Download the new york city experience - American Society of Law Medicine

OBESITY PREVENTION AND THE USE OF LAW :
HOW FAR CAN LOCALITIES GO?
THE NEW YORK CITY EXPERIENCE
SEPTEMBER,, 2010
Lynn
y
Silver,, MD,, MPH
Assistant Commissioner
New York City Department of Health and Mental Hygiene
The New York City
B
Board
d off H
Health
lth
•
1805 – The NYC Board of Health meets for first time, with Yellow Fever
plaguing the city
city.
•
1822 – Last epidemic of Yellow Fever (but cholera, typhus and
tuberculosis persisted, fueled by crowding and a lack of sanitation)
•
1866 – NYS Law expands Board and insulates it from political
influence by setting aside seats for physicians and scientists.
•
Newly empowered, the Board decreed that "neither hogs nor goats
[could] run at large in our city." Cholera deaths promptly fell by 90%.
URBAN CONDITIONS WERE A BREEDING GROUND FOR 19TH
CENTURY EPIDEMICS
Over-crowding:
Over
crowding:
By 1910, the average density in
lower Manhattan was 114,000
people/ sq. mi; two wards
reached densities > 400,000.
,
(Today’s density: 67,000/ sq. mi.)
+
Inadequate systems for
garbage, water, and sewer, leading
to pervasive filth and polluted
water supplies.
pp
Major epidemics:
Air borne diseases:
Air-borne
TB
Water-borne diseases:
Cholera
Vector-borne diseases:
Yellow-fever
THE SANITARY CODE OF THE BOARD OF HEALTH
CITY OF NEW YORK 1870
• Dealt with housing construction
• Sidewalks and sanitation
• Regulated
g
food and drink,, including
g fats
(rendering rules)
• Regulated retail practices on what
what, where
and when certain products affecting health
could be sold
19TH -20TH CENTURIES: URBAN DESIGN RESPONDED AND THE LEGAL
FRAMEWORK EXPANDED FROM LOCAL HEALTH LAW TO OTHER SECTORS
1842
New York’s water system established – an
aqueduct brings fresh water from Westchester.
1857
NYC creates Central Park, hailed as “ventilation
for the working man’s lungs”, continuing
construction through the height of the Civil War
1881
Dept. of Street-sweeping created, which eventually
becomes the Department of Sanitation
1901
New York State Tenement House Act banned
the construction of dark, airless tenement buildings
1904
First section of Subway opens, allowing population
to expand into Northern Manhattan and the Bronx
1916
Zoning Ordinance requires stepped building
setbacks to allow light and air into the streets
LAW AND URBAN DESIGN HELPED CURE 19TH C. EPIDEMICS
AND WILL HELP SOLVE THE 21ST C. EPIDEMICS
THE 19th CENTURY:
THE 21st CENTURY:
Infectious disease
Chronic Diseases, many of which are
“Diseases off Energy”
Ener ”
19th Century codes, planning and
infrastructure as weapons in the
battle against contagious disease
These strategies were built into the
city fabric, and they were effective
The emerging design solutions for
health parallel sustainable design
solutions
Effective designs will have to be an
invisible, pervasive, and inevitable part of
life.
life
1960 Health Code (+other changes) Worked Before for Non
Communicable Disease: Decline in Childhood Lead Poisoning after
the 1960 Health Code restriction on lead paint in NYC
3000
2500
>= 60ug/dL
1500
>/= 40 ug/dL
1000
500
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99
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0
19
N u m b e r o f C h ild re n
2000
“Actual” Causes of Death
United States,
States 2000
Percent of deaths
0%
5%
10%
Tobacco
Diet & physical inactivity
Alcohol
Infectious agents
Toxic agents
Motor vehicle crashes
Firearms
S
Sexual
l behavior
b h i
Illicit drugs
Mokdad AH, Marks JS, Stroup DF, Geberding JL, JAMA 2004;291:1238-1245
15%
20%
Deaths Attributable to Individual
Risks in the U.S.
