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The Determinants of Health: Getting to the Root Causes

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1 The Determinants of Health: Getting to the Root Causes
University of California, Los Angeles October 2, 2013 Jonathan E. Fielding, MD, MPH, MBA Director and Health Officer, Los Angeles County Department of Public Health Distinguished Professor of Health Services and Pediatrics Schools of Public Health and Medicine, UCLA

2 Warm-Up Exercise Your health is determined by many factors.
In the next 5 minutes allocate a total of 100 points to the factors you believe influence health. Example: X points – your diet/nutrition

3 One Model of Population Health
Mortality (50%) Health Outcomes Morbidity (50%) Tobacco use Health behaviors (30%) Diet & exercise Alcohol use Unsafe sex Clinical care (20%) Access to care Quality of care Health Factors Education Employment Social & economic factors (40%) Income Family & social support Community safety Environmental quality Physical environment (10%) Programs and Policies Built environment County Health Rankings model © 2010 UWPHI

4 Los Angeles County Most populous county in the nation
Larger population than 43 states 26% of Californians live in LA County Over 4,000 square miles 88 incorporated cities 75 miles of coastline ≈140 unincorporated areas 2 islands Sources: US Census Bureau, State and County QuickFacts - LA County (last rev ); California Department of Transportation: LA County Profile (last rev )

5 Los Angeles County Residents
9.9 million residents 24% under 18 years old 12% over 65 years old 16% below poverty level 36% foreign born Over 140 cultures and 200 languages 57% speak a language other than English at home ≈1.7 million students in elementary and high school Thousands attend 27 community colleges and universities ≈ 73,000 residents are homeless Sources: 1) US Census Bureau, State and County QuickFacts - LA County (last rev ); 2) Residents, County of Los Angeles,

6 Los Angeles County Residents,
by Race/ Ethnicity, 2012 Source: US Census Bureau State & County QuickFacts: Los Angeles County, California Accessed September 16, 2013

7 Leading Causes of Death & Premature Death, LA County, 2010
Leading Causes of Premature** Death Rank Cause of Death No. of Deaths Premature Death Rank Years of Life Lost Death Rank 1. Coronary heart disease 12,635 1 57,607 2. Stroke 3,278 8 Homicide 28,442 17 3. Lung cancer 2,941 7 Suicide 22,390 14 4. Emphysema/COPD 2,622 15 Motor vehicle crash 19,750 18 5. Alzheimer's disease 2,242 45 Liver disease 19,425 9 6. Pneumonia/influenza 1,964 21 Drug overdose 18,652 19 7. Diabetes 1,894 10 18,100 3 8. Colorectal cancer 1,285 11 Stoke 14,709 2 9. 1,171 5 Breast cancer 12,999 10. 1,116 12,221 Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology. 56,538 total deaths and 430,926 years of life lost, excluding infants less than 1 year of age and persons of unknown age. **Death before age 75 years.

8 Leading Causes of Death by Race/Ethnicity, LA County, 2010
Race/ethnicity Number of deaths Age-adjusted death rate #1 cause #2 cause #3 cause #4 cause #5 cause White 28,738 667 per 100,000 Coronary heart disease 6, per 100,000 Emphysema/COPD 1, per 100,000 Lung cancer 1, per 100,000 Stroke 1, per 100,000 Alzheimer’s disease 1, per 100,000 Hispanic 13,751 529 per 100,000 Coronary heart disease 2, per 100,000 Stroke per 100,000 Diabetes per 100,000 Liver disease per 100,000 Lung cancer per 100,000 Black 7, per 100,000 Coronary heart disease 1, per 100,000 Stroke per 100,000 Lung cancer per 100,000 Diabetes per 100,000 Emphysema/ COPD per 100,000 Asian/Pacific Islander 6, per 100,000 Coronary heart disease 1, per 100,000 Stroke per 100,000 Lung cancer per 100,000 Pneumonia/ Influenza per 100,000 Diabetes 237 16 per 100,000 Los Angeles County Total* 56,538 615 per 100,000 Coronary heart disease 12, per 100,000 Stroke 3, per 100,000 Lung cancer 2, per 100,000 Emphysema/COPD 2, per 100,000 Alzheimer’s disease 2, per 100,000 Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology; August *Total includes persons of other or unknown race/ethnicity.

9 Leading Causes of Premature Death by Race/Ethnicity, LA County, 2010
White Coronary heart disease Suicide Drug Overdose Lung cancer Liver disease Hispanic Homicide Motor vehicle crash Black Stroke Asian/Pacific Islander Breast cancer Los Angeles County Total* Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology; August *Total includes persons of other or unknown race/ethnicity.

