OBESITY PREVENTION AND THE USE OF LAW :HOW FAR CAN LOCALITIES GO?THE NEW YORK CITY EXPERIENCETHE NEW YORK CITY EXPERIENCE

SEPTEMBER, 2010,

Lynn Silver, MD, MPHy , ,Assistant Commissioner

New York City Department of Health and Mental Hygiene

The New York City B d f H lthBoard of Health

• 1805 – The NYC Board of Health meets for first time, with Yellow Fever plaguing the cityplaguing the city.

• 1822 – Last epidemic of Yellow Fever (but cholera, typhus and tuberculosis persisted, fueled by crowding and a lack of sanitation)

• 1866 – NYS Law expands Board and insulates it from political influence by setting aside seats for physicians and scientists.

• Newly empowered, the Board decreed that "neither hogs nor goats [could] run at large in our city." Cholera deaths promptly fell by 90%.

URBAN CONDITIONS WERE A BREEDING GROUND FOR 19TH

CENTURY EPIDEMICS

Over-crowding:Over crowding:By 1910, the average density in lower Manhattan was 114,000 people/ sq. mi; two wards reached densities > 400,000.

Major epidemics:

Air-borne diseases:,(Today’s density: 67,000/ sq. mi.)

+

Air borne diseases:TB

Water-borne diseases:Cholera

Inadequate systems for garbage, water, and sewer, leading to pervasive filth and polluted water supplies.

Vector-borne diseases:Yellow-fever

pp

THE SANITARY CODE OF THE BOARD OF HEALTH CITY OF NEW YORK 1870

• Dealt with housing construction• Sidewalks and sanitation• Regulated food and drink, including fats g , g

(rendering rules)• Regulated retail practices on what whereRegulated retail practices on what, where

and when certain products affecting health could be soldcould be sold

19TH -20TH CENTURIES: URBAN DESIGN RESPONDED AND THE LEGAL FRAMEWORK EXPANDED FROM LOCAL HEALTH LAW TO OTHER SECTORS

1842 New York’s water system established – an aqueduct brings fresh water from Westchester.

1857 NYC creates Central Park, hailed as “ventilation for the working man’s lungs”, continuing construction through the height of the Civil War

1881 Dept. of Street-sweeping created, which eventually becomes the Department of Sanitation

1901 New York State Tenement House Act banned the construction of dark, airless tenement buildings

1904 First section of Subway opens, allowing population to expand into Northern Manhattan and the Bronx

1916 Zoning Ordinance requires stepped building setbacks to allow light and air into the streets

LAW AND URBAN DESIGN HELPED CURE 19TH C. EPIDEMICS AND WILL HELP SOLVE THE 21ST C. EPIDEMICS

THE 19th CENTURY:

Infectious disease

THE 21st CENTURY:

Chronic Diseases, many of which are “Diseases f Ener ”

19th Century codes, planning and infrastructure as weapons in the battle against contagious disease

“Diseases of Energy”

The emerging design solutions for health parallel sustainable design solutions

These strategies were built into the city fabric, and they were effective

solutions

Effective designs will have to be an invisible, pervasive, and inevitable part of lifelife.

1960 Health Code (+other changes) Worked Before for Non Communicable Disease: Decline in Childhood Lead Poisoning after the 1960 Health Code restriction on lead paint in NYC

3000

2000

2500

1500

er o

f Chi

ldre

n

>= 60ug/dL

>/= 40 ug/dL

1000

Num

be

500

0

1970197119721973197419751976197719781979198019811982198319341985198619871988198919901991199219931994199519961997199819992000

“Actual” Causes of DeathUnited States 2000United States, 2000

0% 5% 10% 15% 20%Percent of deaths

0% 5% 10% 15% 20%

Tobacco

Diet & physical inactivity

Alcohol

Infectious agents

Toxic agentsToxic agents

Motor vehicle crashes

Firearms

S l b h iSexual behavior

Illicit drugs

Mokdad AH, Marks JS, Stroup DF, Geberding JL, JAMA 2004;291:1238-1245

Deaths Attributable to Individual Risks in the U.S.

