Embrace the Convergence: Recruiting Allies and Establishing Common Ground for Tough Times- Merriam...

The Healthy Communities Agenda: How We Can Work Together

Dee Merriam, FASLACommunity Planner

National Center for Environmental Health

U.S. Centers for Disease Control and Prevention

“The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.”

June 13, 2009

Congress for the New Urbanism

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

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

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

Injury -Vehicle Crashes

Miles per capita– more than doubled in one generation

Miles per Capita: 1960 to 1995 From 4,000 to 9,200 VMT per person

Disease in the 21st Century • Mental Disorders: Depression,

Anxiety, Developmental, Substance Abuse

• Macro-environment: Climate, Conflict

• Aging Populations

• Overweight: Chronic Diabetes II, Heart Disease

Climate-The European Heat Wave of 2003

Excess deaths

France 14,802

Germany 7,000

Spain 4,230

Italy 4,175

UK 2,045

Netherlands 1,400

Portugal 1,316

Belgium 150

TOTAL 35,118Source: Earth Policy Institute

Climate

Recovery from surgery

• All cholecystectomies in a Pennsylvania hospital, May-October, 1972-1981

• Exclusions: age <20 or >69; serious complications; history of psychological problems

• Matched pairs: “tree view” patients with “brick wall view” patients

Results: The “tree view” patients had• shorter hospitalizations (8.70 days vs 7.96

days)

• less use of analgesic medications• fewer negative nurse notes (e.g. “needs

much encouragement,” “upset and crying”)

Ulrich, Science, 1984

Recovery from surgery

Trees and urban Life

Studies in Robert Taylor Homes,Chicago• 28 identical high-rise buildings along a 3-mile

corridor• Some have nearby vegetation, others do not• Residents randomly assigned to apartments• A “natural experiment”

University of IllinoisHuman-Environment Research LabWilliam Sullivan, Frances Kuohttp://www.herl.uiuc.edu/

Robert Taylor Homes interview study

• 145 residents

• Asked about social dynamics and aggressive behavior

• Compared answers from people living with and without nearby nature

Know Peopleon Floor

Know NextDoor Neighbor

Unity / Cohesionnot at all

a little

quite

very

somewhat

Strength of CommunityPositive Interactions

No Trees

No Trees

No Trees

trees

no trees

Many VisitorsDaily

Socializewithin Bldg.

Know Peoplein Bldg.

Strength of Community Positive Interactions

not at all

a little

quite

very

somewhat

No Trees

No Trees

No Trees

trees

no trees

Acknowledge Each Other

HelpEach Other

not at allnot at all

a littlea little

quitequite

veryvery

somewhatsomewhat

Strength of Community Positive Interactions

No Trees

No Trees

trees

no trees

00

.1.1

.2.2

.3.3

.4.4

.5.5

.6.6

spiteful threatened to hit

threw orsmashed

threw atpartner

Proportion Yes

Aggressive behavior against partnerNegative Interactions

No Trees

No Trees

No Trees

No Trees

treesno trees

0

.1

.2

.3

.4

.5

.6

Hit withsomething

Hit with fist

Beat themup

Used gun or knife

Proportion Yes

No Trees

No Trees

No Trees

No Trees

Aggressive behavior against partnerNegative Interactions

trees

no trees

Inactivity, Overweight & Health

Inactivity Overweight

Increased mortality Cardiovascular disease Cancers Depression Gall bladder disease Osteoporosis Dyslipidemias Hypertension

Evidence links inactivity and overweight with…

United States 1990 to 2000

0

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

-Adj

uste

d R

elat

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

Percentage of US Adults with Diagnosed Diabetes - 1994

1 state exceeds 6%

Percentage of US Adults with Diagnosed Diabetes - 2001

2 states exceed 9%

Percentage of US Adults with Diagnosed Diabetes - 2007

10 states exceed 9%

Sam’s Check Up

10 year old boy

“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

• Weight loss program

• Referral to “overweight” clinic

• TV out of the bedroom; no soft drinks in the house

• Exercise program; Encourage sports

"Outstanding in Its Field"

Hubbard Lake Elementary School, Hubbard Lake, Michigan.

