richard j jackson md professor and chair, environmental health sciences ucla school of public health...

• Richard J Jackson MD Professor and Chair, Environmental Health Sciences

• UCLA School of Public Health

• dickjackson@ucla.edu

Trail Leaders are Health Leaders

Our shaping of the built environment shapes our health, wealth, and future.

The Check Up

40 year old parent of two children

• -- complains of “low energy”

“Problem” List

• Physical exam unremarkable but • 28 pounds overweight• BP 155/95• Blood glucose elevated, urine normal• Cholesterol 270• Signs of Depression• No exercise. …Drives to work 25 miles each way• Spends 3 to 4 hours a day sitting in a vehicle

Treatment Plan

• Meeting with Nutritionist

• Weight loss program

• Exercise club membership

• Pedometer: 10,000 steps a day

• Getting more control of work and life commitments

Two Months Later…

• Day is already too full

• No Time for exercise

• No place to Walk

– Antihypertensive medication

– Oral Hypoglycemic agent

– Antidepressant– Cholesterol lowering

agent

• Monthly medication costs: – $385

2 months later our colleague is taking:

U.S. Health Care Expenditures as Percent of GDP Projections

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

An Aging PopulationPercentage of U.S. Population over

Age 65

Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population Copyright 1996, Watson Wyatt Worldwide.

0

5

10

15

20

25

1930 1950 1970 1990 2010 2030 2050

Year

Perc

en

tag

e o

f P

op

ula

tion

Persons employed in health service sites: United States -- 2005

• All employed civilians 141,730,000

• All health service sites: 14,052,000– Hospitals: 5,719,000

– Nursing care facilities: 1,848,000

http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary

Of the 4,800,000 new jobs in the US 2000-2005

• How many were in Health Care?

• 1.8 million -- 40%

http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary

• “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

• We have rigged the “environment” against us…

Obesity Trends* Among U.S. AdultsBRFSS, 1990

No Data <10% 10%–14%

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

Obesity Trends* Among U.S. AdultsBRFSS, 1997

No Data <10% 10%–14% 15%–19% ≥20

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

Obesity Trends* Among U.S. AdultsBRFSS, 2004

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

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

Bariatric Procedures: Annual Numbers

JAMA 2005: pp1909-1917

California Prevalence of Overweight* Children aged 5 to 20 years

California Prevalence of Overweight* Children aged 5 to 20 years

* > 95th percentile BMI-for-age, CDC Growth Charts, 2000. ** Year 2010 target: reduce the proportion of children and adolescents aged 6 to 19 years who are overweight to 5%.

Year 2010

target**

2003 California Pediatric Nutrition Surveillance (PedNSS)

21.7%

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: $1.1 billion

• (Oct 2005 prices)

• CO2 emissions from extra fuel: 3.8 million tons

Data sources: NCHS; US Dept. of Transportation

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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

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d R

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ive

Ris

k

Body Mass index (kg/m2)

MenMen

WomenWomen

<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

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes and Gestational Diabetes Trends Among

Adults in the U.S., BRFSS 1993-94

Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes and Gestational Diabetes Trends Among

Adults in the U.S., BRFSS 2001

Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

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

Life Expectancy Is Declining in Some Pockets of the Country

NICHOLAS BAKALAR -- New York Times

Too Many Calories?

“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

Percentage of Trips in Urban Areas Made by Walking and Bicycling: North America and Europe 1995

Pucher J and Dijkstra L. Promoting Safe Walking and Cycling to Improve Public Health: Lessons From The Netherlands and Germany. AJPH, September 2003;93(9):1509-16.

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1.61.9

2.4

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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

• How does this have to do with how we build?

The United States has paved over 60,000 square miles of its natural landscape.

Less Density = More Driving

Miles per capita– more than doubled in one generation

Miles per Capita: 1960 to 1995 From 4000 to 9200 VMT per person

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

More time in a car Higher probability of obesity

More walking: Less obesity

Higher density and connectivity: Lower obesity– Atlanta study 2004

Schools• Since World War II

– Number of Schools declined 70%

– Average School Size• grew fivefold, from 127 to 653 students

• 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’s Children Annual 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%

Institute of Medicine

The purpose of public health is to fulfill society’s interest in

assuring the conditions in which people can be healthy

Institute of Medicine

The purpose of public health is to fulfill society’s interest in

assuring the conditions in which people can be healthy

Mindfulness about FoodMindfulness about what

and how we eat

“…students have better attendance, are less likely to drop out, exhibit fewer discipline problems, and perform better when attending a smaller high school.”

Secretary of Education Richard Riley Oct 4, 2000

Educational Benefits of Walking and Biking to School

• Increases concentration

• Improves mood and ability to be alert

• Improves memory and learning

• Enhances creativity

Children’s Contact with Nature

• School age children with ADHD who had higher contact with nature showed better concentration, task completion, and following of directions.

Coping with ADD: The Surprising Connection to Green Play Settings” Environment and Behavior, 33 (1), 54-77 AF Taylor, FE Kuo, WC Sullivan, 2001

Outdoor Physical Activity

• Studies in older children show that improved mood and emotional well-being are associated with physical activity.

• Mood may be affected not only by the physical activity itself but also by exposure to sunlight if the activity occurs outdoors

Steptoe A, Butler N. Sports participation and emotional wellbeing in adolescents. Lancet. 1996;347:1789-1792.Wirz-Justice A, Graw P, Krauchi K, et al. “Natural” light treatment of seasonal affective disorder. J Affect Disord. 1996;37:109-120.

NYC Mayor Bloomberg Announces PlaNYC to place a park or playground within a ten minute walk for every New Yorker.

August 2007 Trust for Public Land

10% increase in

urban parks = 4°C

decrease in urban

surface temperature

School Gardens

Exercise, Learning, Cooperation, Fun, and

It Tastes good

“Farmer in Chief”

Michael PollanNew York Times

October 12, 2008

Reversing “The Disease” of the 21st Century…

• Depression

Income and Happiness

SOURCE: Layard, R. Happiness and Public Policy. The Economic Journal 116 (March): C24-C33. Page C25.

What does make people happy?

Human Contact

• Being with People we love and who love us

Exercise in Healthy Places

• Treatment for Depression—

• Exercise

• Sunlight• Nature Contact

• The health need for places to walk

Health – Planning Collaborations

• SF Bay Area (11 counties) meeting Dec 2006

• Los Angeles County (300 attendees) April 2007

• Marin, Napa, Sonoma, Solano, El Dorado, San Mateo, Sacramento, San Francisco, Placer, Yolo, Santa Barbara, San Diego, Riverside, Monterey, Humboldt

AB 1358 -Complete Streets Act

February 8-10, 2007

John P. Kouletsis, A.I.A.

Director, Strategy, Planning, & Design

National Facilities Services

New Partners for Smart Growth

Building Safe, Healthy and Livable Communities

Leveraging Size and Prominence to Promote Sustainable Design

The New Bicycle Commuter

• 30 minute bicycle trip burns 250 calories each way (for a 190 pound man)

• 3 days per week = 1500 calories per week, 78,000 calories/year.

• Converts to 22 pounds of body fat.

The New Bicycle Commuter One year follow up

• Weight - 168 pounds (BMI 24.5)

• BP - 130/78

• Blood sugar – Normal

• Cholesterol – 175

• Energy level and Mood - Good