1. Community and Public Health- How Equity and Environment Matters: Health in all Policies and Places George R. Flores MD, MPH The California Endowment HSHPS Hispanic/Latino Immigrant Health and Faculty Development Workshop Conference on Latino Immigrant Health Stanford University July 22, 2010

2. What Surrounds Us Shapes Our Health

3. 3 Robert Wood Johnson Foundation and University of Wisconsin, 2010

4. Ecological Frame for Energy Balance

5. Behaviors & Environment 70% Access to Care, 10% Genetics20% Prevention, 4% Medical Services 96% $2.2 Trillion Lots for Care – Not Enough Health Factors Influencing Health National Health Expenditures SOURCE: Centers for Disease Control and Prevention, Blue Sky Initiative, University of California at San Francisco, Institute of the Future, Prevention Institute

6. Policy Priority for Health Promotion and Wellness Affordable Care Act – Prevention & PH Fund $15B / 10 yrs – National Prevention & H Promotion Council – National Prevention & H Promotion Strategy ARRA Communities Putting Prevention to Work Healthy People 2020 The First Lady’s “Let’s Move” Campaign SB 375 Sustainable, healthy environments

7. National Strategy for Health Promotion and Wellness – Initiatives that prioritize prevention and wellness – Focus on preventing the leading causes of death and factors that underlie these causes – Policies, programs, environmental and systems changes – Aimed at individuals, families, and communities – Support life-long good health rather than waiting to treat – Promote equity – Leverage state, local, public, private collaboration

8. Shift from Illness to Wellness 8 Shift from just helping patients cope with the odds to also empowering communities to change the odds Shift priority from high intensity individual care to community-wide prevention and health promotion

9. 9 Robert Wood Johnson Foundation and University of Wisconsin, 2010 Policy Opportunities for Equitable and Healthy Environments

10. Shift Attention Upstream air pollution, molds tobacco smoke toxic exposure proximity to fast food food access / affordability marketing unhealthy food distance from parks unsafe neighborhoods long commutes traffic, pedestrian, bike hazards urban sprawl Asthma Certain Cancers Diabetes Heart disease Obesity Unintentional injury

11. Inequitable and Unhealthy – Environmental Conditions of Latino Immigrants Border crossing Sanitation / water Housing Toxics Remoteness / isolation Safety Transportation Air quality Park/recreation access Food access

12. Community-level Prevention and Health Promotion 12  1° prevention / promotion for health- supportive environmental conditions  Comprehensive, collaborative, multi- sector community engagement  Evidence-based practice / practice-based evidence  Informed and mobilized advocacy for policy and systems change  Latino organizations with aligned messages and policy positions  Promotoras are trusted change agents

