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Tipping the scales of progress Heart Disease and Stroke in Canada 2006

www.heartandstroke.ca

Tipping the scales of progress Heart Disease and Stroke in Canada 2006

June 2006

Editorial Board Dr. Andy Wielgosz

– Scientific Editor, Cardiologist

Manuel Arango

– Assistant Director, Government Relations, Heart and Stroke Foundation of Canada

Corinne Hodgson

– Data Consultant

Dr. Barbara Riley

– Centre for Behavioural Research and Program Evaluation, University of Waterloo – Lead Writer

Stephen Samis

– Director, Health Policy, Heart and Stroke Foundation of Canada

Summary of Policy Recommendations Tipping the Scales of Progress - Heart Disease and Stroke in Canada 2006 is the seventh edition of our biennial publication on the status of cardiovascular diseases in Canada. The emphasis in this edition is on policy recommendations for disease prevention at a population level.

The Heart and Stroke Tobacco Control

Foundation recommends that governments provide

The Heart and Stroke Foundation of Canada (HSFC) recommends that governments in Canada continue to develop, implement and enforce comprehensive tobacco control strategies, including:

• • • •

comprehensive smoking bans in all workplaces and public places;

tax credits/breaks for enhancing physical activity.

increased taxation on tobacco products. prohibition of tobacco product "point of sale" advertising and promotion. elimination of deceptive labeling e.g., "light" and "mild".

Obesity and Chronic Disease Prevention The Heart and Stroke Foundation recommends that governments and school boards:

• • •

require one hour per day of structured physical activity for elementary and secondary school students. remove unhealthy or "junk" food in school-site vending machines. improve healthy food choices in schools, including cafeterias.

The Heart and Stroke Foundation recommends that governments:

• •

remove sales taxes from restaurant foods that are ‘healthy’1.

• • • • •

tax ‘unhealthy’ foods, but only in combination with tax incentives.

remove sales taxes from ‘healthy’ food products such as single servings of bottled water, pre-packaged salads and fruit trays in retail stores.

remove sales taxes from sports and recreation equipment, such as bicycles, skates etc. provide tax breaks to individuals for the purchase of public transit passes. treat transit passes provided by companies to their employees as a non-taxable benefit. provide tax credits/breaks for enhancing physical activity such as the purchase of gym memberships, fitness classes etc.

1

Nutrition standards for ‘healthy’ food choices have been developed by the Heart and Stroke Foundation of Canada through its Health CheckTM program.

HEART DISEASE AND STROKE IN CANADA 2006

iii

The Heart and Stroke Foundation recommends that the federal government:

•

implement and adequately fund a coordinated strategy to address common chronic disease risk factors.

The Heart and Stroke Foundation recommends that governments:

•

address socioeconomic factors, such as poverty, and other determinants of health that place communities at high risk for cardiovascular disease.

•

allocate at least 7% of transportation-related infrastructure2 funds toward the development of community infrastructure that promotes the use of active modes of transportation e.g., bicycle trails/paths, walking trails/paths and sidewalks.

•

ensure that social infrastructure that supports physical activity e.g., parks and community and recreation centers are included in the gas tax transfer program.

• •

enhance investments in public transit and infrastructure that promote physical activity. encourage mixed use developments that enable people to walk or bike to a variety of shops and services in their neighbourhoods.

Strengthening the Evidence-base The Heart and Stroke Foundation recommends that the federal government:

•

develop a comprehensive, long-term non-communicable diseases surveillance system, that includes cardiovascular diseases.

•

repeat the upcoming Canadian health measures survey at regular intervals to provide trend data based on physical measures.

•

work with the Foundation and the Canadian Institute for Health Information (CIHI) to develop a national cardiac arrest registry.

•

invest in a Canadian longitudinal, lifelong cohort study, which includes a birth cohort and an aging cohort.

•

reduce the time lag from collection to reporting of economic burden of illness data to a maximum of two years; break down economic burden cost data by specific CVD subcategories and by major cardiovascular risk factors; refine economic burden costing methods in order to keep "unattributable" costs low.

•

lead in the development of enhanced surveillance of primary cardiovascular care and hospitalized care that can track individuals across inter-provincial jurisdictions, making such data available on a routine basis, in collaboration with the Canadian Institute for Health Information (CIHI) and the provinces.

2

iv

U.S. federal government allocates 10%

TIPPING THE SCALES OF PROGRESS

Table of Contents Our Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Heart Disease and Stroke in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Policy Priorities to Prevent Disease in the Canadian Population . . . . . . .13 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

HEART DISEASE AND STROKE IN CANADA 2006

1

Our Message Tipping the Scales of Progress - Heart Disease and Stroke in Canada 2006 is the seventh edition of our biennial publication on the status of cardiovascular diseases in Canada. This issue celebrates some favourable trends, such as the continued decline in smoking rates.

...the forecast for Canadian children is worrisome, especially with rising rates of obesity, inadequate levels of physical activity, and inadequate consumption of vegetables and fruits.

But this report also highlights the need for ongoing vigilance to prevent Canadians, young and old, from becoming victims of the country’s single largest cause of death – cardiovascular disease. What are known as major modifiable risk factors – tobacco use, physical inactivity, unhealthy diets and obesity – remain unacceptably high in our population – and the forecast for Canadian children is worrisome, especially with rising rates of obesity, inadequate levels of physical activity, and inadequate consumption of vegetables and fruits.

