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GHME Conference 2013

Would addressing high-priority risk factors from the Global Burden of

Disease (GBD) Study 2010 potentially reduce health

inequalities?: A case study

Nick Wilson, Tony BlakelyUniversity of Otago, Wellington, New Zealand

nick.wilson@otago.ac.nz

uow.otago.ac.nz/BODE3-info.html

Aim & Methods

Aim: To determine if addressing the top 10 risk factors for a region in the GBD Study 2010 would help reduce ethnic inequalities in health – using New Zealand (NZ) as a case study.

Methods: Comparison with previous NZ work, literature searches (RF distribution in NZ; availability of preventive population-level interventions).

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New Zealand’s location

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Risk factor (as per GBD 2010 Study)

GBD 2010 – Australasia Region (Lim et

al 2012)

Previous (2004) risk factor ranking for NZ

(Ministry of Health, 2004)

High body-mass index 1 6

Tobacco smoking, including SHS 2 2

High blood pressure 3 5

Alcohol use 4 13 (with other drugs)

Physical inactivity & low physical activity 5 7

High fasting plasma glucose 6 8 (pre-diabetes)

Diet low in fruits 710 (with low vegetable

intake)

Diet low in nuts and seeds 8 Not considered

High total cholesterol 9 4

Drug use 10 13 (with alcohol)

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Table 2: Evidence for unequal distribution of the top ten risk factors (Māori vs non-Māori)

Prioritized risk factor [RF]

RF higher for Māori vs non-

Māori? Evidence-base

High body-mass index + Many studies & national health surveys

Tobacco smoking, including SHS

+ Many studies & national health surveys (also for SHS exposure)

High blood pressure + Many studies & national nutrition surveys

Alcohol use + Many studies & national surveys

Physical inactivity & low physical activity

+ (partial & women only)

Some studies – but inactivity only (no differences by physical activity levels)

High fasting plasma glucose

+ Many studies & national surveys

Diet low in fruits + Some studies & national surveys

Diet low in nuts and seeds

+ (women only)

Just 1 national survey

High total cholesterol No Survey data

Drug use + Many studies & national surveys

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Figure 1: Rate ratios for selected risk factors for Māori men & women (relative to non-Māor)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Sedentary Cannabis in thepast year

High body-mass(obese)

Hazardousdrinking of

alcohol

Tobacco smoking(current)

Ad

juste

d r

ate

rati

os

Men Women

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Figure 2: Prevalence of hypertension and smoking for Māori vs non-Māori

0

5

10

15

20

25

30

35

40

45

50

Hypertension Tobacco smoking (current)

Pre

vale

nce

(%

)

Maori NZ European/Other

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Table 3: Extent of population-level preventive actions in NZ Prioritized risk factor Level of response in NZ (prevention)

High body-mass index Minimal

Tobacco smoking, including SHS

Relatively advanced internationally (Smokefree 2025 goal, series of tax increases, new marketing restrictions)

High blood pressure Minimal

Alcohol use Moderate (tax, laws)

Physical inactivity & low physical activity

Minimal

High fasting plasma glucose Minimal

Diet low in fruits Minimal

Diet low in nuts and seeds Nil

High total cholesterol Minimal

Drug use Moderate (harm reduction, new law)

• Smokefree nation goal (<5% prevalence by 2025) – strong Māori leadership.

• Ongoing annual tobacco tax increases (10%).• Expanding outdoor smokefree areas – parks etc.• Mass media campaigns; some Māori focus.• Prohibited retail displays (in 2012)• Plans for a plain packaging law.• National quitline

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Example: Tobacco control activities in NZ

Tariana Turia, Assoc Minister of

Health & Māori Party Leader

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Promoting “auahi kore” (smokefree in Māori language)

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Table 4: Examples of population-level preventive interventions reported as “cost-saving”

Prioritized RF Examples (refs in Wilson et al 2012 Bull WHO & available on request)

High body-mass index A 10% tax on unhealthy food; reduction of TV advertising (high fat/high sugar foods & drinks); traffic light nutrition labeling.

Tobacco smoking, including SHS

Tobacco taxation increases; “National Tobacco Campaign”.

High blood pressure Reduction of dietary salt; community heart health programs; use of a polypill.

Alcohol use Alcohol taxation increases, alcohol advertising restrictions, and restricting the number of outlets.

Physical inactivity & low physical activity

Mass media-based campaigns; community programs to encourage use of pedometers

High fasting plasma glucose

Nil identified (but some interventions still “cost-effective”).

Diet low in fruits Community-based fruit and vegetable promotion activities (1/24 interventions).

Diet low in nuts & seeds Nil identified.

High total cholesterol Community heart health programs; use of a polypill.

Drug use Supervised injection facility

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But limitations with the value of this evidence:

• Results of some health economic evaluations – high uncertainty (eg, elasticities, attenuation effects)

• While laws tend to impact on all ethnic groups – less so for health promotion activities (unless: well targeted, well-resourced communities)

• Only one NZ CEA within these 10 RF groups (Quitline)

• Low political acceptability for some interventions in NZ (eg, NZ economy dependent on fatty food exports)

• GBD results for risk factors – good fit with previous NZ work

• Most (9/10) RFs higher in Māori New Zealanders (2 women only)

• NZ – fairly minimal response to preventing these RFs (some exceptions, eg, smoking)

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Conclusions (i)

For the 10 RFs:

• cost-effective population-level preventive interventions available for 9/10

• cost-saving ones for 8/10

At least for NZ, acting on the GBD 2010 RF results has good potential to:

• achieve health gain

• reduce health inequalities

• save health sector resources14

Conclusions (ii)

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