# Presentation: 625860

## Health in All Policies:Lessons Learned by LA County PDH

- CDC Leaders to Leaders Conference
- July 8, 2008

*Jonathan E. Fielding, M.D., M.P.H., M.B.A*
*Director of Public Health and Health Officer*
*    **	**L.A. County Department of Public Health*
*Professor of Health Services and Pediatrics*
*Schools of Public Health and Medicine, UCLA*

## Los Angeles County – Background

- 4,300 square miles
- 88 incorporated cities and 2 islands
- 10.3 million residents (more than 42 States)
- 46% Latino, 32% White, 13% Asian/Pacific Islander, 10% African American, 0.3% American Indian
- Over 100 different languages spoken by significant size populations
- 15% living in poverty (14% of families & 24% <18)
- 22% of adults and 8% of children have no health insurance

**Notes:**
Before we talk about what it is that Public Health does in LA County, we should first review some basic info about the County.  As you can see from this slide, LA County is enormous both in size and population.  In fact, LA County’s size and diversity influence almost every aspect of delivering health services in LA.

## Crude Death Rate for Infectious Diseases, U.S., 1900 - 2000

- Crude Death Rate for Infectious Diseases, U.S., 1900 - 2000

- MMWR, CDC, 1999

- * Rate is per 100,000

## Policy and Public Health

- Historically, policy changes have yielded some of the biggest improvements in public health
- Tobacco: smoking bans
- Injury prevention: helmet laws
- Disease prevention: immunization requirements, sanitation improvements
- The biggest levers we can move are often policy levers

## Policies Can Work on Multiple Levels

- Level 1 – Reducing burden of disease
- e.g. Siting schools away from freeways to reduce asthma burden
- Level 2 – Reducing risk factors for disease
- e.g. Smoking bans and tobacco retail licensing to reduce smoking opportunities
- Level 3 – Focus on underlying determinants of disease
- e.g. Create a healthier built environment by incorporating health into land use decisions

## Level 1 – Reducing the Disease Burden: LAUSD school siting policy

- Pollutant levels are correlated with distance from freeway
- High concentrations of regulated air pollutants such as PM10, NOx, and VOC’s are found in close proximity to freeways.
- Concentrations of ultrafine particles are found at levels significantly above background within **500 feet **of freeways.
- Potentially adverse health impacts have been identified up to **1500 meters** away from freeways.
- Health effects associated with traffic related pollutants include:
- Decreased lung function and lung development in children
- Increased rates of respiratory disease, e.g., asthma, bronchitis
- Increased rates of premature births, low birth weight, and cardiac birth defects
- Increased rates of heart attack and other heart disease

## [school siting policy]

**Notes:**
This map shows how close the 101 freeway is to over a dozen LAUSD schools in the Hollywood area.  There is at least one school within 500 feet of the freeway and dozens more that are within 1500 feet of the freeway.

## LAUSD School Siting Policy

- LAC DPH’s Involvement:
- Provided technical assistance to determine risks associated with siting schools close to freeways
- Collaborated with LAUSD to develop the policy
- Educated LAUSD Board Members about importance of the measure
- Resulting policy prohibited siting of schools within 500 feet of freeways

## Slide 9

## Level 2 – Reducing Risk Factors:Tobacco Control

- Current Tobacco Control and Prevention Priorities in Los Angeles County:
- Countywide tobacco cessation initiative
- Tobacco retail licensing (TRL)
- 	-	Reduce tobacco availability to youth in the retail environment through local licensure
- Smoke-free outdoor areas
- 	-	Reduce exposure to secondhand smoke (SHS) through the adoption of smoking bans in parks and beaches
- Smoke-free multi-unit housing
- 	-	Reduce exposure to SHS through the adoption of policies that restrict smoking in apartments and common areas

## Measuring Progress on Policy Change

- Tobacco retail licensing
- 	-	implemented in 17 jurisdictions, including the cities of 	Los Angeles, Glendale, Compton, Long Beach and 	the County of Los Angeles
- Smoke-free parks and beaches
- 	-	implemented in 36 jurisdictions, including the cities of 	Santa Monica, Los Angeles, Malibu, and Long Beach, 	and the County of Los Angeles
- Smoke-free multi-unit housing
- 	-	implemented in one city (Calabasas) and being 	considered in three others (S. Pasadena, Glendale, 	and Santa Monica)

