1. 1 Chronic Disease Prevention: The Power of Public Health By Dr. John Frank, Scientific Director, CIHR-Institute of Population & Public Health 11 th World Congress on Public Health Conference August 2006

2. 2 Presentation at a Glance Chronic Disease Prevention Challenges Selected examples What does the evidence tell us? Need for a population and public health approach

3. 3 Yach, D. et al. JAMA 2004;291:2616-2622. Global Mortality From Chronic Diseases

4. 4 Yach, D. et al. JAMA 2004;291:2616-2622. Deaths Attributable to 16 Leading Causes in Developing Countries, 2001

5. 5 20-Year Trends in Smoking: Current smokers by age, Canada, 1981-2001 A Canadian Success Story but….

6. 6 Age-Standardized Mortality Rates for Cardiovascular Diseases, Canadian Males and Females, 1950-1999. Source: Health Canada, 2003. Age-standardized to the 1991 Canadian population.

7. 7 Source: 2004 CPHI report, Improving the Health of Canadians.

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9. 9 Renewing our Public Health Principles 1) Seek the root causes of disease and disability - a focus on determinants 2) Consider and deal with whole populations 3) Understand and apply the principles of social change, over the life course

10. Most Public Health Interventions Health Outcomes Most Health Care Political Social Cultural Economic Spiritual Ecological Technological Forces Nation-States Regions (Urban Entities) Neighborhoods / Communities Families / Couples / Households Lifecourse of Individuals Population Health Framework Biological Endowment Gene-Environment Interactions Physical & Social Environmental Exposures 10

11. 11 The Bell-Curve Shift in Industrial Populations Increasing Serum LDL Cholesterol & CHD Risk % of Population In Western industrialized populations, the entire bell-curve of risk- factor levels is shifted due to dietary and other lifestyle factors, so even low levels within the population confer CHD risk. Thus a large number of people at small risk give rise to more cases of disease than the small number who are at high risk.. Population – level factors (largely environmental) Individual (largely genetic for CHD) Source: Rose G. Sick Individuals and sick populations. 1985; Int J Epid 12:32-38.

12. 12 The Importance of Population Distributions of Exposure Source: The World Health Report : 2002. Reducing Risks, Promoting Healthy Life. Chapter 2, Figure 2.3 27

13. 13 Action on Obesity: Three Different Paradigms Environmental and Policy Approaches Educational, High Risk and Clinical Preventive Services Approaches Treatment Upstream Downstream Individually-orientedPopulation-oriented Compliments of PHRED program

14. 14 Community-based interventions – Hype or Hope? Usually suffer from methodological and conceptual limitations - poor study design, lack of evaluation, theoretical basis is limited given complexity of interactions Small or modest effect sizes at the individual level vs. what was expected, especially given other social trends Source: Sorensen G., Emmons K, Hunt MK, Johnston D., 2003. Implications of the results of community intervention trials. Annu. Rev. Public Health,19:379-416.

15. 15 Interventions targeted only at individual- level knowledge, attitude and behaviour cannot succeed alone Should therefore not be seen as the panacea to solving complex societal problems, especially given duration and intensity of such interventions and the countervailing forces arraigned against them Community-based interventions – Hype or Hope? (contd) Source: Sorensen G., Emmons K, Hunt MK, Johnston D., 2003. Implications of the results of community intervention trials. Annu. Rev. Public Health,19:379-416.

16. 16 BUT THERE IS HOPE…. Impacts can be realized if community-based interventions: Are properly resourced and sustained over time Community-led, addressing the social and cultural context in which individual behaviours are manifested Are complemented by comprehensive population- level interventions that address: Environmental supports/controls Economic levers Enforcement (regulations / legislation) Research funding agencies need to put more emphasis on supporting policy and program intervention research Source: Smedley BD and Syme SL (eds.). Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington: National Academy of Sciences, 2000.

17. 17 Calling for Sustainable Investments in the Public Health System – the Champion for Upstream Thinking Our focus on the (sick-)care system problems needing urgent attention should not detract us from our responsibility to invest in public health. More is needed to strengthen the front-line where most of public health takes place Community-level creativity must be tapped to change social norms – local public health professionals working in intersectoral coalitions