urban environment and cardiovascular health: erc project heart healthy hoods

Centre for Global NCDs Seminar Series November 14 2016

Urban Environment and Cardiovascular Health: ERC Project

Heart Healthy Hoods Manuel Franco MD, PhD

Associate ProfessorSchool of Medicine, University of Alcala, Spain

Adjunct Associate ProfessorDepartment of Epidemiology

Johns Hopkins Bloomberg School of Public Health

http://hhhproject.eu

First, some questions

• Let´s think first about the place where you live/work

• Let´s think now about the opportunities for being physically active and mantain a healthy diet where you live

• Let´s think now about the social norms regarding physical activity and diet where you live


Second, some reflections about Madrid

• Opportunities / resources for being physically active and mantain a healthy diet in Madrid

• Social norms regarding physical activity and diet in Madrid


Physical activity environment in Madrid, HHH study

International Journal of Epidemiology 2015, Franco M

Miguel, 45 years old, lives in Villaverde, Madrid. Low-income area.

Miguel goes out for a walk every afternoon to the park. “I used to run all the distance of the bike lane but I started having knee problems and now I prefer walking. When I am in a good mood I can walk all the way to the next large neighbourhood.”


Food environment in Madrid, HHH study

International Journal of Epidemiology 2015, Franco M In press

María, 45 ys, resident of Villaverde. Low-income area. María and her friends meet twice per week to have a dinner snack at the Dehesa Boyal park, a pinewood and main park in San Cristobal. María lives in Spain for the last 4 years, unemployed for the last 8 months, and she often thinks about coming back to the Dominican Republic where her family lives.


Opportunities for NCDs prevention within

Urban Health Research1. By 2050: 66% of the world population will live in cities2. Challenge of aging and chronic diseases already in our cities 3. Social determinants as working conditions, unemployment

and poverty are clearly patent in our cities4. Segregation patterns and health inequalities are social

phenomena measurable in our cities

5. Cities, municipalities, districts, offer great (structural)1 opportunities to improve population health

6. New sources and types of health and urban data, allong with novel methodologies and interdisciplinary teams

7. Urban health research is directly linked to action(1) Franco, Bilal and Diez-Roux, J Epidemiol Comm Health 2015

Social and Physical Urban Environment and CV Health:

The Much Needed Population Approach

Manuel Franco MD, PhD

Starting Grant 2013 Start Date April 1st 2014

ERC Starting GrantsFUNDING 1.5 million € for 5 years

OBJECTIVE To encourage independent careers of excellent investigators providing enough support in the critical moment (starting to develop their own team).

ELEGIBILITY PI must have a PhD degree in the last 2 to 7 years. Available to non-EU researchers.

REQUISITES At least one relevant publication without his/her thesis advisor

At least 50% effort

PROFILE High potential, project with potential social Impact in Europe.

Presenter’s Name

Date

PhysicalEnvironment

Social Environment

SOCIALEPIDEMIOLOG

YStudies social determinants of disease

Methodologies from Social Sciences and Public Health

Focus on population preventive approach

Addresses growing social inequalities in health

First cause of death in Europe (47% of all deaths in 2010)

Increasing prevalence (50 mill. patients in 2009 in Europe)

Rising social and economic costs (196 billion € in 2009)

Traditional medical preventive approaches are individual

CardiovascularHealth

Presenter’s Name

Date

PhysicalEnvironment

Social Environment

CardiovascularHealth

HEARTHEALTHYHOODS

Obesity

Physical Activity

DietAlcohol

Physical ActivityEnvironment

Food Environment

CVD

Smoking

Tobacco Environment

Social and PhysicalEnvironment

Individual Cardiovascular Health

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Heart Healthy Hoods Study Main Goal


To study the impact of the

social and physical environment in terms of

tobacco, alcohol, food and physical activity

on residents cardiovascular health

Heart Healthy Hoods Overall Objectives


1. To include a qualitative approach to understand the context and meanings of the urban environment in relation to cardiovascular health

2. To develop measurements to characterize the social and physical urban environments in a systematic and accurate fashion

3. To understand the already known relation between the urban environment and cardiovascular health in the United States with this relation in Europe

Heart Healthy Hoods Secondary Objectives


To provide scientific evidence to researchers, the

general population and policy makers to intervene at

the population level to prevent the first cause of

death in Europe.

