Taking Action to Prevent Chronic Disease - Action Cancer Ontario

157 Pages·2012·1.39 MB·English

Taking Action
to Prevent
Recommendations for a Healthier Ontario
Chronic Disease
Technical Appendix
Chronic diseases are the leading cause of death in Ontario.
These largely preventable diseases diminish our quality of
life, economy and communities.
Published by the Ontario Agency for Health Protection and Promotion, and Cancer Care Ontario
Agency for Health Cancer Care Ontario
Protection and Promotion
620 University Avenue, Toronto, Ontario M5G 2L7
Agence de protection et
de promotion de la santé Telephone: [phone]
www.cancercare.on.ca
Public Health Ontario
480 University Avenue, Suite 300, Toronto, Ontario M5G 1V2
Telephone: [phone]
www.oahpp.ca
© Queen’s Printer for Ontario, 2012
Permission to reproduce How to cite this publication
Except as otherwise specifi cally noted, the information in this publication Cancer Care Ontario, Ontario Agency for Health Protection and Promotion
may be reproduced, in part or in whole and by any means, without charge or (Public Health Ontario). Taking action to prevent chronic disease: recommen-
further permission from Cancer Care Ontario or Public Health Ontario for non- dations for a healthier Ontario—technical appendix. Toronto: Queen’s Printer
commercial purposes, provided that due diligence is exercised in ensuring the for Ontario; 2012.
accuracy of the information reproduced; that Cancer Care Ontario and Public
Alternative formats
Health Ontario are identifi ed as the source institution; and that the reproduc-
We are committed to ensuring accessible services and communications to
tion is not represented as an offi cial version of the information reproduced, nor
individuals with disabilities. To receive any part of this document in an alter-
as having been made in affi liation with, or with the endorsement of, Cancer
nate format, please contact Cancer Care Ontario’s Public Aff airs Department at
Care Ontario and Public Health Ontario.
416.971.9800, TTY 416.217.1815, or at publicaff [email protected] or Public
For permission to reproduce the information in this publication for commercial
Health Ontario’s Public Aff airs Department at 647.260.7100, or at [email protected].
redistribution, please email: publicaff [email protected] or [email protected]
This report is a supplementary document to Taking Action to Prevent Chronic
ISBN 978-1-4435-8973-4 PDF
Disease: Recommendations for a Healthier Ontario. Both publications are avail-
able online at
Canadian cataloguing in publication data
www.cancercare.on.ca/takingaction or www.oahpp.ca/takingaction.
Taking Action to Prevent Chronic Disease: Recommendations for a Healthier
Ontario—Technical Appendix
Includes bibliographical references.
Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix i
Acknowledgements
This report was produced by the joint Public Health Ontario/Cancer Care Ontario Prevention Working Group.
Public Health Ontario (Ontario Agency
for Health Protection and Promotion)
Prevention Working Group Heather Manson, MD, FRCPC, MHSc
is a Crown corporation dedicated to
Director, Health Promotion, Chronic Disease and Injury
protecting and promoting the health Chairs
Prevention, Public Health Ontario
of all Ontarians and reducing inequities Heather Manson, MD, FRCPC, MHSc
(Capacity for change recommendations)
in health. As a hub organization, Public Director, Health Promotion, Chronic Disease and Injury
Health Ontario links public health Prevention, Public Health Ontario Loraine Marrett, PhD
practitioners, front-line health workers Linda Rabeneck, MD, MPH, FRCPC Director, Surveillance, Prevention and Cancer Control,
and researchers to the best scientifi c Vice President, Prevention and Cancer Control, Cancer Care Ontario
intelligence and knowledge from around Cancer Care Ontario (Risk factor and disease evidence)
the world. Mary Fodor O’Brien, MHSc, RD
Leads
Nutrition Specialist, Public Health Ontario
Kenneth R. Allison, PhD
(Healthy eating recommendations)
Senior Scientist, Health Promotion, Chronic Disease and
Ruth Sanderson, MSc
Injury Prevention, Public Health Ontario
Manager, Analytic Services, Public Health Ontario
(Physical activity recommendations)
(Risk factor and disease evidence)
Brian Hyndman, MHSc
Beth Theis, MSc
Senior Planner, Public Health Ontario
Manager, Surveillance, Prevention and Cancer Control,
(Alcohol recommendations)
Cancer Care Ontario
Alethea Kewayosh
(Risk factor and disease evidence, physical activity and
A/Director, Aboriginal Cancer Control,
alcohol recommendations)
Cancer Care Ontario
Rebecca Truscott, MHSc, RD
(Capacity for change recommendations)
Health Promotion Specialist, Nutrition, Prevention
Scott Leatherdale, PhD
and Cancer Control, Cancer Care Ontario
Associate Professor and Cancer Care Ontario
(Healthy eating recommendations)
Research Chair, School of Public Health and Health
Systems, University of Waterloo
(Tobacco recommendations) Special thanks go to the expert panels on tobacco,
alcohol, physical activity, healthy eating and capacity
for change. Please see Appendix 2 of the main report
for membership.
