Urban Health:Public Health Lessons from Los Angeles

Wharton School of BusinessOctober 18, 2007

Jonathan E. Fielding, M.D., M.P.H., M.B.A

Director of Public Health and Health Officer

L.A. County Department of Public Health

Los Angeles County – Background

• 4,300 square miles• 89 incorporated cities and 2 islands• 9.9 million residents (more than 42 States)• 46% Latino, 32% White, 13% Asian/Pacific

Islander, 10% African American, 0.3% American Indian

• Over 100 different languages spoken by significant size populations

• 15% living in poverty (14% of families & 24% <18)

• 22% of adults & 8% of children have no health insurance

Why Should We Care About Urban Health?

• Urbanization represents a major demographic shift in human history– At beginning of 19th century 5% of people lived in

urban areas– At end of 19th century 45% of people were living in

urban areas– Today almost 400 cities have pops. > 1 million

• Studying urban health requires us to investigate the relation between the urban context and the distribution of health and disease within an urban population

Source: Galea & Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of PH, 2005 (26).

Determinants of Health in Urban Areas

• Characteristics of the urban environment that affect population health– Access to health and social services– Physical environment

• Land use and community design• Pollution• Housing• Water

– Social environment• Poverty• Social cohesion• Education opportunities

Source: Galea & Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of PH, 2005 (26).

What Is Urban Health?

• South Los Angeles:– Poor residents– Crowded but much lower

density than mid-West and each coast cities

– Fewer community resources (such as greenspace, food outlets, ERs/trauma centers)

• Los Angeles suburbs:– Higher income residents– Housing density lower than

inner city– More community resources

(parks, grocery stores & restaurants, hospitals)

Urban area is often characterized by dense inner city surrounded by less dense suburbs

Leading Causes of Death Based on Crude Mortality, Los Angeles County, 2004

1,069

1,166

1,340

1,414

2,201

2,272

2,641

3,034

4,121

15,296

Homicide

Breast cancer

Alzheimer's disease

Colorectal cancer

Diabetes

Pneumonia & influenza

Emphysema

Lung cancer

Stroke

Coronary heart disease

Number of deaths

Leading Causes of Premature Death (Before age 75) - Los Angeles County, 2004

14,873

15,928

16,181

17,591

17,783

19,626

20,060

32,189

48,241

64,366

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000

HIV

Diabetes

Stroke

Drug overdose

Liver disease

Lung cancer

Suicide

Motor vehicle crash

Homicide

Coronary heart disease

Years of life lost

Leading Causes of Disability-Adjusted Life Years (DALYs) in Los Angeles County, 1998

28,454

28,818

30,707

32,130

36,285

36,727

41,740

45,098

62,993

70,248

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000

Drug Overdose/Other Intoxication

Lung Cancer

Alzheimer's/Other Dementia

Stroke

Homicide/Other Violence

Osteoarthritis

Diabetes Mellitus

Depression

Alcohol Dependence

Coronary Heart Disease

DALYs

Leading Causes of Death & Premature Death For Males in LA County, 2004

Leading Causes of Death & Premature Death For Females in LA County, 2004

How We Can Approach Disease• Level 1 – Treating disease condition

– e.g. enhancing disease management for diabetes• Level 2 – Reducing risk factors for disease

– e.g. improve nutrition and increase physical activity to prevent diabetes

• Level 3 – Focus on underlying determinants of disease– e.g. ensure opportunities for people to achieve

optimal health by• Supporting anti-poverty programs so people can afford to eat

healthfully• Supporting the development of greenspaces and parks so

people can be physically active

How We Can Reduce the Overall Disease and Injury Burden

• Level 1 – Treating disease conditions– Pros:

• No substitute for non-preventable conditions• Applying good disease management can reduce

burden of many diseases • New medical advances can further reduce burden

– Cons: • Usually costly and less cost-effective than working

on other levels• For people without regular access to care, the

benefits of medical advances are minimized

Effectiveness of Chronic Disease Self-Management Programs

• Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis

• Data on diabetes, osteoarthritis and hypertension:

Self-management interventions led to a statistically and clinically significant pooled effect size of:

1) -0.36 (95% CI, -0.52 to -0.21) for hemoglobin A1c, equivalent to a reduction in HgbA1c level of about 0.81%.

