the check up · 2011. 10. 12. · 2011 tpha annual conference 14 weight gain • rates of...

9/15/2011

2011 TPHA Annual Conference 1

Richard J Jackson [email protected]

Public Health: Touching Every Life, Linking Every Community

The Check Up

10 year old boy

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“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

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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:

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• The “environment” is rigged against the child…

• And the doctor.

U.S. “Health” Care Expenditures as Percent of

GDP

Keehan et al: Health AffairsMarch/April 2008 27: 145-155

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Health Care Spending as % of GDP

Male Life Expectancy

US Life Expectancy is #49 Worldwide – CIA Chartbook

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10 leading causes of death -United States, 1900

0 2 4 6 8 10 12 14

Pneumonia

Tuberculosis

Diarrhea and enteritis

Heart disease

Stroke

Liver disease

Injuries

Cancer

Senility

Diphtheria

Percentage

• “Even under the most optimistic estimates, of the 30 years of increased life expectancy achieved between the 1890s and 1990s…????? can be attributed to medical care.”

Bunker cited in Prescription for a Healthy NationFarley and Cohn 2004

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• “…of the 30 years of increased life expectancy 1890 -1990…

5 years can be attributed to medical care.”

The rest has come from immunization and changes in the living environment.

Bunker cited in Prescription for a Healthy NationFarley and Cohn 2004

Medical Care is NOT… Health Care

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CDC Headquarters - Atlanta

July 6, 1999 Buford Highway Atlanta, Georgia

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Disease in the 21st Century

• Diseases and costs of care for Aging Populations.

• Overweight: Diabetes II, Heart Disease

• Mental Disorders: Depression, Anxiety, Developmental, Substance Abuse

• Macro-environment: Climate, Conflict

• The Built Environment –how we build our homes, workplaces, towns, cities and world

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60,000 square miles of TheUnited States has been Paved Over. The equivalent area of the entire state of Georgia

60,000 square miles

And Photosynthesis is our friend!

Chamblee, GA Runoff to North Peachtree Creek

The More We Pave the Poorer the Water Quality

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The More We All Drive,The Longer It Takes to Get There

Traffic along LA freeways and Wilshire Blvd.

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Atlanta Journal-Constitution, March 10, 2006

Mother convicted of vehicular homicide after her child was struck and killed by a partially blind driver who consumed alcohol prior to the crash

The driver was only charged with hit-and-run

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Weight Gain• Rates of overweight and obesity have

tripled among 12-19 year olds and quadrupled among 6-11 year olds in the last three decades

Babey SH, et al. (2009.) Bubbling Over: Soda Consumption and Its Link to Obesity in California. UCLA Center for Health Policy Research.

Obesity Trends* Among U.S. AdultsBRFSS, 1991

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

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No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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• Obesity Trends US Adults 2010

NHANES -- Measured

NHANES – In person interview-- self-reported

BRFSS – Telephone Interview

Body Mass Index US Females 1988-1994

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Hardee's introduces new

Mega-Calorie “Monster

Thickburger”

• 1,420 calories

• 107 grams of fat

• 7.1 hours of moderate walking

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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 only 17% more money

• A Bargain!

University of Wisconsin-Madison, Rachel N. Close and Dale A. Schoeller

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“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

Supersizing Jet Fuel Use• Mean weight gain of Americans in 1990s:

10 pounds• Airline distance flown in 2000 in US:

515 billion passenger-miles• Weight transported 1 mile by 1 gallon of fuel:

7.3 tons (passengers or cargo) • Jet fuel to transport added weight in 2000:

350 million gallons• Cost of extra fuel: $1.4 billion

• (Sept 2008 prices)

• CO2 emissions from extra fuel: 3.8 million tons

Data sources: NCHS; US Dept. of Transportation

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Mega-Mileage Moms

•Average minutes per day spent in car:- Women overall: 64 minutes- Single mothers: 75 minutes

Surface Transportation Policy Project: 2000

Overall: Compared to 1969Americans drive:- 88% farther to shop - 137% farther for errands

•Family “chauffeur”

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The Less We Walk,The Less Fit We Become

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Credit: Hummel Architects, Boise, ID

Why did we eliminate walkable local schools?

