Lynn Silver, MD, MPH Assistant Commissioner New York City Department of Health

1. Lynn Silver, MD, MPH Assistant Commissioner New York City Department of Health

2. When we think about public health interventions, there are a variety of approaches. We know that basic changes in poverty, hosuing and education have the greatest effects on health, but these are generally outside of the scope of PH authorities. As public health authroities our eforts have focussed on changing the our physical and social environments in ways that can make healthier choices the easiest choice. From flouridation of water to seat belts such approaches are amongst the most effective. Banning trans fat or calorie labeling are newer applications of this classic public health approach, used in chronci disease prevention, an areas had long focused on less successful individual behavior change strategies. When we think about public health interventions, there are a variety of approaches. We know that basic changes in poverty, hosuing and education have the greatest effects on health, but these are generally outside of the scope of PH authorities. As public health authroities our eforts have focussed on changing the our physical and social environments in ways that can make healthier choices the easiest choice. From flouridation of water to seat belts such approaches are amongst the most effective. Banning trans fat or calorie labeling are newer applications of this classic public health approach, used in chronci disease prevention, an areas had long focused on less successful individual behavior change strategies.

3. 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

4. NYC SMOKE-FREE AIR ACT OF 2002 Between 1993 and 2002 smoking rates had remained virtually unchanged TAXATION: Most effective strategy to decrease tobacco use. A 2002 doubling of the excise tax resulted in a marked fall in smoking rates and has since been followed by increases in 2008 and 2009. Tax accounts now accounts for 57% of NYC pack price (World Bank recommends two-thirds) 3. Increased the price of cigarettes in NYC to about $9.21 per pack NYC NYS Federal Total Excise Tax Approx Pack Price (inc. Sales Tax) 2002 (before increase) $0.08 $1.11 $0.39 $1.58 2002 (after increase) $1.50 $1.50 $0.39 $3.39 2009 (before fed tax) $1.50 $2.75 $0.39 $4.64 $8.47 2009 (after fed tax) $1.50 $2.75 $1.01 $5.26 $9.21 Comprehensive Indoor Air laws: prohibiting smoking in almost all workplaces, including restaurant and bars 1. Smoke-Free Air Act of 2002 (NYC, effective March 30, 2003) 2. Clean Indoor Air Act (NYS, effective July 24, 2003) Nicotine Patch Giveaways Hard Hitting Media campaigns since 2006Between 1993 and 2002 smoking rates had remained virtually unchanged TAXATION: Most effective strategy to decrease tobacco use. A 2002 doubling of the excise tax resulted in a marked fall in smoking rates and has since been followed by increases in 2008 and 2009. Tax accounts now accounts for 57% of NYC pack price (World Bank recommends two-thirds) 3. Increased the price of cigarettes in NYC to about $9.21 per pack NYC NYS Federal Total Excise Tax Approx Pack Price (inc. Sales Tax) 2002 (before increase) $0.08 $1.11 $0.39 $1.58 2002 (after increase) $1.50 $1.50 $0.39 $3.39 2009 (before fed tax) $1.50 $2.75 $0.39 $4.64 $8.47 2009 (after fed tax) $1.50 $2.75 $1.01 $5.26 $9.21 Comprehensive Indoor Air laws: prohibiting smoking in almost all workplaces, including restaurant and bars 1. Smoke-Free Air Act of 2002 (NYC, effective March 30, 2003) 2. Clean Indoor Air Act (NYS, effective July 24, 2003) Nicotine Patch Giveaways Hard Hitting Media campaigns since 2006

6. 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

7. REDUCING HEART DISEASE RISK IN NYC§81.08 FOODS CONTAINING ARTIFICIAL TRAS FAT

8. Heart disease is the number one cause of death in New York City, state, the country and the world More than 19,000 New Yorkers died from heart disease in New York City in 2004. Nearly one third were younger than 75 years old. Source: The World Health Report, 2003, The World Health Organization (WHO).Heart disease is the number one cause of death in New York City, state, the country and the world More than 19,000 New Yorkers died from heart disease in New York City in 2004. Nearly one third were younger than 75 years old. Source: The World Health Report, 2003, The World Health Organization (WHO).

9. DEATHS DUE TO MAJOR CARDIOVASCULAR DISEASES IN NYC, 1994-2004

10. 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.