Population-based disease prevention is our most powerful and efficient tool to improve and sustain the health of Canadians. Thus, the emphasis in this edition is on policy recommendations for disease prevention at a population level.

Effective prevention requires action from every sector of society and all levels of government. Public policy at federal, provincial and municipal levels, and across sectors such as environment, transportation, urban planning, finance, education, housing, labour and social infrastructure must support health goals.

The Heart and Stroke Foundation is committed to working with all partners just as it has been committed to prevention since it was founded 50 years ago.

Within a broad array of opportunities, the Foundation is currently targeting its efforts on obesity prevention and tobacco control.

Although this document focuses primarily on data available at the national level, our call to action is directed to all levels of government, in both the health and non-health sectors, including elected officials and policy makers.

All of these sectors make important contributions to prevention.

While our recommendations are supported by the data examined in this document, they go beyond the direct implications of the data. This is necessary because of some of the existing gaps in Canadian data. This also speaks to the need to act on urgent problems based on the best existing evidence – rather than delaying action until complete or best possible evidence is developed.

2

TIPPING THE SCALES OF PROGRESS

It will take our collective and coordinated efforts to improve We recommend policy actions that:

• • • • •

the cardiovascular health of Canadians.

require an urgent response; build on current momentum and successes; are informed by best available evidence;

have a high potential for impact on population health, including reducing health disparities; and are practical and feasible in today’s social and economic climate.

It will take our collective and coordinated efforts to improve the cardiovascular health of Canadians.

It also took a collective effort to produce this publication. We thank the Canadian Institute for Health Information (CIHI), the Public Health Agency of Canada, Statistics Canada and Health Canada for providing data and assisting with analyses. The Heart and Stroke Foundation however is solely responsible for the policy actions recommended in this report.

Examples of involvement by the Heart and Stroke Foundation in population-based disease prevention:

•

Led a national "think tank" in the Fall of 2005 to identify obesity-related research priorities for selected policy options; currently developing a request for proposals to fund research on the relationship between community planning and design in Canada and active, healthy living and obesity (to be released Fall 2006).

• •

Targeting strategic funds to obesity-related research;

• •

Advocates for healthy living measures, such as healthy food in school vending machines;

Development of the Health CheckTM program to help consumers identify healthy food choices, which now includes approximately 600 participating products;

Advocates with other health organizations for greater investments in disease prevention and for healthy living measures, such as economic incentives and community environments that support healthy eating and physical activity.

HEART DISEASE AND STROKE IN CANADA 2006

3

Heart Disease and Stroke in Canada What the data show us Mortality rates from various forms of cardiovascular diseases have decreased significantly over the past 20 years.3 Between 1979 and 2003, the age-standardized mortality per 100,000 for cardiovascular diseases declined by 53% in men and women. Figures 1 and 2.

FIGURE 2 Age-standardized mortality rate/100,000 for selected cardiovascular diseases aged 20+, Men, 1979 to 2003 Age-standardized mortality rate per 100,000

Age-standardized mortality rate per 100,000

FIGURE 1 Age-standardized mortality rate/100,000 for selected cardiovascular diseases aged 20+, Women, 1979 to 2003 900 800 700 600 500 400 300 200 100 0 1979

1984

1989

All CVD

1994

IHD

AMI

Data Source: Canadian Mortality Data Base, Statistics Canada.

1999

Stroke

2004

900 800 700 600 500 400 300 200 100 0 1979

1984

All CVD

CHF

1989

IHD

Data Source: Canadian Mortality Data Base, Statistics Canada.

Age-standardized to 2001, 5 year age groups.

1994

AMI

1999

Stroke

2004

CHF

Age-standardized to 2001, 5 year age groups.

Hospitalization rates (age-standardized, per 100,000 population) have also declined for all cardiovascular diseases and for both men and women. Figure 3.

Age-standardized hospitalization rate per 100,000

FIGURE 3 Age-Standardized Hospitalization Rates, All Cardiovascular Diseases by Sex, 1994-1995 to 2003-2004 2500

2000

1500

1000

500

0 1994-95

1995-96

1996-97

1997-98

1998-99

Men

1999-00

2000-01

2001-02

2002-03

2003-04

Women

Notes: Hospitalizations are based on most responsible diagnosis as recorded in the hospital abstract. Hospitalizations for pregnancy and childbirth are excluded. All ages are included (including newborns). Standardized to the Canadian population, 1990.

Source: Hospital Morbidity Database, CIHI

3

4

Canadian Mortality Data Base, Statistics Canada. Age-standardized to 2001, 5 year age groups

TIPPING THE SCALES OF PROGRESS

Declines in hospitalization rates are apparent for every major type of cardiovascular disease. Figure 4.

Between 1994-95 and 2003-04, the rate of hospitalization for cerebrovascular disease (CBVD or stroke) fell 32%, for congestive heart failure (CHF) 31%, for ischemic heart disease (IHD) 26%, and for acute myocardial infarction (AMI or heart attack) 9%. Nevertheless, cardiovascular diseases remain one of the leading causes of hospitalization among Canadians. Figure 5.