Thousands of Deaths

Danaei G et al. The Preventable Causes of Death in the United States: Comparative Risk Assessment ofDietary, Lifestyle, and Metabolic Risk Factors. PLoS Med 6(4): e1000058. doi:10.1371/journal.pmed.1000058

NYC’s APPROACH TO CHRONIC DISEASE AND OBESITY: LEARNING FROM THE PAST

Seek to change the environment to promote:• Increased consumption of healthy foods• Decreased consumption of unhealthy foodsp y• Increased physical activity• Decreased tobacco use• Decreased tobacco use

THERE IS NO SIMPLE SOLUTION

TO STEM THE TIDE OF OBESITY AND CHRONIC DISEASE WILL REQUIRE A DIKE WITH MANY SANDBAGS BEFORE OUR FEET WILL BE DRY

(borrowed from Katz)(borrowed from Katz)

SOME POTENTIAL POLICY APPROACHES TO THOSE GOALS = Health in All?

• Taxation Policy• Regulation of food productiong p• Regulation of retail environment and

community food availabilityR l ti f l i d i d• Regulation of planning, design and construction practices as well as use of zoning

• Regulation of the transportation environmentRegulation of the transportation environment• Regulation of health care providers• Regulation of information, signage and

commercial speech practices• Subsidies and mechanisms to affect price

Use of public and private purchasing power• Use of public and private purchasing power

CHRONIC DISEASE PREVENTION IN NYC:FOOD RELATED POLICIES

• Daycare Regulations– 2006, Board of Health,

• Trans Fat Restriction– 2006, Board of Health - later City Council2006, Board of Health later City Council

• Calorie Labeling Regulations– 2006 – 2007, Board of Health2006 2007, Board of Health

• Public Procurement and Vending StandardsStandards

– 2008 – 2009, Mayoral Executive Order• National Salt Reduction InitiativeNational Salt Reduction Initiative

– 2009, Voluntary

DO THESE MEASURES WORK?

TRANS FAT USE IN NYC FOOD SERVICE ESTABLISHMENTS2005-2008

MEAN CALORIES PURCHASED BY CHAIN2007 - 2009

35

26

-96

35

Popeye's

Pizza Chains (3)

Taco Bell

-80

-59

Au Bon Pain

KFC*

*

44

133

-37

Burger King

Wendy's

Subway *

44

-44

-125 -100 -75 -50 -25 0 25 50 75 100 125 150

McDonald's

Burger King

Change in Mean Calories

*

Change in Mean Calories

* t-test; p<0.05

In NYC Fast Food Establishments

DIFFERENCE IN CALORIES PURCHASED BETWEEN THOSE WHO USE AND THOSE WHO DO NOT USE CALORIE INFORMATION, 2009

-101

-137

90

Popeye's

Pizza Chains (3)

Taco Bell

-23

-41 Au Bon Pain

KFC

-139

-91

Wendy's

Subway*

*

-133

-156

-175 -150 -125 -100 -75 -50 -25 0 25 50 75 100

McDonald's

Burger King**

Difference in Mean Caloriest-test; p<0.05*

In NYC Fast Food Establishments

CALORIE LABLEING: THE STARBUCKS STUDY

• Studied over 100 million transactions, i b f d ft l icomparing before and after calorie

labeling • 6% decline in mean calories after labeling

went into effect• No negative effect on revenue

(Bollinger et al 2010)(Bollinger, et al, 2010)

SUGAR SWEETENED BEVERAGE TAX

• Introduced in New York State by Governor Paterson twice (2009, 2010 budgets)Paterson twice (2009, 2010 budgets)

• Penny per ounce excise tax would:– Reduce consumption by 15-20% among NewReduce consumption by 15 20% among New

York State residents– Prevent 37,400 diabetes cases within next

decade– Prevent 145,000 adults from becoming obese– Health benefits larger among African Americans

& Hispanics than among non-Hispanic Whites

Clare Wang, 2010

What do People Think? Quinnipiac Poll 2010: People Care About Food

• To balance the City Budget would you support a tax on sugary soft drinks?

