1. BUILT ENVIRONMENT and CHILDHOOD OBESITY: FROM RESEARCH TO ACTION Maida P. Galvez, MD, MPH Region 2 PEHSU Director AAP District 2 Chapter 3 President Associate Professor, Department of Preventive Medicine and Pediatrics Icahn School of Medicine at Mount Sinai

2. Goals for Today Describe the Role of the Environment on Childhood Obesity Discuss Interventions Share success stories

4. Built Environment

8. Childhood Obesity is Epidemic in East Harlem -as per CDC age/gender specific BMI data. BMI <85th% ile normal BMI >85th% ile - <95th% ile at risk BMI >95th% ile overweight Girls n=398 60% n=238 16% n=64 24% n=96 Boys n=105 47% n=49 15% n=16 38% n=40

9. HIGH POVERTY NEIGHBORHOODS 42.3% East Harlem children living in poverty –In 2012, Federal Poverty Level =$23,283 for family of four

11. 1 in 5 children living in poverty in New Brunswick 2012 Ranges from 12% in Dieppe to 34% in Campbellton After Tax Low Income Measure –2 adults, 2 children=$33,3936 –US poverty line=$23,283

12. HOUSING: How New York Lives 2014 Nearly third of public housing tenants reported water leaks East Harlem ranked #1 in average # of housing concerns for Manhattan African Americans are most likely to live in poorly maintained housing

13. NEIGHBORHOOD SCHOOLS 143,000 NYC students attend failing schools In a class of 30 minority kindergarteners, only 2 will graduate from college Families For Excellent Schools Report 2014 In 2013, only 29% of students in East Harlem had passing scores for 3 rd grade reading Citizens Committee for Children 2015

14. Case

15. Child Injury ages 15-19 Leading cause of death due to injury in NYC youth Firearm injury 200 deaths from 2002-2011 91% were homicides (national avg 64%) Black, male, Bronx and very high poverty neighborhoods NYC Fatality Report 2013

16. Child Injury ages 5-9 and 10- 14 Leading cause of death due to injury in NYC children –Motor vehicle crashes –101 deaths from 2002-2011 –Emerging from parked vehicles –Crossing between lights NYC Fatality Report 2013

18. DOT changes –Shorter crossing distances –Pedestrian islands –Pedestrian plazas –Bike lanes –20 mph speed limit

19. Safety Motor Vehicle accidents Pedestrian safety Supervision Poor lighting Violence Crime

20. Physical Activity East Harlem children n=324 Outdoor time/week: 2 hours Structured physical activity: 0 hours

21. The Gates in Central Park 2005

22. Urban Design and Public Health 1864

25. Local Food Environment Healthy Foods –18% East Harlem –58% Upper East Side –NYCDOHMH

26. Research Question Are there physical features unique to an inner-city, minority community that impact dietary quality, physical activity and risk for childhood obesity?

27. What we’ve learned…

28. East Harlem Food Stores Type# of stores Convenience Stores 182 Specialty Stores 20 Supermarkets10 Grocery Stores 9

29. East Harlem Restaurants Type# of stores Fast food stores 139 Restaurants57

30. Race and food store availability in an inner-city neighbourhood In 2004, there were no Grocery Stores or Supermarkets in the predominantly African American Census blocks.

31. Galvez MP, Morland K, Raines C, Kobil J, Siskind J, Godbold J, Brenner B. Public Health Nutr. 2007 Oct15:1-8 African American Census blocks compared to Racially Mixed grocery storesn=0 supermarketsn=0 convenience storesPR = 0.25, 95% CI 0.07-0.86 specialty food storesPR = 0.42, 95% CI 0.07-2.45 full-service restaurantsPR = 0.19, 95% CI 0.02-1.41 fast-food restaurants PR = 0.34, 95% CI 0.09-1.22 Latino Census blocks compared to Racially Mixed convenience stores PR = 1.80, 95% CI 1.20-2.70 specialty food stores PR = 3.84, 95% CI 2.06-7.15 full-service restaurants PR = 1.87, 95% CI 1.04-3.38 fast-food restaurants PR = 2.14, 95% CI 1.33-3.44 grocery storesPR = 0.61, 95% CI 0.20-1.86 supermarketsPR = 1.49, 95% CI 0.68-3.24 Prevalence Ratios for Food Store Availability

32. Neighborhood Environment Convenience stores were present in 55% of the Census blocks on which a child lived. Fast food restaurants were present in 41% of blocks.

