Introduction and Session 1

Ornamental Horticulture Roundtable

A health creating society
• Modern societies actively market
unhealthy lifestyles
WHO European Region
Building a health creating society
Nigel Crisp
Health and Horticulture:
building a health creating society
4th July 2016
Nigel Crisp

WHO European Region
Nigel Crisp

WHO European Region
• Health is made at home, hospitals
are for repairs
Traditional African saying
Nigel Crisp

The UK and Europe
• Children
• Older people
• Mental illness
• Inequalities
Nigel Crisp

Everyone has a role to play…
A health creating society where
everyone – gardeners, architects,
teachers, employers, citizens,
business - has a role to play in
creating healthy robust citizens and
communities
Nigel Crisp

Building a health creating
society
In 1948 all the people and organisations
involved in health care came together
around the common goal of health care
for all
Now we need everyone and everybody
that affects health to come together in a
common goal to build a health creating
society
Nigel Crisp

Session 1: Strategic & academic evidence: health, wellbeing
& horticulture
1000 Dr William Bird (GP & Intelligent Health)
Horticulture, Health & Wellbeing: a GP’s perspective
1010 Dr Justin Varney (Public Health England)
How Horticulture & PHE can work together
1020 Dr Agnes van den Berg (Environmental Psychologist)
An International Perspective: Greenspace & Health
1035 Dr Ross Cameron (Sheffield University)
Gardening: Value in terms of Human Health & Wellbeing
1045 Questions on Session 1

Dr William Bird MRCGP MBE
4th July 2016
Health and
Horticulture
Conference
A GP’s
Perspective

© 2015 Intelligent Health
We were
designed to
be
connected
to nature
The Story
Yet 54% of the world’s
population live in cities
Is this disconnection the
underlying cause of the
epidemics of obesity and other
chronic diseases?
Do we need healthy
landscapes?

If we take an hour to equal 1,000 years,
then four days is 100,000 years – the time
from the origin of mankind to today
4 days
ago
100,000
years ago
hunter
gatherers
10 hours
ago
10,000
years ago
agriculture
4 hours
ago
4,000
years ago
civilisation
10 hours
ago
10,000
years ago
agriculture
4 hours
ago
4,000
years ago
civilisation
technologyindustrialisationindustrialisation
9 minutes
ago
9 minutes
ago
80 seconds
ago

Sociable Green Valued
Our factory setting is to be in a
sociable group, supportive environment and
have a purpose
People Place Purpose

Loneliness Hostile Rejection
People Place Purpose
Fear and Chronic Stress

How does nature benefit health?
(a) Less stressed,
(b) More exercise,
(c) More positive social
interactions and
(d) Better quality
environment for health
promotion (i.e. has
lower levels of air
pollution)
Hartig T., Mitchell R., De Vries S.
and Frumkin H. (2014) Nature and
health. Annual Review of Public
Health 35, 207–228.

The Effect of Trees on Cognitive
Performance
–3
–2
–1
0
1
2
3
4
5
6
7
No Tree Min Awareness Mod Awareness Heightened Awareness
Lin, Ying-Hsuan, et al. "Does awareness effect the restorative function and
perception of street trees?“ Cognitive Science 5 (2014): 906.
Digit Span Backward Test

Exposure to Neighbourhood Green Space
and Mental Health
Beyer, Kirsten MM, et al. Int.J of environmental research and public health 11.3 (2014): 3453-3472

Association Between Trees, Vegetation,
Depression and Stress
–1.6
–1.4
–1.2
–1.0
–0.8
–0.6
–0.4
–0.2
0.0
25% more Tree Cover 25% Higher NDVI 25% more Greenspace
Depression Stress
Normalized Difference Vegetation Index (NDVI)
Beyer, Kirsten MM, et al. Int.J of environmental research and public health 11.3 (2014): 3453-3472

Green Space reduces Health Inequalities
1.0
1.2
1.4
1.6
1.8
2.0
2.2
No green Little green Some green More green Very green
Exposure to green
Highest
Income
Middle
Income
Lowest
Income
Linear (Highest
Income)
Linear (Middle
Income)
Linear (Lowest
Income)
Mitchell, R. and Popham, F. (2008) Effect of exposure to natural environment on health inequalities:
an observational population study. The Lancet 372(9650):pp. 1655-1660.
Incidence Rate Ration

Nature and the Unborn Child
High
Blood Pressure
in pregnant
women increased
by 14% for every
300 meters away
from green
space
Birth
weight and
baby’s head
size were larger
within the 500
metres of
green space
1. Grazuleviciene R et al Int J Environ Res Public Health 2014 11 2958-2972
2. Dadvand P Env Health Perspectives 120 10