2) Decreased systolic blood pressure by 5 mm Hg (effect size, -0.39 [CI, -0.51 to -0.28]).

3) Decreased diastolic blood pressure by 4.3 mm Hg (effect size, -0.51 [CI, -0.73 to -0.30]).

4) Data on osteoarthritis statistically significant but clinically trivial for pain and function outcomes.

Chodosh et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143:427-438.

ROI From Changes in Employee Health Risks on A Company’s Health Care Costs

• Estimate of the impact of corporate health-management and risk-reduction programs for The Dow Chemical Company using a prospective return-on-investment (ROI) model

• Methods: risk and expenditure estimates derived from multiple regression analyses

• Results: “Break-even” scenario would require company o reduce each of 10 population health risks by 0.17% points per year over course of 10 years

• Conclusion: results support continued investments in health improvement programs to achieve risk reduction and cost savings

Goetzel et al. Estimating the Return-on-Investment from changes in employee health risks on the

Dow Chemical Company’s Health Care Costs. J Occup Environ Med. 2005;47:759-768.

Level 1 – Treating the Disease:Healthcare Spending

• Financial outlay:– 16% (~$2 trillion) of U.S. GDP spent on health care in

20051

– Projected to increase to 20% by 20152

– U.S. has highest health care spending per capita ($6,700 in 2005), more than twice as high as the median OECD country3

• ROI:– U.S. healthcare system performance ranked #37 in

world (out of 191 countries)4 – U.S. ranked #38th in world in life expectancy5

1 (Catlin et al. 2007, Health Affairs); 2 (Borger et al. 2006, Health Affairs); 3 (Anderson et al. 2007, Health Affairs), (OECD) Organization for Economic Cooperation and Development; 4 (World Health Report 2000); 5 (United Nations: World Population Prospects: 2006 revision)

Level 1 – Treating the Disease:U.S. Healthcare Expenditures, 1970-2004

1970 1980 1993 2000 2004

Total spending (billions $) 75 255 917 1,359 1,878

Spending per capita ($) 357 1,106 3,461 4,729 6,280

Spending as percent of GDP 7.2% 9.1% 13.8% 13.8% 16.0%

Source: Smith, et.al., Health Affairs, 2006

Level 1 – Treating the Disease:Efficacy of Disease Management

• 23% of adults in LAC report being diagnosed with hypertension (2005)– percent of adults taking medication to lower

blood pressure has increased from 65% in 1999 to 73% in 2005

• 24% of adults in LAC report being diagnosed with high cholesterol (2005)– only 52% taking medication to lower

cholesterol

PFP Report – High Impact, Low Cost Clinical Preventive Services

Source: Dr. Eduardo Sanchez, PFP (2007)

PFP Report – High Impact, Low Cost Clinical Preventive Services

Source: Dr. Eduardo Sanchez, PFP (2007)

Actual Causes of Death in the United States in 2000

Estimated Percentage of Cause No. Total Deaths

Tobacco 435,000 18Diet/activity patterns 365,000 15Alcohol 85,000 4Microbial agents 75,000 3Toxic agents 55,000 2Motor vehicles 43,000 2Firearms 29,000 1Sexual behavior 20,000 1Illicit use of drugs 17,000 <1

Total 1,124,000 47

Sources: Mokdad, Marks, Stroup & Gerberding, JAMA 2004 Mokdad, Marks, Stroup & Gerberding, JAMA 2005

Deaths

How We Can Approach Disease• Level 2 – Addressing the behavioral risk factors

for diseases– Pros:

• Relatively few risk factors heavily impact incidence of various diseases

• Each risk factor affects multiple diseases• Preventing disease often has much better ROI than treating

and managing disease– Cons:

• Must address both prevention (to reduce incidence) and risk-reduction (to reduce prevalence)

• Variable evidence of effectiveness of interventions by behavior

• Very large disparities still exist between various demographic groups even after effective intervetions

22.2 22.119.7

18.0

14.3 14.2

11.1 11.4

0

10

20

30

1997 1999 2002 2005

Men Women

Percent of Adults who Smoke Cigarettes by Gender - LA County, 1997-2005

Level 2 – Addressing Risk Factors:Effect of Smoking Reduction Efforts

• About 50% of decline in heart disease mortality due to medical treatments, other 50% due to reductions in risk factors1