Thousands of Deaths
Danaei G et al. The Preventable Causes of Death in the United States: Comparative Risk Assessment of
Dietary, Lifestyle, and Metabolic Risk Factors. PLoS Med 6(4): e1000058. doi:10.1371/journal.pmed.1000058
NYC’s APPROACH TO CHRONIC DISEASE AND OBESITY:
LEARNING FROM THE PAST
Seek to change the environment to promote:
•
•
•
•
Increased consumption of healthy foods
Decreased consumption
p
of unhealthy
y foods
Increased physical activity
Decreased tobacco use
THERE IS NO SIMPLE
SOLUTION
TO STEM THE TIDE OF OBESITY AND CHRONIC DISEASE WILL REQUIRE A
DIKE WITH MANY SANDBAGS BEFORE OUR FEET WILL BE DRY
(borrowed from Katz)
SOME POTENTIAL POLICY APPROACHES TO
THOSE GOALS = Health in All?
•
•
•
•
•
•
•
•
•
Taxation Policy
Regulation
g
of food p
production
Regulation of retail environment and
community food availability
R
Regulation
l ti off planning,
l
i
d
design
i and
d
construction practices as well as use of zoning
Regulation of the transportation environment
Regulation of health care providers
Regulation of information, signage and
commercial speech practices
Subsidies and mechanisms to affect price
Use of public and private purchasing power
CHRONIC DISEASE PREVENTION IN NYC:
FOOD RELATED POLICIES
•
Daycare Regulations
–
•
2006,, Board of Health
Trans Fat Restriction
–
•
2006, Board of Health - later City Council
Calorie Labeling Regulations
–
•
2006 – 2007, Board of Health
Public Procurement and Vending
Standards
–
•
2008 – 2009, Mayoral Executive Order
National Salt Reduction Initiative
–
2009, Voluntary
DO THESE MEASURES
WORK?
TRANS FAT USE IN NYC FOOD SERVICE ESTABLISHMENTS
2005-2008
MEAN CALORIES PURCHASED BY CHAIN
2007 - 2009
35
Taco Bell
-96
Pizza Chains (3)
Popeye's
* -59
26
KFC
* -80
Au Bon Pain
Subway
-37
133
Wendy's
Burger King
* -44
-125
-100
-75
-50
44
McDonald's
-25
0
25
Change in Mean Calories
*
*
t-test; p<0.05
In NYC Fast Food Establishments
50
75
100
125
150
DIFFERENCE IN CALORIES PURCHASED BETWEEN THOSE WHO USE
AND THOSE WHO DO NOT USE CALORIE INFORMATION, 2009
Taco Bell
Pizza Chains (3)
-137
-101
Popeye's
-23
-41
* -91
Au Bon Pain
Wendy's
* -156
Burger King
* -133
*
KFC
Subway
*-139
-175
90
-150
McDonald's
-125
-100
-75
-50
-25
Difference in Mean Calories
t-test; p<0.05
In NYC Fast Food Establishments
0
25
50
75
100
CALORIE LABLEING:
THE STARBUCKS STUDY
• Studied over 100 million transactions,
comparing
i
b
before
f
and
d after
ft calorie
l i
labeling
• 6% decline in mean calories after labeling
went into effect
• No negative effect on revenue
(Bollinger et al
(Bollinger,
al, 2010)
SUGAR SWEETENED BEVERAGE TAX
• Introduced in New York State by Governor
Paterson twice (2009, 2010 budgets)
• Penny per ounce excise tax would:
– Reduce consumption by 15-20%
15 20% among New
York State residents
– Prevent 37,400 diabetes cases within next
decade
– Prevent 145,000 adults from becoming obese
– Health benefits larger among African Americans
& Hispanics than among non-Hispanic Whites
Clare Wang, 2010
What do People Think?
Quinnipiac Poll 2010: People Care About Food
•
To balance the City Budget would you support a tax on sugary soft
drinks?