ii Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix
Cancer Care Ontario—an Ontario
government agency—drives quality
Contributors Cancer Care Ontario
and continuous improvement in disease
Dafna Carr, MBA, Director, Policy, Planning and
Public Health Ontario prevention and screening, the delivery
Knowledge Translation and Exchange
Marlon Drayton, MSc, MSA, Senior Policy Analyst of care and the patient experience,
Phat Ha, MPH, Research Coordinator Elisa Candido, MPH, Research Associate (epidemiology) for cancer, chronic kidney disease and
Maria Chu, MA, MISt, Health Information Specialist access to care for key health services.
Karin Hohenadel, MSc, Epidemiologist
Stephanie Ryan-Coe, BA Hons, Senior Communications Known for its innovation and results
Juliana Jackson, MHA, Senior Policy Analyst
Strategist driven approaches, Cancer Care Ontario
Alexandra Kyriakos, MA, Director, External Aff airs leads multi-year system planning,
Steven Savvaidis, MHSc, Manager, Program Training
Allison McArthur, MISt, Library and Information contracts for services with hospitals and
and Consultation Centre
Specialist providers, develops and deploys infor-
Suriya Veerappan, MA (Candidate), Public Aff airs mation systems, establishes guidelines
Christiane Mitchell, MAP, Research Assistant
Advisor
and standards and tracks performance
Jennifer Modica, MA, Communications Specialist
targets to ensure system-wide improve-
Cancer Quality Council of Ontario liaison
Michelle Murti, MD, CCFP, MPH, Public Health and (Secretariat) ments in cancer, chronic kidney disease
Preventive Medicine Resident and access to care.
Rebecca Anas, MBA, Director
Jennifer Robertson, PhD, Senior Evaluator
Christine Chan, PGDipPH (Distinction), MPH
Beate Sander, PhD, Scientist, Health Economics Epidemiology (Candidate), Senior Policy Advisor
Anne Simard, MHSc, Chief Public Aff airs Offi cer Jennifer Stiff , MRes, Senior Policy Advisor
Peter Tanuseputro, MHSc, MD, CCFP, Public Health and
Project lead
Preventive Medicine Resident
Melissa Tamblyn, MPA
Editor
Chris Mercer, BA
Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix iii
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
2.1 Disease Burden. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.2 Risk Factor Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.3 Risk Factor and Disease Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.4 Economic Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.5 Approach to the Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.6 Equity Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3. Risk Factor and Disease Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
3.1 Burden of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.2 Prevalence of Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
3.3 Risk Factor Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
4. Risk Factor and Disease Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4.1 Tobacco Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
4.2 Alcohol Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
4.3 Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
4.4 Unhealthy Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
5. Economic Burden. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6. Evidence Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
7. Equity Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
8. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
8.1 Risk Factor and Disease Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
8.2 Economic Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
8.3 Gaps in Risk Factor Population Health Assessment and Surveillance in Ontario . . . . . . . . . . . . . . .139
8.4 Equity Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
iv Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix
1. Introduction
The rise in prevalence of chronic diseases throughout the world is a growing disease among disadvantaged populations; and addressing barriers to the
cause for concern in the public health sector. The increasing burden of chronic prevention of chronic disease among First Nations, Inuit and Métis (FNIM)
diseases has negatively impacted quality of life, and contributed to poverty communities.
and adverse economic eff ects.
