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1 Thank you for joining The Guideline Advantage this afternoon! To access the audio portion: Dial: (866) Participant Code: We will be starting the presentation shortly. 1

2 Nutrition, Physical Activity and Cancer: What s the Connection? Webinar Presented November 20, 2013

3 Vision & Goal Vision To improve the health of all patients through widespread application of primary and secondary prevention guidelines in the United States through data collection, analysis, feedback and quality improvement in the ambulatory setting. Goal To improve the long-term compliance with the ACS, ADA and AHA/ACC guidelines, which in turn supports our shared organizational mission to prevent chronic diseases and to improve the lives of those living with the nation s most prevalent chronic diseases. The Guideline Advantage is based on the success of nearly 10 years experience in inpatient quality improvement and over 2 millions lives touched.

4 Program Model 2 Practices submit collective clinical data to Forward Health Group for The Guideline Advantage 1 Providers can use several different technology platforms 4 Performance is measured, Professionals can set measureable goals and chart improvements in performance 3 Data are processed, analyzed and provided back to the practice via a practice portal

5 Technically speaking how does it work? As a part of quality improvement, clinical data must be aggregated into a data warehouse to facilitate analysis and reporting. ELECTRONIC MEDICAL RECORD Data import Data Infrastructure Database Data Extract Customer Data Mart Key activities include: - Data Alignment - Denominator Calculation - Numerator Calculations - Attribution - Benchmarking

6 Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as defined by the customer Patient Lists and action list functionality Views & filtering options for Teams Comparison, Benchmarking & Historical Trending Customer Driven Functionality, including demographic information displays, incentive program tracking, & non-clinical custom groupings Complete data advisory service, including comprehensive consultations and guidance in identifying data sources, mapping, data cleansing and alignment Fixed implementation fee and annual licenses

7 Advantages to Practices & Physicians On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition

8 The Guideline Advantage s Measures Diabetes Mellitus Preventive Care Screening Cancer Cardiovascular HbA1c Control LDL Control High Blood Pressure Control Annual nephropathy screening (urine albumin) BMI Screening & Follow-up Influenza Vaccination Tobacco Use and Counseling Blood Pressure Screening LDL Measurement Colorectal Cancer Screening Mammography Screening Cervical Cancer Screening Ischemic Vascular Disease: Aspirin Use & Lipid panel Hypertension: Blood Pressure Control CAD: Lipidlowering Therapy CAD: Antiplatelet Therapy CAD: Blood Pressure Control CAD: Tobacco Use *Measures are subject to change

9 Alignment with National Programs Million Hearts Initiative The Guideline Advantage reports on the ABCS measures of interest to Million Hearts Uniform Data System (UDS) The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers

10 Leading practices for effective participation Use existing EHR platform; don t interrupt work flow to collect data; offer vend or neutral program model Provide tools and resources (Webinars, CME programs, etc.) to help develop a culture of quality improvement Provide feedback and consult with practices on how to disseminate information Encourage focus on 1-2 areas only Direct practices to resources to support improvement Recognize and link to incentives These are just a few of the best practices shared by the program.

11 Nutrition, Physical Activity and Cancer: What s the Connection? Colleen Doyle, MS, RD Director, Nutrition and Physical Activity American Cancer Society

12 CDC, US Census 234,646,608

13 148,197,858 CDC, US Census

14 CDC, US Census 194,509,688

15 Causes of Cancer Estimate percentage of total cancer deaths attributable to established causes of cancer Tobacco Adult diet/obesity Sedentary lifestyle Occupational factors Family history of cancer Viruses/other biologic agents Perinatal factors/growth Reproductive factors Alcohol Socioeconomic status Environmental pollution Ionizing/ultra-violet radiation Prescription drugs Medical procedures Salt/other food additives/contaminants Source: Harvard Report on Cancer Prevention, Cancer Causes and Control, November/December, 1996

16 2012 Recommendations for Individuals: 1) Maintain a healthy weight throughout life. 2) Adopt a physically active lifestyle. 3) Consume a healthy diet, with an emphasis on plant sources. 4) If you drink alcoholic beverages, limit consumption. Communities: Work together to make it easier for people to eat better and be more active.

