Change in Disease Patterns

According to the 1993 report by the Chinese Health Statistics Digest, disease patterns have changed significantly. The incidence of infectious diseases has decreased, while cancer, cerebral and cardiovascular diseases have increased. Healthy lifestyles are the key for prevention of chronic disease and improvement of quality of life. Exercise is also a very good regulator for modern life. Unfortunately, percentages of physical activities among the Chinese decreased. An investigation of 112,529 Chinese workers showed that 41.9% did not exercise at all, and only 27% exercise occasionally. Lifestyle-related chronic diseases are continuously increasing: there are more than 50 million hypertensive patients, about 20 million diabetic patients, and around 1 million people die from cerebral stroke every year. The incidence of mental illness has increased to 11.7 per thousand in 1992.

Along with economic development in China, there has been a steady increase in the production of major foods such as meats, eggs, milk, and fish. As a result, dietary patterns and lifestyles of the Chinese people have changed, especially in big cities. Food consumption data taken from 12 provinces and cities across China has illustrated that people's intake of grains and potatoes decreased 10.9% and 49.9% respectively from the 1980s, while intake of meats (+81.1%), eggs (+200.0%), milk (+323.0%), and fish products (+97.4%) has significantly increased. A study on the relationship between diet composition and health in Shanghai over a span of 35 years demonstrated that the death rates from cancer, cerebral, and cardiovascular diseases was negatively correlated with the amount of grains consumed, and positively correlated with the consumption of meats, eggs, and fats (1991). Chinese people are still facing problems of both nutrition insufficiency and nutrition excess. Results of the 1992 Nationwide Nutrition Survey showed that 14.9% of the Chinese population and 32.9% of Beijing residents were overweight. This points to a trend of increasing obesity. The Chinese Medical Statistics Authorities assume that the prevalence of lifestyle-related disease and chronic disease has further increased toward the end of the century. The Chinese government and many academic organizations, including both professional and non-professional groups, have been working tirelessly on the prevention and treatment for chronic disease. Many research projects for health promotion have been successfully initiated, yet we do not specifically call it health promotion. More often, the terms " health care," "disease prevention," or "chronic disease control," are used in the Chinese language. The Chinese Ministry of Health houses a Department of Chronic Disease Control.

Outlook to the New Millennium

For the new millennium, my hope is that the Government will enhance strategies to incorporate multiple disciplines and support more comprehensive studies on chronic diseases. More studies on both the harmful and beneficial effects of the environment and lifestyles on health are needed, as are targeted policies for different populations, different economic strata, and specific nationalities. Furthermore, I suggest that we adopt vigorous measures to exploit natural plant and herbal resources, and explore health-beneficial components in these natural resources of health (e.g., the effects of kiwi fruit and haw for lipid-lowering effects). Finally, I would like to see some creative educational programs to spread cultural and scientific knowledge among the people which will tremendously impact the future of health promotion.

Jidi Chen is the Director of the Institute of Sports Medicine at Beijing Medical University in China and can be reached at jidichen@public.fhnet.cn.net (e-mail) or (fax). (01186)-10-6-2355515

I think we are about to see an evolutionary growth step in the science of health promotion, specifically in the science which shows us the techniques which are most effective in facilitating lifestyle and health improvements. We have seen three distinct phases in the science of health promotion: epidemiology, program evaluation, and the beginning of intervention research.

Strong Links Between Lifestyle Factors and Health Outcomes

Epidemiologic research has demonstrated what are now known to be strong links between lifestyle factors such as smoking, sedentary lifestyle, excess stress, poor nutrition, obesity, social isolation, and other lifestyle factors and health outcomes including quality of life, illness and death. In some cases, such as smoking, nutrition and sedentary lifestyle, the mechanisms linking the lifestyle factor and the health outcome are clear. In other cases, such as obesity, social isolation and excess stress, we are still learning the mechanisms. While we continue to improve the methodology of our epidemiologic research, and to sort out the many possible confounding factors, many of the links between lifestyle factors and health outcomes are irrefutable.