• NY state ban on smoking at worksites associated with 8% drop in hospital admissions for heart attacks2

– Similar declines seen in cities that have implemented smoking bans (e.g. Bowling Green, OH, Pueblo, CO, Helena, MO)

• One study estimates about 40% of the decline in male death rate from lung CA between 1991-2003 due to reductions in tobacco smoking3

1 (Ford et al, 2007 NEJM)2 (Juster et al, 2007 AJPH)3 (Thun and Jemal, 2006, Tobacco Control)

16%

21% 21%

17%15%

21% 21%

15%13%

18%20%

14%12%

16%

25%

13%

0%

10%

20%

30%

40%

Latino White Black Asian/PacificIslander

1997 1999 2002 2005

Percent of Adults who Smoke Cigarettes by Race - LA County, 1997-2005

Large disparities still exist!

Level 2 – Addressing Risk Factors:Benefits of Regular Physical Activity

• Life span increase: 2 years• Risk of Cardiovascular Disease: 40% less• Rates of High Blood Pressure and

Diabetes: Reduced• Risk of breast & colon cancer: Reduced• Mood and mental health status: Improved• Body Mass Index (BMI): Reduced• Health care costs: $300-$400 less

per year for adults• Cost: low to moderate; major cost

can be individual opportunity cost but cost varies greatly

Source: Surgeon General’s Report, 1996

One Way to Increase PA

What Are the Combined Effects Of Treatment & Risk Factor Reduction?

• The best news you never heard

• Gradual improvements are not newsworthy

• Not high tech

• No single intervention to feature

• No quick fix

Trends in the Leading Causes of Death,Los Angeles County, 1993-2004

Rate (per 100,000) *

Cause of death 1993 2004 Percent change

Coronary heart disease 283 176 -37.8%

Stroke 63 48 -23.8%

Lung cancer 49 35 -28.6%

Emphysema 34 31 -8.8%

Pneumonia/influenza 45 26 -42.2%

Diabetes 16 25 +56.3%

Colorectal cancer 21 16 -23.8%

Alzheimer’s disease 4 16 +300.0%

Breast cancer 30 23 -23.3%

Homicide 20 10 -50.0%

HIV/AIDS 26 5 -80.8%

* age-adjusted to year 2000 U.S. standard population

Behavioral Causes of Death - 2000

Source: Schroeder, NEJM,

9/20/07

Life Expectancy at Birth by Sex & Race/Ethnicity - LA County, 2000

75.8 75.377.3

67.4

80.881.2 80.3

83.6

75.3

85.2

60

65

70

75

80

85

90

Total White Latino Black Asian/PI

Yea

rs

Male

Female

Life expectancy in LA County increased by approx 2.6 years from 1991 to 2000

Source: 1991 PEPS and Census 2000 Summary File 1

Movements in Wrong Direction• Alzheimers – As population continues to

live longer, disease will become more common

• Diabetes – Increase all Type 2 and directly correlated with increase in overweight and obesity

• While not on list, dental disease is very common, often inadequately treated—and mostly preventable

Estimated Number Of NewAlzheimer Cases (In Thousands)

Source: Hebert et al. (2001). Alzheimer’s Disease and Associated Disorders, 15(4), 169-173.

959

820

615491

454411377

0

200

400

600

800

1000

1200

1995 2000 2010 2020 2030 2040 2050

Year

New

Cas

es in

Tho

usan

ds

Trends in the Leading Causes of Death,Los Angeles County, 1993-2004

Rate (per 100,000) *

Cause of death 1993 2004 Percent change

Coronary heart disease 283 176 -37.8%

Stroke 63 48 -23.8%

Lung cancer 49 35 -28.6%

Emphysema 34 31 -8.8%

Pneumonia/influenza 45 26 -42.2%

Diabetes 16 25 +56.3%

Colorectal cancer 21 16 -23.8%

Alzheimer’s disease 4 16 +300.0%

Breast cancer 30 23 -23.3%

Homicide 20 10 -50.0%

HIV/AIDS 26 5 -80.8%

* age-adjusted to year 2000 U.S. standard population

Alzheimer's Disease Age-Adjusted Mortality Rates* per 100,000 Population, Los Angeles County, 1994-2003