33. Children living on a block with 1+ convenience stores were more likely to have a BMI %ile in the top tertile. (OR 1.53, 95% CI 1.02-2.30, p value 0.04) Galvez et al Academic Peds 2009

34. Where are NYC children making food purchases? On the way to or from school: Convenience stores72% Food stands64% Fast food restaurants35% In schools: Drink vending machines14% Snack vending machines 2%

35. Snacking behaviors

36. Children using food resources >3x per week consumed: 108 calories (95% CI: 32.25, 182.67) 0.43 servings/day of SSB (95% CI: 0.29, 0.58) 0.31 servings/day snacks/sweets (95% CI: 0.06, 0.6)

37. BCERC: Environmental Determinants of Puberty in Girls National Cohort of 1200 girls ages 6-8 years –Cincinnati, OH –California Bay Area –NYC

38. Regional Differences Exist n=1010 NYCOHCA Use food resources86%78%60% 3+ times per week47%18%6%

39. What Physical Activity Resources are Children Using? Outdoor Areas Parks 81% School grounds 72% Community gardens27% Organized Physical Activity Resources Recreational centers40% Afterschool programs35% Summer camps18%

40. Reported Use of PA Resources and BMI (BMI 85th percentile). Adjusted OR (95% CI)P value Outdoor areas 0.94 (0.54-1.64)0.82 Parks 0.84 (0.25-2.91)0.79 Recreational Facilities 0.66 (0.33-1.32)0.24 School Facilities 1.28 (0.61-2.65)0.51 After school programs 0.88 (0.51-1.53)0.65 Summer camps 0.52 (0.26-1.01)0.05 * adjusted for race/ethnicity, family income, population density

41. PA Resources and PA levels Availability of an afterschool program increased hours of scheduled physical activity –(OR = 3.25, 95% CI 1.41–7.50). Availability of a playground increased a child’s outdoor unscheduled physical activity –(OR = 1.95, 95% CI 1.11–3.43). The more resources a child had available the greater their level of unscheduled physical activity. -Galvez et al Academic Pediatrics 2013

42. Families with income <$25,000 and with lower caregiver education were more likely to have no resources on their block.

43. How far we’ve come….

44. the feeling that I got when I moved in here was that everybody was appreciative to be here, and so it's like, yes, I got out of where I was. I'm here and I'm in this beautiful building. I want to do something even better for myself. Now I want to eat better. Now I want to exercise. That's the feeling that I got.” ABS Architecture and Danois Architects

47. Advocacy and Policy

48. Take Home Messages Neighborhood Makes a Difference Your Voice Makes a Difference We all play a role in shaping healthy communities and promoting children’s health.

50. Acknowledgements Drs. Phil Landrigan, Bob Wright, Susan Teitelbaum, Barbara Brenner, Mary Wolff and the GUH team Drs. Perry Sheffield, Joel Forman, Lauren Zajac, Cappy Collins, Sarah Evans, and Maya Leventer Roberts, Bambi Fisher, Norm Zuckerman, Alice Freund and Damiris Agu and PEHSU collaborators P30 COEC Carol Horowitz and Lisa Herron – P30 ES023515 AAP COEH District 2 Chapter 3 National Institute of Environmental Health Sciences –NIEHS Grant #2 P01 ES009584 and ES012645 Environmental Protection Agency –EPA Grant #R827039 and #RD831711 National Cancer Institute –NCI Grant #CA93447 National Center for Research Resources (GCRC) –NCRR grant #MO1-RR-00071 Agency for Toxic Substances and Disease Registry –ATSDR Grant #ATU 300014 NYSDOH Centers of Excellence in Children’s Environmental Health

51. This material was supported by the American Academy of Pediatrics and funded under cooperative agreement award 1U61TS000237-01 from the Agency for Toxic Substances and Disease Registry (ATSDR). The US Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of commercial products/services mentioned.

52. Paediatric Environmental Specialty Unit Misericordia Community Hospital –16930 – 87 Ave, Edmonton AB, Canada T6G 0E3 –1-780-735-2443 –Toll Free in Alberta: 1-877-214-2331 Staff: –Dr. Irena Buka –Dr. Alvaro Osornio –Lorie Grundy R.N. MScN (lorie.grundy@albertahealthservices.ca)

53. How Can You Get Involved? AAP Green Book Parent Teacher Association Greening Committees Community Board Children and Nature Initiatives Environmental Pediatrics Electives/Fellowship

54. Resources RWJ Active Living Research –http://activelivingresearch.org/http://activelivingresearch.org/ BEAT Institute PlaNYC FIT City Annual Conference