Credit: Manitovic Public School District

And Compel Children to Ride to Big Distant Ones

Credit: Constance E. Beaumant, NTHP

Credit: South Carolina Coastal Conservation League

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• Percent of children who walk or bike to school:

• 1974 66%• 2000 13%

(CDC, 2000)

Fitness of California’s ChildrenAnnual California Fitnessgram • Conducted in Grades 5, 7, and 9

• Measures 6 major fitness areas (e.g. aerobic capacity, body composition, flexibility)

• 2004 Results: Who passed all standards?

Grade 5 25%

Grade 7 29%

Grade 9 26%

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Many Disease Risks Go Up Due to Obesity…

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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)

Men

Women

<22 <23 23-

23.9

24-

24.9

25-

26.9

27-

28.9

29-

30.9

31-

32.9

33-

34.9

35+

1.0

2.91.0

4.31.0

5.01.5

8.12.2

15.8

4.4

27.6

40.3

54.0

93.2

6.711.6

21.3

42.1

Percentage of US Adults with Diagnosed Diabetes - 1994

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By the year 2050—21% of the US population will have diabetes--33% if everyone receives good treatment

Diabetes Projected Risks:For Babies Born in 2000

Girls: 38% lifetime risk – If diabetic before age 40, Lifespan

shortened by 14 years (Quality of life by 19 years)

Boys: 33% lifetime risk

If diabetic before age 40, Lifespan shortened by 12 years. (Quality of life by 22 years)

V Narayan et al: JAMA 8 Oct 2003

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17 teaspoons of SUGAR

250 calories

40 minutes of hard

basketball

ONE 20 oz SODA per day

soda

Becoming Obese is a “Personal” Decision! (?)

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People “Decide” What To Consume

• Super Bowl XXXVIII ads at $75,000/second

• Anheuser-Busch: 5 minutes

• Pepsi Cola: 3 minutes

Theresa Devine & Amy Vetal

BILLBOARDS VS. HEALTH: Considering the Impact of Billboards on Health

BILLBOARD TYPES• ALCOHOL: 12• ENTERTAINMENT: 26• FOOD: 1• PRODUCT: 16• WEIGHTLOSS: 0• OTHER: 10TOTAL 65

CASE STUDY: SUNSET BLVD (HOLLYWOOD)

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BILLBOARDS VS. HEALTH: Considering the Impact of Billboards on Health

Case Study LaBrea, Hawthorne


BILLBOARDS VS. HEALTH: Considering the Impact of Billboards on HealthCASE STUDY: LA BREA HAWTHORNE)

BILLBOARD TYPES• ALCOHOL: 17• ENTERTAINMENT: 3

• FOOD: 4• PRODUCT: 3• WEIGHTLOSS: 4• OTHER: 4TOTAL 35

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High Fructose Corn Sugar

• US annual per capita consumption of HFCS

• 63 pounds

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• Cold Stone Creamery PB&C Shake:

• A 24-oz. “Gotta Have It” size shake of peanut butter, chocolate ice cream, and milk has a day’s calories (2,010) and three and a half days’ worth of saturated fat (68 grams)..

1

1.61.9

2.4

0

0.5

1

1.5

2

2.5

Lean Obese

Risk of Death

Active

Inactive

Hu et al. NEJM, December 23, 2004; 351(26):2694-2703.

Nurse Study 1976-2000

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More time in a car Higher probability of obesity

More walking Less obesity

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Higher density and connectivity Lower obesity Atlanta study 2004

The More We Drive, The More We Crash

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For every age group from 3 through 33--crashes were the No. 1 cause of death

Pedestrian Fatality Rates for Collisions at Different Speeds

Zegeer et al 2002

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Automobile fatality rates by city, 1998(excluding pedestrian fatalities; deaths/100,000/year)

9.80

10.52

11.33 13.12

Source: NHTSA

2.51New York

3.76San Francisco

6.55Portland

9.80Houston

10.52Phoenix

11.33Dallas

13.12Atlanta

5.36Philadelphia

Number of Lives Saved per year if National Car Fatality Rate same as:

• New York City 24,000

• Portland 15,000

• Atlanta None– 15,000 additional

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The More We Drive,The Poorer We Become

• Transportation spending is the second largest component of consumer expenses, currently taking up an average of 19 percent of their monthly income (monthly home mortgage payments generally at least 33 percent).

Americans work 500 hours a year –2 hours per day—just to pay for their cars

12.5 working weeks!

