Richard J Jackson
MD MPH FAAP
HonAIA HonFASLA
dickjackson@ucla.edu
UCLA
Fielding School of Public Health
/
Antelope Valley
Wellness Symposium
October 29, 2015

The 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
• Referral to “overweight” clinic
• Weight loss program
• TV out of the bedroom; no soft drinks in
the house
• Exercise program; Encourage sports

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
– Antidepressant
– Cholesterol lowering
agent
• Monthly medication costs:
– $385
2 months later the patient is taking:

• The “environment” is rigged against
the child…
• And the doctor,
• And the rest of US.

USA Today 10/20/2011

August 20, 2015

“Ask physicians across the country
what problems they want solved, and
they won't hesitate to tell you. They
worry about the growing health risks
they observe in patients based on
lifestyle choices, obesity and a
variety of social factors which they
feel powerless to change.”
Robert Pearl MD Forbes Magazine Aug 20, 2015

Life Expectancy at Birth and Health Spending
2011

• “Even under the most
optimistic estimates, of the 30
years of increased life
expectancy achieved between
the 1890s and 1990s, only 5
years can be attributed to
medical care.”
Bunker cited in Prescription for a Healthy Nation
Farley and Cohn 2004

CDC Headquarters - Atlanta

July 6, 1999

• The Built
Environment –
how we build
our homes,
workplaces,
towns, cities
and world

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

Commuting by driving is mostly not good for you.
Traffic along LA freeways and Wilshire Blvd.

We Used to Build Real Towns and Neighborhoods
but Now…

Nature Does Not Tolerate Monocultures for
long…

Two houses, adjoining back yards
(From Streetsblog, 02/28/2013)

For every age group
from 3 through 34--
crashes were the No. 1
cause of death

Pedestrian Fatality Rates for
Collisions at Different Speeds
Zegeer et al 2002

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%

Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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

“Supersizing” a fast-food meal –
the real costs
• Paying 67 cents to supersize an order — 73%
more calories for 17% more money
• — adds an average of 36 grams of
adipose tissue.
• The future medical costs for that
“bargain” would be $6.64 for an obese
man and $3.46 for an obese woman.
University of Wisconsin-Madison, Rachel N. Close and Dale A. Schoeller

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-AdjustedRelativeRisk
Body Mass index (kg/m2
)
WomenWomen
MenMen
<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
2.9
1.0
4.3
1.0
5.0
1.5
8.1
2.2
15.8
4.4
27.6
40.3
54.0
93.2
6.7
11.6
21.3
42.1

Percentage of US Adults with Diagnosed
Diabetes - 1994

Percentage of US Adults with
Diagnosed Diabetes - 2001

Percentage of US Adults with Diagnosed
Diabetes - 2007

NHANES
National Health and Nutrition Examination Survey

Prevalence of
and Trends in
Diabetes Among
Adults in the
United States,
1988-2012
Andy Menke; Sarah Casagrande; Linda Geiss, Catherin Cowie
JAMA. 2015;314(10):1021 doi:10.1001/jama.2015.10029

How Diabetes &
Prediabetes Diagnosed
In This Study
• Diabetes
– Prior Clinical Diagnosis or
– Hemoglobin A1c level of >6.4%
– Fasting Plasma Glucose >125 mg/dL
• Prediabetes
– Hemoglobin A1c level of 5.7- 6.4%,
– FPG level of 100 - 125 mg/dL

Diabetes Prevalence NHANES
(using Hemoglobin A1c , FPG)
Sample of US Population
All Age Groups, Races, Income and Education
1988-1994 2000-2002 2011-2012
9.8% 10.8% 12.4%
For Prediabetes
36.5%

10,000 steps
• 3234 people with Pre-Diabetes
(IGT –Impaired Glucose Tolerance)
• Walked or exercised five times a week
for 30 minutes for six months
• Lost 5% to 7% of their body weight
• Reduced their risk of diabetes by 58%

Survival of 1263 men with Type 2
Diabetes: Fit vs Unfit
Low Cardiorespiratory Fitness and Physical Inactivity as Predictors of Mortality in Men with
Type 2 Diabetes." 18 April 2000 Annals of Internal Medicine 132, pp 605-611 M. Wei et al

“The Status of
Baby Boomers’
Health in the
United States:
The Healthiest
Generation?”
JAMA Internal
Medicine
February 4, 2013

Overall Health Status US
Persons Aged 46-64
NHANES 1988-1994 NHANES 2007-2010
Report “excellent” health
32% 13%
Limitations to Life Functions
9% 14%
Using Walking Assist (wheelchair, cane, etc)
3% 7%

“Lifestyle Factors” US
Persons Aged 46-64 (NHANES)
1988-1994 2007-2010
Smoking
28% 21%
Obesity
29% 39%

“Lifestyle Factors” US
Persons Aged 46-64 (NHANES)
1988-1994 2007-2010
No Regular Physical Activity
17% 52%

Thinking about solutions

US High Fructose
Corn Sugar
Consumption
per capita per day
• Year Pounds Calories
• 1965 0 0
• 1970 0.5 2
• 1980 19 53
• 1990 50 134
• 2000 64 179

Likely Results of a Sugar Sweetened
Beverage (SSB) Tax
• “A national tax of 1 cent per
ounce on sugar-sweetened
beverages (SSBs) would
decrease consumption by 23%
and raise $14.9 billion in the
first year alone.”
Brownell KD, et al. The public health and economic benefits of taxing sugar-sweetened beverages.
NEJM. 2009;361(16):1599-1605.

