Chronic Disease Prevention and C

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Chronic Disease Prevention and C Powered By Docstoc
					Chronic Disease Prevention and Control
        in Austin/Travis County

  Denton Cardiovascular Health Summit
           August 26, 2010
Agenda:

  Burden of Chronic Disease in Austin/Travis
   County
  Behavioral Risk Factor Data
  What we are doing to address chronic disease
  PRISM Modeling for priority setting and
   projecting impact of proposed interventions
Burden of
 Chronic Diseases
    Leading causes of disability and death in
     Texas and in the United States
    Account for 3 out of every 4 deaths
    Cause major limitations in daily living for
     more than 1 of every 10 Americans
    Chronic diseases account for 1/3 of the
     years of potential life lost before age 65
    Account for 75% of the $1 trillion spent
     on health care each year in the United
     States
The leading causes of death have
changed in this century from
infectious diseases to chronic diseases
 In 1900, pneumonia and influenza, TB, and
  gastritis, enteritis, and colitis were the 3 leading
  causes of death accounting for nearly 1/3 of all
  deaths.
 Today, heart disease, cancer and stroke are the
  3 leading causes of death accounting for almost
  2/3 of all deaths.
                     Leading Causes of Death, Travis County, 2007
                                        0         200           400       600           800             1000     1200


               Malignant Neoplasms                                                                        1001



              Diseases of the Heart                                                               917



                 Accidents (Injuries)                         332



 Cerebrovascular Diseases (Stroke)                      242



                  Organic Dementia                      239



Chronic Lower Respiratory Diseases                  212



               Alzheimer's Disease            133



      Intentional Self-Harm (Suicide)       111



                   Diabetes Mellitus        100




                     Data Source: Texas Department of State Health Services, Center for Health Statistics
                                         http://soupfin.tdh.state.tx.us/death10.htm
                              Diseases of the Heart1 Age Adjusted Mortality Rate
                   500
                                           Travis County 1999-2006
                   450



                   400



                   350


                                                                                                                                1999
                   300
                                                                                                                                2000
Rate per 100,000




                                                                                                                                2001
                                                                                                                                2002
                   250
                                                                                                                                2003
                                                                                                                                2004
                   200                                                                                                          2005
                                                                                                                                2006


                   150



                   100



                    50



                     0
                         Male                  Female          White Non-Hispanic   Black Non Hispanic       Hispanic   Total

                          1   ICD 9 Codes: I00-I09, I11, I13, I20-I51
                          Data Source: Texas Department of State Health Services, Center for Health Statistics
                          http://soupfin.tdh.state.tx.us/death10.htm
                                    Age-Adjusted Heart Disease Mortality Rate
                                           by Zip Code of Residence
                                              Travis County, Texas




                                                                 Rate
This map has been produced by the
Austin/Travis County Health &                                           0 - 62
Human Services Department as a
working staff map. No warranty is
made by A/TCHHSD regarding its
                                                                        63 - 165
accuracy or completeness.
                                                                        166 - 203

2001-2004                                                               204 - 241

Rates per 100,000                                                       242 - 611
       Cancer Death Rates*, for Men, US, 1930-1999
 100    Rate Per 100,000
                                                                       Lung


  80




  60


                     Stomach                                                                      Prostate
                                                          Colon and rectum
  40




  20                                                                                       Pancreas



                           Leukemia                   Liver
   0
   1930   1935    1940   1945   1950    1955   1960     1965   1970   1975   1980   1985    1990    1995
*Age-adjusted to the 2000 US standard population.
Source: US Mortality Public Use Data Tapes 1960-1999, US Mortality Volumes 1930-1959,
       National Center for Health Statistics, Centers for Disease Control and Prevention, 2002.
                     Cancer Death Rates*, for Women, US,
                                 1930-1999
             Rate Per 100,000
100



 80



 60
                                                                                                              Lung
              Uterus                              Breast
 40


             Stomach                                  Colon and rectum
 20                        Ovary

                                                                        Pancreas
  0
      1930   1935   1940   1945    1950   1955    1960   1965    1970    1975    1980    1985   1990   1995
  *Age-adjusted to the 2000 US standard population.
  Source: US Mortality Public Use Data Tapes 1960-1999, US Mortality Volumes 1930-1959,
          National Center for Health Statistics, Centers for Disease Control and Prevention, 2002.
                         Lung and Bronchus Cancer1 Age Adjusted Mortality Rate
                   120
                                       Travis County 1999-2006

                   100




                   80
                                                                                                                                                   1999
                                                                                                                                                   2000
Rate per 100,000




                                                                                                                                                   2001
                                                                                                                                                   2002
                   60
                                                                                                                                                   2003
                                                                                                                                                   2004
                                                                                                                                                   2005
                                                                                                                                                   2006
                   40




                   20




                    0
                              Males             Females         White Non-Hispanic Black Non-Hispanic           Hispanic*                  Total

                         1   ICD 9 Codes: C34
                         * Thenumber of deaths due to Lung and Bronchus Cancer for Hispanics is too small for rate calculation in 2001 and
                         2003.
                         Data Source: Texas Department of State Health Services, Texas Cancer Registry, http://www.cancer-rates.info/tx/
                                    Age-Adjusted Lung Cancer Mortality Rate
                                           by Zip Code of Residence
                                             Travis County, Texas




                                                                Rate
This map has been produced by the
Austin/Travis County Health &                                          0 - 13
Human Services Department as a
working staff map. No warranty is
made by A/TCHHSD regarding its
                                                                       14 - 35
accuracy or completeness.
                                                                       36 - 45

2001-2004                                                              46 - 56

Rates per 100,000                                                      57 - 333
                                Diabetes Mellitus1 Age Adjusted Mortality Rate
                                          Travis County 1999-2006

                   120




                   100




                    80
                                                                                                                                               1999
                                                                                                                                               2000
Rate per 100,000




                                                                                                                                               2001
                                                                                                                                               2002
                    60
                                                                                                                                               2003
                                                                                                                                               2004
                                                                                                                                               2005
                                                                                                                                               2006
                    40




                    20




                     0
                         Male               Female          White Non-Hispanic     Black Non-Hispanic          Hispanic                Total

                          1ICD 9 Codes:E10-E14
                          The number of deaths due to Diabetes Mellitus for Black Non-Hispanics is too small for rate calculation in
                          1999, 2005, and 2006.
                          Data Source: Texas Department of State Health Services, Center for Health Statistics,
                          http://soupfin.tdh.state.tx.us/death10.htm
                                    Age-Adjusted Diabetes Mortality Rate
                                         by Zip Code of Residence
                                           Travis County, Texas




This map has been produced by the
Austin/Travis County Health &
                                                              Rate
Human Services Department as a
working staff map. No warranty is
made by A/TCHHSD regarding its
                                                                     0 - 13
accuracy or completeness.
                                                                     14 - 24

2001-2004                                                            25 - 33

Rates per 100,000                                                    34 - 130
Behavioral Risk Factors
and Disease Prevalence
From BRFSS

          Cigarette Smoking
          Overweight/Obesity
          Lack of Physical Activity
          Poor Nutrition
          Diabetes
                     Leading Causes of Death, Travis County, 2007
                                        0         200           400       600           800             1000     1200


               Malignant Neoplasms                                                                        1001



              Diseases of the Heart                                                               917



