US Spending on Personal Health Care and Public Health, 1996-2013.

Importance: US health care spending has continued to increase, and now accounts for more than 17% of the US economy. Despite the size and growth of this spending, little is known about how spending on each condition varies by age and across time. Objective: To systematically and comprehensively estimate US spending on personal health care and public health, according to condition, age and sex group, and type of care. Design and Setting: Government budgets, insurance claims, facility surveys, household surveys, and official US records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated into 29 conditions). For each record, spending was extracted, along with the age and sex of the patient, and the type of care. Spending was adjusted to reflect the health condition treated, rather than the primary diagnosis. Exposures: Encounter with US health care system. Main Outcomes and Measures: National spending estimates stratified by condition, age and sex group, and type of care. Results: From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these 155 conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion (uncertainty interval [UI], $96.7 billion-$106.5 billion) in spending, including 57.6% (UI, 53.8%-62.1%) spent on pharmaceuticals and 23.5% (UI, 21.7%-25.7%) spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion (UI, $82.7 billion-$92.9 billion), and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion (UI, $67.5 billion-$94.1 billion). The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion (UI, $47.4 billion-$64.4 billion) and $64.4 billion (UI, $57.8 billion-$70.7 billion), respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4% [UI, 6.4%-6.4%] and 5.6% [UI, 5.6%-5.6%] annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8% [UI, 2.8%-2.8%] and nursing facility care (2.5% [UI, 2.5%-2.5%]). Conclusions and Relevance: Modeled estimates of US spending on personal health care and public health showed substantial increases from 1996 through 2013; with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category. The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control US health care spending.

30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies.

BACKGROUND: Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years. METHODS: Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981-1982, 1991-1992, 2002-2003 and 2011-2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution. RESULTS: 5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Maori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Maori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients. CONCLUSIONS: In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Causes of international increases in older age life expectancy.

In high-income countries, life expectancy at age 60 years has increased in recent decades. Falling tobacco use (for men only) and cardiovascular disease mortality (for both men and women) are the main factors contributing to this rise. In high-income countries, avoidable male mortality has fallen since 1980 because of decreases in avoidable cardiovascular deaths. For men in Latin America, the Caribbean, Europe, and central Asia, and for women in all regions, avoidable mortality has changed little or increased since 1980. As yet, no evidence exists that the rate of improvement in older age mortality (60 years and older) is slowing down or that older age deaths are being compressed into a narrow age band as they approach a hypothesised upper limit to longevity.

Migration and Pacific mortality: estimating migration effects on Pacific mortality rates using Bayesian models.

Pacific people living in New Zealand have higher mortality rates than New Zealand residents of European/Other ethnicity. The aim of this paper is to see whether Pacific mortality rates vary by natality and duration of residence. We used linked census-mortality information for 25- to 74-year-olds in the 2001 census followed for up to three years. Hierarchical Bayesian modeling provided a means of handling sparse data. Posterior mortality rates were directly age-standardized. We found little evidence of mortality differences between the overseas-born and the New Zealand-born for all-cause, cancer, and cardiovascular disease (CVD) mortality. However, we found evidence for lower all-cause (and possibly cancer and CVD) mortality rates for Pacific migrants resident in New Zealand for less than 25 years relative to those resident for more than 25 years. This result may arise from a combination of processes operating over time, including health selection effects from variations in New Zealand's immigration policy, the location of Pacific migrants within the social, political, and cultural environment of the host community, and health impacts of the host culture. We could not determine the relative importance of these processes, but identifying the (modifiable) drivers of the inferred long-term decline in health of the overseas-born Pacific population relative to more-recent Pacific migrants is important to Pacific communities and from a national health and policy perspective.

The burden of cancer in New Zealand: a comparison of incidence and DALY metrics and its relevance for ethnic disparities.