All of the recommendations presented in the report are based on evidence (in
Chronic diseases are the leading causes of death and disability.1–3 In 2005, they the form of research fi ndings and experiential and/or contextual information).
took the lives of over 35 million people worldwide. This is double the number Recommendations are action-oriented and aim to reduce the prevalence of
of people that died from infectious diseases (including HIV/AIDS, malaria and risk factors for chronic disease in Ontario.
tuberculosis).4 In 2007, chronic diseases were responsible for 79% of all deaths
This Technical Appendix augments the main report by providing more detailed
in Ontario. Worldwide, in 2008, chronic diseases accounted for more deaths
information concerning the:
than all other causes combined: 63% of the 57 million global deaths.5
■ prevalence of the risk factors addressed in the report
The burden of chronic disease is a major concern, and prevention of chronic
■ disease and economic burden associated with these risk factors
disease is becoming a focus for governments at all levels. Some examples
include: ■ relationship between each risk factor and chronic diseases
■ UN Summit on Non‐communicable Disease (NCD) Prevention and Control ■ approach to the identifi cation and review of the evidence used to
September 20116 generate the report recommendations
■ WHO 2008–2013 Action Plan for the Global Strategy for the Prevention ■ potential impact of the recommendations on inequities in the burden of
and Control of NCDs7 chronic diseases
■ Lancet NCD Action Group and NCD Alliance8 It is hoped that the Technical Appendix will serve as a helpful resource, both
for understanding the underlying rationale for each of the report recom-
■ Chronic Disease Prevention Alliance of Canada: Framework for the
mendations and to support action on the recommendations. If implemented
Primary Prevention of Chronic Disease9
as part of a comprehensive strategy that engages all levels of government and
■ Preventing and Managing Chronic Disease: Ontario’s Framework10
civil society, and also embraces health equity, the recommendations discussed
■ Commission on the Reform of Ontario’s Public Services (2012)11 in the Technical Appendix will help to reduce the prevalence of chronic
disease, and associated social and economic burdens.
To guide action on the primary prevention of chronic disease, Cancer Care
Ontario and Public Health Ontario released a report to the Ontario govern- Ontario can meet the challenge of chronic disease prevention.
ment in March 2012. The report, titled Taking Action to Prevent Chronic
Disease: Recommendations for a Healthier Ontario, (referred to as the “report”),
proposed 22 recommendations for policies and other interventions to address
four major risk factors associated with chronic disease: tobacco use, alcohol
consumption, physical inactivity and unhealthy eating. In addition, the report
provides recommendations for taking a cohesive approach to chronic disease
prevention at the system level; reducing inequities in the burden of chronic
Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix 1
2. Methods
To generate informed recommendations for interventions to prevent or ■ Chronic (lower) respiratory diseases: ICD–10: J40‐J47 (or ICD–9: 490–494,
ameliorate the key modifi able risk factors for chronic diseases (and their 496)
related determinants), the authors of the report undertook an extensive
Note: eff ective with the ICD–10 revision, ICD–9 code 495 [extrinsic allergic
review of supporting data and evidence. Chapter 2 of the Technical Appendix
alveolitis] is no longer included. This aff ects data for few, if any, deaths per
provides an overview of methodology, specifi cally the methods used to:
year in Ontario.
■ quantify the disease burden attributable to chronic diseases in
2.2 Risk Factor Prevalence
Ontario
■ identify the prevalence of the key modifi able risk factors for chronic Overall Risk Factor Prevalence
diseases in Ontario
Indicators for risk factor prevalence: data sources
■ review the associations between the risk factors and chronic diseases ■ Current smoking (adult), obesity, physical inactivity, inadequate vegetable
■ identify the economic burden arising from the risk factors in Ontario and fruit consumption: Statistics Canada, Canadian Community Health
Survey (CCHS), 2009–2010 share fi le (excludes non‐response). Retrieved
■ review the body of evidence on policies and other interventions
September 21, 2011 from Public Health Agency of Canada’s Chronic
addressing the risk factors
Disease Infobase web site http://66.240.150.17/cubes/intro-e.html (Note:
■ assess the extent to which the proposed recommendations could
estimate for current smoking age 20+ calculated separately by PHAC staff
potentially impact (positively or negatively) health inequities, and
as a special request.)
identify potential mitigation strategies for these inequities
■ Youth smoking: Youth Smoking Survey (YSS), 2008–09, Supplementary
2.1 Disease Burden Tables to the Youth Smoking Survey, 2008‐09. Retrieved September 15,
2011 from the Youth Smoking Survey web site: http://www.yss.uwaterloo.