Age-standardized hospitalization rate per 100,000

FIGURE 4 Age-Standardized Hospitalization Rates, Ischemic Heart Disease, Acute Myocardial Infarction, Cerebrovascular Disease and Congestive Heart Failure, 1994-1995 to 2003-2004

FIGURE 5 Hospitalizations for Various Categories of Cardiovascular Diseases vs. All Other Hospitalizations, 2003-2004 Other Cardiovascular Conditions 5%

IHD 5%

AMI 3% Stroke (CBVD) 2% CHF 2%

450 400 350 300 250

All Other Hospitilization 83 %

200 150 100 50 AMI = Acute Myocardial Infarction

0 1994-95

1995-96

1996-97

1997-98

1998-99

1999-00

2000-01

2001-02

2002-03

IHD = Ischemic Heart Disease (excluding AMI)

CHF=Congestive Heart Failure

CBVD = Cerebrovascular Disease

Notes: Hospitalizations for cardiovascular diseases are based on the most responsible diagnosis as recorded in the hospital abstract.

Hospitalizations for pregnancy and childbirth are excluded. Men and women are included as well as all ages (including newborns).

2003-04

Source: Hospital Morbidity Database, CIHI

IHD

IHD=Ischemic Heart Disease

AMI

AMI=Acute Myocardial Infarction

CBVD

CHF

CBVD=Cerebrovascular Disease

CHF=Congestive Heart Failure

Notes: Hospitalizations are based on the most responsible diagnosis as recorded in the hospital abstract. Hospitalizations for pregnancy and childbirth are excluded. Men and women are included as well as all ages (including newborns). Standardized to the Canadian population, 1990.

Source: Hospital Morbidity Database, CIHI

The numbers of cases are not the same as the rates. The decline in rates means smaller proportions of Canadians in each age group are succumbing to cardiovascular diseases, which reflects progress in both treatment and prevention. The numbers of cardiovascular disease-related hospitalizations are decreasing, with the exception of heart attack-related hospitalizations, which have increased steadily over the past decade. Figure 6. Figure 7.

FIGURE 6 Number of hospitalizations for Ischemic Heart Disease, Acute Myocardial Infarction, Cerebrovascular Disease and Congestive Heart Failure, 1994-1995 to 2003-2004

FIGURE 7 Number of Hospitalizations for All Circulatory Disease

by Sex, 1994-1995 to 2003-2004 300,000

Number of Hospitalizations

Number of Hospitalizations

140,000 120,000 100,000 80,000 60,000

250,000

200,000

150,000

100,000

50,000

40,000 0

20,000

1994-95

1995-96

1996-97

1997-98

1998-99

1999-00

2000-01

2001-02

2002-03

2003-04

0 1994-95

1995-96

1996-97

1997-98

1998-99

1999-00

2000-01

2001-02

2002-03

2003-04

Men

IHD

AMI

CBVD

CHF

Women

Notes: Hospitalizations are based on the most responsible diagnosis as recorded in the hospital abstract. Hospitalizations for pregnancy and childbirth are excluded. All ages are included (including newborns).

Source: Hospital Morbidity Database, CIHI

IHD=Ischemic Heart Disease

AMI=Acute Myocardial Infarction

CBVD=Cerebrovascular Disease

CHF=Congestive Heart Failure

Notes: Hospitalizations are based on the most responsible diagnosis as recorded in the hospital abstract. Hospitalizations for pregnancy and childbirth are excluded. Men and women are included as well as all ages (including newborns).

Source: Hospital Morbidity Database, CIHI

HEART DISEASE AND STROKE IN CANADA 2006

5

The number of Canadians living with some form of heart disease (based on self reports) remains high and increases with age. Figure 8.

FIGURE 8 Percent Self-Reported Heart Disease and Stroke

by Age Group, 2003 30

With the aging Canadian population and a general growth of the

28.0

population, the actual numbers of

25

Percent

20 17.6

people experiencing cardiovascular

15 11.8

10

8.2

7.4

6.9

diseases is expected to increase.

6.7 5.6

5

3.7

3.4 1.3

1.3

20-49

Stroke

2.5 1.2

1.1

0.2 0.3 0.2

0

3.0

50-64

65-79

Heart Attack

80+

Congestive Heart Failure

1.0

Therefore the burden of disease

All (20+)

is not expected to ease.

Any Heart Disease

Heart Attack and Congestive Heart Failure only asked of those who reported having heart disease.

Source: Chow CM, Donovan L, Manuel D, Johansen H, Tu JV; Canadian Cardiovascular Outcomes Research Team.

Regional variation in self-reported heart disease prevalence in Canada. Can J Cardiol. 2005 Dec;21(14):1265-71.

Risk Factors Our lifestyle choices and the environments in which choices are made have a major impact on the development of cardiovascular diseases including ischemic heart disease and stroke.

Smoking Smoking is a leading risk factor for cardiovascular disease. The population trends have been favourable, with a decline in the rate of smoking among the general Canadian population. In 2004, among those 15 and over, 20% reported having smoked. Even the 15-19 year-old age group – a group previously resistant to smoking cessation interventions – has experienced a significant decline in smoking rates, from 28% in 1999 to 18% in 2003. Figure 9. Canada is a leader in tobacco control.