10 Crude Death Rate for Infectious Diseases, US, 1900 - 2000
* Rate is per 100,000 MMWR, CDC, 1999 MMWR, CDC, 1999

11 Number of Tuberculosis Cases, LA County, 2000-2010

12 AIDS Cases, AIDS Deaths and Persons Living with AIDS, LA County, 1991-2011
1. Number of new cases diagnosed each year. 2. Number of deaths occurred each year among persons reported with AIDS. 3. Number of persons living with AIDS at the end of each calendar year. *Data are provisional for HIV Epidemiology, Division of HIV and STD Programs, Los Angeles County Department of Public Health Annual HIV Surveillance Report, February 2012: 1-36.

13 59,500 living with HIV (including AIDS) in LAC
2012 Estimated Number of Persons Living with HIV and AIDS in Los Angeles County 12,800 1,200 1,600 43,900 Estimated 59,500 living with HIV (including AIDS) in LAC (1) Estimate that 21.5% of HIV+ in LA County are unaware of their infection; modified from CDC estimate. (2) Of 4,853 notifications pending investigation, estimate half of 2,400 who have detectable VL or confirmatory test to be unduplicated cases. (3) Out of the 3,200 cases reported as code, half are thought to represent unduplicated cases. Source: LAC Division of HIV and STD Programs, reported as of 12/31/2011. 13

14 Chronic Diseases are the Leading Cause of Death in the US
Chronic diseases are responsible for 7 out of every 10 deaths Top 5 Causes of Death in U.S. (1980, 2009) 1980 2009 1 Heart disease 2 Cancer 3 Cerebrovascular diseases (Stroke, hypertension) Chronic lower respiratory diseases 4 Unintentional injury 5 Chronic obstructive pulmonary disease Four of the top five causes of death are chronic diseases 14 1) Centers for Disease Control and Prevention. Health, United States, Available at nchs/data/hus/hus07.pdf#summary, and Chronic Disease Overview: 2) Centers for Disease Control and Prevention. Deaths: Final Data for National Vital Statistics Reports, Vol 58, Number 19 14

15 Projected Rise in Cases of Seven of the Most Common Chronic Diseases, 2003-2023
*This study evaluated the burden of seven of the most common chronic diseases/conditions (cancer, diabetes, heart disease, hypertension, mental disorders, pulmonary conditions, and stroke). 15 Source: DeVol, R, Bedroussian, A, et al. An Unhealthy America: The Economic Burden of Chronic Disease. The Milken Institute. October Full report available at: 15

16 The Centers for Disease Control and Prevention (CDC) estimates up to…
…could be prevented, if Americans were to do 3 things: Stop smoking Start eating healthy Get in shape 40% of cancer 80% of heart disease and stroke 80% of type 2 diabetes 16 Mensah G. Global and Domestic Health Priorities: Spotlight on Chronic Disease. National Business Group on Health Webinar. May 23, Available at: 16

17 Healthy People 2020 Ecologic Model of Health Determinants of Health
Interventions Outcomes Behavioral outcomes Specific risk factors, diseases, &conditions Injuries Well-being & health-related Quality of Life Health equity Policies Programs Information Assessment, Monitoring, Evaluation & Dissemination

18 Trends in Leading Causes of Death, LA County, 1995-2009
Cause of Death 1995 2009 Percent Change Coronary heart disease 258 129 -50% Stroke 60 34 -43% Lung cancer 47 31 -34% COPD 33 30 -9% Alzheimer’s disease 5 21 +320% Pneumonia/influenza 44 -52% Diabetes 22 20 Colorectal cancer 14 -30% Liver disease 13 12 -8% Breast cancer (females) 29 -28% HIV/AIDS 26 3 -89% Homicide 17 7 -59% Rate (per 100,000) Age-adjusted to year 2000 U.S. standard population Source: OHAE, LAC DPH 18

19 Life Expectancy at Birth by Sex and Race/Ethnicity, LA County, 2011
Sources: 2010 Linked Death Files, Los Angeles County Department of Public Health, Data Collection and Analysis (DCA) Unit. 2009 to 2010 Linked Birth Files, Los Angeles County Department of Public Health, Data Collection and Analysis (DCA) Unit. July 1, 2010 Population Estimates, prepared for County of Los Angeles, Internal Services Department, Social Services Systems Division, released 1/26/2013.

20 Coronary Heart Disease Mortality by Race/Ethnicity, LA County, 2001-2009
Age – Adjusted rate per 100,000 Los Angeles County Public Health, Office of Health Assessment & Epidemiology

