Richard J Jackson MD MPH Professor and Chair, Environmental Health Sciences UCLA School of Public Health.

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1 Design Sacramento for Health Dedicated to Judy Corbett and the Local Government Commission Richard J Jackson MD MPH Professor and Chair, Environmental Health Sciences UCLA School of Public Health dickjackson@ucla.edu Yes, medical care But Health Policy is Farm Policy Transportation Policy Housing Policy And Proposition 13 is Health Policy. 1

2 The Check Up 45 year old builder, 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 2

3 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 3

4 2 months later our colleague is taking: Antihypertensive medication Oral Hypoglycemic agent Antidepressant Cholesterol lowering agent Monthly medication costs: $385 U.S. Health (Medical) Care Expenditures as Percent of GDP Projections Keehan et al: Health Affairs March/April :

5 10 leading causes of death - United States,

6 CDC Headquarters - Atlanta July 6,

7 Disease in the 21 st Century Diseases and costs of care for Aging Populations. Overweight: Diabetes II, Heart Disease Mental Disorders: Depression, Anxiety, Developmental, Substance Abuse Macro-environment: Climate, Conflict The Built Environment how we build our homes, workplaces, towns, cities and world 7

8 60,000 square miles And Photosynthesis is our friend! The United States has now paved over the equivalent area of the entire state of Georgia 8

9 American Farmland Trust The Heat Island 9

10 Ground Level Ozone Levels increase in late afternoon as traffic and temperature peak 10

Asthma Study in 12 Southern California High Schools 3535 children with no history of asthma in 6 high and 6 low air pollution high schools 5 years later: 265

11 Asthma Study in 12 Southern California High Schools 3535 children with no history of asthma in 6 high and 6 low air pollution high schools 5 years later: 265 developed asthma. High ozone high schools: asthma rate was 3.3x higher in children playing three or more sports. Low ozone high schools: sports had no effect on asthma rates 11

12 More Density = Less Driving Miles per capita more than doubled in one generation Miles per Capita: 1960 to 1995 From 4000 to 9200 VMT per person 12

13 25% Less Vehicle Miles Traveled with Compact Development 30% Less Ozone Air Pollution with Compact Development 13

For every age group from 3 through 33-- crashes were

14 For every age group from 3 through 33-- crashes were the No. 1 cause of death Automobile fatality rates by city, 1998 (excluding pedestrian fatalities; deaths/100,000/year) 6.55 Portland 3.76 San Francisco Phoenix Dallas Houston Atlanta 2.51 New York 5.36 Philadelphia Source: NHTSA 14

15 California Highway Patrol 1969 Licensed Drivers: 11.4 million Miles Driven: 112 billion CHP staffing: 5, Licensed Drivers: 22.6 million Miles Driven: 320 billion CHP staffing: 7,

Average minutes per day spent in car: - Women overall: 64 minutes

16 Overall: Compared to 1969 Americans drive: - 88% farther to shop - 137% farther for errands Mega-Mileage Moms Family chauffeur Average minutes per day spent in car: - Women overall: 64 minutes - Single mothers: 75 minutes Surface Transportation Policy Project:

17 Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 17

18 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 18

19 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 19

20 Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% California Prevalence of Overweight* Children aged 5 to 20 years 21.7% Year 2010 target** * > 95th percentile BMI-for-age, CDC Growth Charts, ** Year 2010 target: reduce the proportion of children and adolescents aged 6 to 19 years who are overweight to 5% California Pediatric Nutrition Surveillance (PedNSS) 20

3 tons (passengers or cargo) Jet fuel to transport added weight in 2000: 350 million gallons Cost of extra fuel: $1.