The rate of smoking in Canada is less than in many industrialized nations. Figure 10.

FIGURE 9 Percent of Population Smoking by Year and Age Group 30

25

28 25

35

25 24

32.0

23 22

30.3

22 21

30

21 20

20

18

27.0 26.0

18

24.2

25 22.2

15

Percent

10

5

19.8

10 5

Source: Canadian Tobacco Use Monitoring Survey (CTUMS) 2004.

Source: OECD Health Data 2005

TIPPING THE SCALES OF PROGRESS

.

U.S

.

U.K

an

erla nds Neth

Jap

Italy

Fra

0 15 and over

nce

2004 d

2003

Fin lan

2002

ada

2001

a

2000

Can

1999

15 - 19 Years

6

17.5

17.0

15

trali

0

20

Aus

Percent

FIGURE 10 International Comparison of Daily Smokers Among Adult Populations, 2003

However, not all groups have benefited equally, with smoking rates remaining higher in lower income groups. Figure 11.

FIGURE 11 Daily Smoking, Both Sexes, by Income Quartile, 1994 to 2003, Age 20+ 40 35

Percent

30 25 20 15 10 5 0

1994

1996

1 (poorest)

1998

2

2001

2003

3

4 (richest)

Source: 1994, 1996 and 1998: National Population Health Survey; 2001, 2003: Canadian Community Health Survey; age standardized to the 1991 Canadian population. Statistics Canada, custom tabulation

Based on trends to date, the rates of smoking among men and women are projected to continue to decline over the next fifteen years i.e., from 2001 to 2015. However, this projected change varies by income level. In 2001, those in the lower income quartiles were more likely to smoke than those in the higher quartiles. This was true for both men and women. While the gap between the poorest and richest income quartiles is expected to decrease, it is uncertain whether it will disappear. Figure 12. Figure 13.

FIGURE 12 Daily Smokers Projection, Men

FIGURE 13 Daily Smokers Projection, Women

35%

30%

30%

25%

25% 20% 20% 15% 15% 10% 10% 5%

5% 0%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Q1 (poorest)

Q2

Projections provided by Health Analysis and Measurement Group, Statistics Canada

Q3

Q4 (richest)

0%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Q1 (poorest)

Q2

Q3

Q4 (richest)

Projections provided by Health Analysis and Measurement Group, Statistics Canada

HEART DISEASE AND STROKE IN CANADA 2006

7

Diet Trends in vegetable and fruit consumption are also changing favourably, although there remains room for significant improvement. The proportion of Canadian adults (age 20+) consuming fewer than five servings of vegetables and fruit per day improved between 2001 and 2003, from 66% to 64% among those in the lowest income strata and from 59% to 55% among those in the highest4. Differences by income level require attention and action. Since 1999, the Heart and Stroke Foundation of Canada has collaborated with the Canadian Cancer Society and the Canadian Produce Marketing Association to implement a campaign in Canada to encourage the consumption of 5 to 10 servings per day of vegetables and fruit (known as the "5 to 10 a Day" campaign). Similar "5 to 10 a Day" initiatives are taking place across the world. In 2003, forty-one percent of Canadians recognized this campaign5.

Another significant diet-related risk factor for coronary heart disease is the consumption of trans fats – Canadians have one of the highest rates of consumption of these fats in the world. Federal government action is urgently required to effectively eliminate processed trans fats in Canadian foods6.

Obesity One of the greatest concerns is the growing problem of obesity. Figure 14. Currently, almost 60% of adults age 18 and over, or 14.1 million Canadians are overweight7 or obese8. Almost a quarter (23% or 5.5 million) of the Canadian population is obese.

FIGURE 14 Percent Adults Overweight and Obese

by Age Group, 2004 80 70

68

59 54

Percent

70

69

65

60

57

50

38

39

45 41

40

36

36 33

36

21

20

25-34

35-44

30 20

25 30

10

30 25

24

23

11

0 18-24

45-54

Overweight

55-64

65-74

75+

All (18+)

Obese

Overweight defined as BMI > 25.0 and less than 30.0; Obese defined as BMI >30.0 Source: M Tjepkema. Measured Obesity. Adult obesity in Canada: Measured height and weight.

Nutrition: Findings from the Canadian Community Health Survey. Issue no. 1. Statistics Canada 82-620-MWE2005001, 2005

4

Source: Statistics Canada. Rates age-standardized with 1991 Canadian population.

AC Nielsen Omnibus Survey, 2003.

6 Note: The Heart and Stroke Foundation is currently co-chairing a multi-stakeholder task force, along with Health Canada, that is mandated to develop recommendations and strategies for effectively eliminating processed trans fats in Canadian foods.

7 Overweight is defined as a Body Mass Index (BMI) of between 25 and 30 kg/m2.

8 Obese is defined as a Body Mass Index (BMI) greater than 30 kg/m2.

5

8

TIPPING THE SCALES OF PROGRESS

These obesity rates represent a dramatic increase in all age groups over the past 25 years. Figure 15.

International comparisons of obesity rates are difficult to make, due to differences in the way the data are collected. Best available data suggest that Canada’s obesity epidemic, like other countries’, is approaching that of the U.S. Figure 16.