21 Behavior as a Determinant of Health
Healthy People 2020 Ecologic Model of Health

22 Trends in Adult Cigarette Consumption, US, 1900–2005
Annual adult per capita cigarette consumption and major smoking and health events Master Settlement Agreement; California first state to enact ban on smoking in bars First Surgeon General’s Report Broadcast ad ban End of WW II Early in the 20th century, several events coincided that contributed to increases in annual per-capita cigarette consumption, including the introduction of blends and curing processes that allowed the inhalation of tobacco, the invention of the safety match, improvements in mass production, transportation that permitted widespread distribution of cigarettes, and the use of mass media advertising to promote cigarettes (USDHHS, 1995). Cigarette smoking among women began to increase in the 1920s, when targeted industry marketing and social changes reflecting the liberalization of women's roles and behavior led to the increasing acceptability of smoking among women (USDHHS,1980; Waldron, 1991). Annual per-capita cigarette consumption by adults (i.e., 18 years or older) increased dramatically from 54 cigarettes in 1900 to a peak of 4,345 cigarettes in 1963 (CDC, 1994). For the year 2005, per-capita consumption was estimated at 1,716 cigarettes per person, a 3% drop from 1,791 in 2004 (USDA, 2006). Some decreases correlate with events such as the first research suggesting a link between smoking and cancer in the 1950s, the 1964 Surgeon General’s Report, and increased tobacco taxation and industry price increases during the 1980s. In 1998, the year of the Master Settlement Agreement, California was the first state to enact a ban on smoking in bars. By the end of 2006, more than 20 states had a tax of at least $1.00 per pack on cigarettes. Centers for Disease Control and Prevention (CDC). (1994). Surveillance for selected tobacco-use behaviors—United States, 1900–1994. MMWR 43 (no. SS-3). U.S. Department of Agriculture (USDA), Economic Research Service. (2006, April 28). Tobacco Outlook. Report TBS-260. Retrieved December 31, 2006, from U.S. Department of Health and Human Services (USDHHS). (1995). For a Healthy Nation: Returns on Investment in Public Health. Atlanta, GA: Public Health Service, Office of Disease Prevention and Health Promotion and CDC. U.S. Department of Health and Human Services. (1980). The Health Consequences of Smoking for Women. A Report of the Surgeon General. Washington, DC: Public Health Service, Office on Smoking and Health. Waldron I. (1991). Patterns and causes of gender differences in smoking. Soc Sci Med 32:989–1005. Number of cigarettes Nonsmokers’ rights movement begins Cigarette price drop Federal cigarette tax doubles 20 states have > $1 pack tax Great Depression Year Centers for Disease Control and Prevention. (1999). MMWR 48:986–993. Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society. 22

23 Costly Toll Of Tobacco Tobacco use is single most preventable cause of death, with 10 million annual deaths estimated by 2030. 50,000 annual deaths in the US due to secondhand smoke exposure alone. In LAC, an estimated 336,000 children are exposed to secondhand smoke at home One million+ smokers in LAC. Adult smoking prevalence was at 13.1% in 2011 1 out of every 7 deaths in LAC is caused by tobacco use (≈ 9,000 deaths) Despite impressive declines in the number of people in Los Angeles County who smoke (now at 14.3%), certain vulnerable populations have not benefitted from tobacco control efforts, continue to smoke at alarmingly high rates, and are suffering grievous consequences. Tobacco use remains the single most preventable cause of death, responsible for more than 440,000 deaths per year in the United States. By the year 2030, an estimated 10 million annual deaths will occur worldwide due to tobacco. There are 50,000 deaths every year in the United States due to second hand smoke exposure alone. 23 23

24 Percent of Adults Who Smoke Cigarettes by Gender, LAC, 2002-2011
Los Angeles County Health Survey

25 Prevalence of Cigarette Smoking by Age, LA County, 2011
Percent Age Group Los Angeles County Health Survey

26 The Toll of Alcohol 2,500 people in LA County die from alcohol-related causes each year Roughly 78,000 years of potential life lost Alcohol is associated with digestive diseases, neuropsychiatric conditions, cardiovascular disease, malignant neoplasms, pregnancy-related conditions, fetal alcohol syndrome, and high risk sex Alcohol has been implicated in DUIs, falls, suicide, poisonings and occupational injuries Excessive alcohol consumption costs LA County an estimated $10.8 billion annually Los Angeles County Department of Public Health. Facts & Figures: Alcohol in LA County, Oct and Reducing Alcohol-Related Harms in LA County: A Cities & Community Health Report, March 2011.

27 Percent of Adults who Reported Binge Drinking in the Past Month in LA County, 2002-2011
Binge drinking for males is drinking 5 or more drinks on one occasion at least one time in the past month. Binge drinking for females is drinking 4 or more drinks on one occasion at least one time in the past month. Source: LA County Health Survey 27

28 Percent of Adults who Reported Binge Drinking in the past month, by Gender in LA County, 2011
Binge drinking for males is drinking 5 or more drinks on one occasion at least one time in the past month. Binge drinking for females is drinking 4 or more drinks on one occasion at least one time in the past month. Source: LA County Health Survey 28

29 Drug Abuse in Los Angeles County
Over 60,000 residents were admitted to publicly funded treatment programs from Most frequently reported drugs for which treatment was received were: marijuana/hashish (27%) alcohol (26%) methamphetamine (18%) cocaine/crack (13%) Los Angeles County, Department of Public Health, Substance Abuse Prevention and Control. Fact Sheet: Drug Use and Misuse in Los Angeles County Sept 2010.

