Methods to evaluate a community s cardiovascular health for 25 x 25

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Clara Chow Head Cardiac Program, The George Institute Program Director Community

1 Department of Cardiology Westmead Methods to evaluate a community s cardiovascular health for 25 x 25 A/Prof. Clara Chow Head Cardiac Program, The George Institute Program Director Community Based Cardiac Services, Westmead Hospital Supported by a Career Development Fellowship co-funded by the National Heart Foundation and NHMRC

2 Overview What is a community s cardiovascular health Chow IJE 2009 Community level risk factors examples and concepts Methods developed through the EPOCH studies for PURE Chow PLoS One 2010 EPOCH 1 Corsi PLoS One 2011 EPOCH 2

3 Location matters East Finland Northern Europe US railroad West Finland Zuphen, Netherlands Rome railroad, Italy Montegiorgio, Italy Crevalcore, Italy Slavonia, Yugoslavia Southern Europe Zrenjanin,Yugoslavia Dalmatia, Yugoslavia Corfu, Greece Japan Tanushimaru, Japan Ushibuka, Japan VKrshna,Yugoslavia Crete, Greece Deaths from Coronary Heart disease per 10,000 CHD death rates per 10,000 standardized by single years of age of men ages free from evidence of CVD at entry. Keys, A et al Prev Med 1984;13:

4 Differences in Life Expectancy within a small area in London Travelling east from Westminster, each tube stop represents nearly one year of life expectancy lost Canning Town 76 yrs Westminster Waterloo River Thames 75 yrs 73 yrs London Bridge Bermondsey Canada Water 72 yrs 71 yrs Canary Wharf North Greenwich 70 yrs 69 yrs Southwark 74 yrs London Underground Jubilee Line 1 Source: London Health Observatory based on Office for National Statistics data

5 Causal pathway Environmental Influences Individual behaviors e.g. physical activity, smoking, diet Individual biological risk factors e.g. obesity, cholesterol, diabetes Heart Disease

6 Environmental factors linked to Heart disease Community Clean indoor air regulation Tobacco taxes/ price Regulating age of youth smoking Tobacco cessation support programs Social/ cultural norms Tobacco use Individual Behavioral RFs Individual biological RFs Physical Activity Walkability of built environment Safety from crime/ traffic Places for walking Access to facilities Land use mix Smoking Blood pressure Overweight/ obesity Stress/ anxiety/ depression Social behavior Diabetes Cholesterol Nutrition and diet Social networks Social capital Others Air pollution Universal health care/ Access to health care Poverty Food policy Access/ availability of healthy choices eg fruits/ veg Exposure to unhealthy choices eg fast food/ vendor machines/ large portion size CK Chow IJE 2009

7 Environmental influences on 3 important determinants of Heart Disease Tobacco Physical activity Nutrition

8 Prevalence of tobacco use in males

9 Policy and Social acceptability Easier to SMOKE here Easier to QUIT here

10 Cigarette price-consumption relationship: South Africa, Cigarette consumption per adult Real Price Consumption per adult Real Price Source: Saloojee 1995 Year

11 Ease of access

12 Cigarette pack labeling

13 Nutrition and diet

14 Access and availability Percent Obese McDonalds per 10,000 population

15 Culture: what constitutes an enjoyable meal? Fast food : American style Fast food : Japanese style

16 Value for money 1/3 of the cost Similar amount of Calories More fat Less nutritious & Less likely to fill you up

17 Changing the food environment Meals and Vending machines North American Schools Junk food banned in schools Jamie Oliver campaign in UK

18 Physical Activity

19 Why do people not take exercise? Access to leisure facilities Those with access to recreational resources more likely to take physical activity (Diez Roux et al., 2007) Fear of crime Objectively measured and perceived experience of crime associated with less exercise (McGinn et al., 2008) Quality of the environment Objectively measured and perceived quality of the built environment associated with more exercise (McGinn et al., 2008)

