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Preventing Chronic Disease:

Introduction The relationship between obesity and breast cancer has been extensively investigated. However, how obesity and breast cancer interplay to affect mortality and life expectancy of women in the United States has not been well studied. Methods We used data from the National Health Interview Survey, 1997–2000. Our sample included nonsmoking, nonpregnant women who reported a body mass index of at least 18.5 kg/m and no cancer other than breast cancer at the time of the survey. A survival model with Gamma frailty and Gompertz baseline was used to estimate relative risks of total mortality and project life years lost associated with breast cancer by obesity status and age. Results Breast cancer increased risk of mortality depending on degree of obesity and decreased life years by 1 to 12 years depending on race, age, and obesity status. Relative risks for death increased with degree of obesity. Obese women under age 50 across all racial groups were predicted to lose the most life years; racial groups other than whites and blacks lost the most life years (11.9 y), followed by whites (9.8 y) and blacks (9.2 y). Conclusion The number of life years lost associated with breast cancer was more marked for more obese than for less obese women and for women under age 50 and women aged 70 or older than for women aged 50 through 69. Public health initiatives should put more emphasis on the prevention and control of obesity for these target populations. Introduction Breast cancer is the most commonly diagnosed cancer in women and the second leading cause of death among women (1). Obesity is a known risk factor for postmenopausal breast cancer (2,3) but may be inversely related to premenopausal breast cancer incidence (4). Obesity is also associated with increased all-cause mortality (5–7). However, it is unclear how obesity and breast cancer interplay to affect mortality and life expectancy of adult women. Some studies have focused on obesity in relation to breast cancer incidence (8–10); others have explored the relationship between obesity and mortality from breast cancer (11–13). Few studies have examined life expectancy associated with breast cancer (14,15). To our knowledge, no studies have considered this association in relation to body mass index (BMI). Our study is the first to consider BMI in the relationship between breast cancer and mortality rate as well as life years lost associated with breast cancer. Our study used both life years lost and mortality rate, which are accepted outcome measures of population health (16,17). The goal of this study is to investigate the mortality risks associated with breast cancer according to BMI level and race and to predict life years lost among women in the United States. We used data from a national probability sample of the US population and a class of survival model. The projection of life years is computed on the basis of mortality estimates and the observed characteristics of the sample as a snapshot of their life span. This approach is not restricted by the length of mortality follow-up and the observed mortality rates, and thus provides an alternative to the life table approach (14). Methods Data and the sample Data from the National Health Interview Survey (NHIS) and the NHIS Linked Mortality Public-Use Files were used in this study (18). The NHIS is a cross-sectional household interview survey providing health information on the civilian, noninstitutionalized household population of the United States. The NHIS consists of 3 major components: Family, Sample Adult, and Sample Child. From each family, 1 sample adult (aged 18 years or older) and 1 sample child (if any children under age 18 are present) are randomly selected, and information on each is collected from the sample adult core and the sample child core questionnaires. The Sample Adult Data Files from 1997 to 2000 were used and linked to the data in the NHIS Linked Mortality Public-Use Files by personal identification numbers. Mortality data followed up the NHIS sample from the date of interview through December 31, 2006. We focused on female breast cancer; therefore, our sample included only women. The sample exclusion criteria were the following: 1) women with any missing data; 2) women who had smoked more than 100 cigarettes in their entire life, because analyses can be confounded by illnesses associated with smoking (6,7); 3) women pregnant at the time of survey, because BMI levels are unstable during pregnancy; 4) women who reported having had any type of cancer other than breast cancer, to exclude the possibility of breast cancer as a secondary cancer; and 5) underweight women, because disease-driven weight loss could perplex the analysis. Outcome variable and covariates 2 Page 2 of 11 Preventing Chronic Disease | Obesity, Mortality, and Life Years Lost Associated With Br...


