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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 00 99 20 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 19 87 19 86 19 85 19 34 19 83 19 82 19 81 19 80 19 79 19 78 19 77 19 76 19 75 19 74 19 73 19 72 19 71 19 19 70 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