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


Figure 4: Prevalence of Diabetes, Ontario, 1994 – 2003 Sex

10

Both Male Female

Mean Percent

8

6

4

2 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:

Crude rate, not age-standardized Statistics Canada, National Population Health Survey and Canadian Community Health Survey.

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Figure 5: Percentage of Canadians 12 Years and Over Who are Physically Inactive by Sex, Canada, 1994 – 2003

Sex

70

Both Male Female

60

Percent

50

40

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year Note: Source:


Figure 6: Percentage of Canadians 18 Years and Over Who Are Obese by Sex, Canada, 1994 – 2003 Sex

20

Both Male Female

Percent

15

10

5

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


202

Figure 7: Percentage of Canadians 18 Years and Over Who Are Obese by Sex, Ontario, 1994 – 2003 Sex

20

Both Male Female

Percent

15

10

5

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


Figure 8: Percentage of Canadians 18 Years and Over Who Are Overweight by Sex, Canada, 1994 – 2003 Sex

60

Both Male Female

50

Percent

40

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


203

Figure 9: Percentage of Canadians 18 Years and Over Who Are Overweight by Sex, Ontario, 1994 – 2003 Sex

60

Both Male Female

50

Percent

40

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


Figure 10: Percentage of Canadians 12 Years and Over Who Smoke Daily by Sex, Canada, 1994 - 2003


Percent

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


204

Figure 11: Percentage of Canadians 12 Years and Over Who Smoke Daily by Sex, Ontario, 1994 – 2003


Mean Percent

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year Note: Source:


Figure 12: Percentage of Canadians 12 Years and Over Who Have High Blood Pressure by Sex, 1994 – 2003


25

20

Percent

15

10

5

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


205

Figure 13: Percentage of Ontarians 12 Years and Over Who Have High Blood Pressure by Sex, 1994 – 2003

Sex

25

Both Male Female

20

Percent

15

10

5

0 1994/95

1996/97

1998/99

2000/01

2003

Year Note: Source:


Figure 14: Percentage of Current Drinkers 12 Years and Over Who Had Five or More Drinks on One Occasion (Less Than 12 Times a Year) by Sex, Canada, 1994 – 2003


40

Percent

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year Note: Source:


206

Figure 15: Percentage of Current Drinkers 12 Years and Over Who Had Five or More Drinks on One Occasion (Less Than 12 Times a Year) by Sex, Ontario, 1994 – 2003


40

Percent

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year Note: Source:


Figure 16: Percentage of Current Drinkers 12 Years and Over Who Had Five or More Drinks on One Occasion (More Than 12 Times a Year) by Sex, Canada, 1994 – 2003


40

Percent

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year

Note: Source:


207

Figure 17: Percentage of Current Drinkers 12 Years and Over Who Had Five or More Drinks on One Occasion (More Than 12 Times a Year) by Sex, Ontario, 1994 – 2003 Sex Both Male Female

40

Percent

30

20

10

0 1994/95

1996/97

1998/99

2000/01

2003

Year Note: Source:


208

APPENDIX III: TARGETS FOR CANCER 2020 – CANCER PREVENTION & CONTROL

minutes vigorous physical activity at least 3 days per week)

(Source: Cancer Care Society and Cancer Care Ontario. Targeting Cancer: An Action Plan for Cancer Prevention and Detection (Cancer 2020 Summary Report), 2003.)

Alcohol consumption • Reduce alcohol consumption: If you do not drink already, do not start and if you do drink, consume less than 2 drinks daily and 9 (for women)/14 (for men) drinks per week

Tobacco use • Prevalence in Ontario teens to be at 2% or less • Prevalence in Ontario adults to be at 5% or less • 90% of daily smokers would make a minimum of one quit attempt per year • Reduction of second-hand smoke: less than 1% of children exposed to second-hand smoke in private homes and vehicles, and all public places 100% smokefree

Occupational carcinogens and environmental carcinogens • Enhance surveillance • Identify priority substances • Reduce and control substances

Diet and nutrition • 90% of Ontarians will consume 5 or more servings of fruits and vegetables per day • Healthy body weight • Less than 10% of Ontarian will be obese (BMI >30)

UV exposure • Reduce by 75% the unprotected time spent outside • Reduce by 75% the percentage of Ontario young adults under age 35 using tanning equipment • Reduce by 75% the percentage of Ontarians getting sunburned

Physical activity • At least 90% of Ontarians will participate in activity according to Canada’s Physical Activity Guide (60 minutes light physical activity daily or 30-60 minutes moderate physical activity 4 days per week or 20-30

Viral infections • Reduce rates of HIV/AIDS and hepatitis C infection by at least 50% • Promote healthy sexuality, harm reduction programs and screening

209

APPENDIX IV: CANADA’S FOOD GUIDE AND CANADA’S GUIDE TO ACTIVE LIVING

210

211

APPENDIX V: CHRONIC DISEASE FRAMEWORK BY MILLS (2003)

(Source: C. Mills. Towards Integrated Chronic Disease Prevention: A Draft Model for Discussion, Figure 1, 2003)

212