Obesity and Food Environments

December 9, 2010

Webinar sponsored by the American Medical Association, in partnership with Health Care Without Harm and Kaiser Permanente

Moderator: Preston Maring, MD, Associate Physician-in-Chief, Kaiser Permanente Medical Center Oakland Presenter: Ted Schettler, MD, MPH is the Science Director at Science and Environmental Health Network (SEHN). Ted received his MD from Case-Western Reserve University and a masters degree in public health from the Harvard School of Public Health. He practiced medicine for many years in New England. Ted has worked extensively with community groups and non-governmental organizations throughout the US and internationally, addressing many aspects of human health and the environment. He has served on advisory committees of the US EPA and National Academy of Sciences and continues to work closely with Greater Boston Physicians for Social Responsibility. Presenter: Leslie Mikkelsen is co-founder and Project Director for the Strategic Alliance for Healthy Food and Activity Environments. Under Ms. Mikkelsen's leadership, Prevention Institute has developed ENACT (Environmental Nutrition and Activity Community Tool) and the ENACT Local Policy database, an on-line interactive tool that provides specific strategies, policy language, and materials to support implementation across a range of venues including children's institutions, communities, health care and works sites. She is the winner of the American Public Health Association 2008 Catherine Cowell Award for Excellence in Public Health Nutrition. Presenter: Judith Bell, President of Policy Link, oversees policy development, strategic planning, program implementation, and policy campaigns. She leads projects focused on equitable regional development policy to enhance the income and assets of the poor. Her portfolio includes the fair distribution of affordable housing throughout regions, equity in public investment and land use, and community strategies to reduce health disparities. Her advocacy work with PolicyLink has included efforts to improve access to healthy foods, solutions to overcrowding in K-12 schools, and equitable approaches to infrastructure investment.

Preston Maring, MD Associate Physician-in-Chief

Kaiser Permanente Medical Center Oakland Preston.Maring@kp.org

Ted Schettler, MD, MPH Science Director

Science and Environmental Health Network tschettler@igc.org

Leslie Mikkelsen Project Director

Prevention Institute leslie@preventioninstitute.org

Judith Bell President Policy Link

Judith@policylink.org

All webinars in this series are recorded and will be available for download within one week of original date. Individual PowerPoint presentations will also be available for download when approved by presenters. For more information on this webinar series, including CMEs for

physicians, and to view past events, please visit http://www.noharm.org/us_canada/events.

Obesity and Food Environments

December 9, 2010

Webinar sponsored by the American Medical Association, in partnership with Health Care Without Harm and Kaiser Permanente

Nutrition, the food system, and chronic disease

Ted Schettler MD, MPHScience and Environmental Health Network

www.sehn.org

The Setting

• Obesity/overweight – 2/3 US adults, prevalence x2 in ~25 yrs• Pre/Diabetes – 40% US adults, prevalence DM ~x2 over 20 yrs• Cardiovascular disease – still leading cause of death. • Metabolic syndrome = early signs of other cluster diseases;

35% adults, ~55%>60 yrs• Alzheimer’s disease – ½ >84 yrs old, 5.3M

Environmental Drivers of Chronic Disease

Western Disease Cluster•Diabetes •Obesity•Abnormal Lipids•Metabolic Syndrome•Cardiovascular Disease

•Food system/Diet•Fossil Fuels•Socio-economic Stress•Environmental Chemicals•Built Environment/

incl. transportation

•Inflammation•Disrupted Insulin Signaling•Oxidative Stress

Alzheimer’s Parkinson’s

Altered Pathways

Environmental Factors

Chronic Disease

Altered Pathways

Environmental Drivers of Chronic DiseaseEnvironmental

Factors

InflammationDisrupted Insulin Signaling

Oxidative Stress

Chronic Disease

Mechanisms of Action

Inflammation

• Inflammation is a dimension of diabetes, metabolic syndrome , obesity, CVD, some neurodegenerative disorders, and other chronic illnesses.

• Numerous inflammatory markers involved (e.g. CRP, interleukin 6, tumor necrosis factor, prostaglandin E2, and others)

• Activated microglia produce inflammatory mediators that activate more cells to produce additional inflammatory mediators.