## Lessons Learned fromTobacco Control Efforts

- Public education important but not sufficient; need to focus as much or more on the environment than the individual
- Tobacco control laws are critically important
- Cities are a key leverage point for continued policy and environmental change
- Community organizations and their constituents can be extremely effective policy change agents
- Requires long term commitment of support to CBO’s to build capacity needed to organize and facilitate policy campaigns
- Community-based policy campaigns require a sequence of steps or “phases”
- Success ultimately attributable to a comprehensive multi-pronged approach

**Notes:**
Since 1995, California Assembly Bill 265 has required physical fitness testing of all public school children in grades 5, 7, and 9.
A state advisory board recommended a battery of physical fitness tests that included body mass index (or BMI) calculated from height and weight, which are measured by physical educators and school teachers each Spring.
Beginning in 2001, test results are collected annually and reported to the Governor, state legislature, and as part of the School Accountability Report Card.

## Level 3: Addressing the Underlying Determinants of Health

- The Evans - Stoddart Model

## Level 3 – The Underlying Determinants of Health: the Physical Environment

- Definition of the built environment:
- The built environment encompasses all buildings, spaces, and products that are created, or modified, by people.  It includes homes, schools, workplaces, parks/recreation areas, greenways, business areas, and transportation systems.
- The importance of regional planning:
- Decisions made by cities and counties about zoning, development, and transportation have tremendous influence on the health of the local population

## Multiple Possible Adverse Health Impacts From Poor Community Design

**Notes:**
In recent years, more and more public health professionals have started to team up with urban and regional planners to discuss the ways in which urban design can promote or damage a population’s health. Our department is actively searching for opportunities to become more heavily involved in issues like local urban and transportation planning.

In the future, DPH will take a more active role in:
	- Forging partnerships with local planning and transportation officials in order to bring health to the planning table
	- Using data to arm and inform stakeholders and decision-makers
	- Expanding the role of pubic health in commenting on development plans & conduct health impact assessments

## Summary of Health Effects of Air Pollution

- Amount of goods transported through California projected to nearly quadruple between 2000 and 20201
- Will have significant impact on air quality and health2
- Diesel particulate matter (PM)
- concentrated around ports, railyards, and heavily trafficked roads3
- premature deaths
- cancer
- respiratory disease
- lost workdays
- global warming (2nd to CO2)

- Annual Health Impacts in CA from PM and Ozone4

- 1 (Cal EPA, 2005); 2 (Pacific Institute, 2006)
- 3 (CA/EPA Air Resources Board); 4 (CA/EPA Air Resources Board,  2004)

## Achievements to Date in LA County

- LAC Public Health and Regional Planning Directors have agreed to have their staff work collaboratively on General Plan update
- Public Health has met with Regional Planning and provided feedback/suggestions on “Shaping the Future 2025” in support of healthy, livable communities
- Policies supporting healthy, livable communities have been incorporated into the Draft Preliminary General Plan

**Notes:**
The Los Angeles County General Plan is a comprehensive statement of public policy guiding long-term development and resource protection for the unincorporated parts of Los Angeles County. 

The unincorporated areas include more than 2,600 square miles and represent two-thirds of the County's land and one-tenth of its population unofficially grouped into 137 non-contiguous areas. If the unincorporated portion of LA County were in fact a city, it would be the third largest in the State, after Los Angeles and San Diego. 

“Shaping the Future 2025” is the name of the document which the Regional Planning Department provided to the public to review and comment on its DRAFT General Plan.

The Department of Public Health has worked closely with this effort to support a future which includes greater areas of healthy, livable communities.

## DPH’s Focus on Health Equity &the Social Environment

- Department-wide workgroup on reducing health inequities
- Focus on the root causes of inequities, particularly underlying social conditions

- Five domains
- Neighborhood conditions
- Education across the life course
- Income and employment
- Social connectedness
- Health care and health promotion
- Action plan is currently under development – policy work will be large component

## Annual Age-adjusted Mortality Rate by Median Household Income - LA County, 2003-2005*

***provisional data used for 2005**

**Notes:**
The graph follows the expected trend of higher mortality at lower levels of income

## Percentage of the Population Living in Poverty, LA County, 1970-2000

## Economic Hardship & Childhood Obesity

## Cities/Communities with Lowest and Highest Childhood Obesity Prevalence 

***Table excludes cities/communities where number of students with BMI data < 500. **
**Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools. **

