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  • 1. The Healthy Communities Agenda: How We Can Work Together Congress for the New Urbanism June 13, 2009 Dee Merriam, FASLA Community 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.”
  • 2. U.S. Health Care Expenditures as Percent of GDP Projections Keehan et al: Health Affairs March/April 2008 27: 145-155
  • 3. Injury -Vehicle Crashes For every age group from 3 through 33-- crashes were the No. 1 cause of death
  • 4. Miles per capita– more than doubled in one generation Miles per Capita: 1960 to 1995 From 4,000 to 9,200 VMT per person
  • 5. Disease in the 21st Century • Mental Disorders: Depression, Anxiety, Developmental, Substance Abuse • Macro-environment: Climate, Conflict • Aging Populations • Overweight: Chronic Diabetes II, Heart Disease
  • 6. 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 35,118 Source: Earth Policy Institute
  • 7. Climate
  • 8. 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
  • 9. Recovery from surgery 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
  • 10. 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 Illinois Human-Environment Research Lab William Sullivan, Frances Kuo http://www.herl.uiuc.edu/
  • 11. Robert Taylor Homes interview study • 145 residents • Asked about social dynamics and aggressive behavior • Compared answers from people living with and without nearby nature
  • 12. Strength of Community Positive Interactions no trees very trees quite somewhat a little No No No Trees Trees Trees not at all Know People Know Next Unity / Cohesion on Floor Door Neighbor
  • 13. Strength of Community Positive Interactions no trees very trees quite somewhat a little No No No Trees Trees Trees not at all Many Visitors Socialize Know People Daily within Bldg. in Bldg.
  • 14. Strength of Community Positive Interactions no trees very trees quite somewhat a little No No Trees Trees not at all Acknowledge Help Each Other Each Other
  • 15. Aggressive behavior against partner Negative Interactions .6 no trees trees .5 .4 Proportion .3 Yes .2 .1 No No No No Trees Trees Trees Trees 0 spiteful threatened threw or threw at to hit smashed partner
  • 16. Aggressive behavior against partner Negative Interactions .6 no trees .5 trees .4 Proportion .3 Yes .2 .1 No No No No Trees Trees Trees Trees 0 Hit with Hit with Beat them Used gun something fist up or knife
  • 17. Aggressive behavior against partner Negative Interactions 1.6 no trees 1.4 1.2 trees Mean Values 1 0.8 0.6 0.4 0.2 No No No Trees Trees Trees 0 Psychological Mild Violence Severe Violence Aggression Aggressive and Violent Behavior
  • 18. Inactivity, Overweight & Health Evidence links inactivity and overweight with… Inactivity Overweight Increased mortality Cardiovascular disease Cancers Depression Gall bladder disease Osteoporosis Dyslipidemias Hypertension
  • 19. United States 1990 to 2000
  • 20. Relationship Between BMI and Risk of Type 2 Diabetes 100 93.2 Age-Adjusted Relative Risk Men 75 Women 54.0 50 40.3 42.1 27.6 21.3 25 8.1 15.8 2.9 4.3 5.0 11.6 2.2 6.7 1.0 1.5 4.4 1.0 1.0 0 <22 <23 23 24 25 27 29 31 33 35+ - - - - - - - 23.9 24.9 26.9 28.9 30.9 32.9 34.9 Body Mass index (kg/m2) Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122:481.
  • 21. Percentage of US Adults with Diagnosed Diabetes - 1994 1 state exceeds 6%
  • 22. Percentage of US Adults with Diagnosed Diabetes - 2001 2 states exceed 9%
  • 23. Percentage of US Adults with Diagnosed Diabetes - 2007 10 states exceed 9%
  • 24. Sam’s Check Up 10 year old boy
  • 25. “Problem” List • Physical exam unremarkable • Ht 54” (50%) • Wt 115# (95%) • BP 140/90 • Blood glucose elevated, urine normal • Cholesterol 220 • Signs of Depression
  • 26. Treatment Plan • Weight loss program • Referral to “overweight” clinic • TV out of the bedroom; no soft drinks in the house • Exercise program; Encourage sports
  • 27. "Outstanding in Its Field" Hubbard Lake Elementary School, Hubbard Lake, Michigan.
