Richard J JacksonMD MPH FAAP
HonAIA HonFASLA [email protected]
UCLA Fielding School of Public Health
/
Antelope ValleyWellness Symposium
October 29, 2015
The Check Up
10 year old boy
“Problem” List
• Physical exam unremarkable• Ht 54” (50%) • Wt 115# (95%)• BP 140/90• Blood glucose elevated, urine normal• Cholesterol 220• Signs of Depression
Treatment Plan
• Referral to “overweight” clinic • Weight loss program • TV out of the bedroom; no soft drinks in
the house• Exercise program; Encourage sports
Two Months Later…
• Lost One pound• Can’t change the food at school• Day is already too full• No Time for exercise; “not good at
sports”• No place to Walk
– Antihypertensive medication
– Oral Hypoglycemic agent
– Antidepressant– Cholesterol lowering
agent
• Monthly medication costs: – $385
2 months later the patient is taking:
• The “environment” is rigged against the child…
• And the doctor, • And the rest of US.
USA Today 10/20/2011
August 20, 2015
“Ask physicians across the country what problems they want solved, and they won't hesitate to tell you. They worry about the growing health risks they observe in patients based on lifestyle choices, obesity and a variety of social factors which they feel powerless to change.”
Robert Pearl MD Forbes Magazine Aug 20, 2015
Life Expectancy at Birth and Health Spending 2011
• “Even under the most optimistic estimates, of the 30 years of increased life expectancy achieved between the 1890s and 1990s, only 5 years can be attributed to medical care.”
Bunker cited in Prescription for a Healthy Nation Farley and Cohn 2004
CDC Headquarters - Atlanta
July 6, 1999
• The Built Environment – how we build our homes, workplaces, towns, cities and world
The United States has now paved over the equivalent area of the entire state of Georgia
60,000 square miles
And Photosynthesis is our friend!
Commuting by driving is mostly not good for you.
Traffic along LA freeways and Wilshire Blvd.
We Used to Build Real Towns and Neighborhoods but Now…
Nature Does Not Tolerate Monocultures for long…
Two houses, adjoining back yards(From Streetsblog, 02/28/2013)
For every age group from 3 through 34--crashes were the No. 1 cause of death
Pedestrian Fatality Rates for Collisions at Different Speeds
Zegeer et al 2002
Obesity Trends* Among U.S. AdultsBRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Fast Food Restaurants
• “ black/low income” neighborhoods ~
2.4 per sq. mile• “white” neighborhoods:
1.5 per sq. mile
American Journal of Preventive Medicine, October 2004
“Supersizing” a fast-food meal – the real costs
• Paying 67 cents to supersize an order — 73% more calories for 17% more money
• — adds an average of 36 grams of adipose tissue.
• The future medical costs for that “bargain” would be $6.64 for an obese man and $3.46 for an obese woman.
University of Wisconsin-Madison, Rachel N. Close and Dale A. Schoeller
0
25
50
75
100
Relationship Between BMI and Risk of Type 2 Diabetes
Chan J et al. Diabetes Care 1994;17:961.Colditz G et al. Ann Intern Med 1995;122:481.
Age
-Adj
uste
d R
elat
ive
Ris
k
Body Mass index (kg/m2)
WomenWomen
MenMen
<22 <23 23-
23.9
24-
24.9
25-
26.9
27-
28.9
29-
30.9
31-
32.9
33-
34.9
35+
1.02.91.0
4.31.0
5.01.5
8.12.2
15.8
4.4
27.6
40.3
54.0
93.2
6.7 11.6
21.3
42.1
Percentage of US Adults with Diagnosed Diabetes - 1994
Percentage of US Adults with Diagnosed Diabetes - 2001
Percentage of US Adults with Diagnosed Diabetes - 2007
NHANESNational Health and Nutrition Examination Survey
Prevalence of and Trends in
Diabetes Among Adults in the
United States, 1988-2012
Andy Menke; Sarah Casagrande; Linda Geiss, Catherin Cowie JAMA. 2015;314(10):1021 doi:10.1001/jama.2015.10029
How Diabetes & Prediabetes Diagnosed
In This Study
• Diabetes– Prior Clinical Diagnosis or– Hemoglobin A1c level of >6.4% – Fasting Plasma Glucose >125 mg/dL
• Prediabetes – Hemoglobin A1c level of 5.7- 6.4%,– FPG level of 100 - 125 mg/dL
Diabetes Prevalence NHANES (using Hemoglobin A1c , FPG)
Sample of US PopulationAll Age Groups, Races, Income and Education
1988-1994 2000-2002 2011-20129.8% 10.8% 12.4%
For Prediabetes36.5%
10,000 steps
• 3234 people with Pre-Diabetes(IGT –Impaired Glucose Tolerance)
• Walked or exercised five times a week for 30 minutes for six months
• Lost 5% to 7% of their body weight • Reduced their risk of diabetes by 58%
Survival of 1263 men with Type 2 Diabetes: Fit vs Unfit
Low Cardiorespiratory Fitness and Physical Inactivity as Predictors of Mortality in Men with Type 2 Diabetes." 18 April 2000 Annals of Internal Medicine 132, pp 605-611 M. Wei et al
“The Status of Baby Boomers’ Health in the
United States: The Healthiest Generation?”