PP slide courtesy of Doug Allen

Destinations are not connected.

Sam’s house

Park

Joe’s house

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

– Cholesterol lowering agent

– Antidepressant• Monthly medication

costs: $385

2 months later our patient could be taking:

• The “environment” is rigged against the patient…

• And the doctor.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

5 states over 10%

1985No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1990Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

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

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

5 states over 15%

1991No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1992No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1993No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1994No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1995No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1996No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1997No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

3 states over 20%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1998No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

1999No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2000No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2001No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Alabama over 25%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2002No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2003No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2004No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2005No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2006No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

2007No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Only

1 state under 20%

NHANES -- Measured

NHANES – In person interview-- self-reported

BRFSS – Telephone Interview

BMI US Females 1988-1994

download from CDC at:

www.cdc.gov / nccdphp / dnpa / obesity / trend / maps

The data shown in these maps were collected through the CDC’s Behavioral Risk Factor Surveillance System (BRFSS).

Creating or improving access to places for physical activity can result in a 25% increase in the percent of persons who exercise.

•www.thecommunityguide.org •AmJ Prev Med 2002

Walking good for…Obesity!

Heart disease!Cancer!

Depression!Diabetes!

Gall bladder!Social life!

Higher density and connectivity Lower obesity Atlanta study 2004

Physical activity

Air pollution

And by the way…

Infrastructure costs Social capital

CO2 emission

s

Depression

Injuries

Osteoporosis

The sidewalk level:

The NationalThe National “ “Never Walk” Never Walk”

CampaignCampaign

12 Strategies

Strategy #1:

Don’t Build Sidewalks

Strategy #2:

Build Repellant Sidewalks

Strategy #3:

Allow Sidewalks to Disintegrate

Strategy #4:

Build Treacherous Sidewalks

Strategy #5:

Obstruct Sidewalks

Strategy #6:

Use creative design.

Strategy #7:

Crosswalks should be dysfunctional, if not silly.

Strategy #8:

Combine Multiple Strategies

Strategy # 9:

Never place an interesting or useful destination within walking distance of where anybody lives

Strategy #10:

Just Say It

Strategy # 11:

Turn places to park into architectural icons.

Strategy # 12:

Make everything car-accessible.Everything!

Pharmacies

Dry Cleaners

Baked goods

Groceries

Booze

Tobacco

Photo courtesy of Lyle McCoon, Jr., Nicholasville/ Jessamine County (KY) Parks & Recreation

Gambling

Photo courtesy of Lyle McCoon, Jr., Nicholasville/ Jessamine County (KY) Parks & Recreation

Auto Service

Fine Food

Coffee

Banking

A nice touch…Braille buttons for

blind drivers

Mail Boxes

Utility Bills

Drive-thru sewer

payments:Mt. Juliet,

Tennessee

Tunnel of Vows Drive-Thru Wedding ChapelLas Vegas, NV

Drive-up wedding windows

Child support payments

Drive-Thru Funerals

Gardner Memorial ChapelDavidson, TN

Junior Funeral HomePensacola, FL

Trees…then

Trees…now

The next frontier of drive-thru:Health care?

Parking

?

Resources

Healthy Places web Site:www.cdc.gov/healthyplaces

BRFSS– data and trends regarding public health:http://www.cdc.gov/nccdphp/tracking.htm

2008 guidelines Physical Activity Guidelines:http://www.cdc.gov/physicalactivity/everyone/

guidelines/adults.html

Dee Merriam- 770-488-3981- dmerriam@cdc.gov

Dee Merriam 770-488-3981

dmerriam@cdc.gov www.cdc.gov/healthyplaces