0

4

8

12

16

20

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Rat

e p

er 1

00,0

00 p

op

ula

tio

n

Males Female LA County

Alzheimer's Disease Age-Adjusted Mortality Rates* per100,000 Population, by Race/Ethnicity, Los Angeles County,

1994-2003

0

5

10

15

20

25

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Rate

per

100,0

00 p

op

ula

tio

n

White Hispanic Black Asian/Pacific Islander LA County

Impact of Alzheimer’s Disease

• Healthcare costs – medical care; hospitalizations; skilled nursing; home care; long term care costs often lead to depletion of patient’s personal savings and assets

• Personal costs – disease progression with memory loss, wandering, behavioral problems, injuries, depression

• Caregiving – caregiver stress, caregiver illness, paid and unpaid costs of caregiving

• Costs to businesses – absenteeism due to caregiving, etc.

Health Disparities Persist• Caveats

– Not just about health insurance/access• Latino health paradox

– Major difference among Asian American groups

• Possible causes– Does culture play a role?– What about environment?

• Noxious environment theory

– What about income inequities and wealth distribution?• Example of US vs other OECD countries on health indicators

Rank (based on Gini

coefficient)Country

Percent of Country’s Total Disposable Income

Wealthiest(highest 30%)

Poorest (lowest 30%)

1 Denmark 48.3% 13.8%

2 Sweden 45.8% 15.8%

3 Finland 45.6% 17.0%

4 Norway 46.1% 16.3%

5 Netherlands 46.3% 15.8%

6 Germany 48.9% 14.7%

7 Canada 49.2% 14.3%

8 France 49.0% 15.6%

9 Belgium 48.3% 15.5%

10 Australia 49.3% 13.8%

11 Italy 53.2% 12.0%

12 United States 52.5% 11.8%

Note: Data presented by PBS based on OECD Reports: Income Distribution in 13 OECD Countries (2000).

Comparison of Economic Equality Within Nations

Source: Schroeder, NEJM,

9/20/07

3526

44

12

57

25

6

29

12

24

0

25

50

75

Australia Canada New

Zealand

United

K ingdom

United

States

Below average income Above average income

Cost-Related Access Problems, by Income, 2004 (Percent reporting any of 3 access problems because of costs^)

^ Access problems include: Had a medical problem but did not visit a doctor; skipped a medical test, treatment, or follow-up recommended by a doctor; or did not fill a prescription because of cost.* Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

*

*

*

*

*

Health Status by Income, 2004

Percent: AUS CAN NZ UK US

Fair/Poor Health:

Below Average 22* 19* 22* 24* 30*

Above Average 7 7 6 8 6

Any of 6 Chronic Illnesses:^

Below Average 63* 58* 62* 64* 62*

Above Average 41 42 40 39 42

^ Chronic illnesses include: hypertension, heart disease, diabetes, arthritis, lung problems, and depression.* Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

How We Can Approach Disease• Level 3 – Focus on the underlying determinants of

disease and injury– Pros:

• Addressing the underlying determinants of disease can affect positive change for wide variety of diseases

– Cons:• Difficult to understand the complex relationships of the

underlying determinants and interrelated factors that affect health

• Traditional sources of public health funding will not cover cost of these efforts

• Requires working on issues that require knowledge and actions in non-health and non-public health sectors

Interrelated Factors Affecting Urban Health

Source: Dr. Howard Frumkin

The Underlying Determinants of Health and Their Contribution to Premature Death

Source: Schroeder, NEJM, 9/20/07

Level 3 – Addressing the Underlying Determinants:Figuring Out What To Do

• LAC DPH decided to create 2 new strategic initiatives to address factors that affect health in the:– Physical Environment– Social Environment

Underlying Determinants of Health in the Physical Environment

• Air quality– New research showing that small particle pollution

contributes to excess mortality – LA area studies showing that proximity to roads

increases asthma incidence and symptoms – National and international ramifications as pollution in

Midwest affects New England and some of pollution in California originates in China