FIGURE 16 International Comparison of Obesity* Among Adult Populations

FIGURE 15 Change of Adult Obesity Levels by Age Group: 1978/79 vs. 2004 35

35 30

30.6

30

30

30 25 21

20

20

20

20 17 14

15

13 11

23.1

23.0 21.7

20.9

20 15

11 9

10

25

23

Percent

Percent

25

24

10

6

5

5

0

0

18-24

25-34

35-44

45-54

1978/79

55-64

65-74

75+

All (18+)

Canada

2004

Australia

New Zealand***

U.K.

U.S.

Sources: Canada – CCHS 2004; Other countries – Health at a Glance: OECD Indicators 2005 * Measured with direct physical measurements ** Year and age groupings vary (Can, 2003, >18yrs; Aust, 1999, >25yrs; NZ, 2003, >15yrs; UK, 2003, >16yrs; US, 1999/2000, 20-74yrs. *** Different BMI cutoffs were used for Maori and Pacific Islanders

Obese defined as BMI >30.0. Source: M Tjepkema, Measured Obesity. Adult obesity in Canada: Measured height and weight.

Nutrition: Findings from the Canadian Community Health Survey. Issue no. 1. Statistics Canada 82-620-MWE2005001, 2005

Over the last decade, obesity rates, based on self reports, have increased for all income groups. However, those in the poorest income groups consistently demonstrate higher obesity rates than those in the richest income groups. Figure 17.

FIGURE 17 Obesity, Both Sexes, by Income Quartile 1994 to 2003, Age 20+

FIGURE 18 Percent Overweight and Obese Children,

by Age Group, 2004 35

20 18

29

30

16

26

26

25

14 12

Percent

Percent

21

10 8

20 20 18

18

15 15

10

6 4

5 2 0

6

8

9

8

0 1994

1996

1 (poorest)

1998

2

2001

3

Source: 1994, 1996 and 1998: National Population Health Survey; 2001, 2003: Canadian Community Health Survey; age standardized to the 1991 Canadian population. Statistics Canada, custom tabulation

2003

4 (richest)

2 to 5

6 to 11

Overweight

12 to 17

All (2-17)

Obese

Overweight and obese defined according to International Obesity Task Force BMI centile curves based on age and gender.

Source: M Shields. Measured Obesity. Overweight Canadian children and adolescents. Nutrition: Findings from the Canadian Community Health Survey Issue no. 1. Statistics Canada 82-620-NWE2005001, 2005

Of particular concern are the growing rates of overweight and obesity in children and their impact not only on their future health and well-being, but also on the health care system. Overall, 26% of Canadian children 2-17 years of age are overweight or obese, with the percent increasing with age from 21% among those 2-5 years to 29% among those 12-17 years. Figure 18. Children who are obese are at increased risk of remaining overweight or obese as adults.

HEART DISEASE AND STROKE IN CANADA 2006

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Projections of future obesity rates have also been calculated by income category with the assumption that trends observed in the past will remain in the future. These projections are different for the two sexes. In 2001, obesity rates were significantly higher for women in the lower income quartiles, compared to those in higher income quartiles. Figure 19. Over the next decade, it is anticipated that obesity rates will increase among higher income women, while remaining relatively constant in lower income women.

As a result, by 2015 the obesity rates of women in the poorest and highest income quartiles are expected to converge.

FIGURE 19 Obesity Projection, Women

FIGURE 20 Obesity Projection, Men 35%

20% 18%

30% 16% 25%

14% 12%

20%

10% 15%

8% 6%

10%

4% 5%

2% 0%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Q1 (poorest)

Q2

Q3

0%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Q1 (poorest)

Q4 (richest)

Q2

Q3

Q4 (richest)

Projections provided by Health Analysis and Measurement Group, Statistics Canada

Projections provided by Health Analysis and Measurement Group, Statistics Canada

The projected trend is quite different in men. Figure 20. In 2001, there was no difference by income quartile in the obesity rates of adult men. Over the next decade, obesity rates in men are expected to increase steadily for all income quartiles. However, it is anticipated that the increase will be steeper for men in the higher, as opposed to the lower, income quartiles. As a result, by 2015 rates will not only be higher for all men but will be significantly greater for higher, compared to lower, income men.

Physical Inactivity Children who report higher levels of ‘screen time’ (watching TV or videos or playing on the computer) are more likely to be overweight or obese than those who report less screen time. Figure 21.

FIGURE 21 Percent Children 6-11 Years, Overweight and Obese,

by Daily Hours of Screen Time, 2004

In both adults and children, unhealthy

40 35

35

weight is closely linked to inactivity

30

and eating habits.

Percent

25

19

24

15

20

18

15

15 13

10 11

5

7

5

0 1 hr/day or less

> 1-2 hrs/day

Overweight

> 2 hrs/day

Obese

“Screen time” defined as watching TV, playing video games, or using a computer. Source: M Shields. Measured Obesity.