11. Trans Fat Is More Dangerousthan Saturated Fat Good (HDL) Bad (LDL) Cholesterol Cholesterol Trans fat Saturated fat To summarize this evidence in case I’ve lost any of you, trans fat increases your risk of heart disease and is more dangerous than saturated fat. Trans fat, like saturated fat, raises bad (LDL) cholesterol. - However, trans fat also lowers good (HDL) cholesterol.To summarize this evidence in case I’ve lost any of you, trans fat increases your risk of heart disease and is more dangerous than saturated fat. Trans fat, like saturated fat, raises bad (LDL) cholesterol. - However, trans fat also lowers good (HDL) cholesterol.

12. TRANS FAT USE DID NOT DECLINE DESPITE EDUCATION CAMPAIGN

13. 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

15. TRANS FAT COMPLIANCE Like lead in paint, artificial trans fat proved to be a dangerous substance that is fully replaceable and quite simply is not missed once it’s gone. Like lead in paint, artificial trans fat proved to be a dangerous substance that is fully replaceable and quite simply is not missed once it’s gone.

16. TRANS FAT REGULATION SPREAD

17. §81.50 CALORIE LABELING

20. PEOPLE ARE EATING OUT MORE

21. 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. In january 2006 the New York City Board of Health required calorie posting on menus and menu boards. Due to an initial successful; legal challenge the Board had to modify the law and reissue in january 2008. The second law successfully withstood a new legal challenge.In january 2006 the New York City Board of Health required calorie posting on menus and menu boards. Due to an initial successful; legal challenge the Board had to modify the law and reissue in january 2008. The second law successfully withstood a new legal challenge.

22. NYC NOW HAS CALORIE INFORMATION POSTED! CALORIES II DATA RESULTS: * Overall, the % of customers who saw calorie information increased from 23% to 60%, and 67% amongst the highly compliant large chains * Post-regulation, 15% of all customers surveyed report that calorie information affected their purchase, an almost three-fold increaseCALORIES II DATA RESULTS: * Overall, the % of customers who saw calorie information increased from 23% to 60%, and 67% amongst the highly compliant large chains * Post-regulation, 15% of all customers surveyed report that calorie information affected their purchase, an almost three-fold increase