  • 28. Joe’s house Destinations are not connected. Park Sam’s house PP slide courtesy of Doug Allen
  • 29. 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
  • 30. 2 months later our patient could be taking: – Antihypertensive medication – Oral Hypoglycemic agent – Cholesterol lowering agent – Antidepressant • Monthly medication costs: $385
  • 31. • The “environment” is rigged against the patient… • And the doctor.
  • 32. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 5 states over 10% 1985 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Mokdad AH, et al. J Am Med Assoc 2001;286:10.
  • 33. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1990 No 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.
  • 34. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 5 states over 15% 1991 No 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.
  • 35. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1992 No 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.
  • 36. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1993 No 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.
  • 37. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1994 No 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.
  • 38. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1995 No 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.
  • 39. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1996 No 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.
  • 40. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 3 states over 20% 1997 No 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.
  • 41. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1998 No 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.
  • 42. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1999 No 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.
  • 43. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 2000 No 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.
  • 44. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Alabama over 25% 2001 No 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.
  • 45. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 2002 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 46. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 2003 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 47. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 2004 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 48. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 2005 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 49. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 2006 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 50. Obesity Trends* Among U.S. Adults, BRFSS (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Only 1 state under 20% 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 51. BMI US Females 1988-1994 NHANES -- Measured NHANES – In person interview-- self-reported BRFSS – Telephone Interview
  • 52. 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).
  • 53. 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
  • 54. Walking good for… Obesity! Heart disease! Cancer! Depression! Diabetes! Gall bladder! Social life!
  • 55. Higher density and connectivity Lower obesity Atlanta study 2004
  • 56. res sion ↓ Dep ↓ CO2 ↓ Air emissions pollution ↑ Physical activity ↓ Osteoporosis ↓ Injuries And by the way… ↓ Infrastructure costs ↑ Social capital
  • 57. The sidewalk level: The National “Never Walk” Campaign 12 Strategies
  • 58. Strategy #1: Don’t Build Sidewalks
  • 59. Strategy #2: Build Repellant Sidewalks
  • 60. Strategy #3: Allow Sidewalks to Disintegrate
  • 61. Strategy #4: Build Treacherous Sidewalks
  • 62. Strategy #5: Obstruct Sidewalks
  • 63. Strategy #6: Use creative design.
  • 64. Strategy #7: Crosswalks should be dysfunctional, if not silly.
  • 65. Strategy #8: Combine Multiple Strategies
  • 66. Strategy # 9: Never place an interesting or useful destination within walking distance of where anybody lives
  • 67. Strategy #10: Just Say It
  • 68. Strategy # 11: Turn places to park into architectural icons.
  • 69. Strategy # 12: Make everything car-accessible. Everything!
  • 70. Pharmacies
  • 71. Dry Cleaners
  • 72. Baked goods
  • 73. Groceries
  • 74. Booze
  • 75. Tobacco Photo courtesy of Lyle McCoon, Jr., Nicholasville/ Jessamine County (KY) Parks & Recreation
  • 76. Gambling Photo courtesy of Lyle McCoon, Jr., Nicholasville/ Jessamine County (KY) Parks & Recreation
  • 77. Auto Service
  • 78. Fine Food
  • 79. Coffee
  • 80. A nice touch… Braille buttons for blind drivers Banking
  • 81. Mail Boxes
  • 82. Utility Bills
  • 83. Drive-thru sewer payments: Mt. Juliet, Tennessee
  • 84. Tunnel of Vows Drive-Thru Wedding Chapel Las Vegas, NV
  • 85. Drive-up wedding windows
  • 86. Child support payments
  • 87. Gardner Memorial Chapel Junior Funeral Home Davidson, TN Pensacola, FL Drive-Thru Funerals
  • 88. Trees…then
  • 89. Trees…now
  • 90. The next frontier of drive-thru: Health care?
  • 91. Parking
  • 92. ?
  • 93. 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/g uidelines/adults.html Dee Merriam- 770-488-3981- dmerriam@cdc.gov
  • 94. Dee Merriam 770-488-3981 dmerriam@cdc.gov www.cdc.gov/healthyplaces