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An Overview of Chronic Disease Prevention

I Introduction
II Why Take a Chronic Disease Prevention Approach
III What does a CDP Approach Look Like?
IV Current Practice
V Examples of Integration Efforts
VI References

--by Nancy Dubois, THCU consultant and member of the Steering Committee of the Chronic Disease Prevention Alliance of Canada

If you have a resource or point of view to add to this article, let us know by writing to [email protected]. More information on our Letters to the Editor column can be found in the OHPE News section of OHPE 268.0 (http://www.ohpe.ca/ebulletin/ ViewAnnouncements.cfm?ISSUE_ID=268&startrow=1).

I Introduction

This issue of the bulletin focuses on the growing worldwide trend to address population health through an integrated approach that has as its goal the prevention of many related chronic diseases.

II Why Take a Chronic Disease Prevention Approach

The Centers for Disease Control (CDC) define chronic disease broadly as "Illnesses that are prolonged, do not resolve spontaneously and are rarely cured completely". (1) This term is becoming more prevalent in health-promotion circles, and there is movement at international and local levels to adopt this as a premise on which to base efforts to affect the health of populations.

Inherently, the approach makes sense. According to the Advisory Committee on Population Health's (ACPH) 2002 Discussion Paper, "Advancing Integrated Prevention Strategies in Canada: An Approach to Reducing the Burden of Chronic Diseases," "Chronic diseases are the leading causes of death and disability worldwide...approximately 60% of global mortality and 43% of the global burden of disease are due to chronic conditions. In Canada, over two-thirds of total deaths result from four main clusters of chronic disease--cardiovascular, diabetes, cancer and respiratory illness--and more than half of Canadians (16 million people) live with chronic illness. This represents a significant burden for individuals, their communities and the health care system." (2)

The Manitoba Alliance for the Prevention of Chronic Disease, a frontrunner in terms of developing an integrated approach, notes that "chronic diseases are the result of a complex web of causation...research has identified ...a range of personal, social, economic and environmental factors that are important in their own right, but at the same time are interrelated. It is believed that the removal of one or more of these factors will reduce the incidence of chronic diseases." (3)

The lifestyle link to prevention of chronic diseases has been recognized for some time and many multiple risk-factor intervention trials have been implemented worldwide to test this relationship. Most often, the three risk factors addressed through this work were physical inactivity, unhealthy eating and tobacco exposure. Recently, we have seen the addition of obesity/unhealthy weight and unmanaged stress to this list. The Chronic Disease Prevention Alliance of Canada (CDPAC) acknowledges that Canadian and international experience shows evidence that risk-factor prevalence can be modified across entire populations. However, there are no "magic bullets," and a combination of programmatic, mass media, policy and partnership arrangements is required to make meaningful population-health gains. Effective interventions are those that are implemented with sufficient intensity (i.e., the effective dose), comprehensive, well coordinated, multilevel (i.e., community, provincial, national) and sustained over several years.

Although assisting individuals in making healthy lifestyle choices has generally shown some positive effect, this approach is proving to be insufficient in the containment and prevention of chronic disease. The ACPH supports the growing notion that most chronic diseases are linked to underlying societal conditions and factors, such as personal resources and life chances. Risk factors and chronic illnesses are more likely to be experienced by low-income or disadvantaged groups.

This situation will become much more critical as our children continue to develop these conditions earlier in life and as our aging population grows at a rate that our present health-care system cannot begin to handle. These are not concerns to be passed to the next generation. They are here now and are not disappearing any time soon. According to Dr. Roy Cameron of the University of Waterloo, a health promotion and prevention system that is as well-resourced and coordinated as the health-care system is needed to address these alarming trends.

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III What does a CDP approach look like?

The key to a CDP approach is "integration." The ACPH describes four areas of integration, all of which are necessary:
* Addressing the common risk factors simultaneously
* Recognizing and addressing the relationship between lifestyle choices and social conditions
* Consolidating prevention efforts within life settings such as work, school or community
* Engaging partners within and across the systems that impact health--coordinated inter-sectoral and inter-jurisdictional intervention is required, as well as horizontal linkages with other sectors (such as environment, housing and justice).

It is this last dimension that offers the greatest potential, and the greatest challenge. No significant present-day public-health problem can be solved by public health alone (or clinical care alone, or research alone). Integrated approaches across sectors will be required.

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IV Current Practice

A. Internationally

The World Health Organization established the Countrywide Integrated Non-communicable Diseases Intervention (CINDI) programme in 1982 and it currently works in twenty-seven countries to improve health and the quality of life in communities by reducing premature death, disease and disability from major non-communicable diseases, including cardiovascular diseases, cancer, chronic respiratory diseases, accidents, diabetes and mental disorders. At present, there are 105 demonstration areas across the CINDI network. In two-thirds of the member countries, the programme is implemented at the national level. Three principles guide the project. These are:
*Ensuring an effective information base to guide action--this includes systematic surveillance of risk factors and their determinants, systematic development of the evidence base to inform policy and program design, and evaluation and performance measurement.
* Strengthening prevention and health promotion--this includes reducing risk factors and their determinants, enhancing protective factors, promoting health across the life course, building partnerships for intersectoral action, and giving priority to populations most at risk.
* Improving systems of care for those with chronic disease--this includes strengthening the role of prevention in the health-care system, improving early detection and intervention systems, integrating primary health-care systems, and establishing consumer participation.

B. Nationally

The Chronic Disease Prevention Alliance of Canada (http://www.cdpac.ca) is working towards preventing cancer, cardiovascular disease and diabetes through a comprehensive, sufficiently- resourced, sustainable and integrated system of research, policies and programs. Eight national organizations comprise the Steering Committee, but individuals and organizations across the country are encouraged to join the movement via registration on the website.