30 Drug Use Among LA County High School Students*, Grades 9-12
Have ever used marijuana 37.6% Currently∙ use marijuana 19.3% Have ever used cocaine 9.7% Currently∙ use cocaine 3.6% Have ever used inhalants 16.9% Have ever used ecstasy 11% Have ever used heroine 3.8% Have ever used methamphetamines 7.1% *Youth Risk Behavior Surveillance 2009, Centers for Disease Control & Prevention “Current use” is that which occurred in the 30 days prior to the survey Los Angeles County, Department of Public Health, Substance Abuse Prevention and Control. Fact Sheet: Drug Use and Misuse in Los Angeles County Sept 2010.

31 Opioid Prescriptions Filled by Fiscal Year, LA County, 2007-2012
Source: Department of Justice, California Prescription Monitoring Program/ Controlled Substance Utilization Review and Evaluation System (CURES) data.

32 Hospitalizations and Emergency Department (ED) Visits for Opioid Dependence/Abuse, LA County, Source: Office of Statewide Health Planning and Development, Hospital Discharge and Emergency Department Visit Data. Prepared by LA County Department of Public Health, Injury and Violence Prevention Program.

33 Benefits of Physical Activity
Increased life span and improved function Reduced hypertension, heart disease, and stroke Prevention of diabetes and related complications Decreased risk of colon cancer Improved mental health Body weight maintenance and obesity control Increased bone mass Improved immune function Reduced health care costs The benefits of being physically active on a regular basis are documented in thousands of studies. Physical activity can increase the life span while improving quality of life and can help prevent leading physical and psychological disorders. With health care costs continuing steep increases, the lower health care costs of active people is attracting more attention from policy makers. 33 Surgeon General’s Report, 1996 33

34 Physical Activity Guidelines for Americans (PAGA) Study
2011 study assessed self-reported vs. objectively measured physical activity among U.S. adults (n=4,773) using accelerometer data Percentage of adults meeting the PAGA: Self reported: 62% Objectively measured: 9.6% Tucker, J, et al. Physical Activity in U.S. Adults: Compliance with the Physical Activity Guidelines for Americans. AM J Prev Med 2011; 40(4):

35 Makes you wonder how many of these…
Self Reported Levels of Physical Activity Among Adults in LA County, 2011 Makes you wonder how many of these… are actually these? To meet Physical Activity Guidelines at least one of the following at least one of the following criteria must be fulfilled: 1) Vigorous Activity - hard physical activity causing heavy sweating, large increases in breathing and heart rate - for 20+ minutes, > 3 days/wk, 2) Moderate Activity - cause light sweating, slight increases in breathing and heart rate - for 30+ minutes, > 5 days/wk, 3) A combination of Vigorous and Moderate Activity meeting the time criteria for > 5 days/wk. [ Los Angeles County Health Survey 35

36 Prevalence of Adult Obesity, LA County, 1997-2011
Los Angeles County Health Survey Department of Public Health 36 36 36 36 36 36

37 Prevalence of Obesity & Diabetes Among Adults in LA County, 1997-2011
Los Angeles County Health Survey Department of Public Health

38 Prevalence of Obesity Among 5th, 7th, and 9th Graders in LA County Public Schools, CA Physical Fitness Testing, Healthy People 2010 Goal (<5%) Prevalence of Obesity Projected obesity prevalence assuming linear trend Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools.

39 Obesity Prevalence Among 3 and 4 Year Olds in the WIC Program, LA County, 2003-2010
Source: PHFE WIC Program, LA County

40 Cities/Communities with Lowest and Highest Childhood Obesity Prevalence, 2008
Top 10* City/Community Name Obesity Prevalence (%) Rank of Economic Hardship ( ) Manhattan Beach 3.4 2 Calabasas 5.0 8 Hermosa Beach 5.1 1 Agoura Hills 5.3 10 Beverly Hills 5.4 19 Malibu 5.9 4 Palos Verdes Estates 7.3 5 San Marino 7.8 15 Rolling Hills Estate 8.4 9 La Canada Flintridge 8.5 18 Average 10 lowest 6.2% Ave Median Household Income $99,555 Bottom 10* City/Community Name Obesity Prevalence (%) Rank of Economic Hardship ( ) West Athens 30.6 94 South Gate 30.7 110 Florence-Graham 31.0 128 West Whittier-Los Nietos 31.1 81 West Carson 31.4 56 Vincent 32.2 69 East Los Angeles 32.9 117 Hawaiian Gardens 33.4 107 South El Monte 34.5 111 Walnut Park 38.7 113 Average 10 highest 32.7% Ave Median Household Income $37,747 *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; 2000 Census 40 40 40

41 Economic Hardship & Childhood Obesity
41

42 Cost of Overweight, Obesity & Physical Inactivity - California, 2006
Billions Health Care $20.7 Lost Productivity $20.4 Total $41.2* Projected Cost for 2011: $52.7 BILLION Why should we care? Obesity is not just a matter of personal health – it is a costly public health concern that affects economic productivity, state budgets, and personal and family well-being. Cost represents loss of productivity at work and direct and indirect health care costs. Also included are workers’ comp costs. This is for the year 2000. There are a wide number of health consequences associated with being overweight or obese and to not participating in any physical activity: Heart Disease Diabetes Hypertension High Cholesterol Arthritis Asthma Kidney Disease Many Cancers Depression Poor quality of life *Figures may not add to total due to rounding The Economic Costs of Overweight, Obesity, and Physical Inactivity Among California Adults – 2006 (July 2009). The California Center for Public Health Advocacy.