Chronic
Stress
Anxiety and
depression
Physical
Inactivity
Poor diet

Chronic Stress
Stress
Hormones
Physical
Inactivity
And other
poorhealth
behaviours
Chronic Inflammation
Mitochondria as a key component of the stress response. Manoli et al. Trends in Endocrinology and Metabolism Vol 18 No 5 2007

Chronic
Inflammation
Immune system
is constantly
switched on

Inflammation: ‘the cause of causes’
Chronic
Inflammation
Starts in children
as young as
6 years old
ArthritisArthritis
CancersCancers
DiabetesDiabetes
ObesityObesity
DementiaDementia
Cardiovascular
disease
Anxiety and
Depression

Chronic Stress
Stress
Hormones
Physical
Inactivity
And other
poorhealth
behaviours
leads to inflammation
Mitochondrial damage and telomere shortening
Depression
Mitochondria as a key component of the stress response. Manoli et al. Trends in Endocrinology and Metabolism Vol 18 No 5 2007
Cancers Diabetes DementiaCardiovascular

Adding Quality of Green Space
Measures of Quality:
● Accessibility,
● maintenance,
● variation,
● naturalness,
● colourfulness,
● clear arrangement,
● shelter,
● absence of litter,
● general impression.
Dillen, S.M.E. van, Vries, S. de,
Groenewegen, P.P., Spreeuwenberg,
P. Greenspace in urban
neighbourhoods and residents’ health:
adding quality to quantity. Journal of
Epidemiology & Community Health:
2012, 66(6)

Green or Blue
Willingness to visit 0-10
0
10
9
8
7
6
5
4
3
2
1
0
5.96 Urban
Blue Space p= <0.01
4.89 Urban
Green Space P= <0.01
3.66 Urban
No Nature
5.83 Woodland
open countryside
7.68 coast
7.40 open water
White M.P., Smith A., Humphryes K., Pahl S., Snelling D. and Depledge M. (2010) Blue space: the importance of water for
preference, affect and restorativeness ratings of natural and built scenes. Journal of Environmental Psychology 30, 482–493.

Green Gym Vs Aerobics
Comparison of heart-rate response
during two sessions of activity
0
50
100
150
200
Time Minutes
Heart Rate
Green Gym
Step aerobics
V Reynolds 1999
OCHRAD

To make a step change in
activity levels we need to be bold
Let’s
remove
boundaries
and turn a whole
town into a
playground!

Step change across a community

Beat the Street East London

Exploring the local area (66%)
Getting fit (54%)
Having fun (54%)
Spending time with friends or
family (53%)
and feeling more healthy (52%)
Winning Prizes (13%)

Beat the Street Reading
35%
45%
36%
45% 46%
56%
40%
47%
0%
10%
20%
30%
40%
50%
60%
2014 registration 2014 registration
3 months after
2015 registration 2015 registration
3 months after
Took part in 2014 only Took part both years Took part 2015 only
Over two years in Reading there has been a 20% increase in the number of people
reaching the Government recommended activity levels of 150 minutes a week

• Disconnection from nature causes
chronic stress
• We eat badly and exercise less
• More visceral fat, inflammation
• Result: an epidemic of chronic
disease e.g. diabetes , heart disease
• Being healthy is about friends,
family, nature and feeling good about
ourselves.
• Nature reduces stress connects
people, increases activity and is
generally more healthy
We are
designed to
be Hunter
Gatherers
The Story

Building Active
Communities
william.bird@intelligenthealth.co.uk

Dr Justin Varney
National Lead forAdult Health and Wellbeing
Justin.varney@phe.gov.uk
How Horticulture and
Public Health can work
together to improve the
health of the nation

About Public Health England
• We protect and improve the
nation's health and wellbeing, and
reduce health inequalities.
• Locally focussed
o 4 regions, 9 centres
o 8 Knowledge & Intelligence hubs
o Other local presence
• Key roles:
1. System leadership
2. Health protection
3. Local support
41 How Horticulture and PH can work together

42
Overview
• The common challenge on Non-communicable
disease
• Responding to the challenge
• The evidence: Horticulture and health
• Looking ahead
How Horticulture and PH can work together

The current and future challenges
for health and social care in the UK
•Addressing the health and wellbeing gap
•Healthy life expectancies gap
•Increasing burden of preventable disease
•Persistent health inequalities
•Addressing the care and quality gap
•Persistent variations in healthcare
•Addressing the financial gap
•Opportunity costs of not having a prevention focus
The need for a system wide approach of
communities supported by their NHS, local
authorities and voluntary sectors.

