Enabling Healthy Behaviors Through Policy and Environment Change

Enabling Healthy Behaviors through Policy and Environment Change

Sonia Angell, MD, MPH Deputy Commissioner, Division of Prevention and Primary Care New York City Department of Health and Mental Hygiene January 29, 2015 CTSI CEPHR Quarterly Lecture Series Outline

• New York City in the context of the world • Approach to risk modification • A short story… • New and emerging frontiers of focus

Gotham Long Island City, Queens, NY January 29, 2015, 7:11 am

Source: Sonia’s iphone We are more similar than not… Environments are More Similar: Top 10 Retailers, 2011 • North America • Worldwide • Wal-Mart Store • Wal-Mart Stores • Kroger Co • Carrefour • Costco Wholesale Corp • Metro Group • Safeway • Tesco • Supervalue • Schwarz Group • Lobalaw Cos • Kroger Co. • Publix Supermarkets • Costco Wholesale Corp • Ahold USA • Rewe Group • C & S Wholesale Grocers • Aldi • Delhaize America • Target Corp http://supermarketnews.com/profiles/top75/2011/ http://supermarketnews.com/profiles/top25-2011/top-25-2011/ Top 10 Food and Beverage Companies, 2010 • North America • Worldwide • Nestle • Nestle • Tyson • Pepsico Inc. • Kraft • Kraft • Pepsico Inc • ABinBev • Anheuser-Bush InBev • ADM • General Mills • Coca-cola • JBS USA • Mars • Dean Foods • Unilever • Mars Inc. • Tyson • Smithfield Foods Inc. • Cargill http://www.foodprocessing.com/top100/ http://www.foodbev.com/gallery/worlds-top-20-food-beverage-companies Leading Causes of Death Globally

Injuries Other chronic 10% Communicable diseases diseases* 11% 25% Chronic respiratory diseases 7% Diabetes 2% Cancer 15% Cardiovascular 30% Global deaths, 2010 *Includes communicable diseases, maternal, neonatal, and nutritional disorders Adapted from: Lozano R, et al. Lancet 2012;380:2095-2128. Leading Causes of Death in New York City

Heart Disease 32% 32% Cancer

Influenza/Pneumonia

Diabetes

3% Chronic Lower Respiratory 3% Diseases 4% All Other Causes 26% Source: NYC DOHMH, Office of Vital Statistics, 2015; Data for 2012 Deaths Attributable to Leading Factors By Country Income Level, 2004

Source: WHO. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva; 2009. http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf Global Response: Chronic Disease Platform

Common Risk Factors Major Causes . Tobacco . Cardiovascular Disease . Poor diet . Cancer . Harmful use of Alcohol . Diabetes . Physical inactivity . Chronic Lung Disease Metabolic Risk Factors • High Blood Pressure • High Glucose • High Cholesterol

Promoting Health: Make Healthy Choices Easier Choices

Individual Environment & Systems •Culture •Physical Access/Availability •Attitudes/Beliefs •Pricing/Economic •Skills •Communication/Media •Knowledge •Point of Decision •Time Education/Promotion Health • •Affordability Promoting

Behaviors

Environment

Source: Adapted from presentation by Dr. Heidi Blanch, CDC, NCCHPDP, DNPAO Health Impact Pyramid

Source: Frieden TR. Am J Public Health 2010;100(4):590-595.

Restricting Trans Fat Use in Foods: the New York City Experience The Dietary Disconnect

Daily Recommendation (AHA) US mean intake

Sodium: < 2300 mg or < 1500 mg* 3372 mg (Adults)

Saturated fat: < 7% of energy 11.2%

Trans fat: < 1% of energy 2.6%

Total fat: 25-35% of energy 33.6% Cholesterol: < 300 mg 333 mg (M) / 224 (F) * For persons who are ≥51, African American, or have hypertension, diabetes, or chronic kidney disease. Sources: AHA Diet and Lifestyle Recommendations Revision 2006; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6105a3.htm; http://health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf; http://riskfactor.cancer.gov/diet/ usualintakes/energy/; http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/0910/Table_1_NIN_GEN_09.pdf Spectrum of Opportunities • Individuals change in ingredients selected for home prepared foods • Individual change in foods ordered in restaurants • Feeding programs • Labeling (packaged and restaurant foods) • Marketing • Pricing • Media/awareness campaigns • Procurement policies • All of government • Vulnerable/select populations • Private sector institutions • Industry-wide reformulation in restaurant and packaged foods Background: What is Artificial Trans Fat?

