Designing Healthy Communities by Dr. Richard Jackson

Richard J JacksonMD MPH FAAP

HonAIA HonFASLA dickjackson@ucla.edu

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) dickjackson@ph.ucla.edu

UCLA Fielding School of Public Health

We Are What We Eat…And What We Build

http://designinghealthycommunities.org/