                 Accidents (Injuries)                         332



 Cerebrovascular Diseases (Stroke)                      242



                  Organic Dementia                      239



Chronic Lower Respiratory Diseases                  212



               Alzheimer's Disease            133



      Intentional Self-Harm (Suicide)       111



                   Diabetes Mellitus        100




                     Data Source: Texas Department of State Health Services, Center for Health Statistics
                                         http://soupfin.tdh.state.tx.us/death10.htm
                                       Actual Causes of Death,
                                             Texas 2001

              Tobacco                                                                                    24,899
  Overweight/Obesity                                                                  18,649
               Alcohol*                                       11,132

      Auto Accidents                     3,736

                 Drugs*                2,851
                Suicide              2,214

                 DWI**               1,807

              Homicide           1,405
                  AIDS          1,052
                    Fire       218

                           0             5000         10000          15000           20000          25000         30000


Source: Vital Statistics, TDH; * Texas Commission for Alcohol and Drug Abuse; **Mother’s Against Drunk Driving
          Smoking-Attributable Deaths
             Travis County, 2007
Approximately 584 deaths caused by smoking among
 adults 35+ years in Travis County (over 11 each week)
Health Effects of Tobacco Use
    Cigarette smoking remains the leading preventable cause of death in the
     United States, causing an estimated 438,000 deaths - or about 1 out of every
     5 - each year. (In 2007 in Travis County approximately 584 smoking-related
     deaths-over 11 per week)
    Tobacco kills more than AIDS, heroin, cocaine, alcohol, car accidents, fire
     and murder – combined.
    Lung cancer is the leading cause of cancer death among both men and
     women in the United States, with 85- 90 percent of lung cancer deaths
     attributed to smoking.
    Smoking also increases the risk of many other types of cancer, including
     cancers of the throat, mouth, pancreas, kidney, bladder, and cervix.
    People who smoke are up to six times more likely to suffer a heart attack
     than nonsmokers, and the risk increases with the number of cigarettes
     smoked. Smoking also causes most cases of chronic obstructive lung
     disease, which includes bronchitis and emphysema.
    In the United States, approximately 38,000 deaths each year are caused by
     exposure to secondhand smoke.
Second-Hand Smoke (SHS)

    Public Health Issue
        Contains over 4,000 chemicals including 69 known
         carcinogens
        Group A Carcinogen (like asbestos and benzene)
        Health Effects: Adults
             Lung cancer
             Coronary heart disease
        Health Effects: Children
             Lower respiratory tract infections in children < 18 months
              old each year
             Middle ear infections
             Asthma
             SIDS
Even Brief Exposure to SHS Poses
Serious Health Risks
    Even brief exposure to SHS can:
        result in upper airway changes in healthy persons
        lead to more frequent asthma attacks in asthmatic
         children
    Just 30 minutes of exposure to SHS can:
        increase risk of blot clots
        slow the rate of blood flow through the coronary
         arteries
        injure blood vessels and interfere with their repair
Who Smokes – By Education and Income
   Current Population Survey - Tobacco Use Supplement
  Smoking Status by Demographic Characteristics 1965 and 1999.
                            Current Smokers        % Decline
                              1965       1999
  Race/Ethnicity
   White                      41.9       23.5         44%
   African-American           45.2       24.7         45%
   Other                      39.8       19.9         50%
  Education (Years)
   1–8, Elementary            36.7       19.1         48%
   9–11, Some HS                         38.1         18%
                            [ 46.7 ]
   12, HS Graduate                       28.6         39%
   1–3, Some College          44.0       24.4         45%
   4, College Graduate        39.8       13.2         67%
   5+, Post-Graduate          32.8        8.5         74%
  Family Income (quintile)
   Lowest                     33.8       30.9          9%
   2                          42.9       28.7         33%
   3                          46.1       25.0         46%
   4                          46.4       21.4         54%
   Highest                    43.6       16.6         62%
                                             Prevalence of Cigarette Smoking Among Youth1,
                                              Texas’ Public Schools 2001, 2005, 2007, 2009
                                           Percent of Students Who Smoked One or More Cigarettes in the Past 30 Days

                     40



                     35



                     30



                     25
Weighted Percent %




                                                                                                                                      2001
                                                                                                                                      2005
                     20
                                                                                                                                      2007
                                                                                                                                      2009

                     15



                     10



                     5



                     0
                                 Males                  Females            White Non-Hispanic Black Non-Hispanic   Hispanic   Texas

                     1Youth is defined as a student in public schools ranging in age from 15-18 years old.
                     Data Source: Texas Department of State Health Services, Center for Health Statistics
                     http://www.dshs.state.tx.us/chs/yrbs/query/yrbss_form.shtm
                 Prevalence of Cigarette Smoking Among Youth1,
           STEPS to a Healthier Austin Intervention Area’s Public Schools
                                        2007
                         Percentage of students who smoked cigarettes on one or more of the past 30 days




100




80




60




40

                                                                                                         20.5                              19.4

                              14.0                                                           13.8
20        12.5                            11.1                      9.6          9.1                                  7.2       10.7



 0
         Total               Male        Female                     9th         10th         11th        12th        Black*   Hispanic/   White*
                                                                                                                               Latino
                             1Youth is defined as a student in public schools ranging in age from 15-18 years old.
                             Data Source: Centers for Disease Control and Prevention, Youth Risk Behavior Survey
      QN30 - Weighted Data
      *Non-Hispanic.
                      Prevalence of Overweight and Obesity1 among Adults2 2002-2008
                     70




                     60




                     50
Weighted Percent %




                     40
                                                                                                                                             US
                                                                                                                                             Texas
                                                                                                                                             Travis County
                     30




                     20




                     10




                     0
                          2002             2003          2004            2005             2006             2007             2008
                                                                         Year

                                 1BMI   Overweight and Obsesity ≥25
                                 2Adults are defined as respondents 18 years old and older.
                                 Data Source: Texas Department of State Health Services, Center for Health Statistics,
                                 http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm; Austin/Travis County Health & Human Services
                                 Department
                          Prevalence of Overweight Youth1 in Texas’ Public Schools 2001,
                                              2005, 2007, and 2009
                     30




                     25




                     20
Weighted Percent %




                                                                                                                                       2001
                                                                                                                                       2005
                     15
                                                                                                                                       2007
                                                                                                                                       2009



                     10




                      5




                      0
                             Males              Females          White Non-Hispanic     Black Non-Hispanic          Hispanic   Texas

                                 1Youth  is defined as a student in public schools ranging in age from 15-18 years old.
                                 Data Source: Texas Department of State Health Services, Center for Health Statistics
                                 http://www.dshs.state.tx.us/chs/yrbs/query/yrbss_form.shtm
Prevalence of Lack of Physical Activity1 Among Adults2, 2002-2008
                     35




                     30




                     25
Weighted Percent %




                     20
                                                                                                                                                    US
                                                                                                                                                    Texas
                                                                                                                                                    Travis County
                     15




                     10




                      5




                      0
                          2002             2003           2004              2005              2006              2007              2008


                                 1Lack  of activity is defined as respondents who report no leisure-time physical activity during the past month.
                                 2Adults are defined as respondents 18 years old and older.
                                 Data Source: Texas Department of State Health Services, Center for Health Statistics
                                 http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm; Austin/Travis County Health & Human Services
                                 Department
                                             Prevalence of Lack of Physical Activity1 Among Adults2
                                                              Travis County 2008
                     50
                                                                                                       34.4


