Charting New Directions in Health Promotion Policy James Marks, MD, MPH Director, National Center...

Charting New Directionsin Health Promotion Policy

James Marks, MD, MPH

Director, National Center for ChronicDisease Prevention and Health Promotion

Charting New Directionsin Health Promotion Policy

James Marks, MD, MPH

Director, National Center for ChronicDisease Prevention and Health Promotion

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

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

0 10 20

Diphtheria

Senility

Cancer

Injuries

Liver Disease

Stroke

Heart Disease

Diarrhea/Enteritis

Tuberculosis

Pneumonia

Percentage0 5 10 15 20 25 30 35

Chronic Liver Disease

Suicide

HIV

Diabetes

Pneumonia/Influenza

Accidents

Chronic Lung Disease

Stroke

Cancer

Heart Disease

1996

Percentage

The 10 Leading Causes of Deathas a Percentage of All Deaths

United States, 1900 and 1996

The 10 Leading Causes of Deathas a Percentage of All Deaths

United States, 1900 and 1996

*National Vital Statistics Report; 47 (9) November 10, 1998†McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-12Note: Dark shading denotes chronic conditions and risk behaviors

0 5 10152025303540

Most Common Causes of Death,United States, 1996*

Percentage (of all deaths)

Total cardiovascular disease(includes ischemic heart and stroke)

Cancer

Chronic obstructive pulmonarydisease and allied conditions

Injuries

Pneumonia/influenza

Diabetes

HIV infection

Suicide

Chronic liver disease/cirrhosis

Actual Causes of Death, United States, 1990†

0 5 10 15 20

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 FactorsChronic Diseases and Related Risk Factors

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

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

300

250

200

150

100

50

01950 1960 1970 1980 1990 1992

Rate if trend continued

Peak Rate

Actual Rate

Age-a

dju

sted D

eath

Rate

per

10

0,0

00

Popula

tion

Sources: NHANES III (1988-1994), CDC/NCHS and AHA

Heart Disease DeathsUnited States, 1900–1996

Heart Disease DeathsUnited States, 1900–1996

400

600

800

1900 1920 1940 1960 1980 1997

Death

s in

Th

ou

san

ds

Years

200

0

* Age-adjusted to the 1940 U.S. census population

Modified from JNC VI, 1997

Decline in Mortality Rates* for StrokeBlack and White Men, United States, 1972–1994Decline in Mortality Rates* for StrokeBlack and White Men, United States, 1972–1994

-60

-50

-40

-30

-20

-10

0

1970 1974 1978 1982 1986 1990 1994-70

White menWhite men

Black menBlack men

Perc

en

tag

e D

eclin

e

Risk of Stroke Mortality among Racial/Ethnic Minority Groups Compared with Non-Hispanic

Whites, by Age — United States, 1997

Risk of Stroke Mortality among Racial/Ethnic Minority Groups Compared with Non-Hispanic

Whites, by Age — United States, 1997

Non-Hispanic Blacks American Indians/ Alaska Natives

Asians/PacificIslanders

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

85 years

Rela

tive R

isk

Group

Source: MMWR 2000; Vol 49: p96.

Total Cardiovascular Disease Deaths, 1996Age-adjusted death rates per 100,000 populationTotal Cardiovascular Disease Deaths, 1996Age-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

600

500

400

300

200

100

00.80.7 0.6 0.5 0.4

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

The Relationship Between CHD Mortality*and CHD Risk Factors in 49 States, 1991

CHD Risk Index+

CH

D M

ort

ali

ty

Incidence All

Men

Women

All

Men

Women

Average Percent Change 1992–1998

1991–94 1994–98Mortality

Adapted from Annual Report to the Nation, JNCI 2001;93:824–842

Trends in Cancer Incidenceand Mortality, 1992–1998

Trends in Cancer Incidenceand Mortality, 1992–1998

-1.1

-2.7

0.3

-1.1

-1.6

-0.8

-0.5

-0.8

-1.4

-1.9

Age-adjusted Death Rates for Lung Cancer and Breast Cancer Among Women

United States, 1930–1997

Age-adjusted Death Rates for Lung Cancer and Breast Cancer Among Women

United States, 1930–1997

0

5

10

15

20

25

30

35

1930 1936194219481954196019661972 1978198419901996

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.