44 PHE Conference 16 September 2015
Changes in causes of Disability
Adjusted Life Years 1990-2013
Source: Newton et al. (2015) Changes in health in England, with analysis by English regions and areas of deprivation, 1990–
2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet
www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00195-6.pdf

Why prevention matters

46
Disease risk factors in England
Newton et al. (2015) Changes in health in England, with analysis by English regions and areas of deprivation, 1990–
2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet

47
To improve & protect the nation’s health & wellbeing and improve the health of the poorest, fastest
Outcome 1) Increased healthy life expectancy – taking into account health quality as well as length of life
Outcome 2) Reduced differences in life expectancy between communities (through greater
improvements in more disadvantaged communities)
Improving the wider
determinants of
health
1
19 indicators, including:
• People with mental
illness or disability in
settled accommodation
• Sickness absence rate
• Statutory
homelessness
• % of population
affected by noise
• Use of green space
• Social connectedness
• Fuel poverty
Health improvement2
• Excess weight
• Alcohol-related
admissions to hospital
• Proportion of physically
active and inactive
adults
• Self-reported wellbeing
• Falls and falls injuries
in the over 65s
Health protection3
• Air pollution
• Public sector
organisations with
Board approved
sustainable
development
management plans
Healthcare & public
health preventing
premature mortality
4
• Infant mortality
• Mortality from causes
considered preventable
• Mortality from
cardiovascular disease
• Mortality from
respiratory diseases
• Excess winter deaths
How PHE is addressing these challenges

48
Horticulture & Health
Spectrum of intervention types,
methodologies and strength of
evidence
• Therapeutic garden schemes
• Green Gyms
• Health walks
• Therapeutic landscapes
• Garden schemes
• Workplace Wellbeing Charter

How the money flows
49 http://www.kingsfund.org.uk/sites/files/kf/media/nhs-structure-2015.pdf

An alternative guide to the NHS
50 http://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england
The alternative guide to the NHS
in England

Key Commissioning Priorities
• Health
• Acute pressures (A&E, GP apt)
• Recurrent or prolonged treatment costs
• Public Health
• Preventable mortality & morbidity
• Obesity – predominantly childhood
• Life course issues – childhood, old age
• Social Care
• Adult social care costs for residential/domiciliary care
• Employers
• Productivity & sickness absence
TIMESCALE OF
RETURN ON
INVESTMENT

52
Evidence
Growing and strengthening evidence
base for cost-effective interventions
delivered by horticulture
Particularly strong for:
• Mental health / Dementia
• Physical activity
• Wellbeing
• Air quality
Growing evidence base in relation to
physical health, with some good
evidence around initiatives such as
green gyms

Cultural commissioning: a public health perspective
Working together
Historically commissioning of horticulture
schemes for health has been very small scale
primarily non-recurrent pilots & grants.
Moving to sustainable provision requires
cultural shifts for both commissioners and
providers.
Recognition that horticulture is a wide spectrum
encompassing big business and a large
industrial workforce
Recognition that providers need to deliver the
outcomes commissioners are commissioning
for and in a measurable way.
Lots of learning from cultural and physical
activity sectors who are on the same journey.

Looking ahead
• Ageing population with growing
burdens of multiple health
challenges
• Working age is increasing and
millennials will often have
portfolio careers
• Public sector is refocusing and
prioritising on outcome based
commissioning
• Inclusive universalism vs
targeted minority approaches

Prof. Dr. Agnes van den Berg
An international perspective:
Greenspace and health

56
Accumulating evidence
0
1000
2000
3000
4000
5000
6000
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
# hits google scholar “greenspace health"

Epidemiological research
32
24 26
20
10
8
0
5
10
15
20
25
30
35
Numberper1000
depression asthma diabetes
10% green 90% green
Groenewegen, P.P., Van den Berg, A.E., Maas, J., Verheij, R., De Vries, S. (2012). Is a green residential
environment better for health? If so, why? Annals of the Association of American Geographers.

Experimental research
Tyrväinen, L., Ojala, A., Korpela, K., Lanki, T., Tsunetsugu, Y., & Kagawa, T. (2014). The influence of urban green
environments on stress relief measures: A field experiment. Journal of Environmental Psychology, 38, 1-9.
Positive feelings Self esteem Vitality
Before After Before After Before After

Green
space
Health
- Depression
- Anxiety
- Asthma
- Birth weight
- Cancer
- Migraine
- COPD
- ADHD
- etc.
Behaviour
- Exercise
- Social contacts
- Sleep
Summary of knowledge
Physiology
- NK-cells
- Blood sugar
- Cortisol
Psychology
- Relaxation
- Vitality
- Mood
- Attention
1 2

Phytoncides
Fractals
1. Active ingredients
- Volatile organic compounds
- Antimicrobial
- Increase activity NK-cells
- Natural geometry
- Self-similar patterns
- Easy to process

Central mechanism
Enhancement of
the immune system

Key challenge: How to (re-)connect people to
nature

People  green
“green care”
Options
Green  people
“greening”

65
Thank you for your attention!
Website: www.agnesvandenberg.nl
Email: a.e.van.den.berg@rug.nl
@agnes_vdberg

Gardening
Its Value in Terms of
Human Health and Well-being ?
Dr Ross Cameron & Dr Alistair Griffiths
r.w.cameron@sheffield.ac.uk

Context!
• New Species
• Homo westernmanicus
• Physiology of a Hunter
Gatherer
• But, lifestyle of a brick

But, living with ?
Designed for ?