43 Changes in Future Life Expectancies Related to Obesity and Diabetes
Life expectancy has steadily increased over the past two centuries. Current rates of obesity projected to reduce life expectancy by .33 to .75 years over the next century. If rates of obesity and diabetes continue to increase at current rates, reductions in life expectancy may be to 2 to 5 years, or more 43 Olshansky et al NEJM March 17, 2005

44 Portion Control Campaign
"Choose Less, Weigh Less"  With bigger food portions come more calories, and consuming extra calories can lead to obesity, diabetes, heart disease and some cancers. Campaign includes advertising on transit shelters, buses, rail cars, billboards, television, radio and online. Videos of portion size PSAs can be found at:

45 Rethink Your Drink Campaign
Sugar sweetened beverages (SSB) are the largest single source of added sugar and calories in the American diet. On average, nearly 39% of adults in LA County drink at least one SSB per day. > 43% of children 17 or younger consume at least one SSB on an average day. A child’s risk for obesity increases an average of 60% with every additional daily serving of soda.

46

47 Different Approaches to Addressing Overweight/Obesity: Personal Eating Behavior
Share meals Partially fill beverage containers Avoid ‘supersizing’ Ask for reduced portion options Compare nutritional values of your choices on labeled menus

48 Different Approaches to Addressing Overweight/Obesity: Eating Outside the Home
Promote healthy eating in workplaces and schools Remove sweetened beverages and junk food from vending machines (schools, public agencies, businesses) Create incentives for restaurants and cafeterias that offer healthy food items Schools can promote participation in the School Breakfast Program and reduce high calorie snack opportunities in the classroom (e.g. birthday treats) More Americans eating food prepared outside the home, typically higher in fat and calories and lower in nutrients1 % of total energy intake from restaurant and fast food increased by nearly 300% among adolescents from LA County is estimated to have 4x as many fast food restaurants and convenience stores as supermarkets and produce vendors3 Guthrie et al J Nutr Educ Behav; 2) Nielsen, et al., 2002 Obesity Research; 3) ‘Searching for Healthy Food: The Food Landscape in California Cities and Counties’, 2007 CCPHA brief

49 Strategies for Improving the Physical Environment for Nutrition
Current Environmental Change Increased marketing of junk food, tobacco, and alcohol Place limits on marketing of junk food to children (around schools, parks…) Decreased access to fresh, nutritious, affordable food Promote local public markets Provide incentives for businesses that provide healthy food Proliferation of fast food restaurants Use zoning tools to limit the location and density of fast food restaurants Source: Public Health Institute

50 Physical and Social Environments as Determinants of Health
Healthy People 2020 Ecologic Model of Health

51 Our Environments Matter

52 One Model of Population Health
Mortality (50%) Health Outcomes Morbidity (50%) Tobacco use Health behaviors (30%) Diet & exercise Alcohol use Unsafe sex Clinical care (20%) Access to care Quality of care Health Factors Education Employment Social & economic factors (40%) Income Family & social support Community safety Environmental quality Physical environment (10%) Programs and Policies Built environment County Health Rankings model © 2010 UWPHI

53 What is a Healthy Community?
Meets basic needs of all Provides quality and sustainable environment Maintains adequate levels of economic and social development Promotes health Fosters social relationships that are supportive and respectful We often talk about communities being healthier, but what does that really mean? Health communities are those that meet the basic needs of all, have a quality and sustainable environment, have adequate levels of economic and social development, promote health and social equity, and promote social relationships that are supportive and respectful. Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

54 Healthy Communities: Meet Basic Needs of All
Safe, sustainable, accessible, & affordable transportation options Affordable, accessible, and nutritious foods Affordable, high quality, socially integrated and location-efficient housing Affordable, high quality health care Complete and livable communities including high quality schools, parks and recreation facilities, child care, libraries, financial services and daily needs Healthy communities should need the basic needs of its residents. PLACE Program : In 2007, using these funds, LACDPH launched the PLACE grant project — an over $2 million initiative that offered multi-year grants to city/community partnerships to increase physical activity by advancing city policies and implementing changes to the built environment. The five PLACE grantees are: the cities of El Monte, Culver City, and Long Beach; and the non-profit organizations Pacoima Beautiful and the Los Angeles County Bicycle Coalition. PLACE grants began July 2008 and include: • Developing and implementing a bicycle and pedestrian master plan • Developing a health element for a city’s general plan • Creating a greenway vision plan for a tributary of the Los Angeles River • Creating a bike and pedestrian friendly route that connects to a light rail line under development • Creating a circuit walking loop with signage to local destinations • Developing bicycle boulevards that prioritize biking over cars The PLACE program has also worked with local jurisdictions to promote and provide guidance on the development of bike paths, conducting walkability assessments in neighborhoods, and promoting safe routes to school… Many of our community liaison staff, with guidance from PLACE, have been working to incorporate health language into cities’ general plans. There is also work being done regarding the revitalization of Compton Creek. Many of our communities lack accessible and nutritious foods and have an abundance of foods that have low nutritional value at low cost. . . HEAC has been working with….. RENEW Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