23. BEFORE… LOTS OF CALORIES – LITTLE INFORMATION 2007: Except at Subway, only 4% of patrons reported seeing calorie information as provided at that time Americans expend almost half their food dollars on food way from home, and eat at least one third of their calories away from home. Eating out, especially fast food, has been extensively associated with higher caloric intake and weight gain. . In 1970, Americans spent 26% of their food dollars on foods prepared outside their homes; by 2006 they spent almost half (48%).[i] At present, one third of total calorie consumption is outside the home.[ii] A large, representative national survey (the Continuing Survey of Food Intake by Individuals) conducted over two decades, from 1977 to 1996, shows that calorie intake from restaurant/fast food doubled as a percentage of energy intake for Americans over the age of 2.[iii] [i] National Restaurant Association (NRA). Industry at a Glance. 2005. [ii] Guthrie JF, Lin BH, Frazao E. Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences. Society for Nutrition Education 2002; 34:140-150. [iii] Nielson S, Siega-Riz AM, Popkin B. Trends in energy intake in the U.S. between 1977 and 1996: similar shifts seen across age groups. Obesity Research 2002; 10(5): 370-378. For example, since the 1970s, the typical serving size for soft drinks increased by 49 calories, for French fries by 68 calories, and for hamburgers by 97 calories.[i] [i] Nielsen S, Popkin B. Patterns and trends in food portion sizes, 1977-1998. Journal of American Medical Association 2003; 289(4):450-453. About one third (33.2%) of patrons purchased more than 1,000 calories; 8.7%, more than 1,400 calories. The first, a 1994-1996 survey of 17,370 adults and children, found that adults who ate at fast food restaurants consumed 205 more calories per day than those who did not, and children ate 155 more calories. [i] [i] Paeratakul S, Perdinand D, Champagne C, Ryan D, Bray G. Fast-food consumption among US adults and children: dietary and nutrient intake profile. Journal of American Dietetic Association 2003; 103(10):1332-1338. Many studies document that increased calorie intake observed with consumption of fast food results in weight gain.[i] In a study of over 9,000 adults, eating fast food increased the prevalence of overweight by 27-31%;[ii] among 3,394 adults in the Coronary Artery Risk Development in Young Adults Study (CARDIA), fast food eating was positively associated with BMI, and higher levels of fast food consumption correlated with a higher BMI [i] Satia JA, Galanko JA, Siega-Riz AM, Eating at fast food restaurants is associated with dietary intake, demographic, psychosocial and behavioural and behavioral factors among African Americans in North Carolina. Public Health Nutrition: 7(8) , 1089-1096. [ii] Bowman S, Vinyard B. Fast food consumption of US adults: impact on energy and nutrient intakes and overweight status. Journal of the American College of Nutrition 2004; 23(2):163-168Americans expend almost half their food dollars on food way from home, and eat at least one third of their calories away from home. Eating out, especially fast food, has been extensively associated with higher caloric intake and weight gain. . In 1970, Americans spent 26% of their food dollars on foods prepared outside their homes; by 2006 they spent almost half (48%).[i] At present, one third of total calorie consumption is outside the home.[ii] A large, representative national survey (the Continuing Survey of Food Intake by Individuals) conducted over two decades, from 1977 to 1996, shows that calorie intake from restaurant/fast food doubled as a percentage of energy intake for Americans over the age of 2.[iii] [i] National Restaurant Association (NRA). Industry at a Glance. 2005. [ii] Guthrie JF, Lin BH, Frazao E. Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences. Society for Nutrition Education 2002; 34:140-150. [iii] Nielson S, Siega-Riz AM, Popkin B. Trends in energy intake in the U.S. between 1977 and 1996: similar shifts seen across age groups. Obesity Research 2002; 10(5): 370-378. For example, since the 1970s, the typical serving size for soft drinks increased by 49 calories, for French fries by 68 calories, and for hamburgers by 97 calories.[i] [i] Nielsen S, Popkin B. Patterns and trends in food portion sizes, 1977-1998. Journal of American Medical Association 2003; 289(4):450-453. About one third (33.2%) of patrons purchased more than 1,000 calories; 8.7%, more than 1,400 calories. The first, a 1994-1996 survey of 17,370 adults and children, found that adults who ate at fast food restaurants consumed 205 more calories per day than those who did not, and children ate 155 more calories. [i] [i] Paeratakul S, Perdinand D, Champagne C, Ryan D, Bray G. Fast-food consumption among US adults and children: dietary and nutrient intake profile. Journal of American Dietetic Association 2003; 103(10):1332-1338. Many studies document that increased calorie intake observed with consumption of fast food results in weight gain.[i] In a study of over 9,000 adults, eating fast food increased the prevalence of overweight by 27-31%;[ii] among 3,394 adults in the Coronary Artery Risk Development in Young Adults Study (CARDIA), fast food eating was positively associated with BMI, and higher levels of fast food consumption correlated with a higher BMI [i] Satia JA, Galanko JA, Siega-Riz AM, Eating at fast food restaurants is associated with dietary intake, demographic, psychosocial and behavioural and behavioral factors among African Americans in North Carolina. Public Health Nutrition: 7(8) , 1089-1096. [ii] Bowman S, Vinyard B. Fast food consumption of US adults: impact on energy and nutrient intakes and overweight status. Journal of the American College of Nutrition 2004; 23(2):163-168

24. CALORIE LABELING – EVALUATION PLANS Calories I: Completed (April-May 2007). Baseline study of caloric content of purchases. Calories II: Completed (May – October 2008). Evaluated % of consumers seeing information and using posted information. Calories III: Underway. Evaluating changes in menu offerings. Calories IV: Will evaluate changes in caloric content of purchases.

25. CALORIE LABELING I RESULTS * Excluding Subway only 4% of patrons reported seeing calorie information as provided prior to the calorie posting regulation * Of Subway patrons who reported seeing calories information, 37% reported that this information had an effect on their purchase. * Those who reported seeing & using calorie information purchased 99 fewer calories than those who reported seeing the information and that it had no effect.