Overweight Canadian children and adolescents. Nutrition: Findings from the Canadian Community Health Survey Issue no. 1. Statistics Canada 82-620-NWE2005001, 2005

10

TIPPING THE SCALES OF PROGRESS

The relationship with inactivity is similar in adults. A greater proportion of sedentary adults, especially women, are overweight or obese, compared to active adults. It is a major concern that almost half of Canadians, ages 12 and over, report being physically inactive. An aging population adds to the problem, since activity also declines with age. Figure 22.

FIGURE 22 Percent Physically Inactive in Leisure Time (Men and Women) by Age Group, 2003

FIGURE 23 Physical Inactivity, Both Sexes, by Income Quartile, 1994 to 2003, Age 20+

60

70 54 50

51

50

60

47 45

50

30

Percent

Percent

40

27

40 30

20 20 10

10

0

0 12-19

20-34

35-44

45-64

65+

Inactivity defined as less than 1.5 kcal/kg/day of physical activity, based on self-report of frequency, duration and intensity of leisure-time physical activity. Source: Statistics Canada, Canadian Community Health Survey, 2003

All (12+)

1994

1996

1 (poorest)

1998

2

2001

3

2003

4 (richest)

Rates age-standardized with 1991 Canadian population. Source: Statistics Canada

Like obesity, rates of leisure time physical inactivity vary by income. Over the last decade rates of inactivity have consistently been the lowest in the wealthiest income group. Figure 23.

Multiple Risk Factors Eight out of 10 Canadians have at least one of the cardiovascular risk factors of smoking, being overweight, physical inactivity, high blood pressure or diabetes, and 1 in 10 has three or more factors.

Risk can be increased by the severity of the risk factors e.g., the risk of heart disease is higher for someone with Class III obesity than with Class I obesity. Combinations of multiple risk factors have more than a simple additive effect.

High Risk Populations Reporting national or regional averages can sometimes result in a misleading picture, because such data can obscure successes as well as poor results. The prevalence of cardiovascular risk factors varies among groups and across Canada. Social inequality, whether measured at the population or individual level, is the single leading condition for poor health, including cardiovascular diseases and related risk factors. Notably, obesity, smoking and physical inactivity are most prevalent among Canadians with the lowest incomes. The impact of socioeconomic status on health, particularly cardiovascular health, cannot be ignored.

HEART DISEASE AND STROKE IN CANADA 2006

11

First Nations/Inuit and other population groups facing socioeconomic and other challenges are at high risk. For example, smoking rates among First Nations/Inuit and ethnic groups are much higher than in the general population. Whereas the 2004 Canadian Tobacco Use Monitoring Survey (CTUMS) indicates that 20% of the general population of Canada ages 15 and over are current smokers, in First Nation communities up to 46% ages 18 and over report smoking daily.9 Obesity is much more prevalent among off-reserve and on-reserve Aboriginal peoples than in the general population. Figure 24.

FIGURE 24 Overweight/Obesity Among First Nations Communities 45

41

40

38

37

36

35

35 32 30

Percent

30

27

25

23

20 15 10 5 0

Not Overweight

General Population

Overweight

Off-Reserve Aboriginal People

Obese

On-Reserve Aboriginal People

Sources: General Population DCCHS 2.2; Off-Reserve Aboriginal Peoples DCCHS 2.2; On-Reserve Aboriginal Peoples DFNRHS-2 Not Overweight = BMI â&#x2030;¤ 24.9; Overweight = 25 < BMI < 30; Obese = BMI â&#x2030;Ľ 30

In the First Nations Regional Longitudinal Health Survey 2002-03 (FNRHS-2)10, 79% of First Nations adults are not sufficiently active, whereas 49% of First Nations adolescent males and 61% of First Nations adolescent females are not sufficiently active. More than 40% of First Nations youth are either overweight or obese, and close to 60% of First Nations children are either overweight or obese.

The survey found that 8% of First Nations people with acceptable weight reported having cardiovascular disease, compared to 16% who were overweight and 27% who were obese. Circulatory diseases are the leading cause of death among First Nations people.11 One in five (19.7%, age standardized) of First Nations adults age 18+ has been diagnosed with diabetes compared to one in 19 (5.2%) in the general Canadian population age 20+. Heart disease and hypertension are about four times as prevalent among First Nations adults with diabetes as among those without diabetes (14.9% versus 3.3% for heart disease and 42.0% versus 10.3% for hypertension).

Overall, high blood pressure is more prevalent among First Nations adults than the general population of Canada (20.4% versus 16.4%).10

9

First Nations Regional Longitudinal Health Survey (RHS) 2002/03. First Nations Centre, November 2005 First Nations Regional Longitudinal Health Survey (RHS) 2002-03, National Aboriginal Health Organization (NAHO), 2004. http://www.naho.ca/firstnations/english/regional_health.php 11 A Statistical Profile on the Health of First Nations in Canada, First Nations and Inuit Health Branch (FNIHB), 2003. http://www.hc-sc.gc.ca/fnih-spni/pubs/gen/stats_profil_e.html 10

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TIPPING THE SCALES OF PROGRESS

The Inadequacy of Canadian Data Unfortunately, the data on the burden of cardiovascular diseases in Canada are limited. While overall mortality is well accounted for, the nature of the death, ie. whether sudden or expected, and the location are not well documented. A cardiac arrest registry would provide valuable information for planning and evaluating relevant policies.

