Multisectoral Approaches to
Preventing Cardiovascular Disease:
The New York City Experience
April 14, 2009
Lynn Silver, MD, MPH
Assistant Commissioner
New York City Department of Health
Interventions to Affect Health
Examples
Smallest
Impact
B ehavioral
Inter ventions
Clinical
Interventions
Long-lasting
Protective Interventions
Changing the Context
to make individuals’ default
decisions healthy
Largest
Impact
Socioeconomic Factors
Condoms, eat healthy,
be physically active
Rx for high blood
pressure, high
cholesterol
Immunizations, brief
intervention, cessation
treatment, colonoscopy
Fluoridation, calorie
labeling, trans fat,
smoke-free laws,
tobacco tax
Poverty, education,
housing
THREE PUBLIC HEALTH STEPS TO A HEALTHIER
URBAN ENVIRONMENT
• 3 Case Studies from NYC:
– Tobacco Policy - smoking
– Food Policy - dietary risk factors
– Built Environment - physical activity
NYC SMOKE-FREE AIR ACT OF 2002
MPOWER Reduced
Smoking in New York City
Monitor steady adult
Protect people from
smoking prevalence
tobacco smoke
21.6%
22%
20%
18%
18.9%
Raise taxes on
tobacco (City & State)
dangers of
smoking
18%
19.2%
18.4%
16%
Monitor youth
14%
12%
10%
smoking
16.9%
15%
• 300,000 fewer smokers
• 100,000 fewer smoking-related deaths in
future years
17.5%
11%
8.5%
8%
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
% of New York City Smokers
Warn about the
THREE PUBLIC HEALTH STEPS TO A HEALTHIER
URBAN ENVIRONMENT
• 3 Case Studies from NYC:
– Tobacco Policy - smoking
– Food Policy - dietary risk factors
– Built Environment - physical activity
REDUCING HEART DISEASE RISK IN NYC
§81.08 FOODS CONTAINING ARTIFICIAL TRAS FAT
Changing
the Oil…
TRANS FAT & CVD
6-19% of coronary heart disease
events and 30,000 or more
premature deaths are estimated
to occur in the US due to trans
fat consumption.
Willett WC, Skerrett PJ, Giovannucci EL, Callahan M. Eat, Drink, and be
Healthy: The Harvard Medical School Guide to Healthy Eating. New York:
Simon and Schuster; 2001.
TRANS FAT USE DID NOT DECLINE
DESPITE EDUCATION CAMPAIGN
% of Restaurants Known to be Using Trans Fat in Oils and Spreads
Where Use Could Be Determined
% Restaurants Using Trans Fat
in Oils and Spread
100%
75%
Health
Bulletin to
200,000
consumers
Info & tools to food
15,000 suppliers and
>30,000 NYC restaurants
9,000 FSEs
received
additional info
50%
25%
7,800 restaurant
operators trained
50%
50%
0%
2005
2006
REDUCING HEART DISEASE RISK IN NYC
§81.08 FOODS CONTAINING ARTIFICIAL TRAS FAT
• Prohibited all foods
containing artificial trans fat
(>0.5gm per serving) in
restaurants
• PHASE 1, 2007:
– Frying & Spreads
• PHASE 2, 2008:
– All other foods
• All of NYC’s famous foods
are still there
TRANS FAT COMPLIANCE
TRANS FAT REGULATION SPREAD
California
July 2008
§81.50 CALORIE LABELING
BEFORE…
LOTS OF CALORIES – LITTLE INFORMATION
• 2007: Except at Subway, only 4% of
patrons reported seeing calorie
information as currently provided
Does nutrition information
on a tray liner work?
According to our study: No.
Bassett MT, Dumanovsky T, Huang C, Silver LD, Young C, Nonas C, Matte T, Chideya S, Frieden TR. Purchasing
Behavior and Calorie Information at Fast-Food Chains in New York City, 2007. American Journal of Public Health,
2008;98:1457-1459.
STRATEGY: REGULATION
In 2006 & January, 2008 the New York
City Board of Health required chain
restaurants to post calories on menu
boards and menus
Effective March 31, 2008.
NYC NOW HAS CALORIE INFORMATION POSTED!
Starbucks, 2008
Davidson County, TN
NYC’s VOLUNTARY SALT REDUCTION CAMPAIGN
BP REDUCTION THROUGH DECREASING
SALT INTAKE WOULD SAVE MANY LIVES
U.S. adults, 20-74 years
Salt consumption (mg/day)
4,000
•
3,500
•
3,000
2,500
11 million fewer
people with ↑BP
150,000 lives
saved w/ lifetime ↓
in intake (AMA)
2005 U.S. Dietary Guidelines
recommended limit for adults
2,000
1,500
Recommended limit for people with
hypertension, blacks, middle aged and older
1,000
500
0
NHANES I
1971-74
NHANES II
1976-80
NHANES III
1988-94
Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004;24:401-431
NHANES IV
1999-00
UK SALT CAMPAIGN AS MODEL
• Goal: Reduce salt intake by 1/3, from 2005 to
2010
– >50 commitments from all sectors of the food
industry
– Gradual reductions across product categories
• Salt reductions were achieved in processed
and restaurant foods
For Ex. 220mg per serving in US
vs 140 mg in UK
UK Food Standards Agency website: http://www.food.gov.uk/healthiereating/salt/. Accessed: 5/14/08.