Hydrogenation Process

Partially Hydrogenated Vegetable Oil + Hydrogen = Vegetable Oil (PHVO)

Cis-9-octadecenoic acid (Oleic Trans-9-octadecenoic acid acid) (Elaidic acid)

VS. Trans Fat Intake Increases LDL-C

There is “a positive linear trend between trans fatty acid intake and total and LDL-C concentration, and therefore increased risk of coronary heart disease…” – Institute of Medicine Major Food Sources of Artificial Trans Fat for Major FoodAmerican Sources Adults of Trans Fat

Household Other Shortening 6% Potato Chips, 5% Corn Chips, Popcorn 6%

Cakes, Cookies, Fried Potatoes Crackers, Pies, 10% Bread, etc. 51%

Margarine 22%

Data Source: http://www.fda.gov/fdac/features/2003/503_fats.html Trans Fat in the Diet Average daily intake 2.6% of total calories (approx. 5.8 grams)

79% Artificial

Source: Partially Hydrogenated Vegetable Oil 21% Naturally Occurring

Source: Meat and Dairy Products

Source: FDA Consumer magazine. September-October 2003 Issue. Pub No. FDA04-1329C

Prior to January 2006

Ingredients: Liquid Corn Oil, Partially Hydrogenated Soybean Oil, Salt, Vegetable Mono And Diglycerides And Soy Lecithin (Emulsifiers), Sodium Benzoate (To Preserve Freshness), Vitamin A Palmitate, Colored With Beta Carotene (Source Of Vitamin A), Artificial Flavor, Vitamin D3

20 People Are Eating Out More

Rationale for Programming and Approach

• Cardiovascular disease the leading cause of death in the NYC • Trans fat in the diet increases the risk for coronary heart disease • Key public health and scientific authorities recommend reducing trans fat intake • On packaged foods, federal Nutrition Facts Panel labeling requirements going into effect • In restaurants, no practical way for consumers to avoid • NYC DOHMH Recommended Policy: NYC restaurants should voluntarily eliminate the use of trans fat in foods

Restaurant Change through A Market-Based Voluntary Strategy

Trans Fat Education Campaign

Consumers Suppliers

Restaurants

NYC Trans Fat Education Campaign 2005-2006 Survey: • Prevalence of use pre- and post- intervention

Educational Materials to: • 200,000 to consumers • 30,000 to restaurants and other food service establishments (FSEs) • 15,000 to suppliers

Also… • Trans fat module in food protection courses • Printed information on inspection reports • Press launch Evaluation: Trans Fat Use Did Not Decline Despite Education Campaign

% of Restaurants Known to be Using Trans Fat in Oils and Spreads

100%

75%

50%

50% 51%

in Oils and Spread and Oils in 25%

Where Could Use Where BeDetermined % Restaurants Using Trans Fat Trans Using % Restaurants

0% 2005 2006 Health Code Amendment to Restrict Artificial Trans Fat

• Phased in over 18 months • July 1, 2007: frying and spreads • July 1, 2008: all other foods • Food served in manufacturers’ original sealed, packaging are exempt • Applies to all NYC restaurants and mobile vending commissaries • Passed by Board of Health December 2006 • Soon after, New York City Council Restricts the Use of Trans Fat In Restaurants Maintenance: Impact and Monitoring 60% Education Health Code Campaign Restriction Passed Phase I 50% Effective 50% 51%

40% 43% Survey 1 Survey 2

30% Survey 3

Phase II

20% Effective shortenings, or spreads shortenings,

10% 1.9%

% of NYC restaurants using trans fat-containing oils, % NYCof trans fat-containing using restaurants 1.6% Inspection Compliance 0% June '05 Dec. '05 June '06 Dec. '06 June '07 Dec. '07 June '08 Dec. '08 Source: Angell SY, Silver LD, Goldstein GP, et al.. Ann Intern Med 2009;151:129-134. Evaluation: Change in Saturated &Trans Fat in French Fries in Major Fast Food Chains

Source: Angell SY, Silver LD, Goldstein GP, et al. Ann Intern Med 2009;151:129-134.

Change in Trans Fatty Acid Content of Fast-Food Meal Purchases in NYC, 2007 to 2009

• Mean trans fat decreased by 2.5 g, saturated fat increased by 0.55 g, = reduction in trans fat plus saturated fat 1.9 g per purchase • No difference by store location neighborhood income Angell SY et al Ann Intern Med. 2012;157(2):81-86. doi:10.7326/0003-4819-157-2-201207170-00004

State Trans Fat Regulations As of June 2012 WA

VT OR NH MA NY CT MI RI

. NJ

MD OH DE

CA KY

NM SC

EnactedEnacted or or passed passed trans trans fat fat regulation regulation in in food food service service establishments establishments (FSEs) (FSEs) TransTrans fat fat regulation regulation in in FSEs FSEs introduced, introduced, defeated, defeated, or or stalled stalled 31 Slide Source: NYC DOHMH, 11-2013 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm373939.htm Half of U.S. Adults have Non-Optimal Blood Pressure