                     45



                     40

                                                                                                                                                            26.9
                     35

                                                   22.0                                                                  21.3
                                                                                                                                          21.1
Weighted Percent %




                     30
                                    21.4                            20.7

                     25

                                                                                      14.1
                     20



                     15



                     10



                      5



                      0
                                  Travis          Males           Females         White Non-         Hispanic           30-44            45-64              65+
                                                                                   Hispanic
                          1Lack of activity is defined as respondents 18 years and older who report no leisure-time physical activity during the past month.
                          2Adultsare defined as respondents 18 years old and older.
                          In 2008, the sample sizes for Black non-Hispanics and 18-29 year olds were less than 50 respondents and consequently data could not be analyzed.
                          Data Source: Austin/Travis County Health & Human Services Department
                          Prevalence of Lack of Physical Activity1 in Adults2, Travis County, 2008
                     60




                                                                                                                   33.8                 36.2
                                                    30.9
                     50




                                                                         26.0
                     40
Weighted Percent %




                     30
                               21.4




                     20

                                                                                              9.4                                                            10.0



                     10




                      0
                              Travis              HS Grad           Some College            College               < $25K          $25K to $49,999           $50K +

                           1Lack  of activity is defined as respondents 18 years and older who report no leisure-time physical activity during the past month.
                           2Adults are defined as respondents 18 years old and older.
                           In 2008, the sample size for Less than High School was less than 50 respondents and consequently data could not be analyzed.
                           Data Source: Texas Department of State Health Services, Center for Health Statistics
                           http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm
  Prevalence of Poor Nutrition1 in Adults2, Austin-Round Rock MSA, 2007
                     100


                                                                                                  77.8
                      90
                                                                                                                70.8          77.8
                                            75.9
                           72.1                                                                                                                    68.6
                      80
                                                         67.6         66.4                                                                  65.1

                      70
Weighted Percent %




                      60



                      50



                      40



                      30



                      20



                      10



                       0
                           Travis           Males      Females     White Non-    Black Non-     Hispanic       18-29         30-44         45-64   65+
                                                                    Hispanic      Hispanic
                                  1Poor  nutrition is defined as eating certain fruits, fruit juices, or vegetables less than 5 times per day.
                                  2Adults are defined as respondents 18 years old and older.
                                  In 2008, the sample size for Black non-Hispanics was less than 50 respondents and consequently data could not
                                  be analyzed.
                                  Data Source: Texas Department of State Health Services, Center for Health Statistics
                                  http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm
                          Prevalence of Eating 5 or More Fruits and Vegetables Per Day in Youth1 in
                                     Texas’ Public Schools, 2001, 2005, 2007, and 2009
                              Percent Ate Fruits and Vegetables 5 or More Times per Day During the Past 7 Days

                     50


                     45


                     40


                     35
Weighted Percent %




                     30
                                                                                                                                                 2001
                                                                                                                                                 2005
                     25
                                                                                                                                                 2007
                                                                                                                                                 2009
                     20


                     15


                     10


                      5


                      0
                          Texas                Males                Females          White Non-Hispanic          Hispanic   Black Non-Hispanic

                                  1Youth  is defined as a student in public schools ranging in age from 15-18 years old.
                                  Data Source: Texas Department of State Health Services, Center for Health Statistics
                                  http://www.dshs.state.tx.us/chs/yrbs/query/yrbss_form.shtm
                                                Prevalence of Diabetes1 in Adults2,
                                           United States, Texas, Travis County 2002-2008
                12




                10




                8
% Respondents




                                                                                                                           US
                6                                                                                                          Texas
                                                                                                                           Travis County




                4




                2




                0
                               2002          2003              2004             2005             2006        2007   2008
                                                                                Year
                     1Doctor  diagnosed as having diabetes but not diagnosed while pregnant
                     2Adults are defined as respondents 18 years old and older.
                     Data Source: Texas Department of State Health Services, Center for Health Statistics,
                     http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm (US, Texas)
                     Austin/Travis County Health and Human Services Department, (Travis County)
                          Prevalence of Diabetes1 in Adults2 by Sex, Race/Ethnicity, and Age Group, Travis
                                                           County - 2008
                     35



                                                                                                                        15.4
                     30




                     25
Weighted Percent %




                     20



                                                                                                                 9.3
                     15
                                                                                               7.8
                                                              8.7

                             6.9             5.5                               6.4                      5.7
                     10




                      5




                      0
                            Travis          Males          Females         White Non-        Hispanic   30-44   45-64   65+
                                                                            Hispanic

                              1Doctordiagnosed as having diabetes but not diagnosed while pregnant
                              2Adultsare defined as respondents 18 years old and older.
                              Data Source: Austin/Travis County Health & Human Services Department
Economic Data
           Potentially Preventable Hospitalizations
                  Travis County, 2005-2008
Hospitalizations for Number of      Average       Total          Average
Adult Residents of Hospitalizations Hospital     Hospital       $ Impact
  Travis County                     Charge       Charges          for all
                                                                   Adult
                                                                Residents
Angina (without procedures)    228     $16,104    $3,671,690       $5
Congestive Heart Failure      5,942    $24,905   $147,986,462     $207

Hypertension (High Blood
Pressure)                      851     $17,040   $14,501,152       $20
Asthma                        1,951    $17,931   $34,983,318       $49

Chronic Obstructive
Pulmonary Disease             2,075    $24,393   $50,615,186       $71
Diabetes Short-term
Complications                  972     $18,743   $18,218,527       $26
Diabetes Long-term
Complications                 2,337    $32,090   $74,995,296      $105

TOTAL                         14,356   $21,601   $344,971,631     $751
Economic Cost

    In 1998/1999, Texas Smoking-Attributable
     Costs = $10.09 billion
        Direct Medical expenditures - $4.55 billion
        Lost Productivity costs - $5.54 billion
    In 1998, about 15% ($1,265,000,000 or
     $543.87 per recipient) of all Texas Medicaid
     expenditures were spent on smoking-related
     illnesses and diseases. (includes state and
     federal contributions to Medicaid)
Economic Costs Due To Smoking
Travis County, 2007
  584 deaths caused by smoking among adults
                   35+ years

    Loss   of future earnings and productivity of
                     $165.4 million

    2004   Direct Health Care Costs for Travis
                County- $243 million
Texas Employer Costs of Smoking
 Estimated annual EXCESS absence and productivity
   cost per smoker $2,625 (not including health costs)
    Smoke breaks $2,261
       26 minutes per day more than non-smokers (Source: Study by
        Halpern and Rentz) multiplied by the Texas average hourly wage
        $19.76 (Source: Bureau of Labor Statistics, May 2009)
    Absences $364
       2.3 days of additional absences (Source: Study by Halpern and
        Rentz) multiplied by Texas average hourly wage of $19.76. (Source:
        Bureau of Labor Statistics, May 2009)

 Tobacco-free environments reduces smoking prevalence by 3.8% and helps
    ex-smokers by eliminating cues to smoke and (Study by Fichtenberg and
    Glantz).
Comprehensive smoke-free workplace
laws reduce cigarette consumption