| Top 10* |  |  |
| --- | --- | --- |
| City/Community Name | 2005 Youth Obesity Prevalence (%) | Rank of Economic Hardship (1 - 128) |
| Manhattan Beach | 4.2 | 2 |
| Palos Verdes Estates | 6.3 | 5 |
| Beverly Hills | 6.9 | 19 |
| San Marino | 7.1 | 15 |
| Agoura Hills | 7.3 | 10 |
| Calabasas | 8.0 | 8 |
| South Pasadena | 9.0 | 17 |
| La Canada Flintridge | 11.4 | 18 |
| Rancho Palos Verdes | 11.6 | 13 |
| Arcadia | 12.3 | 35 |
| Average 10 lowest | 8.0% |  |

| Bottom 10* |  |  |
| --- | --- | --- |
| City/Community Name | 2005 Youth Obesity Prevalence (%) | Rank of Economic Hardship
(1 - 128) |
| Cudahy | 29.4 | 123 |
| West Whittier-Los Nietos | 29.7 | 81 |
| West Puente Valley | 30.0 | 90 |
| Bell | 30.2 | 115 |
| Willowbrook | 30.5 | 116 |
| Huntington Park | 30.6 | 122 |
| East Los Angeles | 31.9 | 117 |
| Florence-Graham | 32.0 | 128 |
| San Fernando | 32.9 | 103 |
| Maywood | 37.4 | 121 |
| Average 10 highest | 31.5% |  |

## What Factors are Contributing to the Obesity Epidemic: a Partial List

- Increased marketing of junk food and sodas to children
- Increased portion size of food and beverages
- More meals consumed outside the home
- Decreased physical education in schools
- Fewer safe areas for exercise in communities
- Increased TV and computer time
- Less access to fresh, nutritious, affordable food in underserved areas
- Increased time spent in cars

- Can be addressed by _policy work?_
- YES
- YES
- ?
- YES
- YES
- ?
- YES
- YES

## Key New Tool –Health Impact Assessment (HIA)

- HIA is **tool for ****systematically**** evaluating, synthesizing, and communicating information about potential health impacts for more ****informed decision-making, especially in other sectors.**
- An HIA might ask:
- What are the health consequences of high rates of students dropping out from high schools?
- What elements of school site design are most cost-effective in encouraging physical activity?
- Why use an HIA?
- It influences decision makers using a broad understanding of health and a wide range of evidence – it places public health on the agenda
- It highlights potentially significant health impacts that are unknown, under-recognized, or unexpected
- It facilitates inter-sectoral working and public participation in decision making

## Link Between Obesity and Eating Out

**Americans eating out more than ever before--in LA County, one in four children 2-17 years of age ate fast food in the past day (2005 LA County Health Survey).   **
**Supersizing of restaurant food and beverage portions has become widespread.**
**Fast food consumption linked with increased caloric intake and excess weight gain.**
**Studies have shown that most people (even nutritionists) greatly underestimate the caloric content of restaurant menu items.**
**Calorie and other nutritional information not generally available at the point of purchase in restaurants (in contrast to packaged food products which are required by the FDA to include nutrition information).**

- Require chain restaurants with _>_ 15 outlets in CA to provide nutritional information at point of purchase
-  _Menu Boards_: calories
-  _Menus_: calories, fat, sat/trans fat, carbohydrate, sodium
- Applies to standard menu items only

- SB 1420 - Menu Labeling

- Example of Subway menu board in NYC

## Which McDonald’s Menu Option

|  |  |  |
| --- | --- | --- |
| 2 Big Macs | 1,080 cal | 53% |
| 2 Egg McMuffins | 600 cal | 8% |
| 1 Large shake  | 1,160 cal | 11% |
| 4 Hamburgers | 1,000 cal | 22% |

**Field Poll, 523 registered voters, April 2007**

- Has the Most Calories?

## Which McDonald’s Menu Option

|  |  |  |
| --- | --- | --- |
| 2 Big Macs | 1,080 cal | 53% |
| 2 Egg McMuffins | 600 cal | 8% |
| 1 Large shake  | 1,160 cal | 11% |
| 4 Hamburgers | 1,000 cal | 22% |

**Field Poll, 523 registered voters, April 2007**

- Has the Most Calories?