The Romanow Commission on the Future of Health Care in Canada and Senator Kirby's report on the Health of Canadians have both been generally supportive of a CDP approach, but the latter was much more specific and sets the tone for follow-up on these recommendations: "A national chronic disease prevention strategy will improve the health of Canadians and contribute to the sustainability of the publicly funded health care system. The Committee believes that the Chronic Disease Prevention Alliance of Canada can assist with the design and implementation of this strategy. Therefore, the Committee recommends that
"* The federal government, in collaboration with the provinces and territories and in consultation with major stakeholders (including the Chronic Disease Prevention Alliance of Canada), implement a National Chronic Disease Prevention Strategy.
"* The National Chronic Disease Prevention Strategy build on current initiatives through better integration and coordination.
"* The federal government contribute $125 million annually to the National Chronic Disease Prevention Strategy.
"* Specific goals and objectives should be set under the National Chronic Disease Prevention Strategy. The outcomes of the strategy should be evaluated against these goals and objectives on a regular basis." (4)

In addition to the CDPAC, there are several areas within the Population and Public Health Branch of Health Canada that focus on the prevention of chronic disease:
* The Centre for Chronic Disease Prevention and Control provides strategic leadership in the development and implementation of integrated chronic disease prevention and control strategies. The Centre includes The Integrated Chronic Disease Prevention and Control Policy Office and four divisions: The Evidence and Information for Chronic Disease Policy Division, The Chronic Disease Prevention Division, The Chronic Disease Control and Management Division and the Surveillance and Risk Assessment Division.
* The new (in 2003) National Consortium for Best Practices for Integrated Chronic Disease Prevention and Health Promotion is establishing and maintaining an observatory of best practices.

C. In Other Provinces

Several provinces have developed a model, framework and structure to support the integrated prevention of chronic diseases. Many of these have evolved from their provincial heart health programs and share common disease and risk factor approaches. Please see the Resources section of 312.2 for contact information.

D. In Ontario

Ontario is rich in organizations, strategies and supports that address chronic-disease prevention from a variety of risk factor, setting and population perspectives. Efforts are underway on several fronts to coordinate and integrate some of these:
* The Ontario Heart Health Program has just begun its second five-year phase. At both the provincial and local levels, those involved in planning the interventions are looking at the value of expanding beyond heart health to a more integrated approach to CDP.
* The Ontario Ministry of Health and Long-Term Care (MOHLTC), Public Health Branch, provides Mandatory Health Programs and Services Guidelines. Public health units and departments are currently working with the version from 1997, in which there is a CDP section. This means that many, if not all, health departments are organized into a CDP team.
* An "ad hoc" group of about ten voluntary sector organizations, currently led by the Ontario Public Health Association, has met twice to date to discuss how they might coordinate CDP efforts.
* Health Promotion and Wellness, Public Health Branch, MOHLTC, conducted a series of seven focus groups in April and May 2003, with researchers, local contacts, resource centres, NGO's etc., to determine the level of support for a provincially-integrated approach to CDP.
* The twenty-two members of the Ontario Health Promotion Resource System (http://www.ohprs.ca) provide support to health promoters in Ontario on their specific mandate areas. Collectively, most aspects of the lifestyle approach to CDP are addressed.

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V Examples of Integration Efforts

* In the Haliburton, Kawartha, Pine Ridge region, the Heart Health program applied for funding to enhance a Diabetes Prevention program specific to workplaces. For more information, contact Heart Health, Kim Bergeron, Diabetes Workplace Program, or Hallie Atter at (905) 885-9100.
* In February 2003, during their annual "Heart on the Hill" event in Ottawa, the Heart and Stroke Foundation of Canada chose to promote a CDP message to politicians, instead of a singular "heart" focus.
* The Ontario Tobacco Strategy supports the Ontario Tobacco-Free Network (OTN) (http://www.theotn.org), which is an interagency network consisting of the Canadian Cancer Society Ontario Division, the Heart and Stroke Foundation of Ontario and the Ontario Lung Association. The OTN supports a network of local tobacco-free councils, coordinated by public health staff and community volunteers, in their tobacco work throughout Ontario. The OTN also works to raise awareness of tobacco-control activities and issues within their member health agencies.
* The Nutrition Resource Centre (http://www.nutritonrc.ca), Toronto Public Health and Cancer Care Ontario, with funding from the Ontario Women's Health Council, have developed the "Healthy Measures Toolkit." Integrated messages regarding nutrition, physical activity and self esteem are combined in this toolkit for health professionals.

VI References

(1) Centres for Disease Control and Prevention/Washington. 2002. "Chronic Disease." http://www.cdc.gov/washington/overview/chrondis.htm. Accessed May 30, 2003.

(2) Advisory Committee on Population Health (ACPH). 2002. "Advancing Integrated Prevention Strategies in Canada: An Approach to Reducing the Burden of Chronic Diseases." Discussion Paper, June 10, 2002.

(3) Alliance for the Prevention of Chronic Disease (for the Centre for Chronic Disease Prevention and Control Health Canada). 2002. Building the Case for the Prevention of Chronic Disease. Winnipeg, Manitoba. http://www.preventionalliance.mb.ca/articles/building-the-case.pdf. Accessed May 30, 2003.

(4) The Standing Senate Committee on Social Affairs, Science and Technology. October 2002. Volume Six, Part VI, Chapter 13, "Healthy Public Policy: Health Beyond Health Care." The Health of Canadians--the Federal Role. Final Report. Chair: The Honourable Michael J.L. Kirby. Deputy Chair: The Honourable Marjory LeBreton.
http://www.parl.gc.ca/37/2/parlbus/commbus/senate/com-e/soci-e/rep-e/rep... #CHAPTER%20THIRTEEN