AIM: Cancer burden measured in disability adjusted life years (DALYs) captures survival and disability impacts of incident cancers. In this paper, we estimate the prospective burden of disease arising from 27 cancer sites diagnosed in 2006, by sex and ethnicity; and determine how its distribution differs from that for incidence rates alone. METHODS: Using a prospective approach, Markov and cancer disease models were used to estimate DALYs with inputs of population counts, incidence and excess mortality rates, disability weights, and background mortality. DALYs were discounted at 3.5% per year. RESULTS: The age standardised Maori:non-Maori incidence rate ratios were 1.00 for males and 1.19 for females, whereas for DALYs they were greater at 1.42 for males and 1.68 for females. The total burden of cancer for 2006 incident cases (i.e. not age standardised) was estimated to be approximately 127,000 DALYs. Breast (27%), lung (14%) and colorectal (13%) cancers for females and lung (16%), colorectal (14%), and prostate (16%) cancers for males were the top contributors. By ethnicity, Maori experienced a substantially higher burden from lung cancer (around 25% for both sexes). CONCLUSIONS: Due to Maori both having higher rates of cancers with a worse survival (e.g. lung cancer), and tending to have worse survival for each cancer site, ethnic disparities in the age-standardised DALY burden were greater than those for incidence (rate ratios of 1.52 and 1.07 respectively, sexes pooled).

Self-reported experience of racial discrimination and health care use in New Zealand: results from the 2006/07 New Zealand Health Survey.

OBJECTIVES: We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences. METHODS: We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables. RESULTS: Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants. CONCLUSIONS: Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.

The pervasive effects of racism: experiences of racial discrimination in New Zealand over time and associations with multiple health domains.

Self-reported experience of racial discrimination has been linked to a range of health outcomes in various countries and for different ethnic groups. This study builds on previous work in New Zealand to further investigate the prevalence of self-reported experience of racial discrimination by ethnicity, changes over time and associations with multiple health measures. The study uses data from the 2002/03 (n=12,500) and 2006/07 (n=12,488) New Zealand Health Surveys, nationally representative population-based surveys of adults (15+ years). Reported experience of racial discrimination was measured in both surveys and covered 5 items: experience of an ethnically motivated physical or verbal attack; and unfair treatment because of ethnicity by a health professional, in work, or when gaining housing. Ethnicity was classified as Maori, Pacific, Asian or European. Health indicators included measures of: mental health (SF36 mental health scale, psychological distress, doctor diagnosed mental health condition); physical health (self-rated health, SF36 physical functioning scale, cardiovascular disease); and health risk (smoking, hazardous drinking, excess body fat). Logistic regression was used to examine changes in prevalence of reported experience of racial discrimination over time and associations with health. Reported experience of racial discrimination increased between 2002/03 (28.1% ever) and 2006/07 (35.0% ever) among Asian peoples but remained largely unchanged for other ethnic groupings (Maori 29.5%, Pacific 23.0%, European 13.5%). Experience of racial discrimination was associated with all negative health measures except excess body fat. Where there were significant associations, a dose-response relationship was also evident. We conclude that racial discrimination experienced across a range of settings has the potential to impact on a wide range of health outcomes and risk factors. While ongoing research is needed to understand the multifarious nature of racism and the pathways by which it leads to poor health, it is feasible to monitor experiences of racial discrimination in national surveys.

Application of a system dynamics model to inform investment in smoking cessation services in New Zealand.

OBJECTIVES: We estimated the long-term effects of smoking cessation interventions to inform government decision-making regarding investment in tobacco control. METHODS: We extracted data from the 2006 New Zealand Tobacco Use Survey and other sources and developed a system dynamics model with the iThink computer simulation package. The model derived estimates of population cessation rates from smoking behaviors and applied these over a 50-year period, from 2001 to 2051, under business-as-usual and enhanced cessation intervention scenarios. RESULTS: The model predicted larger effects by 2051 with the enhanced cessation than with the business-as-usual scenario, including: an 11% greater decline in adult current smoking prevalence (9 versus 10 per 100 people), 16% greater decline in per capita tobacco consumption (370 versus 440 cigarette equivalents per year), and 11% greater reduction in tobacco-attributable mortality (3000 versus 3300 deaths per year). CONCLUSIONS: The model generated reliable estimates of the effects on health and on tobacco use of interventions designed to enhance smoking cessation. These results informed a decision announced in May 2007 to increase funding for smoking cessation by NZ $42 million over 4 years.

Changing trends in indigenous inequalities in mortality: lessons from New Zealand.