Mortality estimates were calculated from the Ontario Mortality database
ca/index.cfm?section=5&page=288.
using the International Classifi cation of Disease tenth revision (ICD-10) codes
recommended by the Association of Public Health Epidemiologists in Ontario ■ Alcohol consumption: The CAMH Monitor, 2009. Centre for Addiction and
(APHEO) and other organizations. Cancer incidence estimates were calculated Mental Health, CAMH Monitor eReport: Addiction and Mental Health
from the Ontario Cancer Registry; diabetes estimates were drawn from recent Indicators among Ontario Adults, 1977–2009 (CAMH Research Document
publications based on Canadian and Ontario data. Series No. 31).
ICD codes for chronic diseases mortality data extraction: Indicators for risk factor prevalence: defi nitions
■ Cardiovascular disease: ICD–10: I00–I99 (or ICD–9: 390–459) (i.e., all of the ■ Current smoking: the proportion of the population aged 20 years and over
“I” block) who reported being a current smoker (i.e., daily or occasional smokers).
■ Cancer: ICD–0: C00–D48 CCHS 2009–2010 share fi le, question SMK_Q202, excludes non‐response.
■ Diabetes: ICD–10:E10–E14 (or ICD–9:250)
2 Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix
■ Alcohol consumption: the proportion of the population aged 18 years and Indicators for risk factor prevalence by socio‐demographic factors:
over who exceeded the low-risk drinking guidelines recommended by defi nitions
the Centre for Addiction and Mental Health (CAMH) in its 2009 report (i.e., ■ Current smoking: the proportion of the population aged 30 years and over
no more than 14 standard drinks per week for men and no more than 9 who reported being a current smoker (i.e., daily or occasional smokers).
standard drinks for women OR no more than 2 drinks on any one day). ■ Alcohol consumption: the proportion of respondents aged 30 years and
● Note: These guidelines have now been superseded by Canada’s over who drank more than 30 g (approximately 2 drinks) of alcohol on
low-risk alcohol drinking guidelines, but were the basis for the CAMH any day of the week prior to the interview
Monitor 2009 prevalence estimate used in this report. ● N ote: pregnant or lactating females, females who did not answer the
■ Obesity: the proportion of the population aged 18 years and over with pregnancy or lactating questions (but not those who said they do not
a body mass index (BMI) of 30.0 kg/m2 or higher, based on self‐reported know if they are pregnant), and respondents who did not answer one or
height and weight. CCHS 2009–2010 share fi le, derived variable more of the required alcohol consumption questions were excluded.
HWTDISW, excludes non‐response. ■ Obesity: the proportion of the population aged 30 years and over with
■ Physical inactivity: the proportion of the population aged 12 years and a body mass index (BMI) of 30.0 kg/m2 or higher, based on self‐reported
over who are inactive (energy expenditure <1.5 kcal/kg/day) during height and weight .
their leisure time, based on an index of average daily physical activity ● Note: pregnant or lactating females; females who did not answer the
(measured through energy expenditure) over the past 3 months. CCHS
pregnancy or lactating questions (but not those who said they do not
2009–2010 share fi le, variable PACDPAI, excludes non-response.
know if they are pregnant), respondents less than 3 feet tall or over
■ Inadequate vegetable and fruit consumption: the proportion of the popula- 7 feet tall, and those with unknown values for height or weight were
tion aged 12 years and over who reported eating vegetables and fruits excluded.
fewer than 5 times per day. CCHS 2009–2010 share fi le, derived variable ■ Physical inactivity: the proportion of respondents aged 30 years and over
FVCGTOT, excludes non-response.