- Survey respondents who guessed the item has the most calories

## Conducting HIA to Estimate Impactof Menu Labeling Bill

**HIA found that if menu labeling resulted in just 10% of restaurant patrons ordering reduced calorie meals (with an average reduction of 100 calories per meal), a total of **_**38.9%**_** of the 6.75 million pound average **_**annual weight gain**_** in the county population (5 yrs and older) **_**would be averted**_**.  **
**Significantly larger impacts could be realized with increased consumer response to the posted calorie information. **

## Key New Tool - Health Forecasting

- Currently we spend time examining health status, health risks, and health improvement opportunities for today
- But optimal planning requires us to understand how our current activities will influence future health status
- Health forecasting = a modeling project that helps us to estimate what health status will be in the future
- HF allows us to:
- Model future health status based on health behavior patterns, population trends, and other variables
- Compare policy options to determine which are the most cost-effective for improving health
- Demonstrate the health impact of non-health oriented policies
- Model effect of multiple interventions

## Physical Activity & Obesity Are Not Independent

**Median METhrs/week**

**BMI**

**Percent Overweight**

**Age**

**Active**

**Inactive**

**People with low levels of Physical Activity (<8 METhrs/wk) are more likely to be overweight:**

**People with healthy BMI have higher levels of Physical Activity:**

**Source: CA-BRFS 1984-2000**

**Notes:**
Any intervention targeting physical activity or obesity should take into account the association between these two behaviors. The population health forecasting model explicitly enables users to explore the joint distribution and the joint impact on health outcomes

## Identifying Strategies to Reduce Disparities

- Charts show the forecasted percent change in age-adjusted mortality:

**Up to Best**

**+2 METs **
**Hours per **
**week**

**Notes:**
Targeting people with low PA such as in the ‘Up to Best’ scenario enables reduction in racial and ethnic disparities – note however that Latinos are further improving their already low mortality rate

## Further Increases in BMI = Additional $12 B. in Personal Medical Expenditures in CA Annually by 2025

**Total direct personal medical expenditures*, age 18+ (2003 $000,000)**
**All dollars used below are 2003 actual dollars**

- 108,350

- 127,499

- 115,672

## What Health Departments Can Do to Promote Healthy Policies

- Develop appropriate skills
- Hire people with expertise in policy work
- Learn new tools (e.g., HIA)
- Work with new partners that have overlapping goals and objectives
- Look for partners in business, academia, other levels of government
- Educate decision makers and public about the underlying determinants
- Explain why every policy is a health policy
- Use best evidence in choosing policy interventions to support

## Guide to Community Preventive Services

- Excellent source for best evidence on interventions to improve health in populations
- 15 member independent expert panel working with CDC staff and other governmental agencies and interested organizations
- Performs systematic reviews and makes related recommendations based on standardized methods
*www.thecommunityguide.org*

## Slide 36

| Intervention | Recommendation |
| --- | --- |
| Informational Approaches to Increasing Physical Activity (PA) |  |
| Community-wide campaigns | Recommended (strong evidence) |
| “Point-of-decision” prompts | Recommended (strong evidence) |
| Classroom-based health education focused on providing info | Insufficient evidence |
| Mass media campaigns | Insufficient evidence |
| Behavioral & Social Approaches to Increasing Physical Activity |  |
| School-based physical education | Recommended (strong evidence) |
| Social support interventions in community settings | Recommended (strong evidence) |
| Individually-adapted health behavior change | Recommended (strong evidence) |
| Classroom-based health education focused on reducing TV viewing and video game playing | Insufficient evidence
 |
| College-based health education and physical education | Insufficient evidence |
| Family-based social support | Insufficient evidence |
| Environmental & Policy Approaches to Increasing Physical Activity |  |
| Creation of or enhanced access to places for PA combined with informational outreach activities | Recommended (strong evidence) |
| “Point-of-decision” prompts | Recommended (strong evidence) |
| Street-scale urban design and land use policies and practices | Recommended (strong evidence) |
| Community-scale urban design and land use policies and practices | Recommended (strong evidence) |
| Transportation and travel policies and practices | Insufficient evidence |

## Environmental and Policy Approaches to Increase Physical Activity

- The Task Force recommended: **Creating or improving access to places for physical activity**
- Background on interventions:
- Involve worksites, coalitions, agencies, communities to change the local environment
- Examples of changes: creating walking trails, building exercise facilities, providing access to existing facilities nearby
- Findings:
_**In all 10 studies, improving access to places for physical activity was effective in getting people to exercise more**_
_**Median estimates = 25% increase in percent of people exercising at least 3 times a week**_
- These interventions were effective among both men and women and in various settings, including industrial plants, universities, federal agencies, and low-income communities.

**Notes:**
Many of these programs also train participants to use the equipment and offer health behavior education, risk factor screening, referrals to physicians or additional services, health and fitness programs, and support or buddy systems. These multicomponent programs were evaluated as a “combined package” because it was not possible to separate out the effects of each individual component. 