     ―…total prohibition of smoking in the workplace
      strongly affects industry volume. Smokers facing these
      restrictions consume 11%-15% less than average and
      quit at a rate that is 85% higher than average...Milder
      workplace restrictions, such as smoking only in
      designated areas, have much less impact on
      quitting rates and very little effect on
      consumption.”
     ―…financial impact of smoking bans will be
      tremendous –three to five fewer cigarettes per day per
      smoker will reduce annual manufacturer profits a
      billion dollars plus per year.‖
            - Excerpts from Philip Morris internal documents
Smokefree Laws:
Economic Issues
  The US EPA estimates that smokefree
   restaurants can expect to save about $190 per
   1,000 square feet each year in lower cleaning
   and maintenance costs.
  The National Fire Protection Association found
   that in 1998 smoking materials caused 8,700
   fires in non-residential structures resulting in
   direct property damage of $60.5 million.
  Landlords and restaurants with smokefree
   premises have negotiated lower fire and
   property insurance premiums.
Tobacco Industry Expenditures

  In 2006 the Tobacco Industry spent $12.49
   billion on advertising and promotion in the U.S.
  Approximately $1.01 billion was spent in
   Texas in 2006 (over $2.76 million every single
   day)
  Approximately $41.75 million was spent in
   Travis County in 2006 ($114,400 every single
   day)
Corner Store by Anderson HS
Criteria for Evaluating Economic
Studies
     Based on objective data (i.e. sales tax)
     Includes data for a sufficient time period
      before and after the ordinance
     Accounts for underlying economic trends
     Uses appropriate statistical methods
     In peer-reviewed literature
     Source of funding
Texas Economic Studies
Methods
    Quarterly data obtained from the Texas
     Comptroller‘s Office
        Taxable restaurant, bar and mixed beverage sales
        Total retail sales
    Linear regression model to assess the
     economic impact of clean indoor air
     ordinances
                                   Figure 1. Gross Restaurant, Bar and Mixed Beverage Revenues
                                            By Fiscal Quarter*—El Paso, Texas, 1990-2002
                             140

                             120
Gross Revenue ($ Millions)




                             100

                              80

                              60
                                                                         Smoking Ban in effect January 2, 2002
                              40

                              20

                               0
                                1990        1992           1994           1996           1998          2000   2002
                                                                           Year
                                             Restaurants          Bars       Mixed Beverage Revenues
                                          * First fiscal quarter of each year is January 1 –March 31
                              Figure 2. Restaurant, Bar and Mixed Beverage Revenues, Percent of
                                           Total Retail Revenues by Fiscal Quarter*—
                                                   El Paso, Texas, 1990-2002

                            10%
% of Total Retail Revenue




                            8%


                            6%


                            4%                                         Smoking Ban in effect January 2, 2002


                            2%


                            0%
                              1990       1992           1994            1996            1998         2000      2002
                                                                          Year
                                           Restaurants          Bars       Mixed Beverage Revenues

                                        * First fiscal quarter of each year is January 1 –March 31
           Austin Total Bar Sales by Quarter
                                               Ordinance

40000000
30000000
20000000
10000000
       0
      00


              01


                     02


                            03


                                   04


                                          05


                                                   06
     20


             20


                    20


                           20


                                 20


                                        20


                                                 20
              Austin - Total Mixed Beverage Sales

40000000                                            Ordinance

30000000
20000000
10000000
      0
           2000


                   2001


                          2002


                                  2003


                                         2004


                                                2005


                                                          2006
             Austin Mixed Beverage Sales
                                                  Ordinance
35000000
30000000
25000000
20000000
15000000
10000000
 5000000
       0
           2000


                  2001


                           2002


                                  2003


                                         2004


                                                2005


                                                         2006
                         Total    Bars   Restaurants
Summary

    2003 study offered a comprehensive view of all available studies on the
     economic impact of smoke-free workplace laws (Over 97 studies, including 34
     with smoke-free bars)
    The study concluded that:

     “All of the best designed studies report no impact or a    positive
     impact of smoke-free restaurant and bar laws on sales or
     employment. Policymakers can act to protect workers and
     patrons from the toxins in secondhand smoke confident in
     rejecting industry claims that there will be an adverse economic
     impact.”


                                             Scollo M, et al, Review of the quality of studies on the
                                          economic effects of smoke-free policies on the hospitality
                                                       industry, Tobacco Control (2003); 12:13-20.
Poor Quality Literature on Smoke-Free
Bars and Restaurants

   Supported by Tobacco Industry
   Survey of bar owners on predicted impacts or
    anecdotal information
   Bizarre time periods or inappropriate control
    groups for comparison
   Non-peer reviewed
Plausibility

   In Texas there are over 4 times as many adult
    non-smokers as smokers
   Prior experiences
         Airline bans
         Movie theatres
     Texas Adult Survey
Texas Adult Survey (BRFSS)
2009
    If there were a total ban on smoking in
     restaurants, would you eat out:
        More often        27%
        Less often         6%
        No difference   67%
Texas Adult Survey (BRFSS)
2009
    If there were a total ban on smoking in bars
     and music clubs, would you go to bars and
     music clubs:
        More often        19%
        Less often         8%
        No difference   73%
―Back in 2002, when the City Council was weighing Mayor Michael R.
Bloomberg‘s proposal to eliminate smoking from all indoor public
places, few opponents were more fiercely outspoken than James
McBratney, president of the Staten Island Restaurant and Tavern
Association.

He frequently ripped Mr. Bloomberg as a billionaire dictator with a
prohibitionist streak that would undo small businesses like his bar and
his restaurant. Visions of customers streaming to the legally smoke-
filled pubs of New Jersey kept him awake at night.

Asked last week what he though of the now two-year-old ban, Mr.
McBratney sounded changed. ―I have to admit,‖ he said sheepishly,
―I‖ve seen no falloff in business in either establishment.‖ He went on to
describe what he once considered unimaginable: Customers actually
seem to like it and so does he.
                          New York Times Feb 6, 2005
Key Points

    International scientific consensus that SHS kills
    SHS under typical conditions of smoker density and
     ventilation poses unacceptable risks to nonsmokers
    SHS cannot be controlled to acceptable levels of risk
     by ventilation or air cleaning
    No objective evidence to support the claim that
     smoke-free ordinances impose economic penalties on
     restaurant or bar owners
    Restrictions on SHS are no different than any other
     restrictions to protect public health.
Green and Tobacco-Free
    According to the Smithsonian Institute, "it takes ten years for one
     cigarette butt to degrade."
    According to Eco Recycle, "50% of all litter in urban areas is
     tobacco-related products including butts, cellophane wrapping,
     foil inserts and packaging."
    According to Cigarette Litter Org, "4.5 trillion cigarette butts are
     littered worldwide every year."
    According to the Texas Department of Transportation: "130
     million butts will be tossed out in Texas alone this year.―
    Lower safety hazards
         According to CleanUp.org.au, "a cigarette butt can smoulder for up to
          three hours causing a grass fire or even a bushfire."
         According to a study by the Department of Epidemiology and
          Preventive Medicine at the University of California, "Smoking causes
          an estimated 30% of U.S. and 10% of global fire death burdens."
         According to the Burn Prevention Committee of the American Burn
          Association, "Cigarettes are the most common ignition source for
          fatal house fires, which cause approximately 29% of the fire deaths
          in the United States."
What We Are Doing to Address
Chronic Disease
Chronic Disease Coalition?
                                                         •Coordination
                                                         •Networking
                  Chronic Disease Prevention
                     and Control Coalition               •Resources
                                                         and Tools
                                                         •Policy and
                                                         Environmental
                                                         Changes