BACKGROUND: We describe trends from 1951 to 2006 in inequalities in mortality between the indigenous (Maori) and non-indigenous (non-Maori, mainly European-descended) populations of New Zealand. We relate these trends to the historical context in which they occurred, including major structural adjustment of the economy from the mid 1980s to the mid 1990s, followed by a retreat from neoliberal social and economic policies from the late 1990s onwards. This was accompanied by economic recovery and the introduction of health reforms, including a reorientation of the health system towards primary health care. METHODS: Abridged period lifetables for Maori and non-Maori from 1951 to 2006 were constructed using standard demographic methods. Absolute [standardized rate difference (SRD)] and relative [standardized rate ratio (SRR)] mortality inequalities for Maori compared with European/Other ethnic groups (aged 1-74 years) were measured using the New Zealand Census-Mortality Study (an ongoing data linkage study that links mortality to census records) from 1981-84 to 2001-04. The SRDs were decomposed into their contributions from major causes of death. Poisson regression modelling was used to estimate the extent of socio-economic mediation of the ethnic mortality inequality over time. RESULTS: Life expectancy gaps and relative inequalities in mortality rates (aged 1-74 years) widened and then narrowed again, in tandem with the trends in social inequalities (allowing for a short lag). Among females, the contribution of cardiovascular disease to absolute mortality inequalities steadily decreased, but was partly offset by an increasing contribution from cancer. Among males, the contribution of CVD increased from the early 1980s to the 1990s, then decreased again. The extent of socio-economic mediation of the ethnic mortality inequality peaked in 1991-94, again more notably among males. CONCLUSION: Our results are consistent with a causal association between changing economic inequalities and changing health inequalities between ethnic groups. However, causality cannot be established from a historical analysis alone. Three lessons nevertheless emerge from the New Zealand experience: the lag between changes in ethnic social inequality and ethnic health inequality may be short (<5 years); both changes in the distribution of the social determinants of health and an appropriate health system response may be required to address ethnic health inequalities; and timely monitoring of ethnic health inequalities, based on high-quality ethnicity data, may help to sustain political commitment to pro-equity health and social policies.

Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis.

We examined socioeconomic inequalities in cancer survival in New Zealand among 132,006 people ages 15 to 99 years who had a cancer registered (1994-2003) and were followed up to 2004. Relative survival rates (RSR) were calculated using deprivation-specific life tables. A census-based measure of socioeconomic position (New Zealand deprivation based on the 1996 census) based on residence at the time of cancer registration was used. All RSRs were age-standardized, and further standardization was used to investigate the effect of extent of disease at diagnosis on survival. Weighted linear regression was used to estimate the deprivation gap (slope index of inequality) between the most and least deprived cases. Socioeconomic inequalities in cancer survival were evident for all of the major cancer sites, with the deprivation gap being particularly high for prostate (-0.15), kidney and uterus (both -0.14), bladder (-0.12), colorectum (-0.10), and brain (+0.10). Accounting for extent of disease explained some of the inequalities in survival from breast and colorectal cancer and melanoma and all of the deprivation gaps in survival of cervical cancer; however, it did not affect RSRs for cancers of the kidney, uterus, and brain. No substantial differences between the total compared with the non-Maori population were found, indicating that the findings were not due to confounding by ethnicity. In summary, socioeconomic disparities in survival were consistent for nearly all cancer sites, persisted in ethnic-specific analyses, and were only partially explained by differential extent of disease at diagnosis. Further investigation of reasons for persisting inequalities is required.

Did it fall or was it pushed? The contribution of trends in established risk factors to the decline in premature coronary heart disease mortality in New Zealand.

OBJECTIVE: To estimate the contribution of trends in three risk factors--systolic blood pressure (SBP), total blood cholesterol (TBC) and cigarette smoking--to the decline in premature coronary heart disease (CHD) mortality in New Zealand from 1980-2004. METHOD: Risk factor prevalence data by 10-year age group (35-64 years) and sex was sourced from six national or Auckland regional health surveys and three population censuses (the latter only for smoking). The data were smoothed using two-point moving averages, then further smoothed by fitting quadratic regression equations (SBP and TBC) or splines (smoking). Risk factor/CHD mortality hazard ratios estimated by expert working groups for the World Health Organization Global Burden of Disease Study 2001 were used to translate average annual changes in risk factor prevalences to the corresponding percentage changes in premature CHD mortality. The expected trends in CHD mortality were then compared with the observed trend to estimate the contribution of each risk factor to the decline. FINDINGS: Approximately 80% (73% for males, 87% for females) of the decline in premature CHD mortality from 1980 to 2004 is estimated to have resulted from the joint trends in population SBP and TBC distributions and smoking prevalence. Overall, approximately 42%, 36% and 22% of the joint risk factor effect was contributed by trends in SBP, TBC and smoking respectively. CONCLUSION: Our estimate for the joint risk factor contribution to the CHD mortality decline of 80% exceeds those of two earlier New Zealand studies, but agrees closely with a similar Australian study. This provides an indicator of the scope that still remains for further reduction in CHD mortality through primary and secondary prevention.