Insulin Signaling = Normal Metabolism

Insulin signaling

•↓ blood sugar•↓ artery disease•↓ triglycerides

Insulin signaling

• ↑ blood sugar• ↑ artery disease• ↑ triglycerides

InflammationOxidative

stress

Disrupted Insulin Signaling = Inflammatory Metabolism

Altered Pathways

Environment Drives Chronic DiseaseEnvironmental

FactorsChronic Disease

Food System/Diet

Novel Nutrients Are Pervasive, Promote Inflammatory Metabolism

What’s “Novel” in the Western Diet?

“Hypothetical scheme of fat, fatty acid (ω6, ω3, trans and total) intake (as percentage of calories from fat) and intake of vitamins E and C (mg/d). Data were extrapolated from cross‐sectional analyses of contemporary hunter‐gatherer populations and from longitudinal observations and their putative changes during the preceding 100 years [75].” From AP Simopoulos, The importance of the ratio of omega‐6/omega‐3 essential fatty acids. Biomedicine & Pharmacotherapy 56 (2002) 365‐379.

Years

% of calories from

 fat

mg/da

y

Dietary salt

• On average, Americans consume more than 3,400 mgs of sodium daily

• The amount above which health problems appear is 2,300 mgs daily.

• The recommended adequate intake of sodium is 1,500 milligrams per day, and people over 50 need even less.

• Most dietary salt comes from processed foods

High Glycemic Carbohydrates Increase the Risk of Chronic DiseaseHigh glycemic carbohydrates break down quickly during digestion,

rapidly releasing glucose (sugar) into the bloodstream.

ΔPl

asm

a In

sulin

,mg/

dl

Time, mins

INSULINEMIC RESPONSE

Low glycemic food

High glycemic food

Properties of Fatty Acids

Omega-3 Omega-6 Saturated

Food Perishable Durable Increased inSystem Short shelf life Processed foods factory farmed

Increased in Long shelf life animalspasture- fed animals

Immune Anti-inflammatory Inflammatory & InflammatoryProperties Anti-inflammatory

Evolutionary Recent marked Recent marked Recent markedContext decline increase increase

↓Omega-3, (↑Omega-6)

Insulin signaling

• ↑ blood sugar• ↑ artery disease• ↑ triglycerides

InflammationOxidative

stress

Novel Nutrients Disrupt Insulin Signaling, Drive Inflammatory Metabolism

Saturated fat

↓Antioxidants

High Glycemic Carbohydrates

Fructose

• Increase risks- saturated and trans fats- high glycemic carbohydrates- lack of fruits/vegetables/omega 3s- excess omega 6s?

• Reduce risks- fruits, vegetables- omega 3s- low glycemic carbohydrates- Mediterranean diet

Influence of Nutritionon Chronic Disease

Benefits of Mediterranean-Type Diet on Chronic Disease Risk

Clinical intervention studies• 70% ↓ heart attacks, cardiac death & total mortality DeLogeril 94

• 60%↓ cardiac events in CVD patients* Ornish 98

• ~50% ↓ metabolic syndrome Esposito 04

• 39% ↓ in CRP Esposito 04

• ↓insulin resistance Esposito 04

• ↓ weight Esposito 04

Prospective observation studies• 80% ↓ diabetes Martinez-Gonzalez 08

• ~31% ↓ all-cause & cardiovascular mortality, 22% ↓ cancer mortality**calculated from Sofi 08 ↓73% Alzheimer’s mortality Scarmeas 07

• 25-30% ↓ Parkinson’s disease Gao 07

*10% low fat, vegetarian diet + exercise, stress reduction

**For every 2 point increase in adherence (on a 9 point scale), risk reductions were observed of 0.91 for all cause mortality, 0.91 for CV mortality, 0.94 for occurrence and mortality from neoplasm. To convey the implications of these findings, we have applied the risk reductions across a 9 point adherence scale to yield a calculated ~31% ↓ all cause & CV mortality and a 22% ↓ in cancer mortality

Economic implications• Diabetes and pre-diabetes will account for

an estimated 10 percent of total health care spending by the end of the decade at an annual cost of almost $500 billion -- up from an estimated $194 billion this year ("The United States of Diabetes: Challenges and Opportunities in the Decade Ahead.” [UnitedHealthcare, Inc.])