More than 500 program evaluation studies published in peer reviewed literature have revealed that a wide range of workplace health promotion programs can have a positive impact on a wide range of health outcomes. Many of these studies are fraught with methodological weaknesses, including small sample sizes, short study duration, non-experimental designs, and in some cases, unproven measures. Despite these methodological shortcomings, the magnitude of consistently positive findings is sufficient to allow us to conclude that programs do produce positive health outcomes. The methodology of program evaluation will improve now that the weaknesses of past efforts are clear, and as program managers partner with scientists on future efforts. However, sample sizes will continue to be limited by employee populations and participation rates, experimental designs will at times be impossible when programs are offered to all employees, and the cost of high-quality research will often make little sense when program budgets are limited.

Quantum Leap Through Intervention Research

The next quantum leap in understanding will probably come through intervention research. While the goal of program evaluation is to determine the impact of a specific program, the goal of intervention research is to determine which strategies are most effective. Intervention research secures a research setting in which sample sizes are sufficiently large, study duration is sufficiently long, measures are valid and reliable, and study participants are randomly assigned to treatment and control conditions. While the initial work that has been done in this area has been impressive from a methodological perspective, the program outcomes have not, often showing only minimal health improvements. Unfortunately, the scientists managing these early studies had very little previous hands-on experience in managing successful health promotion programs. They understood the science of research, but not the art of health promotion. The next generation of research should be greatly improved because the scientists are beginning to learn to work with practitioners in creating state-of-the-art programs. Also, a new generation of scientists is emerging who have not learned health promotion from a textbook, but have observed and practiced it in their own lives. This is all part of the natural evolution of developing the science in a new field.

Michael O' Donnell, Ph.D, MBA, MPH is the Editor-in-Chief of the American Journal of Health Promotion and can be reached at modonnell@healthpromotionjournal.com.

New Tobacco Control Legislation in Poland

The Polish parliament has just passed far-reaching tobacco control legislation in the hope of curbing some of the tobacco-related morbidity and mortality. Including the 1995 "Law on the Protection of Public Health Against the Effects of Tobacco Use," the comprehensive tobacco control law will cover the following:

• National Tobacco Control Program (annual report to the "Sejm," the Polish Parliament)
• Ban on smoking in public places
• Ban on sale of tobacco to minors (<18) through vending machines, small packages, or in pieces
• Ban on production and sale of smokeless tobacco
• Total ban on tobacco advertising, promotion, and sponsorship (new provision)
• Health warnings on cigarette packs must fill 30% of available space and 20% on advertisements
• Gradual reduction of permissible levels of tar and nicotine (now 15 mg. of tar per cigarette and 1.5 mg. of nicotine per cigarette)
• Tobacco control fund from excise tax for tobacco products (new provision).

This piece of legislation passed Parliament largely due to the efforts of Stanislaw Grzonkowski, Member of Parliament and Chairman of the Health Committee, and Witold Zatonski, Head of the Department of Epidemiology and Cancer Prevention at the M. Sklodowska-Curie Cancer Center and Institute of Oncology. Prof. Zatonski and his team have been very persistent in their efforts to fight tobacco consumption in Poland and Eastern Europe. Kristof Przewozniak of the Cancer Center described the tasks of the tobacco control law as the following:

• To protect non-smokers, in particular children
• To create smoke-free environments
• To promote a tobacco-free lifestyle
• To inform the public on the harmfulness of smoking through health education campaigns, big health warnings on cigarette packs and ads, messages on content of tar and nicotine in cigarettes
• To decrease the maximum permissible levels of tar
• To encourage smokers to quit by anti-promotional price policy and bans of tobacco advertising and promotion
• To treat tobacco dependence.

