2011-9-8

Overview of key concepts and overview of relationship between lifestyle and health
PBH2008
Professor Albert Lee MB BS(Lond)) MPH MD(CUHK) FFPH(UK) FRACGP(Aus) FRCP(Ireland) BS(Lond Professor and Director of Centre for Health Education and Health Promotion, School of Public Health and Primary Care, Consultant in Family Medicine The Chinese University of Hong Kong

PBH 2008 course is a substantive overview of major lifestyle and behavioural issues which are central to health improvement. The course will give a brief overview of the health promotion framework used in public health to tackle these health issues. The issues of health behaviours will be covered in-depth to illustrate their complex interaction with health and wellness, and the public health significance. Students will learn how to apply the basic concepts of primary, secondary and tertiary prevention, and the conceptual framework of health promotion to each of these major behaviour related health problems.

Learning Outcomes
By the end of this course, student should be able to: identify how lifestyle and behavioral modification would lead to health improvement understand the basic epidemiology (e.g. prevalence, scope, risk factors and outcomes) of the most common behavioral health problems and their relationship with chronic diseases facing contemporary society understand the major barriers and societal factors that contribute to these health issues be familiar with the different levels of prevention used in health improvement understand the fundamental conceptual and logistical framework of health promotion that are used to influence behavioral/ lifestyle changes

Learning objectives of this seminar

Identify the importance of modern concepts of health promotion leading to health improvement Understand the importance of strong associations between lifestyle and diseases causing big health burden to our society Set the scene for different levels of prevention for those preventable lifestyle related diseases

Useful reference for this seminar: Naidoo J and Willis J. Foundation for Health Promotion. Balliere Tindall, 3rd Edition 2009. Chapters 4 and 5 Lee A., Fu Jua and Ji Chengyi. Health promotion activities in China from the Ottawa Charter to the Bangkok Charter: revolution to evolution. Promotion and Education 2007; XIV(4): 214-223

What are your answers to the following questions?

What is Health?

I am healthy because??? I feel healthy when???? My health improves when??? Are there any significant person(s) who would affect my health? Will there be any significant event(s) that would modify my health? Who should be responsible for my health?

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The Relationship Between Disease and Illness

A state of complete, physical, mental, social well-being and not merely the absence of disease or infirmity.
WHO 1947 Subjective experience of illness +ve Feels ill, has disease Objective diagnosis of illness ( (ill health) ) +ve Feels well, has disease (screening) Feels well, no disease (healthy) Feels ill, no disease ( (malingering) g g) -ve

Dunn (1991) refer health as wellness, implying that individual engages in attitudes and behaviours that enhance quality of life and maximize personal potential.

-ve

Holistic Health
Physical health: fitness, no illnesses Mental health: feeling good, feeling well to cope with life Emotional health: feeling being loved and cared Social health: sense of having support from family, friends, colleagues etc Spiritual health: feeling able to put into practice moral and/or religious principles and feeling of having purpose in life

(Total well-being)
Healthy Personal Development
Healthy interpersonal relationship, healthy interaction with society and culture

Healthy interaction with nature, making wise decision

Triple burden of Health

Second wave epidemic of cardiovascular disease is flowing through developing countries as result of changing lifestyles. Death and disability from Coronary Heart Disease and Cerebro-vascular Accident will rank number 1 and 4 respectively.
Murray and Loppz: The Global burden of disease. WHO 1996.

World Health Report 2007

Chronic disease accounts for 60% of the worlds death and 47% of the global burden of disease (2003 Reports stated that 1/3 middle age, half in Asia Pacific)

Improving health of Australian

Harper T. Aus Fam Phy 2008: 37(1/2): 5

Emerging new and old communicable diseases (SARS, Avian Flu, food poisoning) as result of ecological change, urbanization, globalization, population movement, changing living environment, changes of farming Rapid economic growth and urbanization, knowledge based economy, advancement of technology, changes of family structure, loss of neighbourhood relationship, lack of time for communication and interpersonal interaction would put individual vulnerable to mental distress as resources for emotional support are depriving

About 70% of the total burden of disease in Australia and nearly 80% of all deaths are attributed to six disease groups: Cardiovascular disease, cancer, injury, mental health, diabetes and asthma. This can be reduced by health promotion and disease prevention p particularly addressing smoking, nutrition, p y y g g, , physical activity and alcohol y consumption.

Multi-faceted approach to prevent the lifestyle related diseases

Priority health-risk behaviors contributing to the leading causes of mortality and morbidity later on in life are often established during youth period and extend to adulthood; and those diseases might not be curable but preventable. Cost effective behavioural and pharmacological treatments for high blood pressure, diabetes, and raised cholesterol have life saving impacts and should be implemented routinely at primary health care level.