Summary Table of Salt reduction Commitmentst: http://www.food.gov.uk/multimedia/spreadsheet/saltcommitmentsum.xls. Accessed: 5/14/08.
NATIONAL SALT REDUCTION INITIATIVE
• Collaborative Launch in October 2008; Mayor Bloomberg
invites industry leaders to join in a national effort to set and
monitor targets for salt reduction that are:
• Voluntary
• Substantive
• Achievable
• Gradual
• Measurable
• 39 city, state, and national health organization partners are
co-sponsoring
• Goal: Food category specific sodium reduction targets
averaging 25% over 5 years.
• The work has begun
SUGAR SWEETENED BEVERAGES
1 can of soda = 10 teaspoons of sugar
12 oz. can:
~150 calories
SODA CONSUMPTION
Leading source of calories in the
US diet: 9% of calories are from
carbonated and non carbonated soft
drinks
•
•
SODA – POTENTIAL REGULATORY
APPROACHES
• Taxation
– Significant taxation of soda, other sugar sweetened
beverages and possibly junk food is amongst the most
feasible, low cost measures for obesity, diabetes and
cardiovascular prevention. Volume linked excise taxes
are preferable.
– NY State has a modest sales tax, efforts to increase
this year to 22% failed
• Counter-marketing
• Other Approaches
– Regulate allowable marketed portion sizes of sugar
sweetened beverages and other junk food
– Restrict locations of sale to reduce ubiquity
THREE PUBLIC HEALTH STEPS TO A HEALTHIER
URBAN ENVIRONMENT
• 3 Case Studies from NYC:
– Tobacco Policy - smoking
– Food Policy - dietary risk factors
– Built Environment - physical activity
URBAN CONDITIONS WERE A BREEDING GROUND FOR 19TH CENTURY
EPIDEMICS
Over-crowding:
By 1910, the average density
in lower Manhattan was
114,000 people/ sq. mi; two
wards reached densities >
400,000. (Today’s density:
67,000/ sq. mi.)
+
Inadequate systems for
garbage, water, and sewer,
leading to pervasive filth and
polluted water supplies.
Major epidemics:
Air-borne diseases:
TB
Water-borne diseases:
Cholera
Vector-borne diseases:
Yellow-fever
NYC’S 19TH & EARLY 20TH CENTURY URBAN DESIGN AS A RESPONSE
TO THE ENVIRONMENTAL ASPECTS OF EPIDEMICS
1842
New York’s water system established – an
aqueduct brings fresh water from
Westchester.
1857
NYC creates Central Park, hailed as “ventilation
for the working man’s lungs”, continuing
construction through the height of the Civil War
1881
Dept. of Street-sweeping created, which eventually
becomes the Department of Sanitation
1901
New York State Tenement House Act banned
the construction of dark, airless tenement buildings
1904
First section of Subway opens, allowing population
to expand into Northern Manhattan and the Bronx
1916
Zoning Ordinance requires stepped building
setbacks to allow light and air into the streets
20TH CENTURY: LACK OF PHYSICAL ACTIVITY
Physical activity has been systematically
designed out of our environments and
replaced by energy use
WE HAVE REPLACED HUMAN AND ANIMAL ENERGY WITH
PETROCHEMICAL ENERGY IN ALMOST EVERY ACTIVITY…
WE HAVE REPLACED HUMAN AND ANIMAL ENERGY WITH
PETROCHEMICAL ENERGY IN ALMOST EVERY ACTIVITY…
FIT-CITY: PROMOTING PHYSICAL ACTIVITY THROUGH DESIGN
A Strategy to Open Dialogue with Planning and Design Communities
Fit-City:
Promoting Physical Activity Through Design
Fit-City 3:
Promoting Physical Activity Through Design
NYC ACTIVE DESIGN GUIDELINES
• City guidelines for physical activity promoting
design for:
– Buildings, streets, and neighborhoods
• NYC DOHMH working with Departments of
Design & Construction, City Planning and
Transportation, and architects & planners.
• Initiated at Fit-City 2 Conference by Department
of Design & Construction Commissioner
• To be published June 2009
STAIR PROMPT CAMPAIGN 2008
• Extensive
Research shows
stair prompts
increase stair
usage
• At a NYC
affordable housing
site stair use
increased from
13% to 22% after
Stair Prompts were
posted
IN ADDITION: CLINICAL STRATEGIES
• Promotion of electronic health records:
• With registry & clinical decision support for CVD
• Development of evidence based treatment
guidelines & formularies
• “Public health detailing” to educate providers to
focus on control of BP, cholesterol, use of aspirin and
smoking cessation
• Access to low cost medications
• Quality improvement support to health services
• Intersectoral collaboration required to reduce
CVD risks
• Strategies may include:
• Building of Voluntary Collaborations & Alliances
• Public Education
• Economic Incentives
• Taxation
• Regulations
THANK YOU
• Thomas R. Frieden, NYCDOHMH Commissioner
• Sarah Perl, Asst. Commissioner, Tobacco
• Karen Lee, Deputy Director, Chronic Disease
• Sonia Angell, Director, Cardiovascular Disease
• Cathy Nonas, Director, Physical Activity & Nutrition
• Laurie Kerr, Senior Policy Advisor, Mayor’s Office
• Maura Kennelly, Special Assistant, Chronic Disease