Improving Community Health Through Policy Next Steps

1. Improving Community Health Through PolicyNext Steps John J. Librett, Ph.D., MPH Centers for Disease Control and Prevention Division of Nutrition and Physical Activity Physical Activity and Health Branch Atlanta, GA

2. TRANSLATING RESEARCH INTO POLICY

3. Physical Activity Policy Framework Evaluation Make The Case Define The Problem Identify Solutions Implement Programs

4. Policy Definitions • Organizing structure and guidance • Legislative or regulatory action • Formal and informal rules • Explicit or implicit • Formal written codes • Written standards that guide choices • Unwritten social norms

5. Policy Research  Identifying relevant policies • Determinants of establishing policy Process of developing and implementing policy • Outcomes of implementation of policy

6. Schools Walk to School Worksite Active Commute to Work Recreation, parks and trails Health Public spaces Safety and crime Economics Neighborhood walkability Connectivity, land use and community design Physical Activity Policy Research Agenda

7. Physical Activity Policy Framework Policy Outcomes of Policy Develop and Implement Policy Determinants of Policy Identify Policies Health Local Transportation Regional Parks/Public Spaces State Worksite National Sector Scale School

8. How are Decisions Made in Public Health Settings? • Anecdote or “Gut Feeling” • Press Reports • Pressure from Policy Makers or Administrators • History

9. Barriers to Using Evidence Based Public Health • Lack of leadership in setting a clear and focused agenda for evidence-based approaches • Lack of a view of the long-term “horizon” for program implementation and evaluation • External (including political) pressures drive the process away from an evidence-based approach

10. Barriers to using Evidence BasedPublic Health (cont) • Inadequate training in key public health disciplines • Lack of time to gather information, analyze data, and review the literature for evidence • Lack of comprehensive, up-to-date information on the effectiveness of programs and policies (overall and in special populations)

11. Triangle of Key Concepts for Optimal Support Valid Research & Evaluation “Enumerate the Problem” Triad for Policy Infrastructure Effective Policies Strong Leadership “Enunciate a Solution” “Create the Team/Facilitate the Process” Hollander, Librett, Fenton et al., 2004

12. Long-standing evidence Cardiovascular disease High blood pressure Diabetes Obesity Colon cancer Osteoporosis Emerging Evidence: Gall stones; Sleep; Immune function, Other cancers; Dementia Substantial Evidence Depression Cholesterol levels Fall injuries Stroke Functional status (ADLs) Preventive Effects ofPhysical Activity

13. High blood pressure Chronic lung disease Cholesterol management Cardiovascular disease Diabetes Osteoporosis Arthritis Obesity Therapeutic Effects ofPhysical ActivityClinical practice guidelines for physical activity:

14. Community Developments Suburban development, many cul-de-sacs Well-connected urban development with mixed land uses

16. Weight and Residential Density: AtlantaAs density of households increases BMI decreases. (SMARTRAQ N=4430)Frank et al, 2004

17. Estimated Annual Costs Attributable to Obesity in the U.S. Overweight and Obesity • Direct health care costs: $93 billion 9% of all health care costs Obesity- $732 more per person $1,486 Medicare $ 864 Medicaid Source : Finkelstein, Fiebelkorn and Wang. Health Affairs, May, 2003.

18. "U.S. Firms Losing Health Care Battle” General Motors Chairman SaysWashington Post, Feb.2005 "Failing to address the health care crisis would be the worst kind of procrastination; the kind that threatens the global competitiveness of our nation's economy.“ • $5.2 billion to cover retirees, employees & families. • $1.9 billion in prescription drugs cost . • $400 million projected increase this year. Your interest? Corporations are seeking healthy environments for their employees.

19. State’s Cost of Obesity Finkelstein, EA, Fiebelkorn, IC, Wang, G. State-Level Estimates of Annual Medical Expenditures Attributable to Obesity. Obesity Research 2004;12(1):18–24.

20. Atherosclerosis Among Children?! • Obesity in children is independently associated with arterial endothelial dysfunction and wall thickening, key early events in atherogenesis that precede plaque formation. “We were surprised that the children had developed vascular abnormalities at such a young age. The arteries of overweight children act like those of middle-aged smokers, increasing their risk of an early heart attack or stroke.  But the damage can be reversed with simple lifestyle measures such as diet and regular exercise, according to a report in today’s rapid access issue of Circulation. • At 1 year, there was significantly less thickening of the carotid wall (P<0.001) as well as persistent improvements in body fat content and lipid profiles in the group continuing an exercise program. Vascular function was significantly better in those children continuing exercise (n=22) compared with children who withdrew from the exercise program (n=19) (P<0.05). Woo, et al. Circulation. 2004; Effects of Diet and Exercise on Obesity-Related Vascular Dysfunction in Children, 109:1981-1986, American Heart Association.