21 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: $1.4 billion (Sept 2008 prices) CO 2 emissions from extra fuel: 3.8 million tons Data sources: NCHS; US Dept. of Transportation Hardee's introduces new Mega-Calorie Monster Thickburger 1,420 calories 107 grams of fat 7.1 hours of moderate walking 21

22 Fast Food Restaurants black/low income neighborhoods ~ 2.4 per sq. mile white neighborhoods: 1.5 per sq. mile American Journal of Preventive Medicine, October 2004 More walking Less obesity 22

23 More time in a car Higher probability of obesity Higher density and connectivity Lower obesity Atlanta study

24 Relationship Between BMI and Risk of Type 2 Diabetes Age-Adjusted Relative Risk <22 < Body Mass index (kg/m 2 ) Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122: Percentage of US Adults with Diagnosed Diabetes

Percentage of US Adults with Diagnosed Diabetes - 2001

25 Percentage of US Adults with Diagnosed Diabetes Percentage of US Adults with Diagnosed Diabetes

Diabetes Projected Risks: For Babies Born in 2000 Girls: 38%

14 years (Quality of life by 19 years) Boys: 33% 12 years.

26 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 Nurse Study Hu et al. NEJM, December 23, 2004; 351(26):

27 Nurse Study Hu et al. NEJM, December 23, 2004; 351(26): Old Schools Credit: Manitovic Public School District Credit: Hummel Architects, Boise, ID 27

28 Modern Schools Credit: South Carolina Coastal Conservation League Credit: Constance E. Beaumant, NTHP We have changed how much we walk or bike Percent of children who walk or bike to school: % % (CDC, 2000) 28

29 the number of cars on the road between 7:15 a.m. and 8:15 a.m. increases 30 percent during the school year --Gene Benton, city traffic engineer Santa Rosa, California School Transportation Costs and Impacts Costs in California $784 Million $1.04 Billion Diesel exhaust levels: 4 times higher in the boss than in front of it Parking lots: heat islands, impervious surfaces. 29

Grade 5 25% Grade 7 29% Grade 9 26% Percentage of Trips in Urban Areas Made by Walking and Bicycling: North America and Europe

30 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% 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):

Percentage of Trips in Urban Areas Made by Walking and

Health: Lessons From The Netherlands and Germany.

31 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): How about the environmental challenges? Perfect Storm November 1,

32 The Era of Easy Oil is Over Changes in CO 2 and Temperature in the last 399,000 years A. V. Fedorov et al. Science 312, 1485 (2006). 32

33 Changes in CO 2 and Temperature in the last 400,000 years A. V. Fedorov et al. Science 312, 1485 (2006). Keeling Curve 33

34 Monthly Mean CO2 at Mauna Loa 1/2005-1/ Global average temperature 34

825 CUMULATIVE greenhouse emissions in 2002, by country Density-equalizing

35 NOAA-measured Global Temperature Change The atmosphere and the earth s surface have become hotter over the last 25 years. Science 12 May 2006: Vol no. 5775, p. 825 CUMULATIVE greenhouse emissions in 2002, by country Density-equalizing cartogram; WHO region size proportional to mortality Jonathan Patz, University of Wisconsin 35

36 Climate-related mortality (per 10 6 population), 2000 Density-equalizing cartogram; WHO region size proportional to mortality Jonathan Patz University of Wisconsin Mindfulness about Food Mindfulness about what and how we eat 36

37 Food Doof 37

38 1 cent per teaspoon HFCS? Average American consumes 63 pounds of HFCS each year (6,048 teaspoons). US population: 300 million $0.01 per teaspoon HFCS would generate $18 billion a year Always good, but especially as we age, what is the best exercise? 38

39 10,000 Steps a Day Originated from Japanese: Manpo-Kei 10,000 steps 3234 people with IGT (Pre-Diabetes) walked or exercised five times a week for 30 minutes lost 5% to 7% of their body weight reduced their risk of diabetes by 58% 39

40 40

Since we moved into our new office with its convenient,

41 P St Sacramento These stairs have become a gathering, meet and greet space for us as well as a way to get from the first to the third floor. Since we moved into our new office with its convenient, attractive stair, almost no one uses the elevator. Thompson E. Penney, FAIA President/CEO LS3P ASSOCIATES LTD. 41

83 Increasing Bicycle Use, Portland, OR Cyclists Per Day Bikeway Miles 12,500 350 10,000 Bridge Bicycle Traffic Bikeway Miles 300 250 7,500 5,000 2,500 1991: 78 miles of bikeways 2,850 daily trips