There are few data on morbidity and nonfatal events, particularly out-ofhospital. For example, nonfatal heart attacks and strokes are counted without identifying whether they are initial or recurrent events for individuals. Presently statistics are not provided about the number of new heart attacks, which occur each year across Canada, although estimates can be obtained by linking various records and databases. A person-oriented system that tracks individualsâ&#x20AC;&#x2122; fatal and nonfatal events across provinces, including their occurrence in as well as out of hospital is required to facilitate surveillance of such data.

A cardiac arrest registry would provide valuable information for planning and evaluating relevant policies.

We do not have reliable data on the number of Canadians suffering from angina or from congestive heart failure. The estimates that exist are based on self-reported data that do not inform us reliably about trends or local variations. A major limitation to obtaining such data is the lack of routinely collected relevant primary care data.

An important component of the burden of disease is its dollar cost, both direct and indirect. At the time of this writing, the most recent economic burden data are from 1998 and the component of unattributable (to any disease) costs was 24%, up from 17.6% in the preceding publication of 1993. Health care and prevention disease prevention policies are substantially weakened by inadequate or unreliable data.

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Policy Priorities to Prevent Disease in the Canadian Population What we must do given the data

The Foundation is committed to an integrated approach to chronic disease prevention and it is pleased to play

Tipping the Scales of Progress presents specific policy recommendations in three targeted areas: 1) tobacco control, 2) obesity prevention, and 3) strengthening the evidence base.

Momentum is strong for tobacco control and obesity prevention. The international Framework Convention on Tobacco Control (FCTC) is a significant global milestone as the first international public health treaty. The FCTC represents the culmination of sustained efforts in tobacco control world-wide.

In 2004, the World Health Organization released its report Global Strategy on Diet, Physical Activity and Health, which calls on governments and industry to actively create relevant policies for health gains.

a leadership role in the Chronic Disease Prevention Alliance of Canada.

In September 2004, the federal government announced the creation of a new Public Health Agency of Canada. The federal government is currently considering the approval of a $300 million strategy to address chronic disease prevention. There is a need for input from nongovernmental organizations in the development of an integrated strategy for chronic disease prevention, particularly at a time when health care reform is under consideration.

The Foundation is committed to an integrated approach and it is pleased to play a leadership role in the Chronic Disease Prevention Alliance of Canada, a networked community of organizations and individuals who share a common vision for an integrated system of chronic disease prevention in Canada.

At the provincial level, the Foundation acknowledges the intent of newly created ministries of health promotion in some of the provinces. Here too an integrated, multi-partner approach is essential for the successful prevention of chronic diseases, in particular cardiovascular diseases.

Substantial attention is now devoted to ensuring that all clinical and public health practices are evidence-based. For cardiovascular and chronic disease prevention, this has included several initiatives to identify and disseminate â&#x20AC;&#x2DC;best practicesâ&#x20AC;&#x2122; that promote tobacco control, healthy eating, and physical activity. Likewise, best practice evidence has guided the development of a national Canadian Stroke Strategy.

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TIPPING THE SCALES OF PROGRESS

Investment in prevention is insufficient. Our public health system12 suffers from persistent under-funding for both infectious and chronic disease prevention and control and from an indefensible imbalance with treatment resources. It is estimated that a mere 2-5% of health budgets are spent on public health, with only a small portion of public health spending being dedicated to non-communicable disease prevention and health promotion. These investments are not proportional to the personal, social and economic burden from heart disease and stroke, and what we know about reducing these burdens.

The overall low level of public health funding and the funding imbalance between prevention and treatment need to be addressed. We can and must do better.

Tobacco Control Downward trends in tobacco use are encouraging, but we cannot be complacent. Estimates suggest that smoking contributes to over 47,000 deaths a year in Canada of which over 17,000 are cardiovascular.

Sustained public support for tobacco control, regulations and legislation are needed to maintain the progress made to date and to ensure even greater impact. In addition, populations at increased risk for smoking, such as First Nations and those living with low incomes, need more focused attention.

The Heart and Stroke Foundation of Canada (HSFC) recommends that governments in Canada continue to develop, implement and enforce comprehensive tobacco control strategies, including:

• • • •

comprehensive smoking bans in all workplaces and public places; increased taxation on tobacco products. prohibition of tobacco product "point of sale" advertising and promotion. elimination of deceptive labeling e.g., "light" and "mild".

Obesity and Chronic Disease Prevention A critical priority is to address the epidemic of obesity and overweight, especially among Canadian children and youth. Physical inactivity and unhealthy eating must be addressed together. Initiatives need to be undertaken in multiple settings, especially workplaces, as well as schools and communities to reach children and youth. Recommendations are made in four areas of concern:

1. Schools A large majority of children and youth spend at least one third of their time at school. Strong evidence supports school-based interventions to promote physical activity and healthy eating.

The Heart and Stroke Foundation recommends that governments and school boards:

• • •

require one hour per day of structured physical activity for elementary and secondary school students. remove unhealthy or "junk" food from school-site vending machines. improve healthy food choices in schools, including cafeterias.

12

Public health system refers to the area of our health system that addresses, among other things, disease prevention and health promotion. It does not refer in this instance to our publicly funded health system.