In addition to the legislative efforts, the Cancer Center has been organizing the "Great Polish Smoke-Out" since 1991. Every year, the mass media is involved in order to create maximum awareness and many prizes are given away for people who declare that they have quit smoking.  The ultimate incentive has been a trip to Rome and a private audience with the Pope.

Health Status of Populations in Central and Eastern Europe

Some extremely interesting health status developments have occurred in Central and Eastern Europe in the 1990s. In spite of the many challenges facing Eastern European countries after the transition to democracy, there has been good news. Mortality from cardiovascular disease (CVD) has fallen dramatically in Central European countries since the early 90s. After 30 years of rising or stagnant CVD morbidity, the trend started to change following the introduction of a market economy and systemic changes. In Poland between 1991 and 1996, mortality rates from CVD fell in both sexes by 40% in the 20-44 age group, by nearly 30% in the 45-64 age group, and 12-14% in the over-65 age group. A similar trend has been noted in the Czech Republic and Slovakia since the beginning of the 90s, and in Hungary since 1993. Hypotheses regarding the downward trend suggest as an underlying cause the introduction of an open market economy which produced dietary changes including a decrease in saturated fat consumption and an increase in the consumption of fruits and vegetables.

At the same time, deaths from CVD and liver cirrhosis rose greatly in Russia and other former Soviet Republics between 1991-94, and stagnated at the mortality level in the years of 1995-96. While in Central European countries the trend of premature mortality in young and middle-aged adults was observed for one or two years after the collapse of the old system, the trend continued in Russia and the former Soviet Republics for 3-5 years. The scope of this trend is unprecedented in peacetime: an additional 1 million young and middle-aged men and women died over a four-year period in Russia. Alcohol consumption seems to be one of the main contributing factors to this additional mortality burden. For example, in Latvia during that time period, annual alcohol consumption rose from 6-8 liters to 20-25 liters per capita. In Hungary, every fifth death among Hungarian men aged 20-44 is due to liver cirrhosis. This is the highest level registered anywhere in the world.

To present and further analyze these developments and discuss intervention programs, the M. Sklodowska-Curie Cancer Center and Institute of Oncology and the Health Promotion Foundation in Poland will host the second international conference on the "Health Status of Central and Eastern European Populations after Transition" next year in May.

For additional information please contact Dr. Witold Zatonski at the M. Sklodowska-Curie Cancer Center.  E-mail: zatonskiw@coi.waw.pl and fax: 48-22-6439234.

Conference Dates

2nd Conference on "Health Status of Central and Eastern European Populations After Transition," Warsaw, June 5-7, 2000.

5th Global Conference on Health Promotion: "Health Promotion – Bridging the Equity Gap," hosted by WHO, PAHO, and the Ministry of Health of Mexico. Mexico City, June 5-9, 2000.

The First International Conference on "Exercise & Nutrition for Better Health and Chronic Diseases," hosted by the Chinese Sports Science Society (CSSS) and organized by the Chinese Sports Medicine Society (CSMS) and Institute of Sports Medicine of Beijing Medical University, Beijing, China, June 11 – 16 , 2000.

SANGALA Project in South Africa - Opportunity for International Research

Since 1997, the South African Association for Biokinetics has been managing the "SANGALA" program for middle and senior management of South African companies. SANGALA stands for South African National Games and Leisure Activities. The program was originally started by former Minister of Sport, Mr. Steve Tshwete, and aimed at the dissemination of knowledge of the value of physical activity, recreation and sport for enhancing health, wellness, and quality of life. The "Corporate SANGALA" program is led by Prof. Gert Strydom of Potchefstroom University, and is endorsed by the South African Heart Foundation. The aim is to supply each member of top and middle management with means to change their lifestyles for the better. It is hoped that individual lifestyle changes will eventually lead to a better and more healthy company profile. The program contains the following elements:

• Invitation to companies to participate in the Corporate SANGALA.
• Assessment questionnaire of individual lifestyle and physical activity profile to all middle- and top-level managers of a company.
• Collection of data and analysis
• Preparation of individualized feedback brochures and company profile.
• Feedback to a company on an individual and company basis.
• Handout of information and brochures.