13. The Evidence Delva J, Johnston LD and O’Malley PM. “The Epidemiology of Overweight and Related Lifestyle Behaviors: Racial/Ethnic and Socioeconomic Status Differences Among American Youth.” American Journal of Preventative Medicine, 33(4S):S178-S186, 2007. Ewing R, Schroeer W and Greene W. “School Location and Student Travel: Analysis of Factors Affecting Mode Choice.” Transportation Research Record: Journal of the Transportation Research Board, 1895:55-63, 2004. Farley TA, Meriwether RA, Baker ET, et al. “Safe Play Spaces to Promote Physical Activity in Inner-City Children: Results From a Pilot Study of an Environmental Intervention.” American Journal of Public Health, 97(9):1625-1631, 2007. Horowitz CR, Colson KA, Hebert PL, et al. “Barriers to Buying Healthy Foods for People with Diabetes: Evidence of Environmental Disparities.” American Journal of Public Health, 94(9):1549-1554, 2004. McGinnis JM, Gootman JA and Kraak VI. Food Marketing to Children and Youth: Threat or Opportunity? Washington, D.C.: Committee on Food Marketing and the Diets of Children and Youth: Institute of Medicine, The National Academies Press, 2005. Menschik D, Ahmed S, Alexander MH, et al. “Adolescent Physical Activities as Predictors of Young Adult Weight.” Archives of Pediatrics & Adolescent Medicine, 162(1):29-33, 2008. Moore LV and Diez Roux AV. “Association of Neighborhood Characteristics with the Location and Type of Food Stores.” American Journal of Public Health, 96(2):325-331, 2006. Neumark-Sztainer D, French SA, Hannan PJ, et al. “School Lunch and Snacking Patterns Among High School Students: Associations with School Food Environment and Policies.” International Journal of Behavioral Nutrition and Physical Activity, 2:14, 2005. Powell LM, Auld MC, Chaloupka FJ, et al. “Associations Between Access to Food Stores and Adolescent Body Mass Index.” American Journal of Preventative Medicine, 33(4S):S301-S307, 2007. Powell LM, Chaloupka FJ, Slater SJ, et al. “The Availability of Local-Area Commercial Physical Activity-Related Facilities and Physical Activity Among Adolescents.” American Journal of Preventative Medicine, 33(4S):S292-S300, 2007. Powell LM, Slater S and Chaloupka FJ. “The Relationship Between Community Physical Activity Settings and Race, Ethnicity and Socioeconomic Status.” Evidence-Based Preventive Medicine, 1(2):135-144, 2004. Staunton CE, Hubsmith D and Kallins W.”Promoting Safe Walking and Biking to School: The Marin County Success Story.” American Journal of Public Health, 93(9):1431-1434, 2003. Wiecha JL, Peterson KE, Ludwig DS, et al. “When Children Eat What They Watch: Impact of Television Viewing on Dietary Intake in Youth.” Archives of Pediatrics and Adolescent Medicine, 160(4):436-442, 2006.

14. Successful community-based models Leading the statewide movement to prevent childhood obesity Partners include community, school, public health department Target food and physical activity environments in schools, after school, neighborhood, health care, media Develop / support advocates for local, state, national policy change Communities predominately Latino HEAC and CCROPP 3 Photo by Tim Wagner for HEAC Healthy Eating Active Communities; Central California Regional Obesity Prevention Program

15. Leading Local Policy Change Salud con Sabor SmartMenu Program– Food vendors in South Los Angeles’ Mercado La Paloma pioneer menu labeling

16. Leading Local Policy Change

17. Equitable Environments Lift all Boats Santa Ana—Latino Health Access championed the creation of a community park in an area lacking any. Tulare—Youth from tiny Pixley worked to renovate Pixley park and advocate for changes to encourage physical activity, including local stroller and bike paths. Bakersfield—Local advocates persuaded community leaders to upgrade a long-neglected park and began a mothers’ walking club to take advantage of a new walking path and other resources. South Los Angeles – Residents reported on the high concentration of fast food restaurants near their homes, leading to a city ordinance.

18. Equitable and Health-supportive Environments in Latino / Immigrant Communities Schools with healthy food & quality PE Safe neighborhoods and playgrounds Accessible & affordable healthy food No marketing unhealthy food to kids Healthy housing and workplaces Public transit, complete streets Youth development programs Sustainable resources for prevention

19. Engaging Multiple Sectors in Building Healthy Latino Communities Insurance coverage and health home Prevention in health reform Equitable land use & transportation policy Healthy schools & neighborhoods Youth development Primary prevention of violence Economic opportunity / green jobs

20. Research Agenda Assess for multiple dimensions of ethnicity + immigration status + place/ environmental conditions Assess for resilience amidst environmental adversity Assess low cost, non-entitlement, early win environmental interventions Factor immigrants into population health impacts of policy options (HIA)

21. Lessons Latino community efforts to prevent obesity are a bellwether for the nation Latino leaders and community residents (including immigrants) engaged in civic action are creating health-supportive environments Policy and systems changes prompted by Latino advocates are leading to greater equity, decreased risk, and more opportunities for healthy behaviors and improved outcomes

22. What Surrounds Us Shapes Our Health

23. http://www.healthyeatingactivecommunities.org http://www.calendow.org http://www. CCROPP.org http://www.californiaconvergence.org