Inequalities in mortality during and after restructuring of the New Zealand economy: repeated cohort studies.

OBJECTIVES: To determine whether disparities between income and mortality changed during a period of major structural and macroeconomic reform and to estimate the changing contribution of different diseases to these disparities. DESIGN: Repeated cohort studies. DATA SOURCES: 1981, 1986, 1991, 1996, and 2001 censuses linked to mortality data. Population Total New Zealand population, ages 1-74 years. METHODS: Mortality rates standardised for age and ethnicity were calculated for each census cohort by level of household income. Standardised rate differences and rate ratios, and slope and relative indices of inequality (SII and RII), were calculated to measure disparities on both absolute and relative scales. RESULTS: All cause mortality rates declined over the 25 year study period in all groups stratified by sex, age, and income, except for 25-44 year olds of both sexes on low incomes among whom there was little change. In all age groups pooled, relative inequalities increased from 1981-4 to 1996-9 (RIIs increased from 1.85 (95% confidence interval 1.67 to 2.04) to 2.54 (2.29 to 2.82) for males and from 1.54 (1.35 to 1.76) to 2.12 (1.88 to 2.39) for females), then stabilised in 2001-4 (RIIs of 2.60 (2.34 to 2.89) and 2.18 (1.93 to 2.45), respectively). Absolute inequalities were stable over time, with a possible fall from 1996-9 to 2001-4. Cardiovascular disease was the major contributor to the observed disparities between income and mortality but decreased in importance from 45% in 1981-4 to 33% in 2001-4 for males and from 50% to 29% for females. The corresponding contribution of cancer increased from 16% to 22% for males and from 12% to 25% for females. CONCLUSIONS: During and after restructuring of the economy disparities in mortality between income groups in New Zealand increased in relative terms (but not in absolute terms), but it is difficult to confidently draw a causal link with structural reforms. The contribution of different causes of death to this inequality changed over time, indicating a need to re-prioritise health policy accordingly.

Tobacco consumption in New Zealand: why did it fall?

OBJECTIVE: To estimate the relative contributions of trends in smoking prevalence and trends in smoking intensity (average number of cigarettes smoked per day) to the observed decline in per capita tobacco consumption in New Zealand from 1984 to 2004. METHOD: Tobacco consumption and smoking prevalence time series data were sourced from Statistics New Zealand and the ACNielsen Omnibus Survey respectively and checked for accuracy against other sources. The contribution of changes in smoking prevalence to the observed decline in tobacco consumption was estimated by counterfactual modelling. The corresponding contribution of trends in smoking intensity was then calculated by difference. RESULTS: Changes in smoking prevalence accounted for 48% of the decline in per capita tobacco consumption from 1984-89 and for 39% thereafter. Correspondingly, changes in smoking intensity accounted for 52% of the consumption decline during the first five years of the study period and 61% thereafter (i.e. from 1990 to 2004). DISCUSSION: Understanding the relative contributions of trends in smoking prevalence and smoking intensity to the observed decline in per capita tobacco consumption is important, because the relationship between smoking intensity and health effects is non-linear. Our results indicate that the dramatic fall in tobacco consumption in New Zealand over the past 30 years will not be accompanied by an equivalent reduction in tobacco-attributable morbidity and mortality. Furthermore, our findings raise doubts as to how much longer tobacco consumption will continue to decline, given that smoking intensity is already low. The key message for the tobacco control program is to re-focus on helping smokers to quit and stay quit.

Do healthy and unhealthy behaviours cluster in New Zealand?