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The 21st century will bring in many challenges to public health

These include:
1. emergence of NEW INFECTIOUS DISEASES 2. resurgence of OLD INFECTIOUS DISEASES

In many developed and also developing countries, priority health-risk behaviors contributing to the leading causes of mortality and morbidity later on in life such as cardiovascular disease, cerebrovascular disease and malignant neoplasm; are often established during youth period and extend to adulthood; and those diseases might not be curable but preventable.

3. rising chronic non communicable diseases (NCD) non-communicable 4. health related social problems, mental health 5. accidents and injuries 6. health care reforms and health financing

Strategies to Combat NCD

A number of risk factors including high cholesterol, high blood pressure, obesity, smoking and alcohol are responsible the majority of these chronic disease burden. Article in Lancet (Yusulf et al, 2004), the researchers concluded, abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, inadeqaute consumption of fruits, vegetables and alcohol, fruits alcohol and inadequate physical activity account for most of the risk of myocardial infarction worldwide in both sexes and at all ages in all regions. There is overwhelming evidence that prevention is possible when sustained actions are directed both at individuals and families; as well as the boarder social, economic and cultural determinants of NCD (Mant, 2004)

What can be done?

Established scientific evidence suggests that there are major health benefits: Eating more fruits and vegetables, as well as nuts and whole grains; Daily physical activity; Moving from saturated animal fats to unsaturated vegetable oilbased fats; Cutting the amount of fatty, salty and sugary foods in the diet; Maintaining a normal body weight (within the Body Mass Index [BMI] range of 18.5 to 24.9) Stopping smoking

Routine clinical data only reveal health issues at the tip of Iceberg
Availability of information Water level
Mortality Disease notification Hospital activities Cancer registry Chronic illnesses registry General Practice morbidity Sickness Health Behaviours Self help / Self care Perception of Health

Risk Factors:
BEINGS models
Biological and Behavioural factors Environmental factors Immuniological factors Nutritional factors Genetic factors Services, Social factors, and Spiritual factors

Quality and Completeness

Poor

Poor

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In many countries, there is a well structured health care system to address diseases ad illnesses but there is NO system addressing health particularly on promotion of positive health health.
Gaps in Health Services Before illness After illness

Key Areas of Community Based Care

Health and Disease Family and Health Health and Society Health and Behaviour Health Promotion and Disease Prevention Health and special population group

Youth health needs in Hong Kong

A Charter for Family Medicine in Europe - WHO Regional Office: By the year of 2000, all Member States should meet the basic needs by providing services on: The youth health surveys in 1999, 2001and 2003 both revealed that substantial high proportion of our young people did not have a healthy eating habit, not performing exercise regularly and also emotionally disturbed. The 1999 survey revealed that less than half of students attended periodic health checks The checks. 2001 survey found correlation of youth health compromising behaviors with emotional disturbance and life satisfaction.
Lee A., et al. Youth Risk Behaviour Surveillance in Hong Kong. Public Health 2004; 118(2): 88-95 Lee A., Lee N., Tsang CKK., Wong., Cheng KFF., Wong SYS., Wong CS. Youth Risk Behaviouir Survey, Hong Kong (2003/04). Journal of Primary Care and Health Promotion 2005; Special issue; 1-47

Health promotion Curative C i Rehabilitation and supporting services Supporting self help activities of individuals, families and groups

In Australia the health of young people continues to deteriorate with youth depression tripled in the past 30 years and about 30% of teenagers have experienced mental health problems before the age of 18 years. 30% of Australian teenage drink alcohol regularly, 16% smoker regularly, and 50% under age 18 have tired cannabis. Most of the health risk behaviors adopted by the adolescents will have greatest health impact later in their life, but the impact has been underestimated.
Rowe L (2005). This summer, start a small social revolution. Aus Fam Phy, 34(1-2): 11-12. Sawyer MG, Arney FM, Baghurst PA, et al (2000). The mental health of young people in Australia: child and adolescent component of the National Survey of Mental Health and Well being. Canberra: Commonwealth Department of Health and Aged Care.

The Role of Medicine in Determining Health

Mckeown and Lowe (1974) concluded that social advances in general living conditions, such as improved sanitation and nutrition, have been responsible for most of the reduction in mortality achieved during the last century. The contribution of medicine to reduce mortality has been minor compared with improved environmental conditions.

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Trend of Cardiovascular diseases (CVD)

Generally speaking, prevalence of cardiovascular disease tends to be stable and has decreased in developed countries, especially western, while tends to be western soaring higher in the developing areas.
Disch harges in Millions

7 6 5 4 3 2 1 0 70 75 80 85 Years 90 95 00 06

Hospital discharges for cardiovascular diseases, a proxy of prevalence (United (United States: 1970States: 1970-2006).
Note: Hospital discharges include people discharged alive, dead and status unknown. Source: NCHS and NHLBI.