• Water quality– Issues of quantity and conservation

• Climate– Global warming impacts public health– Catastrophic events (e.g. hurricanes, heatwaves) have

had devastating effects on urban areas

Underlying Determinants of Health in the Physical Environment

• Urban Planning/Land Use– Walkability– Places for physical activity– Access to mass transit (impacts access to work and

health care services)– Zoning requirements

• Neighborhood safety– Can impact likelihood of residents being physically

active • Housing

– Crowded conditions influence communicable diseases

– Availability of affordable housing and housing stock

0

5

10

15

20

25

30

Mia

mi

NYC LA

Oxn

ard

Riv

ersi

de SF

The Rising Cost of Housing

US average in 2000 = 10%

US average in 2006 = 14%

Percentage of households spending at least 50%

of their income on housing in 2006

Source: US Census data

traffic safety

air pollution

water quality & quantity

obesity & chronic disease

physical activity

crime & violence

social capital

elder health & mobility

mental health

health disparities

Multiple Possible Adverse Health Impacts From Poor Community Design

Health and Sprawl

People living in counties marked by sprawling development:

• Walk less in their leisure time

• Are more likely to have high blood pressure

• Have higher body mass indexes

• Are more likely to be overweight (average 6 pound difference)

Ewing R, et al: American Journal of Health Promotion 18(1) Sept/Oct 2003

Commuting• Los Angeles has the nation's

worst Travel Time Index (TTI), 1.75 -- driving times during peak traffic hours are 75% longer than during off-peak times. (SCAG)

• According to national statistics, Los Angeles is among the top 10 U.S. cities with the most long-distance commuters. (LA Times, September 2006)

•Commuters spend 93 hours in rush-hour commuter traffic. (Texas Transportation Institute)

Let’s Play “Spot the Pedestrian”

Source: Dr. Howard Frumkin

Summary of Health Effects of Air Pollution

• More pre-term babies and birth defects

• Increases in:

– abnormal lung development in children1

– asthma symptoms and other respiratory diseases in children and adults2

– deaths from heart disease and lung cancer3

1 (Gauderman et al. 2007, Lancet)2 (McConnel et al. 2006, Env Health Perspectives; Meng et al. 2006, UCLA CHPR Research Brief)3 (Pope et al. 2002, JAMA)

Summary of Health Effects of Air Pollution

• Amount of goods transported through California projected to nearly quadruple between 2000 and 20201

• Will have significant impact on air quality and health2

• Diesel particulate matter (PM)– concentrated around ports,

railyards, and heavily trafficked roads3

premature deaths cancer respiratory disease lost workdays global warming (2nd to CO2)

Annual Health Impacts in CA from PM and Ozone4

1 (Cal EPA, 2005); 2 (Pacific Institute, 2006)3 (CA/EPA Air Resources Board); 4 (CA/EPA Air Resources Board, 2004)

Mothers living closest to the freeways have more pre-term babies

Danger of Living Close to High Traffic

Air Pollution and Infant Death

Air pollution implicated in infant deaths from respiratory causes and sudden infant death syndrome

Age Increased Risk of Death

28d - 3mo 20% - 36% per 1ppm CO

7mo – 12mo 7% - 12% per 10g/m3

Oil refinery, Wilmington, LA, CA

Ritz et al, “Air Pollution and Infant Death in Southern CA, 1989-2000,” Pediatrics 2006; 118;493-502

Children living Children living

closest to the closest to the

freeways have a freeways have a 2-2-

fold risk of asthmafold risk of asthma

Danger of Living Close to High Traffic

Children living Children living

closest to the closest to the

freeways have a freeways have a 2-2-

fold risk of asthmafold risk of asthma

Danger of Living Close to High Traffic

Potential Effects of Climate Change

Source: Dr. Howard Frumkin

LA County’s “Biggest” EpidemicPrevalence of Adult Obesity:1997 vs 2005

20.9% 21.9% 22.2%23.3%

22.6%25.2% 26.2% 26.1%

23.0%

20.4%18.9%

20.2%23.2%

24.4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Healthy People 2010 Goal: 5%

Projected prevalence (LAUSD) approaches 30% by 2010

Projected prevalence (LA County) approaches 26% by 2010

Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in Los Angeles County public schools.

Overweight Prevalence Among School Children in LA County, 1999-2006

6.6%7.5% 7.6%

8.6%

0%

2%

4%

6%

8%

10%

12%

1997 1999 2002 2005

Year

Pre

va

len

ce

(%

)

† age-adjusted to 2000 US population

Prevalence† of Diabetes Among Adultsin LA County, 1997-2005

Changes in Future Life Expectancies Related to Obesity and Diabetes

• Life expectancy has steadily increased over the past two centuries.