Introduction
Today, seven of the 10 leading causes of death are chronic diseases and more than half of Americans suffer from one or more chronic diseases. 1 Each year millions of people are diagnosed with chronic disease and the outcomes can be devastating, usually leading to decreased quality of life and shortened life expectancy. The chronic disease burden in the United States largely results from: health behaviors such as tobacco use, poor diet, and physical inactivity; health conditions such as hypertension, hyperlipidemia, and excess weight; and other health determinants such as the social conditions in which people are born, live, and work (i.e. education, income, housing, etc.). 1 Four chronic diseases -cardiovascular disease, cancer, chronic lower respiratory disease, and diabetes -accounted for 62 percent of all deaths among Delaware residents. 2 Lack of physical activity is a large contributor to the increase in chronic diseases and subsequently increases in health care spending. The Centers for Disease Control and Prevention (CDC) estimates that $117 billion in annual health care costs are associated with inadequate physical activity. 3 The American Public Health Association identifies that the five most costly and preventable chronic conditions -heart disease, cancer, COPD/asthma, diabetes, and hypertension cost the U.S. nearly $347 billion -30% of total health spending -in 2010. 1 The economic burden of chronic disease in Delaware relative to health care spending from all payers in 2010 was approximately 3 billion dollars. 3 The projected cost in health care spending on chronic disease, in 2020, for Delaware is estimated to increase to well over $6 billion. 3 While the impacts of chronic disease are significant, the good news is many chronic conditions could be prevented, delayed, or alleviated through simple lifestyle changes such as remaining tobacco-free, maintaining a healthy diet, achieving recommended levels of physical inactivity, and getting appropriate screenings. The factors contributing to chronic disease are multi-faceted, making the efforts to find the most effective solutions complex. The solutions to improve health behaviors, health conditions, and other health determinants is largely influenced by the capacity to support prevention and deliver comprehensive health promotion strategies that target a wide range of people, places, and behaviors. If we are to overcome this epidemic of chronic disease, public, private, nonprofit, and philanthropic sector organizations must look to integrate efforts to strengthen capacity so they can deliver services from prevention to treatment.

Building Capacity for Prevention
In Delaware, the Division of Public Health (DPH) is catalyzing innovative work that is reducing chronic disease, managing health care costs, improving overall health outcomes, and increasing capacity to deliver and sustain effective efforts. The efforts highlighted in the following paragraphs are just a few examples of DPH's current work to prevent and alleviate the burden of chronic disease: • Health Equity Guide for Public Health Practitioners and Partners focuses on how to bring non-traditional partners together to develop community-specific interventions related to improving the social determinants of health and health equity.
• LIVESTRONG at the Y is available to cancer survivors and provides support to maintain healthy lifestyles by being physically active and following recommendations for cancer screenings to reduce the risk of cancer recurrence.
• Diabetes Self-Management Program, an evidence-based intervention developed by Stanford University, focuses on people with type 2 diabetes who attend workshops designed to help people gain self-confidence to control their disease symptoms.
• YMCA Diabetes Prevention Program is a prevention-focused program for those at high risk for diabetes to adopt and maintain healthy lifestyles while reducing their chances of developing diabetes.
• Tobacco Prevention and Control Program has worked with over 100 organizations statewide including youth organizations such as the Kick Butts Generation (KBG) and Teens against Tobacco Use (TATU). These organizations encourage and support middle school and high school children to either quit using tobacco or to never begin. An average of 15,000 youth per year participates in KBG and TATU programs each year.
• Delaware Quitline is a tobacco cessation service that helps adult smokers who are ready to kick the habit. Trained tobacco specialists staffing the Quitline assess a person's needs and explore best options for cessation. Since its inception in 2001, there have been over 100,000 calls to the Quitline with over 50,000 enrolling in cessation services. Thirty-three percent of respondents who received treatment from the Delaware Quitline reported remaining smoke-free after seven months.
• Motivate the First State is the first public-private partnership to cultivate behavior change and improve the health of Delawareans by engaging individuals to be more conscious of their health choices by harnessing the power of competition, social connection and philanthropy. Motivate the First State has enrolled 3,126 participants since June 2015 and 79% have remained actively engaged, resulting in over 58,000 hours spent being physically active and participating in other healthy behaviors.
• One Less is a social marketing campaign focused on the positive health benefits of drinking less sugary sweetened beverages rather than highlighting the risks of maintaining current consumption of sugary sweetened beverages. The effort was implemented at all Department of Health and Social Services state service centers as well as all DelDOT owned/ operated facilities. Positive health outcomes were achieved by presenting a choice along with a positive, fun, doable message. Sales were maintained while individuals reported consuming fewer sugary sweetened beverages, along with a myriad of other healthy behaviors as a by-product of taking the "One Less Challenge." • Screening for Life (SFL) provides payment for cancer screening tests to qualified Delaware adults. SFL is working with Quality Insights (QI), to improve breast, cervical cancer, and colorectal cancer screening rates at FQHCs to bring about health system changes. SFL, QI, and the FQHCs have improved upon the use of clinical decision supports embedded in the provider's electronic health records. Screening protocols have been established, staff has been trained, workflow processes have been improved, and patient reminders have been developed, all to ensure cancer screenings are provided at the right time for every patient.
• The Diabetes and Heart Disease Prevention and Control Program has improved health care delivery for those with undiagnosed diabetes and hypertension. By working with Quality Insights, support is given to Delaware health care providers for improving health outcomes among patients. Providers are given staff education and training on the standards of care for pre-diabetes, diabetes and hypertension.
• Patient Navigators at the Federally Qualified Health Centers (FQHC) provide patient navigation services to clients through the breast, cervical, and colorectal cancer screening process. The patient navigators also work to eliminate barriers to cancer screening by connecting clients to services that can provide transportation and translation services, and address other common barriers to screening. The Patient Navigators along with Health Promotion Advocates at the FQHCs also assist patients with other chronic disease screenings such as screenings for hypertension and Type 2 Diabetes. Additionally, they connect Delawareans to chronic disease prevention and control program such as the Delaware Quitline, Diabetes and Chronic Disease Self-Management Programs and the Diabetes Prevention Program.
In addition to the evidence-based strategies described above, DPH continues to support and build coalitions and partnerships, utilize mass media communication, and catalyze proven policy-based interventions to influence and impact chronic disease. This reflects strategies addressing a comprehensive and integrated approach utilizing a wide range of model practices.

