Embracing a Healthy Lifestyle LIFESTYLE DISEASES A SILENT

Embracing a Healthy Lifestyle LIFESTYLE DISEASES: A SILENT DISASTER ANTHONY C. LEACHON, MD UNIVERSITY OF THE PHILIPPINES, MANILA CONSULTANT , DOH ON NONCOMMUNICABLE DISEASES

Disclosures : • Internist -Cardiologist, Manila Doctors Hospital • Retired Medical Director of Pfizer Philippines (19932011) • Director of Information, Publications, and Public Affairs, University of the Philippines, Manila • One Peso Consultant , DOH on Noncommunicable Diseases • Secretary, Philippine College of Physicians • Preventive Health Advocate

MY HEROES Dr. Jose Rizal June 19, 1861 – Dec. 30, 1896 National Hero Pilar Cueto Leachon (Jan. 25, 1935 – Sept. 22, 2003) Marita Leachon Ramirez (June 7, 1962 – June 11, 2011 )

Flow of Presentation • Background on NCDs • What 5 Shocking Lessons we have learned about NCDs/lifestyle diseases • Reasons why we fail in our Health Goals • 3 DOH Pillars to address NCDs • What else can we do to step up NCD efforts ? • Summary

MORTALITY Epidemiologic Transition Infectious Disease Lifestyle/NCDs Omran et al 1970. DEVELOPMENT

Common Risk Factors for NCDs Deaths from 4 chronic diseases Tobacco Poor diet Lack of exercice 3 risk factors Deaths from all other causes 60% of all deaths Cardiovascular Chronic respiratory disease 4 chronic diseases Type 2 diabetes Cancer Oxford Health Alliance 2003

Top 10 Causes of Morbidity and Mortality Philippines July 2010 2005 DOH Data 10 Leading Causes of Morbidity in the Philippines (DOH) 10 Leading Causes of Mortality in the Philippines (DOH) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 3. 4. Pneumonia Acute Watery Diarrhea Malaria Typhoid & Paratyphoid Fever Schistosomiasis Measles Acute Bloody Diarrhea Dengue Hemorrhagic Fever Hepatitis Leprosy *All Preventable with Education and public health infrastructure (DOH 2010) Diseases of the heart Strokes Cancer Chronic Obstructive Pulmonary Diseases 5. Road Accidents and Injuries 6. Diabetes 7. Dengue Fever 8. Maternal Deaths 9. Kidney Failure 10. Perinatal conditions Top 4 & #6: NCDs Accidents: 50 % drunk driving

v. SEA: Epidemic of chronic non-communicable diseases 60% of mortality rates in the region v Environmental factors: promotion of tobacco use, unhealthy diet & physical inactivity v Disadvantaged sector is most affected v Health care systems should be redesigned to deliver chronic care founded on primary health care facilities, but supported by good referral systems v. Surveillance of key modifiable risk factors (monitor magnitude of problem & study effects of interventions) v. Involvement of government & society sectors to establish healthy environment

Lesson # 1 Silent EPIDEMIC 300, 000 deaths in Philippines 800 deaths/day ! Dans, et al Lancet 2011 and DOH data 2. 5 MILLION NCD DEATHS IN 2005

NCD deaths per 100 thousand population 900 Dans et al (Lancet 2011) 800 700 600 500 400 Myan 0 Camb Laos Viet Phil Indo 5 Thai Brun Sing Mal 10 20 30 40 50 60 70 80 Gross National Income (International Dollars x 10 3)

2. HIGHER NCD RISK Globalization Smoking Urbanization Unhealthy Diet Poverty Phys. Inactivity Low Education Stress Blood Sugar Blood Pressure Cholesterol BMI 1. NO ACCESS TO PREVENTION Predisposing Behavioral Environment. Risk Factors MORE Expenses & IMPOVERISHMENT Biologic Risk factors 3. NO ACCESS TO TREATMENT Heart Disease Stroke Cancer Chronic Lung Ds 4. HIGHER MORTALITY Chronic NCD Morbidity/Mortality LIMITED RESERVES Lesson #2 NCDs: Diseases of the POOR