HHH overarching objectivePolicy and research implications


Photography Knowledge

DisseminationCitizen Science

Epidemiology

Health SociologyUniversity of Salamanca

Johns Hopkins School of Public Health

GeographyUniversity of AlcaláCRESH EdinburghLSHTM

Primary Care System Primary Care Research Unit, Madrid

Interdisciplinary team PI: Social Epidemiology

University of AlcaláJohns Hopkins School of Public Health


INTERDISCIPLINARY TEAM

https://hhhproject.eu/people/madrid-team/

Madrid Team

International Collaborations





HHH Team Kickoff September 2014


Madrid City

21 Districts128 Neighborhoods2.412 Census Sections (≅1.500 ps) 3,2 Mill. Residents

HHH will analyze the Integrated Primary Care Health System Electronic Health Records Database of 1,4 million residents 40-75 ys. old


HHH Study Design

Baseline VisitCohort Study

1st Database Mining

Population-based EHR

study4 yr follow up

2,576 participants Final Visit

Final Database Mining

1,4 million people

EnvironmentTobacco Alcohol

FoodPhysical Activity

1st Assessment 2nd AssessmentNeighborhoods

Multilevel AssociationAnalysis


21 distritos

32 Centros de Salud

Participantes de la cohorteN=2576

Profesionales

Métodos CoHHHorte


CentrosC.S. ADELFASC.S. ALPESC.S. ANGELA URIARTEC.S. ARTILLEROSC.S. BARAJASC.S. CANAL de PANAMAC.S. CARAMUELC.S. CERRO ALMODOVARC.S. CIUDAD JARDINC.S. DAROCAC.S. DR. CASTROVIEJOC.S. ENTREVIASC.S. ESPRONCEDAC.S. FEDERICA MONTSENYC.S. GARCIA NOBLEJASC.S. GENERAL RICARDOSC.S. GUAYABAC.S. JAZMINC.S. LAGASCAC.S. LAS CORTESC.S. LAVAPIESC.S. LOS YEBENESC.S. MAR BALTICOC.S. MONOVARC.S. PAVONESC.S. SAN ANDRESC.S. SAN FERMINC.S. SILVANOC.S. TORITOC.S. VALDEBERNARDOC.S. FUENCARRALC.S. VILLAAMIL

CS HHH


Criterios de selección


Resumen calendario global del estudio

Corte 2016 Seguimiento 2017 Corte 2018 Seguimiento

2019

Visita clínica + Encuesta telefónica

Recoger algunos datos de Historia

clínica

Visita clínica + Encuesta telefónica

Recoger algunos datos de

Historia clínica


Visita 1

Visita Telefónica• Dieta• Tabaco• Alcohol• Actividad Física

¿Precisa Analítica?

NO

SI

Analítica + Visita 2 (Entrega

de resultados)

Flujo de visitas

Abrir en HCE episodio A97


a) Mixed Methods Exploratory Study in a Median Area of Madrid (Usama Billal)

b) Results by domainsa) Food

b) Physical Activity

c) Tobacco

d) Alcohol

c) Results by working groupsa) Urban Geography

b) Participatory Action Research PHOTOVOICE

HHH Analyses and Results


Selecting average neighborhoods for cross-city comparisons in Urban Health studies: the Median Neighborhood Index Bilal U, Diez J, Cebrecos A, Franco M (Submitted)

Median Neighborhood Index (MNI)

Average rank distance to the median neighborhood in each city in four sociodemographic and urban form variables: aging (% > 65 years old), education (% with college education), segregation (% foreign-born for Spain, or % non-White for the US), and urban form (population density)


Mixed Methods Approach


Objectives

1. To describe the cardiovascular health profile of a population over 15,000 residents living in an area, analyzing the Madrid Primary Health Care System electronic health records.

2. To explore different quantitative and qualitative measurements characterizing the social and physical urban environment in relation to food, alcohol, tobacco and physical activity.


Methods (quantitative)

• Cardiovascular Disease:– Whole population (>99%) EHR through universal health system.– Validated (1) data on physician-diagnosed: diabetes, hypertension,

dyslipidemia, smoking and obesity.

• Urban environment– Food: location and type of food stores and food services, directly

measured healthy food availability (brief NEMS-S)– Physical activity: SPACES audit tool for walkability and bikeability,

SOPARC audit tool for open spaces.– Alcohol and tobacco: location and type of retailers

References: (1) de Burgos Lunar et al, BMC Med Res Methodol, 2013.


Methods (qualitative)

• 11 semi-structured interviews with key informants: 4 long-term residents, 2 recent immigrants, 1 teacher, 1 community activist, 1 health care provider, 1 public health officer, 1 local food store owner

• Questions on health and the environment, focusing on sociodemographics, food, alcohol, tobacco and physical activity.

• Analysis by triangulation incorporating an interpretative phenomenological analysis.


Methods (integration)

• Geographic Information Systems– Directly collected data + Secondary administrative data– Joined to street sections by relational union or overlaid as

administrative boundaries/blocks.

• Mixed Methods Approach: merging approach – Provides insights on quantitative findings

• Quantitative -> qualitative

– Guides future quantitative data collection (formative)• Qualitative -> quantitative.