JAMA Internal Medicine
February 4, 2013
Overall Health Status US Persons Aged 46-64
NHANES 1988-1994 NHANES 2007-2010
Report “excellent” health32% 13%
Limitations to Life Functions9% 14%
Using Walking Assist (wheelchair, cane, etc)3% 7%
“Lifestyle Factors” USPersons Aged 46-64 (NHANES)
1988-1994 2007-2010
Smoking28% 21%
Obesity 29% 39%
“Lifestyle Factors” USPersons Aged 46-64 (NHANES)
1988-1994 2007-2010
No Regular Physical Activity17% 52%
Thinking about solutions
US High Fructose Corn Sugar
Consumptionper capita per day
• Year Pounds Calories• 1965 0 0• 1970 0.5 2• 1980 19 53• 1990 50 134• 2000 64 179
Likely Results of a Sugar Sweetened Beverage (SSB) Tax
• “A national tax of 1 cent per ounce on sugar-sweetened beverages (SSBs) would decrease consumption by 23% and raise $14.9 billion in the first year alone.”
Brownell KD, et al. The public health and economic benefits of taxing sugar-sweetened beverages. NEJM. 2009;361(16):1599-1605.
“Modern” Schools
Credit: Constance E. Beaumant, NTHP
Credit: South Carolina Coastal Conservation League
• Percent of children who walk or bike to school:
• 1974 66% • 2000 13%
(CDC, 2000)
We have changed how much we walk or bike
Fitness of California ChildrenAnnual Fitnessgram Results
Conducted in Grades 5, 7, and 9Measures 6 major fitness areas
(e.g. aerobic capacity, body composition, flexibility)
2011 Results: Who passed all standards?
Grade 5: 25% Grade 7: 32% Grade 9: 37%
http://www.cde.ca.gov/nr/ne/yr11/yr11rel95.asp#tab1
The Built Environment:
Designing Communities to
Promote Physical Activity in Children
Policy Statement American Academy of Pediatrics
June 2009
Institute of Medicine Report
Accelerating Progress in Obesity Prevention
May 8, 2012
Gain in Longevity for a 45-Year Old Male
5.8 years
8.7 years
0
2
4
6
8
10
Low vs Moderate Low vs High
Years of added life
Additional years of Life:Moving from Low to Moderate Fitness -- 5.8 years
From Low to High –- 8.7 years.
MRI Study of Brain Scans of 120 older adults--
Half –Moderate aerobic
exercise: 45 minutes, three days a week, mostly walking.
Half—No extra aerobic
exercise.
One year later:
MRI Study of Brain Scans of 120 older adults One Year Later—
Half – Moderate aerobic exercise -- 45 minutes, three days a week, mostly walking.
Brain size increased
Half— No extra aerobic exercise --Brain Size Decreased 1.5%
Result: 3.5% difference Further tests showed that increased brain volume translated into better memory.
From the San Diego Planning Journal
• Lancaster Boulevard was a five-lane road w/ travel speeds up to 50 mph.
• In 2010, the city revitalized nine blocks of Lancaster Blvd.
• $11.6 million street renovation project.
• 800 new permanent jobs were created.
• 26% increase in sales tax revenue.
• By 2012, the project attracted $130 million in private investments and generated $274 million in economic output.
Lancaster Boulevard, CA
5
May 2014 UCLA the elevator doors in parking lots 4, 7, and 8UCLA Department of Transportation
NYC Active Design Guidelines
• Resilient Bldgs• Energy Efficient
Buildings• Healthy Bldgs• Smart zoning and
locations
http://www.nyc.gov/html/ddc/html/design/active_design.shtml
http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/call-to-action-walking-and-walkable-communites.pdf
Importance of What Makes People Happy
Marketplace is Shifting--More than 56% of home buyers want a home that is a walkable neighborhood with as little need for driving as possible.
“The BLVD is an endeavor to bring back the downtown experience”Lancaster, California
CicLAvia Los Angeles April 2012
Importance of Fun…and Festivals
Boyle Heights, Los Angeles. The Evolution into Mariachi Plaza
For Mariachi Plaza….”proposed eight-story medical office building and a six-level parking garage, plus a three-floor building with street-level retail would take out a small row of shops immediately north of the plaza…
Atlanta Citizens Turning Out To Help Get Ready for The Belt Line
Importance of Community Pride
Indianapolis Cultural Trail
• 8 miles $69 million• First $15 million from Glick
family (start with philanthropy) • $2 million for Art• Links the city together• Revitalized Business• Helps to Recruit and Retain
Top Talent• And, yes, a GOP Mayor
Importance of Art and Beauty and Nature
Home Price Growth By Neighborhood Type2011-2014
Image Credit: Lehrer + Associates and LA River
Image Credit: Lehrer + Associates and LA River
Economic Benefits of Urban River Parkways
● Medical cost savingso one study found that every $1 invested in trails for
physical activity resulted in nearly $3 direct medical benefit
● Economic developmento sale prices up to 16% higher for homes within 1,500ft of
natural spaceso Colorado: land value increased by $4.20 for every foot
closer to the “greenbelt”o Philadelphia: property values increased from $1,000/acre
2,500ft from park to $11,500/acre within 40ft
The Manhattan Waterfront Greenway 32-mile long walking and bicycling path around the island of Manhattan.
The majority of the Manhattan Waterfront Greenway is physically separated from auto traffic
• Importance of Courage– The NYC High Line
• AIA Report:Local Leaders—
Healthier Communities Through Design
2013
The High LineNYC
A 20 block walk in Manhattan
without a cross street–
and it was delightful even with a 2 year old.
Ten Principles
for Building Healthy Places
The Urban Land Institute 2013
Urban Land Institute’s Healthy Places Toolkit
Released at International Meeting in Paris February 5, 2015
http://www.uli.org/toolkit
http://www.uli.org/toolkit
http://www.uli.org/toolkit
http://www.uli.org/toolkit
Richard J Jackson MD MPH AIA(Hon) FAAP ASLA(Hon) [email protected]
UCLA Fielding School of Public Health
We Are What We Eat…And What We Build
http://designinghealthycommunities.org/