1. Charting New Directions in Health Promotion Policy James Marks, MD, MPH Director, National Center for Chronic Disease Prevention and Health Promotion Charting New Directions in Health Promotion Policy James Marks, MD, MPH Director, National Center for Chronic Disease Prevention and Health Promotion

2. Centers for Disease Control and Prevention

3. The average life expectancy in 1900 was 47.3 years of age. In 1993, it was 75.7 years of age. SOURCE: CDC, National Center for Health Statistics 1900 01020 Diphtheria Senility Cancer Injuries Liver Disease Stroke Heart Disease Diarrhea/Enteritis Tuberculosis Pneumonia Percentage 051015202530 35 Chronic Liver Disease Suicide HIV Diabetes Pneumonia/Influenza Accidents Chronic Lung Disease Stroke Cancer Heart Disease 1996 Percentage The 10 Leading Causes of Death as a Percentage of All Deaths United States, 1900 and 1996

4. *National Vital Statistics Report; 47 (9) November 10, 1998 † McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-12 Note: Dark shading denotes chronic conditions and risk behaviors 0510152025303540 Most Common Causes of Death, United States, 1996* Percentage (of all deaths) Total cardiovascular disease (includes ischemic heart and stroke) Cancer Chronic obstructive pulmonary disease and allied conditions Injuries Pneumonia/influenza Diabetes HIV infection Suicide Chronic liver disease/cirrhosis Actual Causes of Death, United States, 1990 † 05101520 Percentage (of all deaths) Tobacco Poor diet/lack of exercise Alcohol Infectious agents Pollutants/toxins Firearms Sexual behavior Motor vehicles Illicit drug use Chronic Diseases and Related Risk Factors

5. Actual and Expected Death Rates for Coronary Heart Disease, 1950–1992

6. Sources: NHANES III (1988-1994), CDC/NCHS and AHA Heart Disease Deaths United States, 1900–1996 400 600 800 190019201940196019801997 Deaths in Thousands Years 200 0

7. *Age-adjusted to the 1940 U.S. census population Modified from JNC VI, 1997 Decline in Mortality Rates* for Stroke Black and White Men, United States, 1972–1994 -60 -50 -40 -30 -20 -10 0 1970197419781982198619901994 -70 White men Black men Percentage Decline

8. Risk of Stroke Mortality among Racial/Ethnic Minority Groups Compared with Non-Hispanic Whites, by Age — United States, 1997 Non-Hispanic BlacksAmerican Indians/ Alaska Natives Asians/Pacific Islanders Hispanics 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 35–44 years 45–54 years 55–64 years 65–74 years 75–84 years ³85 years Relative Risk Group Source: MMWR 2000; Vol 49: p96.

9. Total Cardiovascular Disease Deaths, 1996 Age-adjusted death rates per 100,000 population Source: National Vital Statistics System, National Center for Health Statistics, CDC 127-149 150-164 165-191 192-231 United States - 172

10. 600 500 400 300 200 100 0 0.80.70.60.50.4 Men Women *CHD Mortality = Mortality from coronary heart disease, aged 45-74 +CHD Risk Index = Effect of 7 risk factors combined (smoking, overweight, physical inactivity, high blood pressure, high cholesterol, diabetes, alcohol abstinence) Mortality data and CHD risk factors prevalence were age-adjusted to the 1990 US population aged 45-74 Regression formulas are: CHD (men) = -155 + 955 (CHD index) CHD (women) = -153 + 528 (CHD index) The Relationship Between CHD Mortality* and CHD Risk Factors in 49 States, 1991 CHD Risk Index + CHD Mortality

11. Incidence All Men Women All Men Women Average Percent Change 1992–1998 1991–941994–98 Mortality Adapted from Annual Report to the Nation, JNCI 2001;93:824–842 Trends in Cancer Incidence and Mortality, 1992–1998 -1.1 -2.7 0.3 -1.1 -1.6 -0.8 -0.5 -0.8 -1.4 -1.9

12. Age-adjusted Death Rates for Lung Cancer and Breast Cancer Among Women United States, 1930–1997 0 5 10 15 20 25 30 35 193019361942194819541960196619721978198419901996 Breast Cancer Lung Cancer Note: Death rates are age-adjusted to the 1970 population. Sources: Parker et al. 1996; National Center for Health Statistics 1999; Ries et al. 2000; American Cancer Society, unpublished data.