21. Community Physical Activity Policyfor Cancer Survivorship "Cancer is not an inescapable fact of life. Things we do, and social policies, make a huge difference.“ "The pieces that are missing in terms of prevention are effective ways by which communities and social policies can help people maintain a healthy body weight and get regular physical activity, the big thing to tackle is, what are the interventions that will actually begin to turn it around?“ Michael Thun, MD Vice President, epidemiology and surveillance research American Cancer Society

22. Convinced? Now What? “Results of the reviewed studies generally indicate that it is safe for cancer survivors to be physically active, even during bone marrow transplant procedures and high-dose chemotherapy.” Agency for Healthcare Research and Quality For cancer Survivors exercise results in positive outcomes related to: • Increase in vigor and vitality • Increae in cardiorespiratory fitness • Increase in quality of life • Reduction in depression • Reduced in anxiety • Reduced in fatigue and tiredness

23. Hakim NEJM 1998;338:94-9.

24. Diabetes Risk Reduction(Diabetes Prevention Program; NEJM, April 2002)

25. Community Physical Activity Policyfor Cancer Survivorship "Cancer is not an inescapable fact of life. Things we do, and social policies, make a huge difference.“ "The pieces that are missing in terms of prevention are effective ways by which communities and social policies can help people maintain a healthy body weight and get regular physical activity, the big thing to tackle is, what are the interventions that will actually begin to turn it around?“ Michael Thun, MD Vice President, epidemiology and surveillance research American Cancer Society

26. Cancer Survivors Need Physical Activity Research Translated to Great Community Physical Activity Policy For cancer Survivors exercise results in positive outcomes related to: • Increase in vigor and vitality • Increae in cardiorespiratory fitness • Increase in quality of life • Reduction in depression • Reduced in anxiety • Reduced in fatigue and tiredness “Results of the reviewed studies generally indicate that it is safe for cancer survivors to be physically active, even during bone marrow transplant procedures and high-dose chemotherapy.” Agency for Healthcare Research and Quality

27. Triangle of Key Concepts for Optimal Support Valid Research & Evaluation “Enumerate the Problem” Triad for Policy Infrastructure Effective Policies Strong Leadership “Enunciate a Solution” Hollander, Librett, Fenton et al., 2004

28. Some Key Characteristics of Evidence Based Public Health • Intervention approaches developed based on the best possible scientific information • Problem solving is multi-disciplinary • Theory and systematic planning approaches are followed • Sound evaluation principles are followed • Results are disseminated to others who need to know and take action

29. Evidence Based Policy Domains • Informational Approaches to Increasing PA • Behavioral and Social Approaches to Increasing PA • Environmental and Policy Approaches to Increasing PA

30. Summary: Strongly Recommended • Modified physical education • Individualized behavioral change • Non-family social support • Create or enhance access • Community-wide campaigns Summary: Insufficient Evidence • Mass media • Health education • TV/video game turn off • College health education • Family-based social support

31. Modified Physical Education Modified curricula and policies Studies designed to modify the amount of physical activity during PE Lifetime activities and games

32. School-Based Approached to Increasing Physical Activity . . . P.A.P.P.I. (?)

33. Physical Activity Promotion through Predator Introduction

34. Kids WalkPrimary Aims • Analyze the scope & impact of Walk to School programs • Identify key determinants that affect active travel to school & program effectiveness http://www.cdc.gov/nccdphp/dnpa/kidswalk/index.htm

35. Community-wide CampaignsInformational Approaches to Increasing Physical Activity Large-scale, high intensity, high visibility Use of TV, radio, newspaper, information sites Multi-component, multi-site ‘Combined Package’

36. VERB http://www.cdc.gov/youthcampaign/index.htm

37. “Point-of-decision” prompts Motivational signs placed by elevators and escalators Encourage stair use for health/weight control Single component

38. StairWELL to Better Health: A Worksite Intervention http://www.cdc.gov/nccdphp/dnpa/stairwell/

39. Behavioral and social approaches • Individually-adapted health behavior change • Other social support

40. Individually-adaptedHealth Behavior Change Goal setting and self-monitoring Building social support Behavioral reinforcement Structured problem solving Relapse prevention

41. Physical Activity Counseling for Exercise Men in Motion PACE+: Counseling for Overweight Women for Diet and Activity PACE+: Counseling Adolescents for Exercise and Nutrition http://www.paceproject.org/homepage.html

42. Social Support in Community Contexts Creating, strengthening, and maintaining social networks Use of ‘buddy’ systems Contracting Walking groups

43. Well-Integrated Screening and Evaluation for Women Across the Nation http://www.cdc.gov/wisewoman/index.htm

44. Environmental and Policy Approaches • Create or enhance access • Urban planning – zoning, land use

45. Creation and/or enhanced access to places for physical activity Built environment - trails and/or facilities access Reducing barriers - safety, affordability Training & incentives Site-specific programs

46. Wheeling Walks

47. http://www.wheelingwalks.org

48. Street-scale Urban Design and Land Use Intervention Characteristics The interventions use policy instruments and practices such as: • Implementation of improved street lighting • Infrastructure projects to • Increase ease and safety of street crossing • Ensure sidewalk continuity • Introduce or enhance traffic calming • Enhance aesthetics of the streetscape

49. Built Environment Changes

50. Built Environment Changes