Lesson #2 The poor suffer the most Prevalence (%) The poor smoke more than the rich. In ASEAN, the lowest quintile of the population suffer more deaths due to smoking. Poorest Wealthiest From DANS, ET. AL, LANCET 2010)

Tobacco use > Food Tobacco and Food Expenditure Ratio, 2008 Poorest Poor Middle Richest Total 2006 0. 029 0. 031 0. 030 0. 024 0. 018 0. 026 2009 0. 027 0. 025 0. 021 0. 015 0. 023 Valerie Gilbert T. Ulep Philippine Institute for Development Studies

The Situation Lesson # 3 : Disease of the Young Of the users of tobacco products: (highest in South East Asia) 17. 5% Girls 28. 3% Boys SOURCE: WHO Report on global tobacco epidemic: Implementing smoke free environment. Geneva, Switzerland. WHO, 2009

Non-communicable Diseases: At a Glance Share of premature deaths, Philippines, 2008 100% 90% Premature deaths 80% 70% 60% 51 45 40% 66 73 30% 20% 10% 0% 49 55 34 27 Cancer Diabetes CVD CLRD Pre-mature Mature Valerie Gilbert T. Ulep Philippine Institute for Development Studies

Estimated deaths from heart attack and stroke (all risk factors) Smoking is the #1 preventable risk factor. Risk Factor Heart Attack Deaths CVD Deaths Total Deaths Smoking 19, 315 29, 184 48, 499 Cholesterol 8, 799 4, 053 12, 852 Obesity HPN Diabetes Lesson # 4 14, 840 Smoking is PH’s 20, 207 top killer; obesity 3 rd 15, 559 25, 401 3, 326 6, 864 35, 047 40, 960 10, 190 Smoking does NOT just cause cancer and lung diseases, it is also the number 1 cause of stroke and heart attack (~50, 000 deaths per year). In fact it causes more stroke and heart attacks than diabetes, hypertension, obesity and high cholesterol - National Nutrition and Health Survey, 2008

Counseling or Education for Risk Factor Modification Ebrahim et al, Cochrane 2011 > > > > Lesson # 5 55 Clinical Trials Education for general 163, 471 patients studied population is not Did not affect longevity effective. Did not prevent heart disease Did Did not not prevent stroke reduce cholesterol lower BP lower smoking rates

Why do we fail at what we set out to do ? 3 reasons why we fail 1. Ignorance : we may err because science has given us only partial understanding ; Education is key ( not quite) 2. Ineptitude : knowledge exists, yet we fail to apply it correctly. Gorovitz and Mac. Intyre, 1970

Smoking Unhealthy Diet Phys. Inactivity Behavioral Risk Factors Blood Disease Sugar Heart Blood Pressure Stroke Cholesterol Cancer BMI Chronic Lung Ds Biologic Chronic NCD Risk factors

Upstream Globalization. Blood Sugar Smoking Urbanization Blood Pressure Unhealthy Diet Poverty Cholesterol Phys. Inactivity Low Education BMI Stress Downstream Heart Disease Stroke Cancer Chronic Lung Ds Biologic Chronic NCD Behavioral Predisposing Risk factors Risk Factors Environment

LIFESTYLE DISEASES : 3 DOH Action Pillars Dec 2011 Tobacco Learning 1. 2. LGU action Legislation • Healthy Diet Exercise Health Education curriculum in schools; workplace wellness programs Public Awareness Campaign for targeted populations through media, academe, and NGOs Local ordinances eg smoke free environment, food label, exercise facilities Sin Tax Increase on tobacco and alcohol – now at approved- Dec 20, 2012 Food Certification Front -of -pack Calorie counter Dec 2012 (FDA – DOH approved); Belly gud, Food plate Infrastructure eg recreational facilities

Goals of Excise Tax Law (in order of priority) 1. 2. 3. Reduce the number of smokers among the YOUNG (<18 years old) Reduce the number of smokers among the POOR Reduce the consumption of cigarettes among current smokers ***Equally important as the health objectives is the revenue gained from the excise tax.