Treated, controlled (taking medications and BP <140/90) 11%

Hypertension Normal (SBP ≥140 or DBP ≥90) (SBP <120 and DBP <80) 19% 40%

Prehypertension (SBP 120-139 or DBP 80-89) 30%

Adapted from: Ogunniyi MO et al. Am J Hypertens 2010;23:859-864. 33 Adult Smoking in New York City

NYC and NYS 24 tax increases 21.6% 21.5% 21.7% Smoke-free 3-yr average 3-yr average 3-yr average Air Act 22 Free patch programs start Hard-hitting 21.5% media campaigns

20 19.2% NYS Federal 18 18.9% tax tax 18.3% increase increase 17.5% NYS 16.1 tax 16.9% increase

% of adults of % 16 15.8% 15.8% 15.5 14 14.8 14.0% 12

Source: CDC Behavioral Risk Factor Surveillance Survey; NYC Community Health Survey The Importance of Place Diabetes Deaths (per 100,000) AIDS Deaths (per 100,000)

Asthma Hospitalizations Hospitalizations for Infant Deaths (per 1,000 (per 100,000 Children) Drug Use (per 100,000) Live Births) Enabling Health in High Risk Populations

Refresh, Retool, Refocus • Attention to • Health equity • Place-based action, engage community experience • Reaching critical populations, eg justice involved • Bridget the divide between public health and clinical care • Harnessing EHRs to serve the dual purpose of individual and population health • Improving quality through system reformation that includes population health (ACA, DSRIP, value based care focus, meaningful use) District Public Health Offices Place and Justice-Involved Populations

Prison Admissions (2009) Percent living in Poverty Percent of total population which is Black and Latino New York City Jail System Impact on Community • Incarceration disrupts the ecology of neighborhoods • Loss of parents and children places burden on families • Large number of people return with significant trauma to both physical and mental health

Place in Jails: Solitary Confinement and Self-Harm

900 10

800 9 8

700 7 600 6 500 5 400

4 Harm Gestures - 300

3 Self 200 2

100 1 SolitaryBeds(punitive) Percent 0 0 2007 2008 2009 2010 2011 2012 Harnessing the Power of EHRs for Change: Solitary Confinement and Risk of Self Harm Among Jail Inmates • Patients in solitary represent 53% of all self- harm acts and 47% of all high lethality self harm acts. • Controlling for other factors, patients in solitary were about 6.9 x as likely to commit acts of self-harm

Harnessing the Power of EHRs for Change in the Community: Primary Care Information Project

Mission • Improve quality of care in medically underserved areas through health information technology • Promote new models of care focusing on prevention and public health priorities Success • Over 17,000 providers joined PCIP and the Regional Extension Center (NYC REACH), including more than: • 1095 independent practices • 63 community health centers • 54 hospitals & outpatient clinics

Imagine a World Where Surveillance is Continuous: Macroscope Surveillance System

• NYC Macroscope goal: Create and validate a system using data from primary care EHRs for population health surveillance for chronic disease

• Approach: Compare cleaned EHR-based estimates to gold standard examination survey (NYC HANES 2013) and telephone survey (Community Health Survey 2013), at population and individual levels

Preliminary Comparisons 2012 NYC 2012 2004 Macroscope CHS* NYC HANES* N=640,860 N=7,004 N=1,261

Obesity** 29.5 25.4 28.2

Hypertension Diagnosis 30.7 30.9 30.9

Hypertension Treatment 76.4 70.4 70.2

*Subpopulation that has seen a doctor in the past year. **CHS obesity self-reported, NYC Macroscope and NYC HANES have measured height and weight. Trends in Life Expectancy in New York City, 2001-2010 Trends in Life Expectancy in New York City by Race/Ethnicity, 2001-2010 Trends in Life Expectancy in New York City by Neighborhood Poverty, 2001-2010

Last Thoughts on NYCs Approach • Data: • Invest, invest, invest • Approach: • Traditional PH approaches work, but they are not always enough. • Health equity must be a lens for our work • We’re smarter together. COLLABORATE, ENGAGE • Pursue interventions that are • Evidence-based or evidence-informed • Scalable models • Sustainable • Lessons learned in any country could be important to every country A robust global learning community is essential

Thanks!

Sonia Angell, MD, MPH Deputy Commissioner, Division of Prevention and Primary Care New York City Department of Health and Mental Hygiene

[email protected]

Suppose 19th Century Public Health Interventions Relied Upon Individual Action?

• “Responsible people boil water” • “Know your butcher” • “Get fresh air” • “Avoid crowds” • “Keep a tidy house” • “Take care of your refuse”

53 Health Impact Pyramid

Source: Frieden TR. Am J Public Health 2010;100(4):590-595.