55 Healthy Communities: Provide Quality and Sustainable Environments
Clean air, soil, and water, and environments free of excessive noise Tobacco and smoke free Preserved natural and open spaces, including agricultural lands Minimize waste, toxic chemicals, & harmful emissions A clean environment is a healthy environment. We know that contaminated soil, toxic chemicals, and waste have a negative impact on health. Clean environments are an integral component of a health community. The Tobacco Control and Prevention Program has been working to support smoke-free policies in Los Angeles County. Most recently, they supported a smoke-free housing ordinance in Santa Monica that prohibits smoking on balconies and any common areas in multi-family housing. They are now working on a smoke-free ordinance for the city of West Hollywood that would ban smoking in outdoor patios and open air public spaces such as restaurants. Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

56 Healthy Communities: Maintain Adequate Levels of Economic and Social Development
Adequate, safe, and healthy job opportunities for all Support for healthy development of children and adolescents Opportunities for high quality and accessible education The South LA Building Health Communities initiative is an effort that DPH has been involved in that words to create healthy environments where children can learn, play and grow. We have been doing a lot of research on the impact educational attainment has on health and are interested in finding ways to work with the LA County Office of Education and the school districts in its jurisdiction. Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

57 Healthy Communities: Promote Health
Access to coordinated, quality health care services Access to preventive care to minimize development of chronic disease The SPA 5/6 Area Health Office has been using media to foster discussion about health inequities in their communities. The documentary “Unnatural Causes” has been shown at 3 community based agencies with the hopes of expanding this effort to schools and other places were people come together. The Area Health Office is working with organizations such as Community Health Councils, LAANE, Esperanza CHC, St. John’s to engage communities on topics such as access to health care, safe and healthy housing, and community involvement. These organizations are vital in implementing policy change … Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

58 Healthy Communities: Foster Supportive and Respectful Social Relationships
Robust social and civic engagement Socially cohesive and supportive relationships, families, homes, and neighborhoods Safe communities free of crime and violence Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

59 Break

60 Adverse Health Impacts From
Poor Community Design â traffic safety á air pollution water quality & quantity obesity & chronic disease physical activity crime & violence social capital elder health & mobility mental health health disparities 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 60

61 Health and Sprawl People living in counties marked by sprawling development: Walk less in their leisure time Are more likely to have high blood pressure Have higher body mass indexes Are more likely to be overweight (average 6 pound difference) These are some of the ways that the built environment here in Los Angeles affects our health. Ewing R, et al: American Journal of Health Promotion 18(1) Sept/Oct 2003 61

62 Commuting Los Angeles has the nation's worst Travel Time Index1 107 minutes is average total travel time per typical weekday when commuting at peak times According to national statistics, Los Angeles is among the top 10 U.S. cities with the most long-distance commuters. As Los Angeles’ population grows and the economy expands, congestion is predicted to worsen in the next few years, therefore creating vehicle emissions. Air Quality Management Plan 1997 62 1) Texas Transportation Institute: 2011 Urban Mobility Report, September ) LA Times, September 2006 62

63 The more we drive and the more our built environment favors driving the less fit we are and the hotter our climate becomes. Adapted from Dr. Richard Jackson

64 Let’s Play “Spot the Pedestrian”
Here’s an example of how urban planning can affect public health. Notice how the lack of safe crosswalk endangers the pedestrians on this street. Source: Dr. Howard Frumkin

65 Economic Benefits of Open Spaces and Walkable Community Design
Open spaces and recreation areas can positively affect property values benefits homeowners higher property tax revenue for local governments Compact, walkable developments = economic benefits to developers higher home sale prices enhanced marketability faster sales or leases Other direct and indirect benefits reducing air pollution flood control improved water quality facilitating healthy lifestyles 65

66 Summary of Health Effects of Air Pollution
Amount of goods transported through CA projected to nearly quadruple between 2000 and 20201 Will have significant impact on air quality and health2 Diesel particulate matter (PM) concentrated around ports, rail yards, & 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 Business, Transportation, and Housing Agency, and California Environmental Protection Agency (Cal EPA). Goods Movement Action Plan Phase 1: Foundations. September 2005 2 (Palaniappian et al Report from the Pacific Institute) 3 (CA/EPA Air Resources Board. Health Effects of Diesel Exhaust. 4 (CA/EPA Air Resources Board. ‘Health Effects of Particulate Matter and Ozone Air Pollution’, January 2004) 1 (Cal EPA, 2005); 2 (Pacific Institute, 2006) 3 (CA/EPA Air Resources Board); 4 (CA/EPA Air Resources Board, 2004)