Health is Wealth: Universal Health Care Realization • • DOH annual budget Excise Tax Tobacco revenue Smoking related expenditures 1. 2. Indirectly, through loss of productivity and income Directly, household spending on chronic medical care, often of catastrophic proportions • • Php 54 Billion Php 35 Billion Php 26 Billion Php 177 Billion (Dans et al 2012) 1. 2. 3. 4. Hospitals and other infrastructures Health Information technology Human resources Health promotions and research initiatives

Sec Ona with Med Org Leading the Way in Sin Tax Lobbying

Sin Tax on tobacco & alcohol Approval at Malacanan Dec 20, 2012

Sin Tax Law Passage and DBM • Dec 20, 2012 : Victory party after signing of the sin tax law by Pres. Benigno Simeon Aquino III • With DBM Sec. Florencio Abad and Dr. Antonio Dans of UPCM • Vital role in the IRR of the sin tax law

Who took the space?

Filipinos gaining weight • 26. 6 per cent of Filipino adults were overweight in 2008 (5. 2 per cent are obese), a marked increase from 16. 6 per cent in 1993. • Overweight is also rising among children aged 5– 10 (up from 5. 8 per cent in 2003 to 6. 6 per cent in 2008). Source National Statistics Coordination Board (NSCB) Nov 2011.

Obesity in Young Filipinos rising Sept 23, 2010 Manila Bulletin • MANILA, Philippines — Obesity is now on the rise among Filipino adults ages 20 and up, and threatens to increase the number of people having degenerative diseases like heart disease, hypertension and diabetes mellitus, as study conducted by the Department of Science and Technology (Do. ST) showed. • The increase was discovered in 2008 when it registered a trend in the study conducted by the Do. ST’s Food and Nutrition Research Institute.

V. Ulep, 2012 Phil Institute for Development Studies

Physical exercise Phil Institute for Development Studies, 2008 30 Prevalence of adult population with adequate exercise, Philippines, 2008 27. 9 26. 9 25 22 24. 8 23. 5 23. 1 22. 4 22. 7 22. 9 24. 3 22. 8 21. 3 20. 8 Prevalence (%) 20 15 10 5 0 Total Male Poorest Poor Middle Female Richest 24. 9

2103 DOH programs : Unhealthy Diet • 1. Calorie counter – Front of Package (Dec 2012) • 2. Food labeling – mandatory to declare salt, sugar, trans fats in addition; Legislation is needed for the long term ( July 2013) • 3. Belly GUD – DOH Executives’ weight reduction , biggest loser type of program (Jan –July 2013) • 4. Pinggan ni Pinoy – Filipino Food plate (to be launched with DOST- FNRI)

Target Calories in a Day Calories per day for Males Calories for Females 1, 800 – 2000 1, 200 -1, 500 calories per day Note: One pound of body mass represents 3, 500 calories per day

Calorie Checklist Eat Low Calorie Foods (50 -100 calories) Avoid High Calorie Foods (300 -800 calories ) • Fish • French fries • Fruits • Burgers • Vegetables • Pork & beef • Chicken without skin • Ice cream • Cereals • Doughnuts • Oatmeal • Processed foods • Water • Ice tea & softdrinks

How sweet is it ?

Bloomberg now wants all of New York state to ban big soft drinks March 2, 2013 • New York City Mayor Michael Bloomberg wants to trim waistlines by expanding the Big Apple’s upcoming ban on big soft drinks. • "Kids, once they get obese, they will be obese as adults. And this year, for the first time in the world, in the history of humanity, more people will die from overeating than from under-eating. "

Burger King : Calorie Count in Korea Dec 2010

Burger King in Korea : Calories disclosed

South Korea Global Update Summary Feb 2013 • South Korea was the first Asian country to press ahead with recommendations for voluntary traffic light labels on children’s food starting 1 January 2011. • On 25 May 2012, the Prime Minister’s Office announced its intention to progressively introduce mandatory traffic light labelling to snacks and beverages starting in 2013, making South Korea the first country globally to mandate traffic light labelling. Since then, two draft bills have been submitted to the Korean National Assembly. • One bill recommends mandatory traffic light labelling on foods preferred by children, including chips, snacks and beverages (e. g. carbonated soft drinks, juices). • The second bill recommends both a mandatory traffic light system and mandatory reference daily intake labelling with a colour coding system. This move could potentially have implications for other countries in the Asia-Pacific region.

Global Food Labelling • Violet : Mandatory • Yellow: Voluntary • White: Information not found