26. CALORIE LABELING II INITIAL RESULTS * Overall, the % of customers who saw calorie information increased from 23% to 60% * Among national chains – which were mostly compliant post-regulation – the % increased from 28% to 67% * Post-regulation, 15% of all customers surveyed report that calorie information affected their purchase, an almost three-fold increase

27. After our success similar measures are rapidly being adopted by state and local governments across the countryAfter our success similar measures are rapidly being adopted by state and local governments across the country

28. FEDERAL MENU LABELING LEGISLATION Menu Education and Labeling Act (MEAL) Introduced March 13, 2008 Does not pre-empt state or local jurisdictions Labeling Education and Nutrition Act (LEAN) Introduced March 10, 2009 Backed by Industry Nullifies existing policies and pre-empts state and local government from establishing harsher policies

29. NYC’s VOLUNTARY SALT REDUCTION CAMPAIGN

31. BP REDUCTION THROUGH DECREASING SALT INTAKE WOULD SAVE MANY LIVES Salt intake has increased by nearly half in the US since the 1970s, and is almost double the recommended limits of 2,300 mg, and more the double the limit applicable to 64% of the NYC populationiof 1,500 mg. The vast majority of sodium in the diet comes from processed and restaurant foods, and therefore is difficult for consumers to reduce individually. National sodium consumption data is based on a single day of dietary recall, which is less accurate than multi-day dietary recall or urinary sodium. Studies that utilize urinary sodium show sodium consumption as high as ~4,000mg a day. However, urinary sodium tests are expensive and therefore limited to smaller sample sizes. Salt intake has increased by nearly half in the US since the 1970s, and is almost double the recommended limits of 2,300 mg, and more the double the limit applicable to 64% of the NYC populationiof 1,500 mg. The vast majority of sodium in the diet comes from processed and restaurant foods, and therefore is difficult for consumers to reduce individually. National sodium consumption data is based on a single day of dietary recall, which is less accurate than multi-day dietary recall or urinary sodium. Studies that utilize urinary sodium show sodium consumption as high as ~4,000mg a day. However, urinary sodium tests are expensive and therefore limited to smaller sample sizes.

32. 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 NYC drew on a successful experience being implemented by the UKs Food Standards Agency seeking to reduce salt by one third between 2005 and 2010 Just as an example. Special K cereal, for example has 140 mg per serving in the UK versus 220 mg. serving here. Ireland, France, Australia, New Zealand also models The 1987 Dietary and Nutritional Survey of British Adults reported average daily salt intake of 9g. (3600 mg sodium) The 2000-2001 National Diet and Nutrition Survey reported average daily salt intake of 9.5g. (3800 mg sodium) The UK’s Health Departments Health Survey in 2006 reported average daily salt intake of 9g (3600 mg sodium). The FSA started their program to help UK consumers reduce their salt intakes in 2003. Since then, a 2.5% reduction of sodium intake has been reported, 7000 amount of deaths averted. NYC drew on a successful experience being implemented by the UKs Food Standards Agency seeking to reduce salt by one third between 2005 and 2010 Just as an example. Special K cereal, for example has 140 mg per serving in the UK versus 220 mg. serving here. Ireland, France, Australia, New Zealand also models The 1987 Dietary and Nutritional Survey of British Adults reported average daily salt intake of 9g. (3600 mg sodium) The 2000-2001 National Diet and Nutrition Survey reported average daily salt intake of 9.5g. (3800 mg sodium) The UK’s Health Departments Health Survey in 2006 reported average daily salt intake of 9g (3600 mg sodium). The FSA started their program to help UK consumers reduce their salt intakes in 2003. Since then, a 2.5% reduction of sodium intake has been reported, 7000 amount of deaths averted.

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34. SALT INITIATIVE – PROGRESS TO DATE 54 food categories identified Stakeholder meetings held for 19 manufacturer food categories Food service category meetings starting summer 2009

35. LEADING HEALTH ORGANIZATIONS AGREE SALT INTAKE MUST BE REDUCED American Medical Association Recommends 50% salt reduction in processed and restaurant foods in next 10 years American Heart Association (AHA) American Public Health Association Institute of Medicine (IOM) National Heart, Lung, & Blood Institute (NHLBI) Healthy People 2010 Goal World Health Organization (WHO)

36. NATIONWIDE EFFORT Leading national health organizations have signed on to become partners American College of Cardiology American College of Epidemiology American Heart Association American Medical Association American Public Health Association American Society of Hypertension Association of Black Cardiologists Consumers Union International Society of Hypertension in Blacks Joint Policy Committee, Societies of Epidemiology National Hispanic Medical Association National Kidney Foundation New York State Chapter, American College of Cardiology Preventive Cardiovascular Nurses Association Society for the Analysis of African-American Public Health Issues World Hypertension League

