Dr William Bird Strategic Health Advisor Natural England

1. Natural ThinkingImproving public health through contact with the Natural Environment: Clearer Future ConferenceSeptember 18th 2008 Dr William Bird Strategic Health Advisor Natural England

2. The Environment Good or bad? HOME SCARY

3. Health Inequalities 1n 1991 the difference between the lowest and highest fifth of life expectancy was 9.7 yrs and it is now 12.3 years. There appears to be no improvement (slight worsening) since the baseline of 1997 The government’s target is to reduce the difference in life expectancy by 10% by 2010

4. Mental Illness Mental illness affects 1 in 6 of the adult population 1 in 5 under 16yr olds have a mental disorder By 2020 the WHO claims that depression will be the second most prevalent cause of ill health The total cost to the economy is £75 billion (£12 billion to NHS)

5. What are we prescribing? • In 2005 27.7 million antidepressant Prescriptions were written in England costing £338 million. • There is doubt whether most anti depressants are any better than Placebo. Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration Irving Kirsch et al • The Chief medical officer states that “Physical activity is effective in the treatment of clinical depression and can be as successful as psychotherapy or medication” (DH 2004)

6. Obesity • The UK has the highest rate in the EU • In the UK rates have tripled in the past 20 years • By 2050 60% of population and 1 in 4 under 16 year olds will be obese • Total cost of obesity to society will be £45 billion by 2020

7. Diabetes • There are 2.2 million people with diabetes in England (4.48% of the population) [i] • This will increase to 3.6 million by 2025 (64% increase) • Half this increase is from the rise in obesity. • for those at high risk regular exercise reduces their chances of developing diabetes by up to 64% • At least five a week • CMO report 2004 DH • [i] Yorkshire and Humber PHO 2005

8. Evidence linking Health and the Natural Environment • The Natural Environment has three main affects on the Human: • Reduces Chronic Stress • Increases Physical activity • Creates a sense of purpose and belonging

10. Social Isolation The Car Traffic Poor Air Quality Reduced Physical Activity Reduced access to Greenspace Planning Social Barriers due to disconnection Obesity Chronic Stress Social Inequalities leading to environmental injustice Health Inequalities leading to environmental injustice

11. How Stress can be seen as a major public Health Problem Social Isolation Reduced access to Greenspace Social Inequalities leading to environmental injustice Physical inactivity and Obesity Chronic Stress Raised Inflammatory Markers Anxiety and Depression Cardiovascular Disease Lung Disease Diabetes Cancer

14. “When asked the best age for children to be allowed out with friends unsupervised most respondents (43 per cent) said aged 14 or over, despite the fact that most of them had been allowed out without an adult at the much younger age of 10 or under” The Children’s Society June 5th 2007

15. Walking IncreasedPhysical Activity Increased access to Greenspace Social Inclusion Good Air Quality Reduced Chronic Stress Anxiety and Depression Cardiovascular Disease Lung Disease Diabetes Cancer

16. Nature Contact in housing projects

20. Benefits of Green Space People living in those flats with an outlook onto trees and grass were associated with: • Reduced stress in children • Increased concentration and self discipline in children • Reduced symptoms of ADHD in children • Increased the amount of play for local children. • Half the incidence of violent and property crimes and domestic violence • Increased strength of community • Increased ability for the poorest single parent mothers to cope with major life issues.

21. Kuo F (2001) Coping with Poverty: Impacts of environment and attention in the inner city. Environment and Behavior, Vol 33 No 1 January 2001.

22. Is greenery associated with obesity? N = 6919 Odds Ratio A Ellaway S Macintyre BMJ 2005;331;611-2 Greenery

23. Children and the Natural Environment • Children use the natural environment to recover from stress. • Children are more active when outdoors. • Children who are not able to explore the natural environment without an adult before the age of 11 are less likely to value the natural environment when older.

24. Summary So Far • Regular Contact with Green Space • Reduces Chronic Stress • Increases Physical activity • Creates a sense of purpose and belonging • Chronic stress causing depression and chronic inflammation • Environmental injustice may be a major component of health inequalities.

25. THE GOVERNMENT • “We must do nothing less than transform the environment in which we all live. We must increase the opportunities we all have to make healthy choices around the exercise we take and the food we eat.” The Prime Minister Jan 2008

26. THE ACADEMICS BMJ 9th June 2007 Editorial “The challenge is to make politicians work for an environment that promotes walking, and to call on doctors to encourage patients to walk…”

27. Physical Activity Care Pathway • Work to include physical activity in the QOF. • Link natural environment through physical activity to obesity, diabetes, mental health and inequalities

29. Every GP practice to plan their Natural Extension. Natural England / NHS Alliance

30. National Walking Campaign • Announced last week (but was dunked by free swimming!) • £7 million over 3 years but will liberate considerable more from PCTs. • Walking should be integral to the advice by doctors and nurses in all Chronic diseases. • Exercise referral is biased to indoor venues. This is wrong. • Clinicians are hopelessly ignorant about the benefits of walking. They want to refer but have no information about how.

31. Walking the Way to Health (WHI) • Over 33k volunteer health walk leaders having been trained by300 cascade trainers • They lead 4000 walks a week in over 550 WHI schemes. • Significant growth to increase capacity and referrals from NHS leading up to 2012.

32. On the Horizon • In Manchester planning to use incentives. • WHO walking evaluation to provide economic proof • Active England and Get Active Alliance and OHF • NHS Forest with Natural England/NHS Sustainability Unit • Olympic Park to be an exemplar of the |Natural Health Service. • Greenery in each hospital space to improve patient experience with Natural England • New Environment and Human Health Unit at Peninsula Medical School

33. NHS Forest • For Manchester, an extra 10% green cover is projected to keep temperatures 1°C above current temperatures over the next 70 years. • If there is no change to green space then temperatures will increase by 3.7°C. • In contrast if there is 10% less green cover then urban temperatures would increase by about 8.2°C

34. NHS Forest • 1.3 million trees (one for each NHS employee) would absorb 689,000 tonnes of CO2 each year. Gill S, Handley J, Ennos R, Pauleit S (2007) • Senior citizens live longer with more space to walk and with nearby parks and tree lined streets near to where they live. Tanaka A, Takano T,Nakamura K, • Each year 1.3 million trees remove 2535 tonnes of pollutants from the air (425 tonnes of ozone and 477 tonnes of particulate). McPherson EG, Simpson JR2005. • A belt of trees can reduce noise levels by as much as 6-8 decibels for every 30 metres width of woodland • A broadleaf can reduce UVB radiation by a factor that is equivalent to a factor 10 sun cream. 60% of the UV radiation

35. From advocacy to action Create a Natural Health Service. • Twin every NHS institution with local Green Space. • Make every environment favourable to walking. • Integrate all NHS physical activity pathways with outdoor activities in local Green Space. • Reduce Environmental injustice by greening up deprived areas.