              Disease/Risk Factor Coalitions and Work Groups


                                 Obesity
   Diabetes         Cancer                     Tobacco         Asthma
                                Prevention
 Community intervention matrix
                     School Community Worksite Health Care


Nutrition
Physical Activity
Tobacco/Smoking
General Health
Asthma
Cancer
CVD
Diabetes
Obesity Prevention
Austin/Travis County CPPW
Award
    Awarded $7.47 Million over 2 years to address
     tobacco
    One of 44 communities selected (out of 263
     applicants)
    Changing the social norms
    Extremely tight timelines
    Expectation to perform
    ―The world is watching‖
    Implications for future funding
Health Care Reform Legislation

SEC. 4002 PREVENTION AND PUBLIC HEALTH FUND
  (a) PURPOSE.—It is the purpose of this section to establish a Prevention and
   Public Health Fund (referred to in this section as the ‗‗Fund‘‘), to be
   administered through the Department of Health and Human Services, Office
   of the Secretary, to provide for expanded and sustained national investment
   in prevention and public health programs to improve health and help restrain
   the rate of growth in private and public sector health care costs.

 (b) FUNDING.—There are hereby authorized to be appropriated to the Fund,
   out of any monies in the Treasury not otherwise appropriated—
     (1) for fiscal year 2010, $500,000,000;
     (2) for fiscal year 2011, $750,000,000;
     (3) for fiscal year 2012, $1,000,000,000;
     (4) for fiscal year 2013, $1,250,000,000;
     (5) for fiscal year 2014, $1,500,000,000; and
     (6) for fiscal year 2015, and each fiscal year thereafter, $2,000,000,000.
CPPW Strategies
   Emphasize high-impact, broad-reaching
     policy,
     environmental, and
     systems changes
Policy, Systems & Environmental
Change


   What they mean is,
      overcome the
   Stickiness Problem.
                       Exercise Participation
                       Effect of Short Bouts, Home Treadmills
                       (Jakicic et.al., JAMA 282, 16)

                      240
Exercise (min/week)




                                                                ?
                      180                                                  LB
                                                                           SB
                      120                                                  SBT



                      60
                            0            6              12      18
                                              months
                                                             mark.fenton@verizon.net
                       Exercise Participation
                       Effect of Short Bouts, Home Treadmills
                       (Jakicic et.al., JAMA 282, 16)

                      240
Exercise (min/week)




                      180                                                  LB
                                                                           SB
                      120                                                  SBT



                      60
                            0            6              12      18
                                              months
                                                             mark.fenton@verizon.net
Self-help vs. Commercial
Weight Loss Programs
     (Heshka et.al., JAMA 289, 14; April 9, 2003)

                    0
Weight Change, kg




                    -1
                    -2
                    -3
                    -4
                    -5
                                                        Self-help
                    -6
                                                        Commercial
                    -7
                         0   6            12   18         24
                                 months

                                                    mark.fenton@verizon.net
MAPPS Strategies

  Media,
  Access,
  Pricing,
  Point of Purchase   Prompts,
  Social Support
         MAPPS Table: Tobacco
                                                      Tobacco

Media                   Media and advertising restrictions consistent with federal law
                        Hard hitting counter-advertising
                        Ban brand-name sponsorships
                        Ban branded promotional items and prizes
Access                  Usage bans (i.e. 100% smoke-free policies or 100% tobacco-free
                         policies)
                        Usage bans (tobacco-free worksites and or school campuses)
                        Zoning restrictions
                        Restrict sales (e.g. internet; sales to minors; stores/events w/o
                         tobacco)
                        Ban self-service displays & vending
Point of Purchase/      Restrict point of purchase advertising
                        Labeling/ signage/ placement to discourage consumption of tobacco
Promotion
Price                   Use evidence-based pricing strategies that discourage tobacco use
                        Ban free samples and price discounts
Social Support &        Quitline and other cessation services (please note that only up to 5%
                         of the total award for tobacco prevention and control can be spent on
  Services               nicotine replacement therapy (NRT).
Media
Access: Tobacco-Free Policies
and Laws
  Only way to protect non-smokers from secondhand
   smoke
  Saves lives and prevents heart attacks (up to 17%
   average reduction in heart attack hospitalizations
   where smoke-free laws enacted)
  Changes the social norm
  Helps motivate smokers to quit
  Worker safety issue - not ―personal nuisance‖
 All workers deserve equal protection
  Smoke-free workplace laws don‘t hurt business
  No trade-off between health and economics
Access

    Tobacco-Free Worksite Policies
    Support Tobacco-Free School and University Policies
    Tobacco-Free Parks and Recreation
    Disparities focus – Tobacco-Free policies with
     supporting cessation services for:
         Human service agencies
         Integral Care,
         Homeless Shelters
         Public Housing
    Tobacco –Free Healthcare Facilities (with system changes to
     promote cessation)
    Tobacco-Free Public Transit
Early Wins: Cap Metro/MHMR


  Creates tobacco-free zones at all passenger
   boarding areas, for Park and Ride and transit
   stations
  Tobacco-free metro rail platforms on September
   1, 2010
  Working towards tobacco-free bus stops
Point-Of-Purchase

  Restrict point of purchase advertising
  Labeling/ signage/ placement to discourage
   consumption of tobacco
Social Support

  Promote the Statewide Telephone Quitline
   (Including Free Nicotine Replacement)
  Create a Community Cessation Resource
   Available for Referral
Cessation services save lives and are an
important part of a comprehensive program
  • 70% of U.S. adult smokers report they want to
    quit
  • Quitting is hard, but most Americans who have
    ever smoked have already quit
  • Immediate health benefits to quitting, even in
    long-time smokers
  • Telephone counseling (quitlines) and low out-of-
    pocket costs for treatment increase
    uptake
  • Cessation services can double or triple quit rate
    –
  MAPPS Table: Nutrition & PA
            Nutrition                                                          Physical Activity

Media       • Media and advertising restrictions consistent with federal       •   Promote increased activity
                law                                                            •   Promote use of public transit
            •   Promote healthy food/drink choices                             •   Promote active transportation (bicycling and walking)
            •   Counter-advertising for unhealthy choices                      •   Counter-advertising for screen time


Access      • Healthy food/drink availability (e.g., incentives to food        • Safe, attractive accessible places for activity (e.g. access to
                retailers to locate/offer healthier choices in underserved         outdoor recreation facilities, enhance bicycling and walking
                areas, healthier choices in child care, schools, worksites)        infrastructure, place schools within residential areas, increase
            •   Limit unhealthy food/drink availability (whole milk, sugar         access to and coverage area of public transportation, mixed
                sweetened beverages, high-fat snacks)                              use development, reduce community designs that leads to
            •   Reduce density of fast food establishments                         injuries).
            •   Eliminate trans fat through purchasing actions, labeling       •   City planning, zoning and transportation (e.g., planning to
                initiatives, restaurant standards                                  include the provision of sidewalks, mixed use, parks with
            •   Reduce sodium through purchasing actions, labeling                 adequate crime prevention measures, and Health Impact
                initiatives, restaurant standards                                  Assessments)
            •   Procurement policies and practices                             •   Require daily quality PE in schools
            •   Farm to institution, including schools, worksites, hospitals   •   Require daily physical activity in afterschool/childcare settings
                and other community institutions                               •   Restrict screen time (afterschool, daycare)