37. NATIONWIDE EFFORT Council of State & Territorial Epidemiologists Association of State and Territorial Health Officials National Association of Chronic Disease Directors National Association of County and City Health Officials States Alaska Department of Health and Human Services California Department of Public Health District of Columbia Department of Health Delaware Department of Health and Social Services, Division of Public Health Maine Center for Disease Control and Prevention Maryland Department of Health and Mental Hygiene Massachusetts Department of Public Health Michigan Department of Community Health New York State Department of Agriculture and Markets New York State Department of Health North Carolina Department of Health and Social Services, Division of Public Health Oregon Department of Health and Human Services, Division of Public Health Pennsylvania Department of Health Tennessee Department of Health Washington State Department of Health West Virginia Department of Health and Human Resources; Bureau for Public Health Cities Chicago Department of Public Health Los Angeles County Department of Public Health New York City Department of Health and Mental Hygiene Philadelphia Department of Public Health Public Health, Seattle and King County

38. NATIONWIDE EFFORT If your city or state is not “signed-on” – consider seeking your public Health officer/commissioners support to sign-on

39. 1 can of soda = 10 teaspoons of sugar

40. Contributes to childhood obesity: Each additional daily sugar-sweetened beverage increases a child’s odds for becoming obese by 1.6 times.  Contributes to childhood obesity: Each additional daily sugar-sweetened beverage increases a child’s odds for becoming obese by 1.6 times. 

41. 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 Senate Finance Committee considering SSB tax as an option for financing Health Care Reform Other Potential Approaches Counter-marketing Regulate allowable marketed portion sizes of sugar sweetened beverages and other junk food Restrict locations of sale to reduce ubiquity

42. Healthy Bodega Initiative Green Carts Stellar Farmer Markets NYC Fresh - incentives for supermarket placement Health Bucks City Food Procurement Guidelines

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44. 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

47. Physical activity has been systematically designed out of our environments and replaced by energy use

50. After the positive changes of the beginning of the century however, our cities began a new transformation. They were redesigned to make making room for cars the highest priority. Cities around the world began to follow suit. After the positive changes of the beginning of the century however, our cities began a new transformation. They were redesigned to make making room for cars the highest priority. Cities around the world began to follow suit.

51. The DOH began in 2004 to pursue a collaboration with the city’s architecture and design community to bring these key professions on board with promoting physical activity. National and international leaders in this area were brought to the City. The response was overwhelmingly positive. In large part through these collaboration we were then able to build strong collaboration within city government with the design, construction, housing and transportation leadership. Simultaneously many aspects of air pollution control and access to parks and green spaces were included in the city’s long-term sustainability plan PLANyc and other physical activity promoting elements, such as a large bicycling network, are being added but these changes will take time.The DOH began in 2004 to pursue a collaboration with the city’s architecture and design community to bring these key professions on board with promoting physical activity. National and international leaders in this area were brought to the City. The response was overwhelmingly positive. In large part through these collaboration we were then able to build strong collaboration within city government with the design, construction, housing and transportation leadership. Simultaneously many aspects of air pollution control and access to parks and green spaces were included in the city’s long-term sustainability plan PLANyc and other physical activity promoting elements, such as a large bicycling network, are being added but these changes will take time.

52. 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 this summer Separate street design manual just issued This collaboration is beginning to bear fruits. The city’s master plans for bicycle transportation is being implemented. The first guidelines for physical activity promoting Design and construction will be issued this spring incorporating the best available evidence. This collaboration is beginning to bear fruits. The city’s master plans for bicycle transportation is being implemented. The first guidelines for physical activity promoting Design and construction will be issued this spring incorporating the best available evidence.