13. Trends in Breast Cancer Incidence and Mortality, 1992–1998 Incidence All White Black All White Black Average Percent Change 1992–1998 1.2 1.1 0.1 -2.4 -2.7 -0.6 1987–951995–98 -1.6-3.4 Mortality Adapted from Annual Report to the Nation, JNCI 2001;93:824–842

14. Female Breast Cancer Cases Diagnosed at Early Stage Percentage of Cases 1985–1987 < 39.1 39.1–48.1 48.2–55.9 56 & over

15. 1995–1997 < 39.1 39.1–48.1 48.2–55.9 56 & over Percentage of Cases Female Breast Cancer Cases Diagnosed at Early Stage

16. 1985–1987 < 39.1 39.1–48.1 48.2–55.9 56 & over Percentage of Cases Colorectal Cancer Cases Diagnosed at Early Stage

17. 1995–1997 < 39.1 39.1–48.1 48.2–55.9 56 & over Percentage of Cases Colorectal Cancer Cases Diagnosed at Early Stage

18. Annual Deaths from Smoking Compared with Selected Other Causes in the United States* * All mortality data are for 1990, except alcohol, which is for 1987. AIDS Number of Deaths (thousands) AlcoholMotor Vehicle FiresHomicideIllicit Drugs SuicideSmoking 440 400 360 320 280 240 200 160 120 80 40 0

19. 0 10 20 30 40 50 19911993199519971999 Year Percent Current Smokers* Source: CDC Youth Risk Behavior Survey *Smoked one or more cigarettes during the previous 30 days. Prevalence in Current Cigarette Use Among High School Students United States, 1991-1999 27.5 30.5 34.8 36.4 34.8 Healthy People 2010 Objective 16

20. declined by 40% by 18% among high school students. Over the two-year period between the first and third surveys, current cigarette use declined by 40% among middle school students and by 18% among high school students.

21. Arizona Adult smoking declined by 21% from 1996 to 1999 Reductions for males, females, young adults, and Hispanics

22. Percentage of Eighth Grade Students Who Reported Smoking During the Past 30 Days, by Tobacco Use Prevention Program Implementation Scores Oregon, 1999–2000* *1999 data from Youth Risk Behavior Survey (YRBS) questionnaire, and 2000 data from either the YRBS or the Oregon Public School Drug Use Survey questionnaire. Source: MMWR 2000; Vol 50: p665. Percentage Nonfunded Schools Implementation for Funded Schools 0 10 20 LowMediumHigh 19992000

23. Obesity Trends* Among U.S. Adults BRFSS, 1991, 1995 and 2000 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) 19911995 2000 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

24. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

25. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

26. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

27. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

28. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

29. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

30. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

31. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

32. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

33. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

34. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

35. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

36. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

37. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

38. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

39. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

40. Diabetes Trends* Among Adults in the U.S., (*Includes Gestational Diabetes) BRFSS 1990, 1995 and 2000 Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10. 19901995 2000 No Data 8%

41. Percentage of Overweight Children and Teens Percentage of Overweight Children and Teens 1963–70 1971–74 1976–80 1988–94 Percentage Boys 6-11Girls 6-11Male Teens 12-17 Female Teens 12-17 Source: Troiano et al. Pediatrics. 1998; 101;497–504 0 2 4 6 8 10 12

42. Daily Physical Education Classes in School 9-12th graders Source: Youth Risk Behavior Survey, CDC 0 5 10 15 20 25 30 35 40 45 1991 Percentage 42% 1997 29%

45. Lifestyle Changes that Promote Sedentary Behavior

46. Predicted Probability of 15–year Survival Free of Coronary Heart Disease, Stroke and Diabetes 50 Year Old Man Non Smoker Normal Weight Active Smoker Heavy InactiveRatio 11%58%5.5 Source: Jones et al., Arch Intern Medicine, 1998; Vol 2436

47. An Aging Population Percentage of U.S. Population over Age 65 Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population Copyright 1996, Watson Wyatt Worldwide. 0 5 10 15 20 25 1930195019701990201020302050 Year Percentage of Population

48. Estimated Per Capita Health Expenditures by Age and Sex, 1995

49. Disability Index* by Age and Health Risk † University of Pennsylvania Alumni 63646566676869707172737475767778 0.00 0.05 0.10 0.15 0.20 0.25 0.30 Disability Index Age * Progression of disability was postponed by approximately 7 years in low risk vs. high risk. † Risk based on body-mass index, smoking, exercise; 0-3 point scale for each; low = 0–2 points, moderate = 3–4 points, high = 5–9 points. Vita et al NE&M 1998:338:1035–41. ** A disability index of 0.1 = minimal disability. High risk Moderate risk Low risk

50. Long-Term Care Financing By Payer, 1998 Total Nursing Home and Home Care Expenditures ($150 billion) Nursing Home Expenditures ($100 billion) Sources: Health Care Financing Administration, Office of the Actuary (Feb 2000); and B. Burwell, "Medicaid Long-Term Care Expenditures in FY 1998" (Cambridge, Mass.: MEDSTAT Group, 1999). Medicaid 40% Medicaid 44% Medicare 20% Medicare 14% Private Insurance 8% Out of pocket 31% Out of pocket 26% Private Insurance 7% All other 7% All other 5%

51. Comprehensive State Chronic Disease Program AddressesAddresses heart disease and stroke, diabetes, cancer, and arthritis AddressesAddresses risk factors — physical activity, obesity, nutrition, and tobacco use ReachesReaches priority populations: youth, underserved and aging in communities, schools, work sites, and health care settings