Image: http://www.thedailygreen.com/environmental-news/latest/save-gas-47031702

http://www.grist.org/list/2011-05-10-two-hours-of-your-work-day-goes-to-paying-for-your-car

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http://www.transact.org/report.asp?id=41

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Changes in Before Tax US Household Incomes 1949-1979

Changes in Before Tax US Household Incomes

1979-2003

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Changes In After-Tax US Household Income1979-2000

The More We Pave,The Hotter It Becomes

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The Heat Island

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The Hotter it Becomes, The Poorer the Air Quality

Asthma Study in 12 Southern California High Schools

• 3535 children with no history of asthma in 6 high and 6 low air pollution high schools

• 5 years later: 265 developed asthma. – High ozone high schools:

• asthma rate was 3.3x higher in children playing three or more sports.

– Low ozone high schools: • sports had no effect on asthma rates

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“Keeling Curve”

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July 2011 Was Hot!Warmest Month on Record for

Washington DC, Oklahoma City, Philadelphia and Austin

• But what made this month unusual wasn't only the hot days, but rather the hot nights.

2,100 Daytime records, 6,700

Nighttime Records

July, 2011 Record High Temperatures

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CUMULATIVE greenhouse emissions in 2002, by countryDensity-equalizing cartogram;

WHO region size proportional to mortality

Jonathan Patz,

University of Wisconsin

Climate-related mortality (per 106 population), 2000Density-equalizing cartogram; WHO region size proportional to mortality

Jonathan Patz

University of Wisconsin

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We need solutions that solve multiple problems

Culinary Institute of America

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Food

Doof

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Always good, but especially as we age, what is the

best exercise?

10,000 Steps a DayOriginated from Japanese: “Manpo-Kei”

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10,000 steps

• 3234 people with IGT (Pre-Diabetes)

• walked or exercised five times a week for 30 minutes

• lost 5% to 7% of their body weight

• reduced their risk of diabetes by 58%

“ These stairs have become a gathering, meet and greet space for us as well as a way to get from the first to the third floor. Since we moved into our new office with its convenient, attractive stair, almost no one uses the elevator.”Thompson E. Penney, FAIA President/CEO LS3P ASSOCIATES LTD.

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How we build affects how safe and happy we are.

US Antidepressant Rx’s19 million

American adults

• Leading cause of disability in the U.S. and worldwide

Source: National Institute of Mental Health (NIMH), 2001

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Exercise for the treatment of depression and anxiety.

• International Journal of Psychiatry and Medicine. 2011;41(1):15-28. Carek, PJ et al

• Department of Family Medicine, Medical University of South Carolina, Charleston 29406, USA.

Depression and anxiety are the most common psychiatric conditions seen in the general

medical setting, affecting millions of individuals in the United States.

• Physical activity has been consistently shown to be associated with improved physical health, life satisfaction, cognitive functioning, and psychological well-being.

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• Conversely, physical inactivity appears to be associated with the development of psychological disorders. Specific studies support the use of exercise as a treatment for depression.

• Exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression and has also been shown to improve depressive symptoms when used as an adjunct to medications.

Cooling Things Off

• Trees• White roofs and other surfaces• Solar Roofs

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Ontario, California

Without “net metering”, owners are discouraged from building the largest system the site will accommodate.

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6% of US Household Electricity Used by Clothes Dryers

LA Times Feb 7, 2009

Total Electricity Use, per capita, 1960 - 2001

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

KW

h

12,000

8,000

7,000

California

U.S.

kWh

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Farmers’ Markets and

Urban Agriculture

Five year Intensive Program In 13 very low income semi-rural cities: Focus on

School Food and Student Eating Habits

• School meals included a wide variety of fresh fruits and vegetables, and junk food was eliminated or sharply curtailed.

• Compliance with California’s competitive food and beverage standards more than doubled during the program period (from 23 percent to 61 percent for food, and from 45 percent to 91 percent for beverages).

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1 cent per teaspoon on sweeteners including HFCS?• Average American

consumes 63 pounds of HFCS each year (6,048 teaspoons).