Point of    • Signage for healthy vs. less healthy items                       • Signage for neighborhood destinations in walkable/mixed-use
            • Product placement & attractiveness                                   areas
Purchase/   • Menu labeling                                                    • Signage for public transportation, bike lanes/boulevards.
Promotion

Price       • Changing relative prices of healthy vs. unhealthy items          • Reduced price for park/facility use
                (e.g. through bulk purchase/procurement/competitive            • Incentives for active transit
                pricing).                                                      • Subsidized memberships to recreational facilities

Social      • Support breastfeeding through policy change and                  • Safe routes to school
                maternity care practices                                       • Workplace, faith, park, neighborhood activity groups (e.g.,
Support &                                                                          walking hiking, biking)
Services
DSHS obesity prevention funding
 Goals:
  Increase availability of affordable healthy food and
   beverages
  Promote healthy food and beverage choices
  Create safe communities that support physical activity
  Promote physical activity/limiting sedentary activity
   among children and youth.

 Phases:
  Phase 1 (through Sept. 2010): Planning
        Asset mapping, focus groups, work plan development
    Phase 2 (through Sept. 2011): Implementation
Partners:
   Austin Travis County Sustainable Food Policy Advisory Board
                                                                     WIC Program
   Sustainable Food Center
                                                                     Greater Austin Hispanic Chamber - Health & Wellness
   Austin Community College District (ACC),                          Committee
   Children's Optimal Health                                        Equator Media Limited
   Theatre Action Project                                           Michael and Susan Dell Center for Advancement of Healthy
   Del Valle Independent School District                             Living –
   Eanes Independent School District                                Wye River Group on Healthcare
   LifeWorks                                                        WRGH
   Austin Public LibraryLiteracy Coalition of Central Texas         Austin Independent School District
   Austin Travis County Integral Care (formerly MHMR)               City of Austin HealthPLUS Employee Wellness Program
   Austin Child Guidance Center                                     The Austin Project
   Pflugerville ISD                                                 Central Texas Community Health Centers d/b/a
   Texas Round-Up, Inc.                                              CommUnityCareAlliance for African American Health in
   YMCA of Austin                                                    Central Texas
   Safe Kids Austin, Led By Dell Children's Medical Center of       Las Comadres para las Americas
    Central Texas                                                    Texas AgriLife Extension Service
   Austin Cycling Association                                       Austin Area Yoga TeachersYouthLaunch
   Texas A&M University                                             Bicycle Sport Shop
   BikeTexas Education Fund                                         City of Austin/Travis Co. WIC Program,
   City of Austin, Neighborhood Connectivity Division               Central Texas Healthy Mothers Healthy Babies
   Seton Asthma Center                                              Seton Family of Hospitals
   American Lung Association of the Central States                  Garza's Gardens gonzalo garza ihs aisd
   Ventanilla de Salud                                              YouthLaunch, Inc.
   Austin Parks and Recreation                                      Mothers' Milk
   ACTIVE Life, Inc.
   Michael & Susan Dell Center for Advancement of Healthy
    Living, UT School of Public Health
Outcomes
Air Monitoring Activities
           Measuring Air Quality
• Cigarettes, cigars and pipes are
  major emitters of respirable
  suspended particles less than
  2.5 microns (PM2.5) in diameter
  that are easily inhaled deep
  into the lungs
• TSI SidePak AM510 Personal
  Aerosol Monitor (weight: 1 lb)


   This instrument measures and records in memory the PM2.5 concentration
    every minute during sampling
   PM2.5 very sensitive marker of SHS
                   PM 2.5 Austin Texas
     1.2




         1




     0.8
PM 2.5
mg/m 3




                                         Before Sept 1 2005
     0.6
                                         After Sept 1 2005



     0.4




     0.2




         0
             Bar
              A
                               Average Level of PM 2.5 Austin Texas

         1.2




          1




         0.8
PM 2.5
mg/m 3




                                                                                        Before Sept 1 2005
         0.6
                                                                                        After Sept. 1 2005




         0.4




         0.2




          0
               Bar A   Bar B    Bar C   Bar D   Bar E   Bar F   Bar G   Bar H   Bar I
                       Levels of SHS Outdoors Close to
                                Levels Indoors


                                                                                           Levels of small particles
                                                                                           detected at varying
                                                                                           distances from 5
                                                                                           cigarettes outdoors,
                                                                                           compared to indoor
                                                                                           living room



                                                                 Indoor level




Klepeis NE et al (2007). Real-time measurement of outdoor tobacco smoke particles. J Air Waste Mgmt Assoc 57:522-534.
Heart Attack Deaths Decline 3 Times Faster in
    County with Anti-Tobacco Campaign


                                Heart Attack Death Rates, age-adjusted

                          140

                          120
    Per 100k population




                          100

                           80

                           60

                           40

                           20

                            0
                                2000         2001          2002        2003



                                 Harris County      Jefferson County   TEXAS
   Using the Prism tool for program
planning and to project program effects
                      Questions Addressed by System Dynamics
                      Modeling Learning to Re-Direct the Course of Change
                                               Prevalence of Diagnosed Diabetes, US
                 40
                            Historical
                              Data
                                                                                                                                              Simulation
                                                                                                                                             Experiments
                 30                                                                                                                               in
Million people




                                                                                                                                             Action Labs



                 20


                                                                                                            Markov Model Constants
                 10                                                                                         • Incidence rates (%/yr)
                                                                                                            • Death rates (%/yr)
                                                                                                            • Diagnosed fractions
                                                                                                            (Based on year 2000 data,
                                                                                                            per demographic segment)
                  0
                  1980         1990             2000             2010              2020             2030              2040              2050



                         Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes
                         prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164.
                         Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through
                         simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.
      Diabetes Burden is Driven by Population Flows
                                                                                       Burden of
                                                                                       Diabetes
                                                                                                               Costs
                                                                                                     (per person with diabetes)

                                                                   Total Prevalence            Unhealthy Days
                                                                (people with diabetes)         (per person with
                                                                                                  diabetes)
                                            Developing                    Developing
                PreDiabetes
People with                                   Diabetes                                               Deaths
                   Onset      People with      Onset     People with Diagnosis         People with
   Normal             e                                  Undiagnosed
                              Undiagnosed        c                        b            Diagnosed       a
Blood Sugar                   PreDiabetes                 Diabetes                      Diabetes
   Levels      Recovering from
                 PreDiabetes
                       d                                         Deaths


     Obesity in the                PreDiabetes                        Diabetes                                 Diabetes
       General                     Detection &                        Diagnosis
      Population                   Management                                                                 Management




                                   Inflow
                                                         Volume


                                                                                 Outflow
       Diabetes Burden is Driven by Population Flows
                                                                                        Burden of
                                                                                        Diabetes
    This larger view takes us beyond                                                                           Costs
    standard epidemiological models                                                                  (per person with diabetes)

    and most intervention programs                                 Total Prevalence            Unhealthy Days
                                                                (people with diabetes)         (per person with
                                                                                                  diabetes)
                                            Developing                    Developing
                PreDiabetes
People with                                   Diabetes                                               Deaths
                   Onset      People with      Onset     People with Diagnosis         People with
   Normal             e                                  Undiagnosed
                              Undiagnosed        c                        b            Diagnosed       a
Blood Sugar                   PreDiabetes                 Diabetes                      Diabetes
   Levels      Recovering from
                 PreDiabetes
                       d                                         Deaths