• Current rates of obesity projected to reduce life expectancy by .33 to .75 years over the next century.

• If rates of obesity and diabetes continue to increase at current rates, reductions in life expectancy may be to 2 to 5 years, or more

(Olshansky et al NEJM March 17, 2005)

Determining Effective Interventions

• Where is the research base?

• Relatively few studies

• Many studies not in “health” or “public health” literature

• Not amenable to design and methods used in most clinical trials

The Guide to CommunityPreventive Services: One Example

• Expert task force, staffed by CDC, assisted by other Federal/ state agencies

• Study methods well defined

Source: Briss, et. al., Annual Review of Public Health, 2004

The Guide to CommunityPreventive Services: One Example

• Consistent set criteria for findings and related recommendations

• Expert consultation panels for each topic e.g. physical activity

Physical Activity Reviews• The Task Force reviewed various ways to promote physical activity

– Informational approaches• “point-of-decision” prompts, e.g. to use stairs (recommended)

– Behavioral and social approaches• School based physical education (recommended)

– Environmental and policy approaches• Creating and/or enhancing access to places for physical activity

(recommended)• Community-scale & street-scale urban design and land use policies and

practices (recommended)• The Task Force reviewed various ways to promote physical activity

– Informational approaches• “point-of-decision” prompts, e.g. to use stairs (recommended)

– Behavioral and social approaches• School based physical education (recommended)

– Environmental and policy approaches• Creating and/or enhancing access to places for physical activity

(recommended)• Community-scale & street-scale urban design and land use policies and

practices (recommended)

Community Guide – Promoting PA: Summary of Findings

• Recommended:– Community-wide info

campaigns– “Point-of-decision” prompts– Individually-adapted health

behavior change– School-based physical

education– Social support interventions in

community settings– Increasing access to places for

PA with info outreach activities– Urban planning approaches

(zoning and land use)

• Insufficient Evidence:– Classroom-based health

education focused on info provision

– Mass media campaigns– Health education with TV/video

game turnoff component– College-age physical

education/health education– Family-based social support– Transportation policy &

infrastructure changes to promote non-motorized transit

Environmental and Policy Approaches to Increase Physical Activity

• The Task Force recommended: Creating or improving access to places for physical activity

• Background on interventions:– Involve worksites, coalitions, agencies, communities to change

the local environment– Examples of changes: creating walking trails, building exercise

facilities, providing access to existing facilities nearby• Findings:

– In all 10 studies, improving access to places for physical activity was effective in getting people to exercise more

• Median estimates = 25% increase in percent of people exercising at least 3 times a week

– These interventions were effective among both men and women and in various settings, including industrial plants, universities, federal agencies, and low-income communities.

Environmental and Policy Approaches to Increase Physical Activity

• The Task Force recommended: Community-scale urban design and land use policies and practices to promote physical activity

• Background on interventions:– Defined as urban design and land use policies and practices that

support physical activity in geographic areas, generally several square kilometers in area or more.

– Involve urban planners, architects, engineers, developers, and public health professionals

– Design elements include the proximity of residential areas to stores, jobs, schools and recreation areas: the continuity and connectivity of sidewalks and streets; and the aesthetic quality and safety aspects of the physical environment

• Findings:– Studies generally compared behavior of residents in auto-oriented

(suburban) communities with those in urban communities– In 12 studies, overall median improvement in some aspect of

physical activity (e.g., # of walkers) was 161%

Environmental and Policy Approaches to Increase Physical Activity

• The Task Force recommended: Street-scale urban design and land use policies and practices to promote physical activity

• Background on interventions:– Defined as street-scale urban design and land use policies that

support physical activity in small geographic areas, generally limited to a few blocks

– Involve urban planners, architects, engineers, developers, and public health professionals

– Design components include improved street lighting, infrastructure projects to increase safety of street crossing, use of traffic calming approaches, & enhancing the street landscape

• Findings:– Studies assessed effectiveness in providing a more inviting and

safer outdoor environment for physical activity– In 6 studies, the overall median improvement in some aspect of

physical activity (e.g., # of walkers) was 35%

Dangers of Poor Food Environment• More Americans eating food prepared outside the home,

typically higher in fat and calories and lower in nutrients1

• Percentage of total energy intake from restaurant and fast foods consumption increased by nearly 300% among adolescents from 1977 to 19962