HEART DISEASE AND STROKE IN CANADA 2006

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2. Tax Incentives and Disincentives Economic strategies such as taxes and subsidies are increasingly recognized by international authorities, such as the World Health Organization as viable and effective strategies for obesity prevention and control. Encouragingly, a number of tax incentives were profiled in the 2006 federal election.

A 2005 review of evidence commissioned by the HSFC found that the use of tax incentives has a positive effect on dietary habits and physical activity. Even small reductions to the cost of healthy foods can have a significant impact on purchasing and consumption rates.

Tax disincentives, on their own, especially if they are small, do not seem to have a significant impact on physical activity and eating behaviours.

The Heart and Stroke Foundation recommends that governments:

• •

remove sales taxes from restaurant foods that are ‘healthy’13.

• • • • •

tax ‘unhealthy’ foods, but only in combination with tax incentives.

remove sales taxes from ‘healthy’ food products such as single servings of bottled water, pre-packaged salads and fruit trays in retail stores.

remove sales taxes from sports and recreation equipment, such as bicycles, skates etc. provide tax breaks to individuals for the purchase of public transit passes. treat transit passes provided by companies to their employees as a non-taxable benefit. provide tax credits/breaks for enhancing physical activity such as the purchase of gym memberships, fitness classes etc.

3. Coordinated Strategy The federal government made a commitment to implement an Integrated Strategy on Healthy Living and Chronic Disease, which has not yet been fully realized. By supporting a series of activities to promote healthy eating and physical activity, a coordinated chronic disease prevention strategy will contribute significantly to obesity reduction in Canada.

The Heart and Stroke Foundation recommends that the federal government:

•

implement and adequately fund a coordinated strategy to address common chronic disease risk factors.

4. Social Determinants of Health Cardiovascular diseases are related to key determinants of health including income, education, social status, housing, employment, job stress, and social networks. Even in communities that are relatively affluent, conditions may not be supportive of a heart healthy lifestyle. The ability to walk or cycle safely in neighbourhoods is integral to being physically active, maintaining a healthy body weight, and increasing social interaction.

13

Nutrition standards for ‘healthy’ food choices have been developed by the Heart and Stroke Foundation of Canada through its Health CheckTM program.

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TIPPING THE SCALES OF PROGRESS

The Heart and Stroke Foundation recommends that governments:

•

address socioeconomic factors, such as poverty, and other determinants of health that place communities at high risk for cardiovascular disease.

•

allocate at least 7% of transportation-related infrastructure14 funds toward the development of community infrastructure that promotes the use of active modes of transportation e.g., bicycle trails/paths, walking trails/paths and sidewalks.

•

ensure that social infrastructure that supports physical activity e.g., parks and community and recreation centers are included in the gas tax transfer program.

• •

enhance investments in public transit and infrastructure that promote physical activity. encourage mixed use developments that enable people to walk or bike to a variety of shops and services in their neighbourhoods.

Strengthening our Knowledge Base Based on the evidence that is currently available, there are a number of policy options that we are confident in recommending to improve cardiovascular health. But there are still important data gaps and many questions remain unanswered. Intervention research is a particularly underdeveloped science.

Information on what programs and types of interventions work, for whom and in what context will improve our ability to implement effective programs of disease prevention, but this newer science needs support.

The Foundation recommends that the federal government:

•

develop a comprehensive, long-term non-communicable diseases surveillance system, that includes cardiovascular diseases.

•

repeat the upcoming Canadian health measures survey at regular intervals to provide trend data based on physical measures.

•

work with the Foundation and the Canadian Institute for Health Information (CIHI) to develop a national cardiac arrest registry.

•

invest in a Canadian longitudinal, lifelong cohort study, which includes a birth cohort and an aging cohort.

•

reduce the time lag from collection to reporting of economic burden of illness data to a maximum of two years; break down economic burden cost data by specific CVD subcategories and by major cardiovascular risk factors; refine economic burden costing methods in order to keep "unattributable" costs low.

•

lead in the development of enhanced surveillance of primary cardiovascular care and hospitalized care that can track individuals across inter-provincial jurisdictions, making such data available on a routine basis, in collaboration with the Canadian Institute for Health Information (CIHI) and the provinces.

14

U.S. federal government allocates 10%

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Conclusion The Heart and Stroke Foundation of Canada is committed to maintaining its leadership role in supporting policies that improve the health of Canadians.

A strong message in this report is the need for health in all policies. We are committed and able to work collaboratively with all levels of government and other stakeholders to achieve health gains through policy actions. We need to think and act at a population level.

The Heart and Stroke Foundation of Canada is committed to maintaining its leadership role in supporting policies that improve the health of Canadians.

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TIPPING THE SCALES OF PROGRESS

Tobacco control is a notable example of our collective success. We can build on this success in two ways. One important way is to remain vigilant in tobacco control efforts, otherwise positive trends will reverse. We cannot afford to repeat the mistakes of the past.

A second way to build on our success in tobacco control is to apply those lessons to other health issues, especially the prevention and control of obesity.

This report calls for urgent action at all levels of government to implement policies that will lead to increased physical activity, better diets and healthier weights in the Canadian population, improved well-being, fewer heart attacks and strokes and thereby a reduced burden to individuals and to society.

Notes:

Notes:

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