– 76% YES (60% of Republicans) • When it comes to trying to improve people’s health habits do you thinkWhen it comes to trying to improve people s health habits, do you think

the Bloomberg Administration policies have gone too far, not far enough, or they are about right?

– About right: 55% (46% of Republicans) Not far enough: 17% (12% Republicans)– Not far enough: 17% (12% Republicans)

• Was the law requiring fast food restaurants to post calories information useful or not useful?

– Useful: 84% (69% of Republicans) D thi k th Bl b d i i t ti i t t N• Do you think the Bloomberg administration is correct to encourage New York City restaurants to use less salt in food preparation or don’t you think so?

– 77% YES (55% of Republicans) • When it comes to your point of view regarding the government getting

involved with things like the salt content and calorie posting of restaurant food – it is important because it helps improve public health or it is just meddling? g

– Important: 79% (50% of Republicans)

PHYSICAL ACTIVITY PROMOTING DESIGN

• New York City Street Design ManualNew York City Street Design Manual (policy, mandatory)

• New York City Active Design Guidelines• New York City Active Design Guidelines (currently voluntary)LEED C dit• LEED Credits

KEY TOBACCO POLICIES IN NYC

• Taxation – Federal, NYS Legislature, New Y k Cit C ilYork City Council

• Smoke Free Indoor Air– NY City Council 2002 NYS 20032002, NYS 2003

• Adolescent Tobacco Use Prevention Act -NYS L i l tNYS Legislature

• Tobacco Signage – Board of Health 2009• Ban on Flavored Smoke Free Tobacco

Products – 2009 NY City Council

NYC ADULT SMOKING PREVALENCE1993-2007

300,000 Fewer SmokersAbout 100,000 Premature Deaths Prevented

24

City and Statetax increases

Smoke free3-yr average

3-yr average3-yr average

21.6%

21.7%21.5%21.6%

20

22

24 Smoke-free workplaces

Free patchprograms

3 yr average

Media campaign

18.4%19.2% 18.9%18

20

f adu

lts

p g

17.5%18.4%16.9%

14

16% o

121993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

CONCLUSIONS

• Well crafted regulation and policy does work• Selected regulatory approaches to reducing g y pp g

chronic disease risk have been effective, at least in changing behavior, others need evaluationevaluation

• Multiple approaches involving different levels of government and society are needed to g yachieve large scale risk reduction

• Cardiovascular disease and obesity outcomes have complex determinantsoutcomes have complex determinants. Assessing the isolated impact of each policy measures will not be easy

LOCAL BOARDS OF HEALTH

• In NYC, the Board of Health has been key, but not the only factor, in our innovative policy work

• 75% of local boards of health have “governing authority” including establishing local ordinancesauthority including establishing local ordinances and regulations (NALBOH 2008)

• Challenges include cost of enforcement• Challenges include cost of enforcement, navigating preemption, protected commercial speech and precedents such as the Borealidecision in NY State which placed limits on thedecision in NY State, which placed limits on the action of such bodies

RECOMMENDATIONS

• Legal frameworks at all levels of government that have been used effectively in the past tothat have been used effectively in the past to vastly reduce the burden of infectious disease should be mobilized once again to address gchronic disease and obesity

• Reinvent traditional areas of authority that protect the public’s health and safety such as food safety, or building safety for the 21st

t b l t ti d ti f b itcentury, by also targeting reduction of obesity related chronic disease

RECOMMENDATIONS

• Locals Boards of Health are one important avenue to achieve some of these changes– As technical regulatory bodies, to be more effective,

consider requiring a predominance of public health and health professionalsand health professionals

• Advocacy and education of the public on key issues are necessary to build support and shift social norms

• Caution and responsibility should accompany innovation and courage lest we jeopardize theinnovation and courage lest we jeopardize the autonomy of key local public health institutions

"It is one of the happy incidents of the federalincidents of the federal system, that a single courageous state may, if g y,its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country “the rest of the country.

Justice Louis D. Brandeis,1932