• Hospital costs: $83 billion (AHRQ)

Health care costs of diabetes

• The average annual health care costs in 2009 for a person with known diabetes were about $11,700 compared with about $4,400 for the non-diabetic public (data drawn from 10 million UnitedHealthcare members)

• Doubles in people with complications of diabetes

Resource: Environmental

Threats to Healthy Aging

by Jill Stein MD, Ted Schettler MD, MPH,

Maria Valenti and Ben Rohrer

Available at:

www.agehealthy.org

Greater Boston Physicians for Social Responsibility (www.psr.org/Boston)and

The Science and Environmental Health Network (www.sehn.org)

Leslie Mikkelsen, MPH RDManaging Director

www.preventioninstitute.org

Dec 9, 2010

Creating Healthy Food Environments

From: Hungry Planet, Manzel, et. al., Ten Speed Press, 2005

From: Hungry Planet, Manzel, et. Al., Ten Speed Press, 2005

Is it just personal choice?

The Food System

$4.2 billionSource: Rudd Center for Food Policy and Obesity, Fast Food FACTS: Evaluating Fast Food Nutrition and Marketing to Youth (2010)

$1.2 millionper day

Source: Rudd Center for Food Policy and Obesity, Fast Food FACTS: Evaluating Fast Food Nutrition and Marketing to Youth (2010)

McDonald’s was responsible for one-quarter of young people’s exposure to Spanish-language Fast Food Advertising

Let’s Move! Initiative“Our kids don't decide what's served to them at school or whether there's time for gym class or recess. Our kids don't choose to make food products with tons of sugar and sodium in super-sized portions, and then to have those products marketed to them everywhere they turn.”

-Michelle Obama

Web-based marketing starts with children as young as age 2

Institute of Medicine Findings: 2005

“Food and beverage marketing targeted to children 12 and under leads them to request and consume high-calorie, low nutrient products” “The dominant focus of marketing to children and youth is on foods and beverages high in calories and low in nutrients, and is sharply out of balance with healthful diets.”

Healthy Eating

Active Living

Convergence

Partnership

www.convergencepartnership.orgFunders Engaged in Multi-Field Equity-Focused Efforts

Recipes for Change are…Food Retail Federal Nutrition Programs

AgricultureHealthy Food in Institutions

Local Actions

Menu Labeling

Healthy Vending

Healthy Kids’ Meals Incentive Ordinance

Santa Clara County, CA

www.noharm.org

Fairview Medical Center - SSB

Adopted a no SSB sales policy– SSB includes sugared sodas, sports

drinks, etcSupport from the CEONo option of SSB on patient traysCatering policy includes no SSB– Promotes water

To date revenue neutral – Sales went to SSB alternatives

First in countryFollowed by Cleveland Clinic

www.isfusa.org

Organic food

Local Bison Burgers

Compost food waste

rBGH-free milk

Fair trade coffee

Holiday tea

White Bean Cookies

Local Granola

Lake Superior fish

Next steps

St. Luke’s Hospital-MN

St. Joseph Mercy HospitalAnn Arbor, MI

Ecology Center’sHealthy Food in Health Care Program

Photo credit: Dave Askins, The Ann Arbor Chronicle

FDA Front of Package Labeling

Update on Actions by the Federal Trade Commission

Issued subpoenas to 48 food companies in September to assess their marketing practices aimed at childrenReport on nutrition standards for marketing to children due in January 2010 has still not been released

Promoting Truly Healthful Food

Wholesome

Sustainable

Just

Read & endorse at:http://www.preventioninstitute.org/sa/settingtherecordstraight.html

www.preventioninstitute.orgwww.eatbettermovemore.org

221 Oak StreetOakland, California 94607

phone: 510-444-7738 fax: 510-663-1280

leslie@preventioninstitute.org

Policy Approaches to Access to Healthy Food

December 9, 2010Judith Bell

President, PolicyLinkProgram Director, Convergence Partnership

PolicyLink is a national research and action institute advancing economic and social equity by Lifting Up What Works. ®

The Convergence Partnership is a collaborative of six major funders and

the CDC engaged in multi-field, equity-focused,

policy and environmental change efforts to achieve healthy people and

healthy places.