who were inactive (EE≤1.5 kcal/kg/day) in their leisure‐time and active
transportation in the past 3 months, based on daily estimated energy
Risk factor equity
expenditure (EE) measured in kcal/kg/day. Active transportation is
Indicator for risk factor prevalence by socio‐demographic factors:
defi ned as walking or biking to and from work or school.
data sources
■ Neighbourhood income quintile: this indicator divides dissemination
■ S tatistics Canada, Canadian Community Health Survey (CCHS), 2007–2008
areas (DAs) into quintiles according to income per single‐person
master fi le.
equivalent (IPPE). IPPE is a household size‐adjusted measure of income
adequacy based on census summary data at the DA level and using
person‐equivalents implied by the low income cut‐off s (LICOs). IPPE was
calculated by dividing the total income of the DA (average household
income multiplied by the number of households) by the total number of
single‐person equivalents. Quintiles of the population by neighbourhood
IPPE were constructed within each census metropolitan area (CMA),
Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix 3
census agglomeration (CA), or residual area not in any CMA or CA, and ■ The physical inactivity indicator used in the equity analyses diff ers from
then pooled across areas. Income quintiles constructed in this manner the indicator used to report physical inactivity for Ontario as a whole.
take into account diff erences in housing costs across Canada within each The indicator used in the socio‐demographic analyses considers physical
province, including Ontario. activity from both leisure time and active transportation rather than
■ Urban/rural residence: respondents living within any Census Metropolitan leisure time activity only.
Area (CMA) or Census Agglomeration (CA) were considered “urban
2.3 Risk Factor and Disease Associations
residents”—and those living outside of any CMA or CA were classifi ed
A literature review of associations between the selected risk factors and
as “rural residents”. Thus, the rural population included those who
chronic diseases began with known expert panel reviews or monographs
lived in towns and rural municipalities outside the commuting zone of
(e.g., International Agency for Research on Cancer monographs, United
larger urban centres (those with population of 10,000 or more in the
States Surgeon General Reports). Medical subject heading (MeSH) terms were
commuting zone). All other areas were considered urban.
then used to search the PubMed database for systematic reviews published
■ Education: refl ects the highest level of education attained by the respon-
subsequent to the expert reviews. Evidence from large systematic reviews and
dent. Three categories were used: less than secondary school graduation;
meta‐analyses, high‐impact journals and well‐known research groups was
secondary school graduation and some post‐secondary education; and
prioritized for inclusion.
post‐secondary graduation.
Classifi cations of the strength of evidence and the language used to describe
■ Immigration: distinguishes immigrants from the Canadian‐born popula-
this were taken directly from the expert panel reviews and vary depending on
tion. Three categories of immigration status were used: Canadian‐born;
the reviewing body and/or report. In general, well-established causal relation-
immigrant fewer than 10 years in Canada; and immigrant 10 years or
ships are referred to as “suffi cient” or “convincing”; possible/probable relation-
more in Canada.
ships are referred to as “probable,” “limited” or “suggestive”; and so on. For a full
■ Aboriginal identity: distinguishes respondents who self‐identify as description of the rating system applied by each expert panel, please see the
Aboriginal (North American Indian, Métis, or Inuit) from those who do reports cited in the references.
not consider themselves to be Aboriginal, based on the derived variable
2.4 Economic Burden
SDCDABT.
Estimates of the economic burden of the four risk factors of interest (tobacco
Additional notes on indicators for risk factor prevalence by socio‐
use, alcohol consumption, physical inactivity and unhealthy eating) in Ontario
demographic factors
were collected through these steps:
■ The age group for these analyses is 30 years and over, which diff ers from
1. A systematic search of the published literature from 2006–2011 was
the age groups used to report risk factor prevalence overall. This is meant
conducted by a library information scientist using the following data-
to restrict the sample to those who have likely completed their education
bases: MEDLINE, EMBASE, CINAHL, and EconLit (see Table 1 for search
and reached adult socio-demographic status.
strategies—searches were performed by combining economic and risk
■ The alcohol consumption indicator used in the equity analyses diff ers
factor search terms).
from the indicator used to report on alcohol consumption in Ontario
as a whole. Prevalence estimates of alcohol drinking will diff er slightly
between the two indicators but can be considered comparable.
4 Public Health Ontario I Cancer Care Ontario — Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario — Technical Appendix