The median estimates from the reviewed studies suggest that creating or improving access to places for physical activity can result in a 25% increase in the percent of persons who exercise at least 3 times a week. 
Most of the studies also reported weight losses or decreases in body fat among program participants. 
These interventions were effective among both men and women and in various settings, including industrial plants, universities, federal agencies, and low-income communities. If appropriately adapted to the target populations, these interventions should be applicable to diverse settings and groups. 

## Environmental and Policy Approaches to Increase Physical Activity

- The Task Force recommended: _**Community-scale**_** urban design and land use policies and practices to promote physical activity**
- Background on interventions:
- Defined as urban design and land use policies and practices that support physical activity in geographic areas, generally several square kilometers in area or more.
- Involve urban planners, architects, engineers, developers, and public health professionals
- Design elements include the proximity of residential areas to stores, jobs, schools and recreation areas: the continuity and connectivity of sidewalks and streets; and the aesthetic quality and safety aspects of the physical environment
- Findings:
- Studies generally compared behavior of residents in auto-oriented (suburban) communities with those in urban communities
_**In 12 studies, overall median improvement in some aspect of physical activity (e.g., # of walkers) was 161%**_

**Notes:**
The Task Force recommends community-scale urban design and land use policies and practices to promote physical activity based on sufficient evidence of effectiveness.
Evidence was considered sufficient based on:
Sufficient effect size
Consistency of results:  levels of PA associated with improved continuity and connectivity of streets and sidewalks;  levels of PA associated with local mixed-use zoning and roadway design that promotes destination walking
Other supporting evidence 
Dose-response across levels of exposure  
Face validity
Other potential benefits include : air quality, social capital, consumer choice, and green space 

## Environmental and Policy Approaches to Increase Physical Activity

- The Task Force recommended: _**Street-scale **_**urban design and land use policies and practices to promote physical activity**
- Background on interventions:
- Defined as street-scale urban design and land use policies that support physical activity in small geographic areas, generally limited to a few blocks
- Involve urban planners, architects, engineers, developers, and public health professionals
- Design components include improved street lighting, infrastructure projects to increase safety of street crossing, use of traffic calming approaches, & enhancing the street landscape
- Findings:
- Studies assessed effectiveness in providing a more inviting and safer outdoor environment for physical activity
_**In 6 studies, the overall median improvement in some aspect of physical activity (e.g., # of walkers) was 35%**_

**Notes:**
Examples of these interventions include:
Infrastructure projects to improve continuity and connectivity of streets, sidewalks, and bike lanes 
Improved street lighting
Zoning regulations and roadway design standards that promote destination walking and co-location of residential, commercial, and school properties
Infrastructure projects designed to enhance traffic calming or enhance the aesthetics of the streetscape

FINDINGS:
Additional possible benefits included improvements in green space, increased sense of community and decreased isolation, and reductions in crime and stress
Increased walking and bicycling on urban streets also poses the risk on increased injury because of increased exposure to vehicle traffic

## Setting Priorities Among High Impact, Low Cost Clinical Preventive Services

- Partnership for Prevention, non-profit organization dedicated to improving use of effective prevention, reviewed 25 preventive services recommended by the USPSTF & the Advisory Committee on Immunization Practices.
- Rankings based on clinically preventable burden, which measures (in QALYs):
- Health impact of the service on the relevant population
- Cost effectiveness of the service
- Cost effectiveness = average net cost per QALY gained
- For full report & more about the National Commission on Prevention Priorities, go to _[www.prevent.org](http://www.prevent.org/)_

## Saving Lives – High Impact, Low Cost Clinical Preventive Services

- Source: Dr. Eduardo Sanchez, PFP (2007)

## Saving Lives – High Impact, Low Cost Clinical Preventive Services

- Source: Dr. Eduardo Sanchez, PFP (2007)

## Saving Lives– High Impact, Low Cost Clinical Preventive Services

- Source: Dr. Eduardo Sanchez, PFP (2007)

## Saving Lives– High Impact, Low Cost Clinical Preventive Services

- Source: Dr. Eduardo Sanchez, PFP (2007)

## Saving Lives– High Impact, Low Cost Clinical Preventive Services

- Source: Dr. Eduardo Sanchez, PFP (2007)

## LA County Public Health – Healthy People Build Healthy Communities

**Notes:**
Thank you for your time and for giving me this opportunity to detail some of the ways that LA County Public Health is helping to ensure and improve the health of our County’s residents for generations to come.  If you have any questions, please contact me.