“Modern” Schools
Credit: Constance E. Beaumant, NTHP
Credit: South Carolina Coastal Conservation League

• Percent of
children who
walk or bike to
school:
• 1974  66%
• 2000  13%
(CDC,
2000)
We have changed
how much we
walk or bike

Fitness of California Children
Annual Fitnessgram Results
Conducted in Grades 5, 7, and 9
Measures 6 major fitness areas
(e.g. aerobic capacity, body composition, flexibility)
2011 Results: Who passed all standards?
Grade 5: 25%
Grade 7: 32%
Grade 9: 37%
http://www.cde.ca.gov/nr/ne/yr11/yr11rel95.asp#tab1

The Built
Environment:
Designing
Communities to
Promote Physical
Activity in
Children
Policy Statement American
Academy of Pediatrics
June 2009

Institute of Medicine
Report
Accelerating Progress
in Obesity Prevention
May 8, 2012

Gain in Longevity for a 45-Year Old Male
5.8 years
8.7 years
0
2
4
6
8
10
Low vs Moderate Low vs High
Years of added life
Additional years of Life:
Moving from Low to Moderate Fitness -- 5.8 years
From Low to High –- 8.7 years.

MRI Study of Brain Scans
of 120 older adults--
Half –
Moderate aerobic
exercise: 45 minutes, three
days a week, mostly walking.
Half—
No extra aerobic
exercise.
One year later:

MRI Study of Brain Scans of 120 older adults One Year Later—
Half – Moderate aerobic exercise --
45 minutes, three days a week, mostly walking.
Brain size increased
Half— No extra aerobic exercise --
Brain Size Decreased 1.5%
Result: 3.5% difference
Further tests showed that increased brain
volume translated into better memory.

From the San Diego Planning Journal

• Lancaster Boulevard was a five-lane road w/ travel speeds up to 50 mph.
• In 2010, the city revitalized nine blocks of Lancaster Blvd.
• $11.6 million street renovation project.
• 800 new permanent jobs were created.
• 26% increase in sales tax revenue.
• By 2012, the project attracted $130 million in private investments and
generated $274 million in economic output.
Lancaster Boulevard, CA
5

May 2014 UCLA the elevator doors in parking lots 4, 7, and 8
UCLA Department of Transportation

NYC Active Design Guidelines
• Resilient Bldgs
• Energy Efficient
Buildings
• Healthy Bldgs
• Smart zoning and
locations
http://www.nyc.gov/html/ddc/html/design/active_design.shtml

http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/call-to-action-walking-and-walkable-communites.pdf

Importance of What Makes
People Happy
Marketplace is Shifting--
More than 56% of home buyers want a home
that is a walkable neighborhood with as little
need for driving as possible.

“The BLVD is an endeavor to bring back the downtown experience”
Lancaster, California

CicLAvia Los Angeles April 2012
Importance of Fun…
and Festivals

Boyle Heights, Los Angeles. The Evolution into Mariachi Plaza

For Mariachi Plaza….”proposed eight-story medical office building and a six-level
parking garage, plus a three-floor building with street-level retail would take out a
small row of shops immediately north of the plaza…

Atlanta Citizens Turning Out To Help
Get Ready for The Belt Line
Importance of Community Pride

Indianapolis Cultural
Trail
• 8 miles $69 million
• First $15 million from Glick
family (start with philanthropy)
• $2 million for Art
• Links the city together
• Revitalized Business
• Helps to Recruit and Retain
Top Talent
• And, yes, a GOP Mayor
Importance of Art and
Beauty and Nature

Home Price Growth By Neighborhood Type
2011-2014

Image Credit: Lehrer + Associates and LA River

Image Credit: Lehrer + Associates and LA River

Economic Benefits of Urban River
Parkways
● Medical cost savings
o one study found that every $1 invested in trails for
physical activity resulted in nearly $3 direct medical
benefit
● Economic development
o sale prices up to 16% higher for homes within 1,500ft
of natural spaces
o Colorado: land value increased by $4.20 for every foot
closer to the “greenbelt”
o Philadelphia: property values increased from
$1,000/acre 2,500ft from park to $11,500/acre within
40ft

The Manhattan Waterfront Greenway
32-mile long walking and bicycling path around the island of Manhattan.
The majority of the Manhattan Waterfront Greenway is physically separated from auto traffic

• Importance of
Courage– The
NYC High Line
• AIA Report:
Local Leaders—
Healthier
Communities Through
Design
2013

The High
Line
NYC
A 20 block walk
in Manhattan
without a cross
street–
and it was delightful even
with a 2 year old.

Ten
Principles
for Building
Healthy
Places
The Urban Land
Institute 2013

Urban Land
Institute’s
Healthy
Places
Toolkit
Released at
International
Meeting in Paris
February 5, 2015
http://www.uli.org/toolkit

http://www.uli.org/toolkit

http://www.uli.org/toolkit

http://www.uli.org/toolkit

Richard J Jackson MD MPH AIA(Hon)
FAAP ASLA(Hon) dickjackson@ph.ucla.edu
UCLA Fielding School of Public Health
We Are What We Eat…
And What We Build
http://designinghealthycommunities.org
/