Exploratory Study Sociodemographic ProfilePrimary Health Care Records

• Total Pilot Area Population: 15,751

• Population in the Primary Care Health System Geocoded to

census section level: 14,857 (95%)

–Possibility of analyzing data for 1.4 million people


• Population 45-106 ys. old: 7,252• Sex: 59% Women• Diabetes Prevalence: 12%• Diabetes Control (HbA1c<7): 63%• Hypertension Prevalence: 34%• Obesity (BMI >30): 20%• Dyslipidemia, all types: 32%

Exploratory Study Cardiovascular ProfilePrimary Health Care Records


a) Mixed Methods Exploratory Study in a Madrid Median Area

b) Results by domains

a) Food (Julia Diez) b) Physical Activity

c) Tobacco

d) Alcohol

c) Results by working groups

a) Urban Geography




Conceptual frameworkUrban Food Environment

• Diet is a cardiovascular risk factor influenced by the local food environment

• Local food environments are a critical influence, that may restrict or increase people’s abilities to make healthy eating decisions.

• Conceptual framework from:

Franco M., Bilal U., Díez J. (2016). Food Environment.

In The Encyclopedia of Food and Health. B. Caballero, Finglas, P., and Toldrá, F. (Eds) Academic Press, Oxford: 3: 22-26


Exploratory study Type of food stores Healthy Food Availability Index


Food environment measures

• Objective. To develop a system to characterize, and track changes of the

local food environment, using in-store audits and secondary databases

• Methods.

1) Ground-truthing (in-store audits)

• Observers assessed all food stores present in all 42 census sections

June-July 2016, using an adapted version of the NEMS-S tool to

better reflect a Mediterranean food environment

• We integrated the NEMS-S tool in a web-based app


2) Secondary database

• Public database “Censo de Locales”, updated monthly and freely

accessible from the city council.

• We selected all food stores located within the 42 census sections,

derived through their code provided in the database.

• We matched the food stores assessed on field and those listed in the

database based on GPS coordinates and business name and address.

• We assessed the level of agreement between the secondary database

and on field observations (sensitivity analysis, and PPV analysis) by

store type and by census section-SES

Food environment measures


Cross-city differences


Walking access to healthy food

Madrid (left) and Baltimore (right)




b) Physical Activity (Pedro Gullón) c) Tobacco

d) Alcohol


a) Urban Geography




Urban Environment and active transportation in Madrid


Madrid Systematic Pedestrian and Cycling Environment Scan (M-SPACES)

- Function- Safety- Aesthetics- Destinations

M-SPACES AUDIT TOOL

Pedro Gullón et al. September 2015 Journal of Urban Health,


M-SPACES AUDIT TOOL

Pedro Gullón et al. 2015 Journal of Urban Health,


M-SPACES AUDIT TOOL



Physical Activity Results


Pedro Gullón, Usama Bilal, Alba Cebrecos, Hannah M. Badland, Francisco Escobar, Iñaki Galán, Manuel Franco

Socioeconomic Determinants of Small-Area Walkability in a European city like

Madrid: The Heart Healthy Hoods Project


Figure 1. Spatial distribution of Walkability Index (a) and Socio-Economic Status Index (b) by deciles in the census section (N=2415) of the city of Madrid


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-2.35 -1.16 -0.85-0.61-0.39-0.14 0.24 0.67 0.95 1.26 2.00Socioeconomic Status Index

95% CI

Figure 2. Restricted cubic splines with 5 knots representing the relationship between SES and walkability in the census sections of Madrid (N=2415)





c) Tobacco (Xisca Sureda) d) Alcohol


a) Urban Geography



Tobacco retail environment, outdoor smoke-free policies

and smoking

HHH Ancillary Study PI: Xisca Sureda

Co-investigators: M. Franco, U. Bilal, FJ Escobar, A Navas, E. Fernández

Alcalá University, ICO Barcelona, Johns Hopkins Bloomberg School of Public Health, Columbia University

Funding: European Research Council Starting Grant 2013 HeartHealthyHoods Agreement n. 336893 and Instituto de Salud Carlos III (PI15/02146)

Tobacco in HHH

Urban determinants of smoking behaviour


Availability & Accessibility

Second-hand smokeexposure in terracesof hospitality venues

Smoking behaviour

Self-reportedsecond-hand smoke

exposure

Urban environments Individual behaviours

Signs of tobaccoconsumption in outdoor places

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Tobacco availability


Density of tobacco point of sales Educational level in Madrid


Measurements and variables: Systematic Social Observation in 42 neighborhoods in Madrid

lugar fecha hora área (m2)

altura (m) ventilación señales olor a

tabaco cenicero cenizas personal fumando

usuarios fumando observaciones

Indicators of the presence of tobacco smoking: number of smokers, presence ofashtrays, presence of cigarette butts and tobacco smell, presence of tobacco vending machines, hours of sales in places where you can get tobacco.