3

U.S. Obesity Trends

1985 1995

2006

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Center for Disease Control (CDC)

The Options in Many Places

Food Access & Health: NYC

Source: New York City Department of City Planning

Source: New York City Department of Health and Mental Hygiene

Food Access & Health: NYC

Source: New York City Department of Health and Mental Hygiene

Food Access & Health: NYC

Source: Wright and Blanchard, 2007

Food Access : Rural America

The Healthy Food Gap

• Accessing healthy food is a challenge for many Americans—more than 23 million—particularly those living in low-income neighborhoods, communities of color, and rural areas.

• Better access corresponds with healthier eating and lower risk for obesity and other diet-related chronic diseases.

• New and improved healthy food retail in underserved communities impacts health, creates jobs and helps to revitalize low-income communities.

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“Let’s Move” kick off February 9, 2010

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Source: California Center for Public Health Advocacy, PolicyLink & UCLA Center for Health Policy Research, 2008

Food Access & Health: CA

PA Fresh Food FinancingInitiative

An innovative program to increase access to fresh foods in underserved communities

across Pennsylvania.

$190 millionTotal Est. Project Costs for Approved Applicants

1.7 million sq. ft.Total Est. Sq. Ft. Developed/Refreshed for Approved

Applicants

5,000 new jobsTotal Est. Jobs Created/Retained for Approved Applicants

400,000 people with access to healthy food

PA Success Story

Variety of projects:

•Supermarkets•Farmers markets

•Coops•Public markets

In different places:

•2/3rds rural, small towns1/3 urban

•One-time Loans and Grants

Approved Projects: 83

Replication in Other States

Illinois

Louisiana

New JerseyNew York

Colorado

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HFFI now embodied in:

•President Obama’s 2011 Budget

•First Lady’s Let’s Move Initiative

•White House Task Force on Childhood Obesity

•Proposed Congressional Legislation

Healthy Food Financing Initiative

HFFI 2011 Budget Proposal

Administered by:

• USDA

• HHS

• Department of the Treasury

Budget Allocation:

• $50 million

• $20 million

• $25 million &• $250 million

NMTCs

Diverse Support for HFFI

Partial List of Supporters:

NAACPAmerican Public Health AssociationAmerican Heart AssociationNational WIC AssociationCommunity Food Security CoalitionOpportunity Finance NetworkFood Marketing InstituteNational Grocers AssociationSave the ChildrenUnited Food and Commercial WorkersUnited Fresh Produce AssociationFood Research and Action CenterWallace Center at Winrock International

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Promising Strategies

Community Supported Agriculture (CSA)Community GardensFarm to School

Local PossibilitiesFarmers’ marketsElectronic Benefits

Transfers (EBT)Point of Sale (POS)

equipment

Promising Strategies

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State and Local Policies:

Soda Tax

School Menus

Child Nutrition Reauthorization

• Healthy Hunger Free Kids Act: S.3307: $4.5 billion increase over 10 years

• Guiding Principles:– Expand program access to reduce

childhood hunger– Improve nutritional quality to promote

health and address childhood obesity– Simplify program management

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Childhood Hunger and Obesity

• Support Breastfeeding in WIC Program

• Promote Nutrition in Child Care• Improve Nutritional Quality of School

Meals• Establish National Standards for All

Foods Sold in Schools• Improve School Food Financing• Expands Access to Meals

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Federal Transportation Reauthorization

Federal Transportation Reauthorization

Impact on physical activity

Link between obesity and time spent driving

Includes funding for pedestrian and bicycle facilities, rails-to-trails, Safe Routes to School and Complete Streets programs

Last authorization: $244 billion over 6 years

Approximately 80% of federal funds are used for highways

Transportation for America23

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Join the Movement!

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www.policylink.orgconvergencepartnership.org

jbell@policylink.org