17 Society Recommendations for Individual Choices Maintain a healthy weight throughout life. Be as lean as possible throughout life without being underweight. Avoid excess weight gain at all ages. If currently overweight or obese, losing even a small amount of weight has health benefits and is a good place to start. Engage in regular physical activity and limit high calorie foods and beverages as key strategies for maintaining a healthy weight.

18 BMI and Specific Cancers Established Men Colon/rectum Kidney Esophagus Pancreas Women Breast (postmenopausal) Colon/rectum Endometrium Kidney Esophagus Pancreas Kushi, et al. CA Cancer J Clin. 2012

19 BMI and Specific Cancers Probable Men Gall bladder Liver Multiple myeloma Non-Hodgkin Lymphoma Prostate Women Gall bladder Liver Multiple myeloma Non-Hodgkin Lymphoma Cervix Ovary Kushi, et al. CA Cancer J Clin. 2012

20 Proposed mechanisms Effects on immune function and inflammation Levels and metabolism of several hormones, including insulin and estradiol Factors that regulate cell proliferation and growth, such as insulin-like growth factor (IGF)-1 Proteins that make hormones more or less available to tissues, such as sex hormone-binding globulin and IGF-binding proteins Excess weight may increase risk of adenocarcinoma of the esophagus by increasing risk of gastroesophageal reflux disease and Barrett s esophagus

21 Why the obesity connection is so important In the United States, overweight and obesity accounts for about 14% to 20% of all cancer deaths. About 2 out of 3 Americans are overweight or obese. Calle, et al. NEJM. 2003; CDC

22 Obesity Among U.S. Adults, % <20% 20% <25% 25% <30% 30% <35% 35% Source: Behavioral Risk Factor Surveillance System, CDC. Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to previous years.

23 Childhood Obesity Childhood obesity has more than doubled in children and tripled in adolescents in the past 30 years. The percentage of children aged 6 11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in The percentage of adolescents aged years who were obese increased from 5% to 18% over the same period. In 2010, more than one third of children and adolescents were overweight or obese. CDC

24 What About Weight Loss?

25 Adopt a Physically Active Lifestyle Adults: Engage in at least 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity each week, preferably spread throughout the week. Children and adolescents: Engage in at least 1 hour of moderate- or vigorous- intensity activity each day, with vigorous-intensity activity at least three days each week. Limit sedentary behaviors such as sitting, laying down, and watching television and other forms of screen-based entertainment.

26 How Physical Activity May Impact Risk May help prevent via both direct and indirect ways Helps maintain a healthy weight Helps in regulation of sex hormones, insulin and prostaglandins Beneficial effects on immune system

27 Consume a Healthy Diet, With an Emphasis on Plant Sources Choose foods and beverages in amounts that help maintain a healthy weight. Limit consumption of processed meat and red meat. Eat at least 2.5 cups of vegetables and fruits each day. Choose whole grains in preference to refined grain products

28 Red and Processed Meats Beef, pork, lamb Deli meats, hot dogs, bacon, sausage 15% to 20% increased risk of cancers of the colon and/or rectum per 100 g red meat or 50 g processed meat consumed per day About 3.5 oz. red meat; 1.7 oz. processed Evidence for some other cancers (esophagus, stomach, lung, pancreas, breast, prostate, stomach and endometrium) is considered limited and suggestive

29 Proposed Mechanisms Several constituents that could increase the risk of cancer; may be more than one Heterocyclic amines and polycyclic aromatic hydrocarbons are produced by cooking meat at high temperatures Nitrates/nitrites and salt used to process meat contribute to the formation of nitrosamines Iron from the heme group of myoglobin in red meat may act as a catalyst to nitrosamine formation and generate free radicals that may damage DNA.

30 Fruits, Vegetables and Grains Overall dietary pattern most important Synergy of nutrients working together likely imparts benefits Eat a variety of colorful fruits and vegetables Tend to be highest in antioxidants and phytochemicals Don t know which nutrients are most protective Choose whole grains instead of refined grains Limit consumption of other refined carbohydrate foods, including pastries, candy, sugar-sweetened breakfast cereals, and other high-sugar foods.