Trends in Breast Cancer Incidenceand Mortality, 1992–1998

Trends in Breast Cancer Incidenceand 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

1987–95 1995–98

-1.6 -3.4Mortalit

y

Adapted from Annual Report to the Nation, JNCI 2001;93:824–842

Female Breast Cancer Cases Diagnosedat Early Stage


Percentageof Cases

1985–1987

< 39.1

39.1–48.1

48.2–55.9

56 & over

1995–1997

< 39.1

39.1–48.1

48.2–55.9

56 & over

Percentageof Cases



1985–1987

< 39.1

39.1–48.1

48.2–55.9

56 & over

Percentageof Cases

Colorectal Cancer Cases Diagnosedat Early Stage


1995–1997

< 39.1

39.1–48.1

48.2–55.9

56 & over

Percentageof Cases



Annual Deaths from Smoking Compared with Selected Other Causes in the United States*

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

Nu

mb

er o

f D

eath

s (t

ho

usa

nd

s)

Alcohol MotorVehicle

Fires Homicide IllicitDrugs

Suicide Smoking

440

400

360

320

280

240

200

160

120

80

40

0

0

10

20

30

40

50

1991 1993 1995 1997 1999

Year

Perc

ent

Curr

ent

Sm

oke

rs*

Source: CDC Youth Risk Behavior Survey*Smoked one or more cigarettes during the previous 30 days.

Prevalence in Current Cigarette UseAmong High School Students

United States, 1991-1999

Prevalence in Current Cigarette UseAmong High School Students

United States, 1991-1999

27.530.5

34.8 36.4 34.8

Healthy People 2010 Objective 16

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

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

ArizonaArizona

• Adult smoking declined by 21% from 1996 to 1999

• Reductions for males, females, young adults, and Hispanics

Percentage of Eighth Grade Students Who Reported Smoking During the Past 30 Days,

by Tobacco Use Prevention Program Implementation ScoresOregon, 1999–2000*

Percentage of Eighth Grade Students Who Reported Smoking During the Past 30 Days,

by Tobacco Use Prevention Program Implementation ScoresOregon, 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.

Perc

enta

ge

Nonfunded Schools Implementation for Funded

Schools

0

10

20

Low Medium High

1999 2000

Obesity Trends* Among U.S. Adults BRFSS, 1991, 1995 and 2000

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

1991 1995

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%

Obesity Trends* Among U.S. AdultsBRFSS, 1985



No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%




No Data <10% 10%-14% 15-19% 20%

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.

1990 1995

2000

No Data <4% 4%-6% 6-8% >8%

Percentage of Overweight Children and Teens

Percentage of Overweight Children and Teens

1963–70

1971–74

1976–80

1988–94

Perc

enta

ge

Boys 6-11 Girls 6-11 Male Teens12-17

Female Teens12-17

Source: Troiano et al. Pediatrics. 1998; 101;497–504

0

2

4

6

8

10

12

Daily Physical Education Classes in School9-12th graders

Daily Physical Education Classes in School9-12th graders

Source: Youth Risk Behavior Survey, CDC

0

5

10

15

20

25

30

35

40

45

1991

Perc

en

tag

e42%

1997

29%

Lifestyle Changes that Promote Sedentary BehaviorLifestyle Changes that Promote Sedentary Behavior

Predicted Probability of 15–year Survival Free of Coronary Heart Disease, Stroke and Diabetes

50 Year Old Man

Predicted Probability of 15–year Survival Free of Coronary Heart Disease, Stroke and Diabetes

50 Year Old Man

Non SmokerNormal Weight

Active

SmokerHeavy

Inactive Ratio

11% 58% 5.5

Source: Jones et al., Arch Intern Medicine, 1998; Vol 2436

An Aging PopulationPercentage 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

1930 1950 1970 1990 2010 2030 2050

Year

Perc

en

tag

e o

f P

op

ula

tion

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

>80

75-7

9

70-7

4

60-6

4

55-5

9

50-5

4

45-4

9

40-4

4

35-3

9

30-3

4

25-2

9

20-2

4

15-1

9

10-1

4

0-4

5-9

65-6

9

Women

Men

Dollars

Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging PopulationCopyright 1996, Watson Wyatt Worldwide.

Age in Years

Estimated Per Capita Health Expendituresby Age and Sex, 1995

Estimated Per Capita Health Expendituresby Age and Sex, 1995

Disability Index* by Age and Health Risk†

Disability Index* by Age and Health Risk†

University of Pennsylvania AlumniUniversity of Pennsylvania Alumni

63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 780.0

0

0.05

0.10

0.15

0.20

0.25

0.30

Dis

abili

ty 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 = 0–2points, 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

Long-Term Care FinancingBy Payer, 1998

Long-Term Care FinancingBy 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).

Medicaid40%

Medicaid44%

Medicare 20% Medicare 14%

Private Insurance

8%

Out of pocket31%

Out of pocket26%

Private Insurance

7%

All other7%

All other5%

Comprehensive State Chronic Disease ProgramComprehensive 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

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Charting New Directions in Health Promotion Policy James Marks, MD, MPH Director, National Center...

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