– 76% YES (60% of Republicans)
•
When it comes to trying to improve people’s
people s health habits
habits, do you think
the Bloomberg Administration policies have gone too far, not far enough,
or they are about right?
– About right: 55% (46% of Republicans)
– Not far enough: 17% (12% Republicans)
•
Was the law requiring fast food restaurants to post calories information
useful or not useful?
– Useful: 84% (69% of Republicans)
•
Do you thi
D
think
k th
the Bl
Bloomberg
b
administration
d i i t ti iis correctt tto encourage N
New
York City restaurants to use less salt in food preparation or don’t you think
so?
– 77% YES (55% of Republicans)
•
When it comes to your point of view regarding the government getting
involved with things like the salt content and calorie posting of restaurant
food – it is important because it helps improve public health or it is just
g
meddling?
– Important: 79% (50% of Republicans)
PHYSICAL ACTIVITY PROMOTING DESIGN
• New York City Street Design Manual
(policy, mandatory)
• New York City Active Design Guidelines
(currently voluntary)
• LEED C
Credits
dit
KEY TOBACCO POLICIES IN NYC
•
•
•
•
•
Taxation – Federal, NYS Legislature, New
Y k City
York
Cit C
Councilil
Smoke Free Indoor Air– NY City Council
2002 NYS 2003
2002,
Adolescent Tobacco Use Prevention Act NYS L
Legislature
i l t
Tobacco Signage – Board of Health 2009
Ban on Flavored Smoke Free Tobacco
Products – 2009 NY City Council
NYC ADULT SMOKING PREVALENCE
1993-2007
300,000 Fewer Smokers
About 100,000 Premature Deaths Prevented
24
22
% of adults
20
18
16
3-yr average
21.6%
3-yr
3
yr average
21.5%
3-yr average
21.7%
City and State
tax increases
Smoke-free
Smoke
free
workplaces
21.6%
19.2%
Free patch
programs
Media
campaign
p g
18.9%
18.4%
17.5%
16.9%
14
12
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
CONCLUSIONS
• Well crafted regulation and policy does work
• Selected regulatory
g
y approaches
pp
to reducing
g
chronic disease risk have been effective, at
least in changing behavior, others need
evaluation
• Multiple approaches involving different levels
of g
government and society
y are needed to
achieve large scale risk reduction
• Cardiovascular disease and obesity
outcomes have complex determinants
determinants.
Assessing the isolated impact of each policy
measures will not be easy
LOCAL BOARDS OF HEALTH
• In NYC, the Board of Health has been key, but
not the only factor, in our innovative policy work
• 75% of local boards of health have “governing
authority” including establishing local ordinances
authority
and regulations (NALBOH 2008)
• Challenges include cost of enforcement
enforcement,
navigating preemption, protected commercial
speech and precedents such as the Boreali
decision in NY State
State, which placed limits on the
action of such bodies
RECOMMENDATIONS
• Legal frameworks at all levels of government
that have been used effectively in the past to
vastly reduce the burden of infectious disease
should be mobilized once again
g
to address
chronic disease and obesity
• Reinvent traditional areas of authority that
protect the public’s health and safety such as
food safety, or building safety for the 21st
century,
t
by
b also
l ttargeting
ti reduction
d ti off obesity
b it
related chronic disease
RECOMMENDATIONS
• Locals Boards of Health are one important
avenue to achieve some of these changes
– As technical regulatory bodies, to be more effective,
consider requiring a predominance of public health
and health professionals
• Advocacy and education of the public on key
issues are necessary to build support and shift
social norms
• Caution and responsibility should accompany
innovation and courage lest we jeopardize the
autonomy of key local public health institutions
"It is one of the happy
incidents of the federal
system, that a single
courageous
g
state may,
y, if
its citizens choose, serve
as a laboratory; and try
novel social and economic
experiments without risk to
the rest of the country
country.“
Justice Louis D. Brandeis,1932