31 If You Drink Alcoholic Beverages, Limit Consumption. Drink no more than one drink per day for women or two per day for men. One drink of alcohol = 12 oz. beer 5 oz. wine 1.5 oz. of 80-proof liquor

32 Alcohol and Cancer Risk Heavy drinking esp. combined with tobacco use - increases risk of cancers of: Mouth & pharynx Larynx Esophagus Liver Even moderate drinking increases risk of breast cancer in women

33 Not well understood Hormonal effect? Possible Mechanisms Direct carcinogenicity of alcohol or its metabolites? May contribute to weight gain

34 I thought a glass of wine was good for me! Moderate intake of alcohol appears to decrease risk of heart disease Other approaches to reduce heart disease risk Not recommended that non-drinkers begin drinking Consider risk of both heart disease and cancer to make an informed decision

35 Conclusion: Adherence to cancer prevention guidelines for obesity, diet, physical activity and alcohol consumption is associated with a lower risk of death from cancer, CVD and all causes in nonsmokers.

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37 Why?

38 Available Calories Have Increased Calories per person per day

39 Where Our Calories Come From Percent of Total Avg. Daily Food NHANES French fries Potato chips, corn chips, popcorn Hamburgers Pizza Cake, sweet rolls, donuts, pastry Alcoholic beverages White bread, rolls, bagels, etc. Misc desserts and sweets Soft drinks, fruitflavored drinks

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41 Evidence of life on Mars.

42 High Calorie Foods Available at Low Cost.Whenever You Want Them! CALORIES Double Cheese Burger = 690 Super Size Coke = 280 Biggie Fries = 570 TOTAL = 1,540 Ad in Sports Illustrated 6/15/02

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47 Marketing and Advertising to Kids Food and Drink Packages Computers and TV Mobile Devices Games and Toys Schools

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49 Physical (In)Activity

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55 From: Healthy People 2010, Understanding and Improving Health, Volume American Cancer Society, Inc. No

56 ACS Recommendation for Community Action Public, private and community organizations should work collaboratively at national, state and local levels to implement policy and environmental changes that: Increase access to affordable, healthy foods in communities, worksites and schools, and decrease access to and marketing of foods and beverages of low nutritional value, particularly to youth. Provide safe, enjoyable and accessible environments for physical activity in schools and worksites, and for transportation and recreation in communities.

57 Multi-strategy, coordinated and comprehensive approach at national, state and local levels Policies that make it easier for people to eat better and be more active What s It Going To Take? Policy and environmental changes in priority systems

58 A New Shift In Communications Messaging that increases awareness of key issues that influence eating and exercise habits From Eat More Fruits and Vegetables to: What s being served at your child s school? Got a salad bar at work? We need better quality produce at this store. From Be More Active to: No sidewalks? Speak up. What s the school policy on PE? Hey can we get some bike racks at the office?

59 Traditional Strategic, Sustainable and Effective Collaborations Health Organizations Government Media Industry Non-Traditional City Planning and Architecture Transportation Planners Parks and Recreation Legal and Policy Experts

60 Calls to Action AHA Guide for Improving Cardiovascular Health at the Community Level, 2013 Recommended Community Strategies and Measurements to Prevent Obesity in the United States (2009) IOM Reports Cancer Prevention and Control (2003) Childhood Obesity (2004) Food Marketing and Advertising (2005) Local Government Actions to Prevent Childhood Obesity (2009) Policy and Action for Cancer Prevention: Food, Nutrition and Physical Activity, World Cancer Research Fund (2008) Guide to Community Preventive Services (2001/2010)

61 Healthcare Professionals Can Make A Difference Be An Advocate For Change In Your Community Track BMI at Every Visit Healthy People in Healthy Communities Promote Fruits, Vegetables, Whole Grains Be A Good Role Model Encourage Physically Active Lifestyles

62 General Population Smoking In The US Annual Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States

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64 Thank you!

65 Questions? Type question into the Q&A tab at the top of your screen. Additional questions Download this slide deck within 7-10 working days from: GuidelineAdvantage.org 65