     Obesity in the                PreDiabetes                        Diabetes                                 Diabetes
       General                     Detection &                        Diagnosis
      Population                   Management                                                                 Management




                                                                                       Standard boundary
                                   Inflow
                                                         Volume


                                                                                 Outflow
                   Diabetes System Modeling Project
         Confirming Fit to Historical Trends (2 examples out of 10)

Obese % of Adults                                             Diagnosed Diabetes % of Adults
40%                                                           8%
      Obese % of adults                                            Diagnosed diabetes % of adults

                                           Simulated                                                   Simulated
30%                                                           6%



20%                                                           4%

                                                                                                       Data (NHIS)
                                     Data (NHANES)
10%                                                           2%



0%                                                            0%
  1980      1985      1990   1995   2000    2005       2010     1980      1985      1990      1995   2000    2005    2010
        The growth of diabetes prevalence since 1980 has been driven
                                  by growth in obesity prevalence
Obese Fraction and Diabetes per Thousand
  130
  0.7

          Diabetes
         Prevalence
   85
 0.35




          Obesity
   40    Prevalence
    0
     1980   1990    2000   2010 2020      2030   2040   2050
                            Time (Year)


                   Risk multiplier on diabetes
                    onset from obesity = 2.6
   Baseline Scenario: Obesity to increase little after 2006, diabetes
           keeps growing robustly for another 20-25 years

Obese Fraction and Diabetes per Thousand
  130                                                           Onset=6.3
  0.7
                                                                 per thou      Estimated 2006
         Diabetes                                                                  values
        Prevalence
   85                                                                    Prevalence=92
 0.35                                                                     AND RISING


         Obesity
   40
                                                                                         Death=3.8
        Prevalence
    0                                                                                     per thou
     1980   1990    2000   2010 2020      2030   2040   2050
                            Time (Year)

                   Risk multiplier on diabetes                   With high (even if flat) onset,
                    onset from obesity = 2.6                   prevalence tub keeps filling until
                                                                   deaths (4-5%/yr)=onset
        Diabetes prevalence keeps growing after
                     obesity stops

                             WHY?
        Unhealthy days impact of prevalence growth, as affected by
              diabetes management: Past and one possible future

Obese Fraction and Diabetes per Thousand
  130                                                          Unhealthy Days per Thou and Frac Managed
                                                                   500
  0.7
                                                                   0.65    Managed
                                                                            fraction
             Diabetes
            Prevalence
   85                                                                375
                                                                   0.325
 0.35




             Obesity                                                       Unhealthy Days
   40       Prevalence
    0
                                                                    250     from Diabetes
                                                                      0
     1980    1990   2000   2010 2020      2030   2040   2050          1980   1990   2000   2010   2020   2030   2040   2050
                            Time (Year)


  Diabetes prevalence keeps growing                                 Reduction in unhealthy days per
          after obesity stops                                      complicated case if conventionally
                                                                             managed: 33%;
                                                                     if intensively managed: 67%

                                                               If disease management gains end, the
                                                                           burden grows
                  A Sequence of What-if Simulations
           Start with the base case or ―status quo‖: no improvements in
           diabetes management or prediabetes management after 2006

      People with Diabetes per Thousand Adults            Monthly Unhealthy Days from Diabetes per Thou
150                                                       500

                                                                                                      Base
                                                          450
125
                                             Base
                                                          400
100

                                                          350

75
                                                          300


50                                                        250
 1980    1990   2000   2010   2020   2030   2040   2050     1980   1990   2000   2010   2020   2030   2040   2050
                Increase fraction of diagnosed diabetes getting managed from
                   Further Increases change in the Management
                58% to 80% by 2015. (No in Diabetes mix of conventional
                and intensive.) What do you think will happen?

      People with Diabetes per Thousand Adults               Monthly Unhealthy Days from Diabetes per Thou
150                                                          500

                                              Diab mgt                                                       Base
                                                             450
125
                                                 Base
                                                             400
                                       Diabetes mgmt does nothing to slow the
100                                        growth of prevalence—in fact, it                                Diab mgt
                                       increases it. As soon as diabetes mgmt
                                                           350
                                       stops improving, unhealthy days start to
75                                           grow as fast as prevalence.
                                                             300


50                                                           250
 1980    1990     2000   2010   2020   2030    2040   2050     1980     1990   2000   2010   2020   2030    2040    2050

        More people living with diabetes                              Keeping the burden at bay for nine
                                                                                years longer
           Increase fraction of prediabetics getting managed from 6% to
           A Huge Push for Prediabetes Management
           32% by 2015. (Half of those under intensive mgmt by 2015.) No
           increase in diabetes mgmt. What do you think will happen?



150   People with Diabetes per Thousand Adults Monthly Unhealthy Days from Diabetes per Thou
                                               500

                                                                                                Base
                                                    450
125                                          Base

                                                    400                                  PreD mgmt
                                        PreD mgmt
100
                                                    350
                                 Diabetes onset rate reduced 12% relative
 75                               to base run. Not nearly enough to offset
                                                       300
                                 the excess onset due to high obesity. By
                                  2050, diabetes prevalence reduced only
 50                                                    250
  1980   1990   2000     2010   2020   2030 9% relative to base run.2000 2010
                                              2040  2050 1980 1990              2020   2030   2040   2050


                       The improvement is relatively modest—the growth is not
                                              stopped
What if it were possible—in addition to the prediabetes mgmt intervention -
      Two Scenarios in which Obesity is Reduced
to gradually lower the fraction obese from 34% (2006) to the 1994 value of
25% by 2030? Or, to the 1984 value of 18%?


                       Obese Fraction of Adult Population

        0.4
                                                             Base


        0.3
                                                      Obesity 25%


        0.2                                           Obesity 18%


        0.1


         0
         1980   1990    2000     2010    2020     2030      2040    2050
          What do you think will happen if, in addition to PreD mgmt, obesity is
         Managing Prediabetes AND Reducing Obesity
          reduced moderately by 2030? What if it is reduced even more?

                                                             Monthly Unhealthy Days from Diabetes per Thou
150   People with Diabetes per Thousand Adults         500

                                                                                                             Base
                                                       450
125                                             Base                                                 PreD mgmt

                                            PreD mgmt 400
                                                                                                       PreD &
100                    Why is obesity reduction so powerful?
                                          PreD &                                                       Ob 25%
                                          Ob 25% 350
                    Mainly because of its strong effect on onset
 75
                   rate among prediabetics; but, also, because it
                                  PreD & Ob 18%
                     reduces PreD prevalence itself. However,
                                                 300                                          PreD & Ob 18%

                    achieving significant obesity reduction takes
 50                                  a long time.250
  1980   1990   2000   2010   2020   2030     2040   2050 1980    1990   2000   2010   2020   2030    2040     2050

       The more you reduce obesity, the
         sooner you stop the growth in                        … Same with the burden of diabetes
      diabetes—and the more you bring it
                    down
        With pure upstream intervention, burden still grows for many years before
         Intervening Effectively Upstream we add the prior diabetes
        turning around. What do you think will happen if AND Downstream
        mgmt intervention on top of the PreD+Ob25 one?