• US population: 300 million

• $0.01 per teaspoon HFCS would generate…

>$20 billion a year

• The Built Environment: Designing Communities to Promote Physical Activity in Children

• Policy Statement American Academy of Pediatrics

• June 2009

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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Year:0

2,500

5,000

7,500

10,000

12,500

0

50

100

150

200

250

300

350

Bridge Bicycle Traffic

Bikeway Miles

Bridge Bicycle Traffic 2,850 3,555 3,885 3,830 3,207 4,520 5,225 5,690 5,910 6,015 7,686 8,250 8,562 8,875 10,192 11,956Bikeway Miles 78 83 86 103 113 144 166 183 213 222 235 252 254 260 262 263

Increasing Bicycle Use, Portland, ORCyclists Per Day Bikeway Miles

1991:78 miles of bikeways

2,850 daily trips

2006:263 miles of bikeways

11,956 daily trips

Cumulative Government Capital Investment in Transit and Highways Since 1956

http://www.calpirg.org/home/reports/report-archives/world-class-public-transit/world-class-public-transit/a-better-way-to-go-meeting-americas-21st-century-transportation-challenges-with-modern-public-transit

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http://www.grist.org/article/2010-08-26-when-streets-tell-the-truth-about-people-riding-in-cars-bikes/

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Charlotte, NC, Light Rail Opened November, 2007

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People at 839 Locations were interviewed in the years before and after Charlotte Light Rail Service Began.

Light Rail Users Had

A significant increase in meeting the weekly Recommended Physical Activity Guidelines

… through walking (OR1.09)

…and through vigorous exercise (OR1.11)

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Light Rail Transit Users Had

…an average reduction of 1.18 BMI points (p<0.05) and

…an 81% reduced odds of becoming obese over time.

For a person who is 5’5” --equivalent to a weight loss of 6.45 lbs.

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APHA National Meeting 2002Abstracts with “land use” - 0


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American Journal of Public Health

Built Environment and Health Special Issue

September, 2003


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APHA National Meeting 2008Abstracts with “land use” -- 82

APHA National Meeting 2009Abstracts with “land use” -- 130

http://apha.confex.com/apha/137am/webprogram/start.html#srch=words%7C%22land%20use%22%7Cmethod%7Cand%7Cpge%7C1

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National Academy of Sciences Committee on Health Impact Assessment

Richard J. Jackson (Chair), University of California, Los AngelesDinah Bear, Attorney at Law, Washington, DCRajiv Bhatia, San Francisco Department of Public Health; University of California,

San Francisco Scott B. Cantor, The University of Texas MD Anderson Cancer Center, HoustonBen Cave, Ben Cave Associates, Ltd., Leeds, United KingdomAna V. Diez Roux, University of Michigan, Ann ArborCarlos Dora, World Health Organization, Geneva, Switzerland Jonathan E. Fielding, Los Angeles County Department of Public Health, Los

Angeles, CAJoshua S. Graff Zivin, University of California, San DiegoJonathan I. Levy, Boston University School of Public Health, Boston, MAJulia B. Quint, California Department of Public Health (retired), BerkeleySamina Raja, University at Buffalo, State University of New York, BuffaloAmy Jo Schulz, University of Michigan, Ann ArborAaron A. Wernham, Pew Charitable Trusts, Washington, DC

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The committee defined health impact assessment as follows:

HIA is a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects.

The committee recommended a six-step framework that includes the

following elements:

• Screening

• Scoping

• Assessment

• Recommendations

• Reporting

• Monitoring and Evaluation

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Cooper River BridgeCharleston SC

• If you build a walkway on a major bridge, how many pedestrians and bicyclists will use it?

Walkway on Cooper River Bridge, Charleston SC

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AK 4

CA 16 CO 1

FL 1

MA 2

NJ 1

Completed HIAs in the United States1999–2008 (N = 39)

MN 4

GA 3

WA 3

OR 1

OH 1PA 1

MD 1

Our patient starts to walk or bicycle to school 1 mile 4 days

per week

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• The family car ran 800 less miles per year

• 40 gallons of gasoline saved

• Saved $400-500/year

• 30 minute walk or bicycle trip burns 125 calories each way (for a 130 pound child)

• 4 days per week = 1000 calories per week, 40,000 calories for school year.

• Converts to 11.5 pounds of body fat.

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The New walk/bike Student Two year follow up (age 12)

• Height – 59” (50%ile)

• Weight – 110# (65%ile)

• BP - 130/78

• Blood sugar – Normal

• Cholesterol – 175

• Energy level and Mood - Good

Richard J Jackson [email protected]

Public Health: Touching Every Life, Linking Every Community

the check up · 2011. 10. 12. · 2011 tpha annual conference 14 weight gain • rates of...

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