53. A NYC stair prompt campaign has been launched. Preliminary data suggest a near doubling of stair use in some sites and evaluation is underway. Strategies to scale up use of prompts and increase stair access are under study. Summary of Annual Impacts from Placement of Stair Prompt Signage Impact of Stair Prompts: ~300,000 total pounds lost.   Represents ~10% of NYC annual average weight gain averted.  (Average pounds gained per year in NYC adults from 2002-2007 was ~3 million lbs per year.)  Total number of additional stair climbers: ~450,000 Potential cases of obesity averted: ~1,500 ADDITIVE IMPACT* Additional Impact of Stair Access ~300,000 total pounds lost Represents ~10% of NYC annual average weight gain averted. (Average pounds gained per year in NYC adults from 2002-2007 was ~3 million lbs per year).   Total number of additional stair climbers: ~450,000 Potential cases of obesity averted: ~1,500 Potential cases of overweight averted: ~2,000 Total Impact of Stair Prompt Combined with Stair Access* ~600,000 total pounds lost.   Represents ~20% of NYC annual average weight gain averted.  Total number of additional stair climbers: ~900,000 Potential cases of obesity averted: ~3,000 Potential cases of overweight averted: ~4,000A NYC stair prompt campaign has been launched. Preliminary data suggest a near doubling of stair use in some sites and evaluation is underway. Strategies to scale up use of prompts and increase stair access are under study. Summary of Annual Impacts from Placement of Stair Prompt Signage Impact of Stair Prompts: ~300,000 total pounds lost.   Represents ~10% of NYC annual average weight gain averted.  (Average pounds gained per year in NYC adults from 2002-2007 was ~3 million lbs per year.)  Total number of additional stair climbers: ~450,000 Potential cases of obesity averted: ~1,500 ADDITIVE IMPACT* Additional Impact of Stair Access ~300,000 total pounds lost Represents ~10% of NYC annual average weight gain averted. (Average pounds gained per year in NYC adults from 2002-2007 was ~3 million lbs per year).   Total number of additional stair climbers: ~450,000 Potential cases of obesity averted: ~1,500 Potential cases of overweight averted: ~2,000 Total Impact of Stair Prompt Combined with Stair Access* ~600,000 total pounds lost.   Represents ~20% of NYC annual average weight gain averted.  Total number of additional stair climbers: ~900,000 Potential cases of obesity averted: ~3,000 Potential cases of overweight averted: ~4,000

54. New York City A1C Registry and Other Clinical Strategies

55. PREVALENCE OF SELF-REPORTED DIABETES AMONG ADULTS IN NYC OK to add (%)?OK to add (%)?

56. Prevalence of Self-Reported Diabetes Among Adults By District Public Health Office (DPHO) Areas in NYC

57. ANNUAL DIABETES COMPLICATIONS IN NYC Microvascular Retinopathy: 350-700 new cases of blindness Nephropathy: 1400 new dialysis cases Neuropathy: 3000 lower-extremity amputation hospitalizations Macrovascular Cardiovascular: 2000 CVD deaths

58. Describes glycemic control in NYC Targets individuals with A1C > 9 – is a high risk strategy rather than a “curve shifter” Gives feedback to providers and patients USE OF A1C REGISTRY SURVEILLANEFOR CHRONIC DISEASE

59. Based on reporting systems for communicable diseases (HIV/STI, TB) and lead poisoning State-licensed laboratories report daily to DOHMH electronically January 2006 amendment to Article 13 of the NYC Health Code DEVELOPMENT OF A1C REGISTRY

60. STATUS OF IMPLEMENTATION Majority of laboratories are reporting 35 of the 39 mandated, >90% of expected volume Nearly 4 million tests among over 1.5 million people Provider and patient outreach 165 sites visited, 125 sites covered by signed letters of agreement for patient letter service ~1100 providers across 74 sites getting reports quarterly ~3700 patients have received letters Supplemental self-management resources Glucose strips kits Free recreation center memberships Telephonic intervention for medication adherence Lifestyle intervention Stanford program Starting Evaluations

61. WORKING TOGETHER: PROVIDERS AND DOHMH Quarterly facility and/or provider reports Letters to patients about A1C results on provider’s behalf and with provider approval Letters to patients overdue for testing or lost to care Resources for patients Parks Department membership coupons Self-blood glucose monitoring kits Self-blood pressure monitoring cuffs Are the resources correct? Will the DOH actually provide supplies, or lists of suppliers? Give out memberships, or applications for memberships? Lists of referrals or referrals?Are the resources correct? Will the DOH actually provide supplies, or lists of suppliers? Give out memberships, or applications for memberships? Lists of referrals or referrals?

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63. PUBLIC HEALTH DETAILING OBESITY CAMPAIGN

64. CHALLENGES FOR EVIDENCE BASED ACTION Absence of a stable source of funding for chronic disease prevention and its evaluation Rigorous studies are expensive – and can often only be done selectively, randomization is often not feasible Evidence on intervention effectiveness is most useful but not widely available In practice, multiple community interventions seek to affect the same behaviors. When implemented simultaneously it is difficult to attribute causality in changes in these behaviors

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