        People with Diabetes per Thousand Adults               Monthly Unhealthy Days from Diabetes per Thou
150                                                      500

                                                                                                              Base
                                                         450
125                                               Base

                                          PreD mgmt 400                                               PreD mgmt
                                   Downstream improvement       acts quickly
100                                             All 3
                                against burden but cannot continue forever.
                                         PreD & Ob 25% 350                                     Pred & Ob 25%
                                Significant upstream gains are thus essential
75
                                  but will likely take 15+ years to achieve.                   All 3 --
                                 A flat-burden future is possible but requires
                                                        300
                                                                                               PreD & Ob 25%
                                      simultaneous action on both fronts.                      & Diab mgmt
50                                                       250
 1980    1990   2000     2010    2020   2030   2040   2050 1980    1990   2000   2010   2020   2030    2040     2050

                         With a combination of effective upstream and downstream
                       interventions we could hold the burden of diabetes nearly flat
                                               through 2050!
    Assumptions for Future Scenarios
Base Case
• Caloric balances stay at 2000 values through 2050

       Altering Food and Activity Environments
          Reduce caloric balances to their 1970 values by 2015
          Focused on
             ‗School Youth‘: youth ages 6-19
             ‗All Youth‘: all youth ages 0-19
             ‗School+Parents‘: school youth plus their parents
             ‗All Adults‘: all adults ages 20+
             ‗All Ages‘: all youth and adults

       Subsidized Weight Loss Programs for Obese Individuals
          Net daily caloric reduction of program is 40 calories/day
           (translates to 1.8 kg weight loss per year)
          Fully effective by 2010 and terminated by 2020
                                    Alternative Futures
                                  Obesity in Adults (20-74)
                                   Obese fraction of Adults (Ages 20-74)
                         50%
Fraction of popn 20-74




                         40%


                         30%


                         20%


                         10%


                         0%
                           1970   1980   1990      2000   2010   2020   2030   2040   2050
                                  Base                SchoolYouth        AllYouth
                                  School+Parents      AllAdults          AllAges
                                  AllAges+WtLoss
                                                      PRISM Base Case Behavior 2000 – 2040
                                                                 for East Travis
                        Junk food
                    interventions: Tax,
                      counter-market                     Tobacco interventions: Tax, restrict
                                                            marketing, counter-market, ban
                                                          smoking in public places, increase
Fruit & vegetable                        Increase use of        use of quit services                                  Reduce
 interventions:                        weight loss services                                                         particulate air
                                            by obese                                                                  pollution
Provide access,
     promote                                                            0.4
                        0.8                                                      Smoker                           0.6
                                                0.6                                                  Secondhand
                               Excess Junk                                     Prevalence                                                    30
                                                              Obesity    0                               Smoke 0            Air Pollution
                                Food Frac.
                         0                          0      Prevalence
                                                                                                                                   PM2.5 0           4
                              Fruit/Veg-Poor 0.8                                                                                                            Non-CV deaths
                                Diet Fraction                      Chronic Disorders                                                                 0            per 1000
                                                                                               0.5
                                                0
                                                                                                            Uncntrld
              4,000                                                                    High                        Disorders 0.4                  CV Events          40    10,000
                                                                                                                                                                                        Total Conseq
                      Average sodium
                                                                   High BP       cholesterol                Chol
Reduce use of           Consumption
                        Sodium                                                                                             BP                                                           Costs per Cap
sodium in food                                                                                                                                            per 1000 0
                                in mg
                      consumption                                                                                         Diab 0                                               0
                    0                                                             Diabetes 0
                                                                                                                                                             CV Deaths              20
                 0.8
                                                                                                                                                             per 1000
                          Inadequate                                            0.2     1  Use of Quality     0.04 Trans Fat Frac.
                                                                                                                                                                                    0
                          PA Fraction                            Distressed               Preventive Care                of Calories
                    0
                                                                    fraction
                                                                                        0        non-CVD           0
                                                                                0.1
                                                                                                                                            Fraction of          0.4
                                                                                                                                            popn 65+
 Physical activity interventions:                                                                                                                                         Improve quality of
   Provide access, promote,                                                        Increase provision           Reduce use of                                    0         acute and rehab
  increase school & childcare                                                       and use of quality        trans fats in food                                          care for CV events
                                                        Increase use of help
         requirements                                   services for distress        Preventive care
    What results should we expect to see in Austin/Travis
         County with ARRA-related interventions?
Tax tobacco = 0.0                          Access to physical activity spaces = 1.0
Restrict tobacco sales & marketing = 0.5   Promote physical activity = 0.5
Tobacco counter-marketing = 1.0            Require more physical activity in school =
Ban workplace smoking = 0.6                    1.0
Use of smoking quit services = 1.0         Physical activity in childcare = 0.5
Air pollution (PM2.5) = 0.0                Use of quality preventive care, no CV
Tax junk food = 0.0                            event = 0.5
Junk food counter-marketing = 1.0          Use of quality of preventive care, post CV
                                               event = 0.5
Access to fruit & vegetables = 1.0
                                           Use of quality of acute and rehab care for
Promote fruit &veg consumption =1.0            CV events = 0.0
Sodium consumption = 0.0                   Use of help services for distressed, no
Trans fat consumption = 0.0                    CV event = 0.0
Use of weight loss services = 0.0          Use of help services for distressed, post
                                               CV event = 0.0

                                                                               106
                     Austin Intervention Scenarios: Expected ARRA Effects
         Tobacco + Individual Services + Diet & PA + Air Pollution & Sodium & Trans fat

          Smoking Prevalence (Adults)                                Obesity Prevalence (Adults)
                                                            0.6
0.4


0.3


0.2                                                         0.3



0.1


 0                                                           0
  2000        2010         2020            2030      2040     2000     2010      2020     2030         2040

         Cardiovascular Events per 1000                       Deaths from All Risk Factors per 1,000
40               (CHD, Stroke, CHF, PAD)                      8

30
                                                              6


20                                                            4


10                                                            2


 0                                                            0
 2000         2010        2020             2030     2040      2000     2010      2020     2030         2040

                             **if all risk factors=0**


                                                                                                   107
                                     Austin Intervention Scenarios: Expected ARRA Effects
                         Tobacco + Individual Services + Diet & PA + Air Pollution & Sodium & Trans fat




                             Years of Life Lost                                     Consequence Costs per Capita
                             from Attributable Deaths                               (medical costs + productivity)
                    80,000                                             6,000



                    60,000                                             4,500
people*years/Year




                    40,000                                             3,000


                    20,000
                                                                       1,500


                        0
                                                                         0
                        2000        2010      2020       2030   2040         2000      2010         2020        2030     2040
                                           Time (Year)                                           Time (Year)

                                                                                    **if all risk factors=0**




                                                                                                                       108
Conclusions

    Planned tobacco, diet and PA interventions in
     Austin/Travis County will reduce
        total consequence costs by $463 per capita per year,
         or $ 12.9 million each year
        the estimated number of deaths in Travis county by 570
         people by 2015, and 2000 by 2040.
    Adding Sodium and Salt reduction to the plan
     could save an additional
        $225 per capita per year of total consequence costs,
         or $ 6.3 million each year
        250 lives in Travis county by 2015, and 3000 more by
         2040.

                                                                109

				
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