Prevalence of hypertension in China

Prevalence of CVD of Austrialia 40

pr revalence(%) 60 50 40 30 20 10 0 1960 1980 1990 year 2003 2008

35 prevelance(%) 30 25 20 15 10 5 0 1989 1995 year 2001 2009

Occasional Paper: Long-term Health Conditions - A Guide To Time Series comparability From The National Health Survey, Australia, 2001 Heart, Stroke and Vascular Diseases. Australian Facts 2004

PK Whelton et al. Prevalence, awareness, treatment and control of hypertension in North America, North Africa and Asia. Journal of Human Hypertension (2004) 18, 545551 National health statistics2009, Ministry of health, China

Coronary Heart Disease

Changing pattern of diseases of different countries What are the implications of p health of that particular nation?

Department of Health, HK: www.healthyhk.gov.hk/phisweb/en/healthy_facts/disease_burden/major_causes_death/

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Multi-levels of Health promotion

Effective public health intervention There is a paradigm shift of pubic health intervention from addressing the devastating effects of the living and working conditions on population health to the modification of health risk behaviours and build up the personal, cognitive and social skills which determine the ability of the individuals to gain access to, understand and make use of the information to promote and maintain good health.
Mid Stream : Appropriate treatment, protection from harm/ disability/injury Upstream : Improving condition For better health

Down stream Rehabilitation, stablisation of illness, coping with illness

Principle of Health Promotion During next 45 minutes, there will be discussion on: - Concepts of Health Promotion p - Influence on health
It involves the population in the context of their everyday life rather than focusing on people at risk for specific diseases (1st dimension of health promotion) It is directed towards action on determinants of health. It combines diverse, but complimentary methods or approaches including education, communication, organizational changes, community development, fiscal measures, legislation and local actions (2nd dimension). It needs healthy public policy. Third dimension of health promotion is reaching people through the sectors where they live and meet such as schools, cities, workplaces) and Healthy Schools and Healthy Cities are classical examples.

Ottawa Charter of Health

Building a healthy public policy Create supportive environments Strengthen community action Develop personal skills Re-orient health services

President US Healthy Initiative June 2002

Be physically active Eat nutritious diet Get preventive screening Make healthy choices

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Bangkok Charter for Health

Advocacy Invest in sustainable policies, actions and infrastructure to address the determinants of health Capacity building for policy development, leadership, leadership health promotion practice practice, knowledge transfer and research, and health literacy Regulate and legislate Partner and build alliances with public, private, non-governmental and international organizations and civil society to create sustainable actions

Healthier, safer, more confident citizens by European Commission has three core objectives:
To protect citizens from risks and threats which are beyond the control of the individual and cannot be effectively tackled alone, e.g. unsafe commercial practice, unsafe products To enhance the ability of citizens to make better decisions about health To mainstream health and consumer policy objectives across all policies putting health on agenda
Kickbush I (2005). The Health society:..Health Promotion International, 20(2):101-103

The move towards Health Society will need:

Expansion of citizens empowerment and choices their rights and general health literacy To recognize the increasing presence of health in the market place and ensure consumer safety

The move towards Health Society will need:

To address the problems of health inequalities To recognise the that boundaries between different components of health care delivery system such as health promotion, disease prevention, treatment, rehabilitation, are becoming increasingly blurred and needs greater integration

Class exercise
Step by step to understand what influence people having coronary heart diseases

Who are at risk of Coronary Heart Disease?

Consider underlying health conditions putting people at risk of coronary heart diseases

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Who are at risk of developing those health conditions?

Consider the lifestyle factors putting people at risk of those conditions

How would those lifestyle factors be modified?

Consider the environmental perspectives (physical and social)

Mandala of Health: a model of the human ecosystem

Culture Community
Lifestyle

What are the personal factors p putting individual at risk? g

Consider the demography

Personal behaviour

Family
Spirit S i it

Psycho-socioeconomic environment

Sick-care system

Body

Mind

Work

Human biology

Physical environment

Human-made environment Source: With kind permission from Hancock and Perkins Health Education, Summer 1985, pps-10

Biosphere

Lee A., Kiyu A., Milman HM., Jara J. Improving Health and Building Human Capital through an effective primary care system. Journal of Urban Health 2007; 84(supp1): 75-85

Three Levels of Prevention

1. Primary Prevention

preventing the onset of disease in asymptomatic people i.e. stop exposing to risk factors. Vaccination is one good example 2. Secondary Prevention 2 S d P ti preventing the progress of disease by identifying the disease at early stage before clinical manifestation i.e. screening 3. Tertiary Prevention preventing avoidable complications and deterioration, i.e. rehabilitation, stabilization of chronic conditions

School Health Promotion (Healthy School movement)

Family Doctor
Individua l Family y

Community Health Promotion (Healthy City) Self help group

Supporting Allied Health Services

Peer

Workplace Health Promotion

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Epilogue
-
Excellent practice emphasizes Primary Prevention; Good practice pays attention to Secondary Prevention; The average practice concentrates on the present illness only