OBJECTIVE: To describe the co-occurrence and clustering of healthy and unhealthy behaviours in New Zealand. METHOD: Data were sourced from the 2002/03 New Zealand Health Survey. Behaviours selected for analysis were tobacco use, quantity and pattern of alcohol consumption, level of physical activity, and intake of fruit and vegetables. Clustering was defined as co-prevalence of behaviours greater than that expected based on the laws of probability. Co-occurrence was examined using multiple logistic regression modelling, while clustering was examined in a stratified analysis using age and (where appropriate) ethnic standardisation for confounding control. RESULTS: Approximately 29% of adults enjoyed a healthy lifestyle characterised by non-use of tobacco, non- or safe use of alcohol, sufficient physical activity and adequate fruit and vegetable intake. This is only slightly greater than the prevalence expected if all four behaviours were independently distributed through the population i.e. little clustering of healthy behaviours was found. By contrast, 1.5% of adults exhibited all four unhealthy behaviours and 13% exhibited any combination of three of the four unhealthy behaviours. Unhealthy behaviours were more clustered than healthy behaviours, yet Maori exhibited less clustering of unhealthy behaviours than other ethnic groups and no deprivation gradient was seen in clustering. DISCUSSION: The relative lack of clustering of healthy behaviours supports single issue universal health promotion strategies at the population level. Our results also support targeted interventions at the clinical level for the 15% with 'unhealthy lifestyles'. Our finding of only limited clustering of unhealthy behaviours among Maori and no deprivation gradient suggests that clustering does not contribute to the greater burden of disease experienced by these groups.

Co-occurrence and clustering of tobacco use and obesity in New Zealand: cross-sectional analysis.

OBJECTIVE: To describe the co-occurrence and clustering/aversion of tobacco use and obesity in New Zealand. METHOD: Data were sourced from the 2002/03 New Zealand Health Survey, a nationally representative household survey that included measured body mass index (BMI) and self-reported smoking status. The association of cigarette smoking, obesity, and the combination of these risk factors with socio-demographic variables was analysed by multiple logistic regression. Clustering/aversion (defined as observed prevalence of [smoking + obesity] > or < expected prevalence, where expected prevalence = prevalence of [smoking] x prevalence of [obesity]) was also estimated. RESULTS: The joint prevalence of smoking plus obesity in the adult population (15+ years) was 4.5%. However, this was 10% for Maori and 8.5% for deprivation quintile 5. Adjusting for relevant covariates, Maori were twice as likely to have both risk factors as non-Maori. A smooth deprivation gradient was found, with deprivation quintile 1 (least deprived) only one-fifth as likely to have both risk factors as quintile 5 (most deprived). There was no evidence of clustering, and aversion (negative clustering) was demonstrated only for middle-aged adults and for Maori. DISCUSSION: Since smoking cessation is associated with weight gain, substantial aversion might have been expected across all subgroups, yet this was not found. The most likely explanations are that the extent of weight gain associated with smoking cessation has been overestimated or is often not sustained. Even so, health promotion and clinical interventions need to take the dually exposed population into account, addressing not only the unhealthy behaviours themselves but also the social context in which dual exposure occurs.

What potential has tobacco control for reducing health inequalities? The New Zealand situation.

In this Commentary, we aim to synthesize recent epidemiological data on tobacco and health inequalities for New Zealand and present it in new ways. We also aim to describe both existing and potential tobacco control responses for addressing these inequalities. In New Zealand smoking prevalence is higher amongst Maori and Pacific peoples (compared to those of "New Zealand European" ethnicity) and amongst those with low socioeconomic position (SEP). Consequently the smoking-related mortality burden is higher among these populations. Regarding the gap in mortality between low and high socioeconomic groups, 21% and 11% of this gap for men and women was estimated to be due to smoking in 1996-99. Regarding the gap in mortality between Maori and non-Maori/non-Pacific, 5% and 8% of this gap for men and women was estimated to be due to smoking. The estimates from both these studies are probably moderate underestimates due to misclassification bias of smoking status. Despite the modest relative contribution of smoking to these gaps, the absolute number of smoking-attributable deaths is sizable and amenable to policy and health sector responses. There is some evidence, from New Zealand and elsewhere, for interventions that reduce smoking by low-income populations and indigenous peoples. These include tobacco taxation, thematically appropriate mass media campaigns, and appropriate smoking cessation support services. But there are as yet untried interventions with major potential. A key one is for a tighter regulatory framework that could rapidly shift the nicotine market towards pharmaceutical-grade nicotine (or smokeless tobacco products) and away from smoked tobacco.