Recommendations
Fully addressing the chronic disease burden will require public health, health care, and many other disciplines to integrate approaches that bring together strategies and interventions to address many risk factors and conditions simultaneously. This will leverage public-private partnerships and stakeholder involvement to create population-wide changes, target the population subgroups most affected, and deploy the efforts across multiple sectors.
To achieve this, several strategic efforts must be supported, including the following: (1) epidemiology and surveillance efforts must be enhanced and strengthened to better monitor trends and inform initiatives; (2) built environment strategies must be supported and integrated with health behavior change efforts; (3) health care systems must be enhanced to more effectively use clinical and other preventive services; and (4) community resources must be better connected to clinical services to improve management of chronic conditions.
Population health outcomes can be improved with better collaboration especially between the public health and health care sectors if greater emphasis is placed on prevention and early detection services. This collaborative approach will improve health equity by building communities that promote prevention and health rather than treatment and disease.
A priority focus on supporting healthy behaviors and effective management of chronic conditions will deliver healthier students to schools, healthier workers to employers, and a healthier general population to the health care system. Nonetheless, to achieve that outcome, more funding will need to be secured to support these efforts. Our health care payments need to be restructured so providers are compensated for innovative efforts that educate and enable patients to focus on prevention, rather than just treating chronic disease.
These recommendations will require a Health in All Policies (HiAP) approach that prioritizes policy to focus on intersectoral collaboration, strategy integration, and systems change. For example, social determinants such as income, education, crime, and housing play a role in health outcomes, but these determinants are often managed by non-health sectors or agencies.
To achieve significant change, a prevention focus must be incorporated into the strategic decisions we make in education, jobs, law enforcement, housing, transportation design, neighborhood development, and zoning discussions, as well as security discussions. A prevention focus in policy will codify and institutionalize the approaches that will prevent or delay the occurrence of chronic diseases, and reduce demand on the health care system, thus supporting an improved quality of life and longer life expectancy for Delawareans.

A Bold Vision for Prevention
DPH's vision is "healthy people in healthy communities," and one approach to achieving that is effective public health interventions and policies that prioritize prevention efforts in the fight to reduce the impact of chronic disease. The evidence supports making an investment in prevention because the benefits of a prevention-focused public health and health care system are farreaching. Creating a culture that supports the benefits of a healthy lifestyle will result in a healthier population with fewer chronic diseases and complications from disease. That type of system becomes proactive, effectively responding to issues before they become burdensome dilemmas that would require significant resources to manage.
Developing a stronger more integrated public health and health care system will create greater capacity to deliver prevention-focused initiatives that support and enable healthier choices to be the easiest choice. Supporting a culture of prevention and health promotion in Delaware communities, businesses, schools, faith-based organizations, and government agencies will provide the catalyst to reduce the incidence of chronic disease, increase productivity, lower the cost of health care, and improve quality of life.
Chronic disease prevention is about having a long view of promoting health -a perspective that envisions everyone (especially the next generation) as having more opportunities to live in healthier communities, being cared for in healthier systems, and enabling everyone to lead healthier and longer lives. DPH wants to ensure that all Delawareans can achieve the highest quality of life because we are focused on prevention and securing a future for everyone that is happier, healthier, and more productive. 2