• Portion sizes have increased• Less access to healthy and affordable food options in

lower income neighborhoods3

• Estimated to be 4x as many fast food restaurants and convenience stores as supermarkets and produce vendors in LAC4

1 (Guthrie et al. 2002 J Nutr Educ Behav)2 (Nielsen, et al., 2002 Obesity Research)3 (Baker et al. 2006 Prev Chronic Disease; Powell et al. 2006 Preventive Medicine)4 (‘Searching for Healthy Food: The Food Landscape in California Cities and Counties’, 2007 CCPHA brief)

Proximity of Fast Food Restaurants toPublic Schools in Los Angeles County

% of schools with 1 or more FF restaurants within 400 meters

School Type elementary 21.7% middle school 24.3% high school 31.2% Neighborhood Income* quantile 1 (lowest) 38.4% quantile 2 24.4% quantile 3 19.8% quantile 4 (highest) 12.2% All Schools 23.4%

* Based on the median household income of the census tract in which the school is located

Strategies for Improving the Physical Environment for Nutrition

Current Environmental Change

Increased marketing of junk food, tobacco, and alcohol

Place limits on marketing of junk food to children (around schools, parks…)

Decreased access to fresh, nutritious, affordable food

Promote local public markets

Provide incentives for businesses that provide healthy food

Proliferation of fast food restaurants

Use zoning tools to limit the location and density of fast food restaurants

Source: Public Health Institute

Underlying Determinants of Health in the Social Environment

• Education– LAUSD has over 25% dropout rate– Key determinant of health because it affects employment, which

affects poverty/ health insurance/ gang membership/ criminal activity/ drug use etc.

• Employment– Middle class is disappearing in Los Angeles

• Poverty status• Health Insurance• Social support and connectedness• Substance Abuse

– Drug overdose was the 7th leading cause of premature death in Los Angeles County in 2004 (17,591 years of life lost)

Annual Age-adjusted Mortality Rate by Median Household Income - LA County, 2003-2005*

400

500

600

700

800

< $30K $30 - 40K $40 - 50K > $50K

Median Household Income

Ra

te /

10

0,0

00

po

p

*provisional data used for 2005

Percentage of the Population Living in Poverty, LA County, 1970-2000

0%

10%

20%

30%

40%

1970 1980 1990 2000

Year

Liv

ing

in

po

vert

y

DPH Strategies Regarding theSocial Environment

How it affects health• Poverty – poor access to

healthy food, housing, clean air, medical care

• Safety – violence, no opportunity for physical activity

• Social Networks – isolation, lack of social support

• Education—high drop out rates; poor school readiness

What DPH can do• Advocate for evidence-

based social programs such as center-based early childhood development programs or rental assistance programs

• Assess and explain how educational/ tax/ social policies affect health and disparities

Key New Tool –Health Impact Assessment (HIA)

• HIA is tool for systematically evaluating, synthesizing, and communicating information about potential health impacts for more informed decision-making, especially in other sectors.

• An HIA might ask:– What are the health consequences of high rates of students dropping out

from high schools?– What elements of school site design are most cost-effective in

encouraging physical activity?

• Why use an HIA?

– It influences decision makers using a broad understanding of health and a wide range of evidence – it places public health on the agenda

– It highlights potentially significant health impacts that are unknown, under-recognized, or unexpected

– It facilitates inter-sectoral working and public participation in decision making

Living Wage HIA• Employees working on city contracts must be

– Paid at least $7.99/hr– Provided health insurance, or an additional $1.25/hr

• Covers approximately 10,000 workers• Health insurance coverage is more cost-effective

in reducing excess mortality than an equivalent amount in the form of wages

• Any changes to the ordinance should consider increasing health insurance coverage

• Applicability: many living wage ordinances throughout the U.S.