The South African Association for Biokinetics would like to extend an invitation to colleagues worldwide to join this interesting program and gather comparable information in their countries which may lead to cooperation between various institutions. Several IIHP partners in Europe have expressed interested to participate. The IIHP will endorse this project and facilitate the international collaboration.

For a copy of the questionnaire or other additional information, please contact Prof. Strydom at 27-18-2991808 (fax) or mbwgls@puknet.puk.ac.za (e-mail).

International Post-Graduate Course Through the IIHP

A number of universities which are part of the IIHP network have expressed an interest in organizing a post-graduate course in health promotion. The intensive course will typically last five days, with six hours each of training. International speakers will be featured and an agreed-upon curriculum in health promotion will be followed. The University of Porto in Portugal has indicated a desire to host the first such training course for its graduate students. Jorge Mota, Dean of the Faculty of Sport Science and Physical Education at the University of Porto, is pressing to advance this idea: "In my mind, we need to take advantage of our phenomenal global network, in particular in the academic world. Through the IIHP, we could offer a unique course which addresses the global issues of health promotion and provide perspectives from experts out of different countries which would greatly benefit our students." Several barriers still have to be overcome with regard to funding and language. Topics for curriculum have been proposed during previous meetings and are currently under review.

Your input is welcome. If you are interested, please contact Wolf Kirsten at wk1861a@american.edu (e-mail) or 1-202-885-1346 ( fax).

Health Promotion Conference in Saudi Arabia

The IIHP is expanding its network to a new region; the Middle East and Arabian Gulf area. American University in Washington DC and the Saudi German Hospitals Group, based in Jeddah in Saudi Arabia, just recently entered a cooperative agreement for the advancement of health promotion through the IIHP. The private Saudi German Hospital (SGH) in Jeddah has been functioning since 1988, and has since grown rapidly with regard to staff, beds, and visiting professors. Four additional hospitals are currently under construction in various cities in Saudi Arabia.

The SGH Group and the IIHP plan to host an international conference in Jeddah in May of 2000. This first- time event will focus on nutrition and lifestyles in the Arab world as the major diseases in the region are diabetes and cancer. The SGH and IIHP envision inviting physicians, public health officials, academicians, government representatives, etc. from the Middle East and Northern Africa to discuss the prevalent health issues and find common strategies and solutions. International experts from various countries will provide a thorough insight to the thematic areas of the conference and highlight successful programs around the world.

For more information, please contact Modia Batterjee at iihpaa@american.edu (e-mail) or at 1-202-885-1346 (fax).

International Conference on Movement and Health in Olomouc, Czech Republic

Palacky University in Olomouc hosted an international conference focusing on the various aspects of physical activity and sports in relation to health from September 11-14, 1999. The host city Olomouc is situated 250 kilometers east of Prague and has been home to a university for over 400 years. Forty years of physical education studies resulted in the establishment of a new Faculty of Physical Culture in 1991.

The conference featured renowned speakers from Europe and the United States, including Dr. Gudrun Doll-Tepper (President of the International Council of Sport Science and Physical Education), Dr. James Sallis (Professor at the Department of Psychology of San Diego State University) and Dr. Robert Karch (Professor of the department of Health and Fitness at American University). Among the topics highlighted were the role of physical activity in relation to health promotion, physical activity and young people, and the significance of adapted physical activity.

Dr. Pavel Stejskal, main coordinator of the conference and professor at the Faculty of Physical Culture, points out the significance of such a conference: "The need for the dissemination of quality information on physical activity and healthy lifestyles is immense in Eastern Europe with regard to the increase in lifestyle-related diseases." The University plans to make this conference a regular event.

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe. It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations. More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation. E-mail the IIHP at iihpaa@american.edu. The IIHP website is http://www.healthy.american.edu/iihp.html