20 Walkability Accessibility of locations, traffic and pedestrian safety, crime rate, neighborhood aesthetics all key determinant of physical activity

21 S V Subramanian 21

22 Instruments to evaluate the built environment Systematic Pedestrian and Cycling Environment Scan (SPACES) (Pikora et al, 2002) Irvine-Minnesota Inventory (Day et al, 2006) Built environment site survey checklist (BESSC) (Weich et al, 2001) Walkability Index (Frank et al, 2009) Neighborhood Walkability Scale (NEWS) (Saelens et al, 2006)

23 EPOCH Environmental Profile of a Community s Health Overview An Instrument to Measure Environmental Determinants of Cardiovascular Health

24 Goal of EPOCH To collect information on environmental factors that may influence cardiovascular health across the PURE communities

25 Tobacco Environment Tobacco environment Social & Economic Social & Economic Domains assessed in Domains EPOCH Physical activity Physical activity Environment Nutrition/ Food Policy Nutrition/ Food Policy

26 Data collection Instruments EPOCH 1: - Objective environmental audit tool EPOCH 2: Survey of resident s perceptions of their community

27 EPOCH 1: Audit of Communities Availability, cost of CV + other basic drugs Menu, health promotion Pharmacy assessment Restaurant assessment Community demographics Cigarette pack Chips & biscuit pack Location, connectedness, facilities Observation walk Photographic assessment Advertisements, amenities, built environ. Built environ Fruit/ veg availability, cost, basic grocery cost Grocery store assessment Tobacco store assessment Geographical Information Location of facilities & health services Advertising, health promotion, brand variety, cost

29 EPOCH I - Direct community observation

30 EPOCH 2 Perceived Environment What participants observe in their community Their awareness of local laws, regulations, and health programs Their opinions about behaviors and laws Tobacco Nutrition & Physical activity Social Home & Work

31 EPOCH 2 - Survey of community members X X X X X =4 out of 5

32 Tool development Quality Label 20 Class A Cigarettes AUSTRALIA Deceptive Label Triple filter charcoal technology CHINA General Label Filter Cigarettes

33 Tool development Photo analysis Traffic signals, Planted trees, Complete sidewalks, well maintained buildings Street lights, street benches

34 Health Claims and Promotion of Healthfulness Health Claims (e.g. free of trans fat) Location Content Promotion of Healthfulness Wholesomeness of ingredients Image(s) of ingredients Nutrition content claims Summary of nutrient information Healthy Line from a brand Free of artificial colours, flavours and preservatives Tool development

35 Reliability of EPOCH instruments Total of 38 items) ICC>0.70 (26 items) ICC (11 items) ICC <0.50 (1 item)

36 Score=56.00 High Scoring for Walkability Score= Low Scoring for walkability

37 Face validity: Junk food advertising (EPOCH1 ) and BMI

38 Face validity: Junk food advertising (EPOCH2 ) and BMI

39 Summary Social and physical environments influence health Measuring and monitoring a community s health can enable us to identify interventions that can improve our community s cardiovascular health Changing an environment can beneficially change risk factor levels exemplified by success of antismoking legislation The efforts of individuals are likely to be effective when they are working with the societal trends Geoffrey Rose

41 Total Caloric Intake (kcal/capita/day) Average caloric consumption varies by country 4000 Total Caloric Consumption across PURE countries 3500 Ghana Pakistan Tanzania Uganda India Zimbabwe Bangladesh Colombia Chile Malaysia Argentina Turkey Brazil Poland South Africa Iran China Sweden Canada UAE Country

42 Sweet drink advertising (EPOCH1 ) and BMI

Global Variability in NCDs PURE

Global Variability in NCDs PURE (Prospective Urban Rural Epidemiology) study CLEAN COOKING AND NCD INDICATORS/ BIOMARKERS MEETING WASHINGTON DC, DEC 16 2014 MyLinh Duong MBBS FRACP On behalf of PURE Investigators