Source: PFP/UCLA HIA – Living Wage in LA

Living Wage HIA – Logic Framework

(Cole, et. al., 2005)

Living Wage HIA Results

Key New Tool - Health Forecasting• Currently we spend time examining health status, health risks, and

health improvement opportunities for today– But optimal planning requires us to understand how our current activities

will influence future health status• Health forecasting = a modeling project that helps us to estimate

what health status will be in the future• HF allows us to:

– Model future health status based on health behavior patterns, population trends, and other variables

– Compare policy options to determine which are the most cost-effective for improving health

– Demonstrate the health impact of non-health oriented policies– Model effect of multiple interventions

• Have benefited from expert advisory group, including Prof. Scott Armstrong

0%

10%

20%

30%

40%

50%

60%

Physical Activity & Obesity Are Not Independent

0

2

4

6

8

10

12

5020 25 30 35 40 4515

Med

ian

ME

Th

rs/w

eek

BMI

Per

cen

t O

verw

eig

ht

Age

6020 30 40 50 70 9080

Active

Inactive

People with low levels of Physical Activity (<8 METhrs/wk) are more likely to be overweight:

People with healthy BMI have higher levels of Physical Activity:

Source: CA-BRFS 1984-2000

Identifying Strategies to Reduce Disparities

-10%

-8%

-6%

-4%

-2%

0%2005 2010 2015 2020

WHITE

BLACK

LATINO

ASIAN-PI

Charts show the forecasted percent change in age-adjusted mortality:

-10%

-8%

-6%

-4%

-2%

0%2005 2010 2015 2020

WHITE

BLACK

LATINO

ASIAN-PI

Up to Best

+2 METs Hours per week

Further Increases in BMI = Additional $12 B. in Personal Medical Expenditures in CA Annually by 2025

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2005 2010 2015 2020 2025

Scenario I - DecreasingBMI

Baseline

Scenario II - IncreasingBMI

( = 1985 levels)

( = 2005 levels)

( = continuing increase in rate equal to rate incrase from 1985 to 2005)

Total direct personal medical expenditures*, age 18+ (2003 $000,000)Direct personal medical expenditures for the non-institutionalized population make up about 50-55% of total medical expenditures as defined by the National Health Accounts

All dollars used below are 2003 actual dollars, NOT adjusted for inflation of medical costs.

* personal direct expenditures for the non-institutionalized population as defined by MEPS

108,350

127,499

115,672

Opportunities• Inter-sectoral cooperation

– E.g. Working with Chambers of Commerce, other employer groups

– E.g Faith based organizations—– E.g. Regional planning---– E.g. Social services (public and private)---– E.g. Transportation– E.g. Education

• Develop shared vision of future and admit interdependency (e.g. need skilled and healthy workforce)

Opportunities• Involve elected and appointed decision makers

at all levels of government– Show why health consequences should be

considered in deliberations on issues as diverse as:• Farm subsidies• Tax policy affecting wealth distribution• Nutritional labelling in fast food restaurants• Zoning/ developer incentives • Bonds to increase mass transit

– Education about sources of best evidence

Opportunities• Maintain a balanced civic health improvement

portfolio– Physical/social environment vs. risk reduction vs.

improved treatment/disease management– Short, intermediate and long term benefits– Regulation vs. voluntary with and without economic

incentives– Attention to entire population vs. disparities

• Monitor key indicators of population health status and determinants and feed back into civic health improvement process

Examples of Some LA CountyPublic Health Successes

• Improved the nutritional quality of food in schools-vending machines and food service

• Called attention to sources of air pollution that adversely affect health, including greatest impact from LA/ Long Beach Ports

• Argued for R rating for films with tobacco use because they contribute to teen-age smoking

• Reduced smoking to 14% of adults• Strongly advocated for nutritional labeling of fast

food (including on order board)• Reduced serious food-borne illness due to

restaurant grading system• Established LA County Health Survey

Tactics to Overcome Challenges

• Work with a wider variety of partners, including physicians, other providers, schools, faith-based orgs., voluntary orgs., and business partners– Increase awareness of the need for emergency

planning and preparedness– Working with partners to engage them in health

promotion activities (e.g., public transportation benefits for employees, healthy food policies)

• Work on some of the factors outside of the medical world that affect health that are not typically considered “Public Health issues”– Social environment issues– Physical environment issues

The Ultimate Public Health Challenge

• Population growth– 75 million annual increase in population

—1/4 U.S. population

– Strain on basic resources in most urban areas in U.S.---water, fuel

– Accelerates global warming with serious health consequences

– Little public discourse

LA County Public Health – Healthy People Build Health Communities