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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- [email protected]
Dee Merriam 770-488-3981
[email protected] www.cdc.gov/healthyplaces