67 Some Examples of Societal Determinants:
Availability of resources to meet daily needs Eg. safe housing Access to educational, economic and job opportunities Access to health care services Quality of education and job training Social support Exposure to crime, violence and social disorder Social norms and attitudes Eg. discrimination, racism Socioeconomic conditions Eg. concentrated poverty Language/Literacy Availability of jobs that pay living wage Healthy People 2020 Overview - Social Determinants of Health Accessed at: healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39

68 Poverty US, CA, LA County: All Ages
U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011 Accessed at:

69 Poverty US, CA, LAC: Under Age 18
U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011 Accessed at:

70 Life Expectancy by Median Household Income of Census Tract, LA County, 2005
Note: Median income of LA County census tracts are for the year 1999 and are obtained from: Census 2000 Summary File 3 - United States prepared by the U.S. Census Bureau, 2002

71 *<200%FPL not available by race/ethnicity
Percent of Persons Living Below the Federal Poverty Level, by Race/Ethnicity, LA County <100% FPL = Percent of persons less than 100% of Federal Poverty Level *<200%FPL not available by race/ethnicity U.S. Census Bureau, Year American Community Survey, Table C17002

72 Family Poverty Rates* and Education Level, California, 2010
In California, in 2010:, the poverty rate among families without any adult high school graduates was 31.3%. At the other extreme, in families headed by at least one college degree holder, the poverty rate was only 5.2%. For families in which the highest level of education is a high school diploma, the poverty rate was 19.2%. Public Policy Institute of California, Just the Facts: Poverty in California. December Accessed March 14, * Below the Federal Poverty Level of Income (about $22,000 for a family of four)

73 Potential Solutions to Keep People Out of Poverty
Educational programs Vocational training Job training Child care supports Literacy programs English as Second Language (ESL) Earned Income Tax Credit Housing subsidies Supplemental food assistance programs (CalFresh, WIC, school nutrition) County Health Rankings 2011; Robert Wood Johnson Foundation. How Social Factors Shape Health: Income, Wealth and Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011 Photo credit: Ruby Washington, New York Times

74 Improved Educational Outcomes Improved Health Outcomes
74

75 Education Matters: More Formal Education = Longer Life Expectancy
Years of School Completed Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008. 75

76 Years of School Completed by Mother, All Ages
And It Matters to the Next Generation: Mother’s Education Related to Infant Mortality Years of School Completed by Mother, All Ages Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008. 76

77 Percent of Adults with Less than a High School Diploma, by Race/Ethnicity, LA County
Note: African American, Asian, Pacific Islander, and American Indian Alaska Native categories include persons reporting both Hispanic and non-Hispanic Origin, therefore categories are not mutually exclusive U.S. Census Bureau, Year American Community Survey, Table B15002 &C15002

78 Workers with less education are more likely to:
Education and Working Conditions Workers with less education are more likely to: have occupational hazards (e.g. pesticide, asbestos exposures) have poor working conditions (e.g. shift work) hold lower paying jobs Robert Wood Johnson Foundation. Education Matters for Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011

79 Education and Working Conditions
Workers with less education are less likely to: have paid sick & personal leave receive retirement benefits have child or elder care resources Robert Wood Johnson Foundation. Education Matters for Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011

80 Potential Actions to Improve Educational Attainment
Increase Nurse Family Partnership Expand early childhood development programs E.g., HeadStart, SmartStart, universal pre-K Comprehensive K-12 school reform to improve achievement Mentorship-model programs to improve high school graduation rates Programs to help dropouts attain GED certificates Targeted programs to improve college enrollment County Health Rankings 2011; Recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America April 2009.

81 What is Public Health? “…public health is what we, as a society, do
collectively to assure the conditions for people to be healthy.” - The Future of Public Health IOM 1988 - The Future of the Public’s Health in the 21st Century IOM 2003 81

82 Public Health is… Science of protecting and improving community health by: Using preventive medicine to reduce the community risk for various diseases Educating the public about things they can do to improve their health (e.g., diet, exercise, safer sex) Controlling the spread of disease Monitoring environmental hazards Promoting policies that improve health Focused on population and communities, not just individuals 82

83 Defining Public Health: 3 Core Functions
Assessment Conduct surveillance to measure the health of the population and determinants; investigate health problems and identify causes Policy Development Inform leaders and the public about health; develop policy solutions and mobilize support Assurance Ensure population health by having a competent workforce to enforce laws; medical care available to all; evaluate progress as part of a quality improvement cycle 83 Institute of Medicine. (1988). The Future of Public Health.