Ethnic disparities in nutrition-related mortality in New Zealand: 1997-2011.

AIMS: To estimate the mortality due to non-optimal levels of systolic blood pressure, total blood cholesterol, body mass index (BMI), and vegetable and fruit intake amongst Maori and non-Maori in New Zealand in 1997. In addition, to estimate the ethnic-specific burden of disease that could potentially be avoided in 2011 if exposure to these risk factors were reduced. METHODS: The study uses comparative risk assessment methodology, a systematic approach to estimating both attributable and avoidable burden of disease developed by the World Health Organization. RESULTS: About 47% of deaths among Maori and 39% of deaths among non-Maori were estimated to be due to the selected risk factors. Age-standardised mortality rates for attributable ischaemic heart disease burden were consistently higher in Maori for individual risk factors. Age standardised mortality attributable to BMI was relatively higher for Maori, especially diabetes mortality. Estimates of avoidable mortality suggest that the health gains for Maori would be relatively greater than for non-Maori across all risk factors, but particularly with improvements in BMI. CONCLUSIONS: Non-optimal levels of systolic blood pressure, cholesterol, BMI, and to a lesser extent vegetable and fruit intake are major modifiable causes of death in New Zealand. Small changes in risk factor levels could have a major impact on population health within a decade, with relatively greater health gains for Maori.

Non-fatal disease burden associated with excess body mass index and waist circumference in New Zealand adults.

OBJECTIVE: To describe the relationship between two measures of body fat and selected non-fatal health conditions in the New Zealand adult population in 2003. METHOD: Data were obtained from the 2002/03 New Zealand Health Survey. A total of 10,026 adults aged 25 years and over were classified according to measured body mass index (BMI) and waist circumference (WC). BMI classes were 18.5-24.9, 25.0-29.9, 30.0-34.9, > or = 35.0 kg/m2. WC classes were < 94, 94-102, > 102 centimetres (cm) for males and < 80, 80-88, > 88 cm for females. Prevalence rate ratio estimates for selected self-reported health conditions were calculated for males and females separately, adjusting for age, ethnicity, deprivation and smoking using logistic regression. RESULTS: Increasing BMI or WC class was associated with increasing prevalence of cardiovascular disease, diabetes, high blood pressure, high blood cholesterol, osteoarthritis, asthma and sleep disorders in both males and females. The association with depression was not statistically significant in either gender. Associations were strongest for diabetes and blood pressure, with adults in the highest BMI or WC class at least 3.5 times more likely to have diabetes and 2-3 times more likely to have high blood pressure compared with those in the lowest classes. CONCLUSIONS: Increasing body fatness, defined by either BMI or WC, was associated with increased prevalence of many important health conditions. If the obesity epidemic is not halted or reversed, the impact on both the New Zealand population and health system will be considerable.

Racism and health: the relationship between experience of racial discrimination and health in New Zealand.

Accumulating research suggests that racism may be a major determinant of health. Here we report associations between self-reported experience of racial discrimination and health in New Zealand. Data from the 2002/2003 New Zealand Health Survey, a cross-sectional survey involving face-to-face interviews with 12,500 people, were analysed. Five items were included to capture racial discrimination in two dimensions: experience of ethnically motivated attack (physical or verbal), or unfair treatment because of ethnicity (by a health professional, in work or when gaining housing). Ethnicity was classified using self-identification to one of four ethnic groups: Maori, Pacific, Asian and European/Other peoples. Logistic regression, accounting for the survey design, age, sex, ethnicity and deprivation, was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Maori reported the highest prevalence of "ever" experiencing any of the forms of racial discrimination (34%), followed by similar levels among Asian (28%) and Pacific peoples (25%). Maori were almost 10 times more likely to experience multiple types of discrimination compared to European/Others (4.5% vs. 0.5%). Reported experience of racial discrimination was associated with each of the measures of health examined. Experience of any one of the five types of discrimination was significantly associated with poor or fair self-rated health; lower physical functioning; lower mental health; smoking; and cardiovascular disease. There was strong evidence of a dose-response relationship between the number of reported types of discrimination and each health measure. These results highlight the need for racism to be considered in efforts to eliminate ethnic inequalities in health.