42 83 Increasing Bicycle Use, Portland, OR Cyclists Per Day Bikeway Miles 12, ,000 Bridge Bicycle Traffic Bikeway Miles ,500 5,000 2, : 78 miles of bikeways 2,850 daily trips 2006: 263 miles of bikeways 11,956 daily trips Year: Bridge Bicycle Traffic 2,850 3,555 3,885 3,830 3,207 4,520 5,225 5,690 5,910 6,015 7,686 8,250 8,562 8,875 10,192 11,956 Bikeway Miles

and learning Enhances creativity Fairfax, California After Starting

43 Educational Benefits of Walking and Biking to School Increases concentration Improves mood and ability to be alert Improves memory and learning Enhances creativity Fairfax, California After Starting Program for Safe Routes to School Manor School Before After Walked/Biked 39% 61% 43

44 School Gardens Exercise, Learning, Cooperation, Fun, and It Tastes good 44

45 Farmers Markets are Health Beneficial 10% increase in urban parks = 4 F decrease in urban surface temperature 45

46 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 AB Complete Streets Act 46

47 APHA National Meeting 2002 Abstracts with land use - 0 APHA National Meeting 2003 Abstracts with land use

48 APHA National Meeting 2005 Abstracts with land use - 55 APHA National Meeting 2008 Abstracts with land use

APHA National Meeting 2009 Abstracts with land use -- 130

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49 APHA National Meeting 2009 Abstracts with land use New Academic Programs on Built Environment and Health Report published January

The Built Environment: Designing Communities to Promote Physical Activity in Children Policy Statement American Academy of Pediatrics June 2009 California Medical Association Resolution 11 January,

50 The Built Environment: Designing Communities to Promote Physical Activity in Children Policy Statement American Academy of Pediatrics June 2009 California Medical Association Resolution 11 January, 2007 That CMA support legislation that enhances the role of public health in local planning, zoning and the school siting process to facilitate the design of communities which foster and support physical activity. 50

51 California Medical Association (CMA) Resolution Adopted October 18, 2009 RESOLVED: That CMA support efforts to develop ambitious regional targets for local governments to reduce greenhouse gas emissions and support land use and transportation strategies to meet those targets: and be it further California Medical Association (CMA) Resolution Adopted October 18, 2009 RESOLVED: That CMA support efforts to reduce vehicle trips by means of land use and transportation measures that promote smart growth, improve air quality, improve community health and reduce chronic illness; 51

California Medical Association (CMA) Resolution 713-09 -- Adopted October 18, 2009 RESOLVED: That CMA support the participation of public health

52 California Medical Association (CMA) Resolution Adopted October 18, 2009 RESOLVED: That CMA support the participation of public health officials in land use decision making and transportation planning to help identify and mitigate potential health impacts. Yes, people do want density 52

53 Envisioning Change Envisioning Change 53

Health Impact Assessment Definition Collection of procedures and tools by which projects, policies, and programs can be evaluated based on their potential effects on the health of a population, and

54 Health Impact Assessment Definition Collection of procedures and tools by which projects, policies, and programs can be evaluated based on their potential effects on the health of a population, and the distribution of those effects within the population Gothenburg consensus statement, 1999 Health Impact Assessment A tool to increase partnerships and communication between public health professionals and planners 54

55 Places of the Heart The health need for them 55

56 Our patient starts to bicycle 5 miles to the Transit Center 3 days per week 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. 56

The New Bicycle Commuter One year follow up Weight - 168 pounds (BMI 24.

57 The New Bicycle Commuter One year follow up Weight pounds (BMI 24.5) BP - 130/78 Blood sugar Normal Cholesterol 175 Energy level and Mood - Good "Soaring Health and Energy Costs, Crashing Economies and Ecosystems: the built environment must be a major part of the solution" Richard J Jackson MD dickjackson@ucla.edu 57

Richard J Jackson MD, MPH, FAAP.

We Are What We Eat And What We Build Richard J Jackson MD, MPH, FAAP HonASLA, HonAIA dickjackson@ucla.edu http://designinghealthycommunities.org/oram/ USA Today 10/20/2011 Commuting by driving is not