84 Public Health’s Top 10 Accomplishments During the 20th Century
Today, Americans live about 30 years longer than in mostly due to Public Health efforts Developing vaccinations Ensuring safer workplaces Controlling infectious diseases Decreasing deaths from heart disease/stroke Ensuring safer and healthier foods Increasing family planning options Recognizing tobacco use is harmful Developing motor-vehicle safety policies Improving health for mothers and babies Source: Centers for Disease Control and Prevention 84

85 Los Angeles County Department of Public Health
Vision: Healthy People in Healthy Communities Mission: To protect health, prevent disease, and promote health and well-being Departmental Stats: Annual budget over $850 million Nearly 4,000 employees 85

86 Some of Our Staff Public Health Nurses Health Educators
Epidemiologists Physicians Community Workers Public Health Investigators Environmental Health Specialists Microbiologists Nutritionists Researchers Veterinarians 86

87 Major Public Health Responsibilities
Preventing and Controlling Disease Promoting Good Health Protecting Health with Safe and Healthy Environments 87

88 Public Health & Health Protection
Early warning, emergency preparedness planning & response 24/7 disease surveillance State-of-the-art laboratory One-of-a-kind partnerships Biological, radiological terrorism Action-oriented response to emerging infections Assuring conditions to protect health Housing and food facility inspections Childhood lead poisoning prevention Licensure of hospitals/long term care facilities

89 Greater Attention to Public Health Risks & Threats, and Preparedness Overall
Naturally emerging disease threats such as pandemic flu, E. coli, West Nile Virus, SARS Diseases used as weapons – anthrax, plague, smallpox September 11th generated greater emphasis on preparedness Preparedness is not really new to us in CA “earthquake country” The public’s health has been enhanced by substantial investments from CDC, State, and local funds.

90 How We Can Reduce Overall Disease & Injury Burden
Level 1 – Treating disease conditions e.g. enhancing disease management for diabetes Level 2 – Reducing disease risk factors & promoting protective factors e.g. improve nutrition and increase physical activity to prevent obesity Level 3 – Focus on underlying determinants of disease e.g. ensure opportunities for people to achieve optimal health by Supporting anti-poverty programs so people can afford to eat healthfully Supporting the development of greenspaces and parks so people can be active

91 Framework for Action: General Model of Health & Improvement Strategies
Jobs, urban design, transportation, agriculture, criminal justice, and economic policy Society Social & Physical Environment Education Worksite Programs Clinical Care & Social Services School Health Intervention Level Hospital Systems Disease Management Assisted Living Clinical Preventive Services Hospice Individual PRIMARY CARE TERTIARY CARE Well Dead Health State Fielding J, Teutsch S. An Opportunity Map for Societal Investment in Health. JAMA, 2011, Vol 305, No 20,

92 Framework for Action: Applied to Type 2 Diabetes
Walkable and Bikeable Communities Society Menu Labeling Social & Physical Environment Affordable Produce Enhancing School-Based Physical Education Social Support Interventions in Community Settings Clinical Care & Social Services Behavioral Interventions to Reduce Screen Time Self-Management Education (Home & Community) Intervention Level Worksite Programs for Overweight & Obesity Case Management & Disease Management Screen Individuals with Hypertension for Diabetes Control Blood Pressure, Lipid Levels, & Smoking Screen Adults for Obesity and Offer Intensive Interventions Dialysis Majority of health $ investments Individual PRIMARY CARE TERTIARY CARE Well Prediabetes Diabetes Dead Health State Fielding J, Teutsch S. An Opportunity Map for Societal Investment in Health. JAMA, 2011, Vol 305, No 20,

93 How Do We Know What Works?
Recommendations for policy and practice, programs and services Intervention results and effectiveness

94 The Guides Are Complementary
Shawna L. Mercer The Guides Are Complementary Individual level Clinical settings Delivered by healthcare providers Screening, Counseling, etc. Clinical Guide (USPSTF Recommendations) Group level Health system changes Insurance/benefits coverage Access to/provision of services Community, population-based Informational (Group Education, Media) Behavioral, Social, Environmental & Policy Change Community Guide (TFCPS Recommendations) 94

95 The Guides: Selecting Interventions for Systematic Review
Over 1,000 single and multi-component interventions to evaluate Those evaluated to date selected on their potential to: burden of disease and injury healthy behaviors and reduce unhealthy behaviors implementation of effective interventions that are not widely used level of interest among providers and decision makers consistent with resource constraints

96 Why Evidence is Essential
Aids in efficiency – doing what we know works first Increases accountability by supporting more efficient use of public and private resources Provides a higher likelihood of successful programs and policies being implemented (opportunity cost of using non-evidence based strategies can be very high) Brownson RC, et al. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health 2009;30: 8-4-08 96

97 To Learn More Visit Us at: publichealth.lacounty.gov
Annual Report | Data and Statistics | LAC DPH Program Websites twitter.com/lapublichealth | youtube.com/lapublichealth


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