For many specimens of Homo
westernmanicus –
Gardens provide the bridge to the
natural world

Background to
Gardens
• Western Society = 90% live in urban areas.
• UK - 87% households have access to a garden (Gibbons et al., 2011).
• Gardens = 22-36% of the total urban area (Mathieu et al., 2007).
• In UK = 1/3 to ½ of urban green space (Loram et al., 2007).
• But decreasing area dedicated to gardens - infill & new houses having
smaller gardens. (Smith, 2010).
• Under-represented in the Green Infrastructure equation (Cameron et al., 2012).

Reported & Derived Benefits
(e.g. Cameron, 2014)
Green Space
• Pain relief
• Blood pressure
• Heart rate
• Less frequent illness
• Improved cognitive function
• Thermal comfort
Gardens
• Reduced mortality
• Higher bone density, less
osteoporosis
• Cholesterol levels
• Reduces onset of dementia
Regular gardening / gardening like
activities thought to help offset
• Heart disease
• Ischemic stroke
• Type 2 diabetes
• Hypertension
• Anxiety
• Depression
• Certain types of cancer

Gardens as Therapeutic Landscapes
• Landscapes with natural features,
provide greatest restoration from
stress (Ivarsson and Hagerhall, 2008) .
• Even within these – restoration
promoted by presence of flowers
and water – stronger correlation
than presence of animals, trees,
hills, natural aromas or sounds
(Ogunseitan, 2005).
• Design of garden may be important
in offsetting stress associated with
work, commuting, family life etc.,
but this warrants further
investigation.

Gardens & Gardening
• Under-researched in Nature-Health agenda
• Rel. little info on private gardens
– (more on community gardens / allotments & hort
therapy)
• H&WB benefits potentially large
• Heterogeneous landscapes though - in typology, but
also uses and attitudes

Gardens & Gardening
• Associated with: (Clayton, 2007; Blair et al., 1991; Dallosso et al., 1988).
– Providing a form of ‘retreat’
– Interacts with nature
– Place to be creative
– Play and recreation
– Socialise (family and friends)
– Utilitarian – grow food
– Physical exercise (depending on task)
– Identity – self–expression
– Also though
• Pressure – chores – social expectations - keep up with the Jones’
• Extent of benefits may relate to individual’s attitude to
gardening.

Why More Emphasis On Gardens?
4 Key Factors

1. Immediate Access
• Little organisation required.
• Frequent activity & repetition
– fits into short periods of
down-time in busy working
lives.
• Children - easy access to
nature and food education.

2. Encourage Physical Activity

Much of the immediate challenge is
about moving from a sedentary to an
active lifestyle

• Food gardening used to encourage physical
activity in children and encourage healthy diet
(Castro et al., 2013)
• Community gardeners had significantly lower
BMIs for same gender syblings (−1.88 female)
(−1.33 male).
• Also lower probability for overweight or obese
than otherwise similar neighbours (Zick et al., 2013).

Calories burned h-1
• General gardening 239
• Raking 262
• Trimming shrubs 278
• Weeding 278
• Digging 318,
• Pushing powered mower 358 (De Simone 2016)
• Compare Moderate Cycling 470-650

3. Gardens as
Restorative Landscapes
• Self-absorbing – Soft fascination. Attention
Restoration Theory – ‘being mentally away from
the stressors’
• Repeat activity – fascination led
• Keen gardeners rarely need much motivation to
garden!
• Ecological, rather than anthropogenic, view of
the world.

Restorative Landscapes
• Older – adults.
– Gardening more than a casual leisure
pursuit - critical to their physical and
psychological wellbeing. (Scott et al., 2014) .
• Allotment gardening – Single session
showed significant improvement in
self-esteem (P<0.05) and mood
(P<0.001) (Wood et al., 2015).
• For patients suffering severe stress /
mod-mild depression - significant
reductions in primary healthcare
visits and inpatient psychiatric care
when placed on a garden orientated
rehabilitation programme. (Währborg et al.,
2014)

4. Creativity – Self Expression
• Gardeners - control over the design / management .
• Positive psychological aspects - self-esteem, feeling of
achievement and fulfilment of talent.
• Form of art therapy.

Introduction and Session 1

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Introduction and Session 1