Information for every measurementsampling: location, area, outdoor or quasi-outdoor space, smoke-free zone signage

Tobacco consumption signs outdoors

SHS exposure outdoor hospitality venues


PM 2.5 measurements

Measurements and variables: Tobacco Airborne Markers

Airborne nicotine

We measured a total of 79 outdoor terraces in 42 neighborhoods

People smoking in a covered terraces





c) Tobacco

• Alcohol (Madrid, Barcelona, Edinburgh, Baltimore)a) Results by working groups

a) Urban Geography



Alcohol in HHHUrban determinants of alcohol behaviour

Sureda X, Villalbí JR, Espelt A, Franco M. Living under the influence: Normalization of alcohol consumption in our cities. Gac Sanit (in press)

OHCITIES instrument


OHCITIES Validation Results


92 on-premise alcohol outlets (50% bars and 20% restaurants)

53,7% with promotion associated to the outlet

We measured 180 items in 92 On-Premise and 24 off-premise alcohol outlets in 7 census sections in Madrid

24 off-premise alcohol outlets (54% grocery stores)

88,2% with promotion associated to the outlet


7 alcohol promotion in public spaces (57% sponsorship)

58 signs of alcohol consumption

Time to complete one census section: between 225 and 87 minutes depending on the total number of alcohol-related elements in the urban environment.

Time to complete each item: on and off-premises aprox. 5-10 min; promotion and signs of alcohol consumption in public spaces aprox. 3 min

OHCITIES Validation Results





c) Tobacco

d) Alcohol (Xisca Sureda)


a) Urban Geography (Alba Cebrecos)b) Participatory Action Research PHOTOVOICE



The aim was to design and implement a multicomponent method based on Geographic Information Systems to characterize and evaluate environmental correlates of obesity: the food and the physical activity urban environments.


METHODOLOGY


f̂ ( x )= 1h𝑛 ∑i=1

n

K ( x− X ih )

Kernel Density Estimation (KDE)

WALKABILITY

HFAI

HFAI & WALKABILITY

STUDY AREA

METHODOLOGY


RESULTS

Manuel Franco, Principal Investigator

Understanding community food environment through Photovoice:

a participatory action research project in Villaverde, Madrid

Co-funded by


Citizen Science


CENTROCENTRO Cibeles Madrid, April 13th – October 30th 2016

https://hhhproject.eu/photovoice/photovoice-publications/

https://hhhproject.eu/photovoice/photovoice-publications/


https://www.youtube.com/v/VIiFggKzVas&yt:cc=on&hd=1

Photovoice whole project video




Photovoice Publications

1. “Understanding the local food environment: a participatory Photovoice project in a low-income area in Madrid, Spain” Under review

2. “Barriers and facilitators for accessing healthy foods: a mixed methods study using GIS, on field measures and photovoice” In progress

3. “Translating participatory research into food policy recommendations: The Photovoice Villaverde Food Project in Madrid.” In progress

4. “Photovoice as a tool to gain empowerment? : Evaluating the transformative potential of a Participatory Action Research project in Villaverde (Madrid) for their female participants.” In progress

5. “Improving the retail food environment in cities. A stakeholder public discussion in Madrid: The Heart Healthy Hoods Project.” In progress


HHH Current Scientific Achievements

• 7 international papers and 3 book chapters

• Bilingual photobook and public exhibition

• 4 funded ancillary studies

• 3 Predoctoral and one Erasmus master fellowships

• Intramural: 2 communications awards

• 4 travel grants for US (Joel Gittelsohn and Luisa Borrell) and UK researchers (Daniel Lewis and Jamie Pearce)


HHH future scientific steps

Waiting on grants: • Photovoice on urban environment and physical activity

• Alcohol Urban Environment in Madrid and Barcelona (Collaboration: Madrid, Barcelona, Edinburgh, Baltimore)

Working on training grant: • Cardiovascular Prevention and Policy Research Initiative for

Europe and Latin America (CAPRIELA)

• Liverpool, Utrecht, Lima and Buenos Aires

Open for collaborations with LSHTM researchers


• Participants

• Whole HHH Madrid team and collaborations

• Different funding agencies: • European Research Council• Fundación Mapfre• Ayuntamiento de Madrid • Fondo de Investigación Sanitaria• Plan Nacional de Investigación• Center for a Livable Future, Johns Hopkins

• LSHTM Centre for Global NCDs

Acknowledgements


HHH TeamThank you very much !

Centre for Global NCDs Seminar Series November 14 2016

¡ Gracias !

Manuel Franco MD, PhD

for the HHH investigators

urban environment and cardiovascular health: erc project heart healthy hoods

Health & Medicine