Building a Healthier Chicago

1
Building a Healthier Chicago
http//www.healthierchicago.org
2

Building a Healthier Chicago DISCLOSURE
INFORMATION James M. Galloway, M.D., F.A.C.P.,
F.A.C.C., F.A.H.A. has no relationships to
disclose

3
The Current Situation

• The United States has the highest GNP in the
  world
• The US spends nearly two trillion dollars a year
  on health care - nearly half of all health care
  dollars spent in the world
• Life expectancy in the US is one of the lowest of
  industrialized countries, behind Jordan and
  Slovenia
• Infant mortality?
• We are 31st!
• Cuba, Slovenia and Estonia do better!

4
The Current Situation

• Chronic illnesses now cost American business over
  a trillion dollars a year
• One third of the US is obese
• Deleterious lifestyles and behaviors, rather than
  medical conditions or genetic predispositions,
  are thought to be the most important and most
  modifiable causes of the majority of deaths from
  chronic disease.

5
Obesity Trends Among U.S. AdultsBRFSS, 1990,
1998, 2006
(BMI ?30, or about 30 lbs. overweight for 54
person)
1998
1990
2006
No Data lt10 1014 1519
2024 2529 30
6
The Current Situation

• The Washington Post reports that the width of a
  standard movie seat used to be 19 inches.
• It is now 23 inches..
• Journal of Pediatrics, 2006, reported that 1
  percent of all American infants and children
  more than 283,000 children are too big to fit
  in a car seat.

Susan Combs, Texas Comptroller of Public Accounts
7
The Current Situation
Mokdad, A.H., Marks, J.S., et al. Actual causes
of death in the United States. JAMA. 2004
2911238-1245.
8
Patients Over 45 Years Receiving Exercise
Counseling from Their Primary-Care Physicians
Percentage
Source National Ambulatory Medical Care Survey
and National Hospital Ambulatory Medical Care
Survey data files, 2003 2005. Available at
http//www.cdc.gov/nchs
9
(No Transcript)
10
The Current Situation

• Since 1970, the prevalence of obesity has
  doubled
• for preschool children
• And tripled for school-aged children
• Currently, 37 of school aged children are obese
  or
• overweight.

Strauss RS, Pollack HA. JAMA, 20012862845-8 Ogde
n et al JAMA 20062951549-55 Margellos-Anast et
al Public Health Reports. 123117-125
11
The Current Situation

• With a focus on obesity alone, 19 of school
  aged
• children are obese.
• Disproportionate numbers nationally
• African Americans 22
• Mexican Americans 23
• Non-Hispanic white 18

Ogden et al JAMA 20062951549-55 Margellos-Anast
et al Public Health Reports. 123117-125
12
Impact of Media Exposure on Childrens Health

• Average weekly time spent
• With parents 17 hours
• At school 30 hours
• With media 45 hours
• Media exposure directly and causally associated
  with negative health outcomes

Nunez-Smith et al. Yale School of Medicine Media
and child and adolescent health A systemic
review, 2008 AMA
13
The Current Situation Economic and Marketing
Influences

• You deserve a break today!
• Finger Lickin Good!
• Have it your way at __________!
• Yo Quiero _________________!
• Betcha cant eat just one!
• Some times you feel like a nut, sometimes you
  dont!
• ___________ melt in your mouth, not your hand!

Aldana SG, The Culprit and The Cure
14
The Social Ecological Model

• The aim must be to establish a health promoting
  environment in the social space in which persons
  make significant health decisions.
• The struggle is for the relevant space that
  various forces, some unconcerned with health and
  some actually detrimental to it, have thus far
  too loosely preempted.
• Social ecology for health means deliberately
  occupying more of that social space and using it
  in the interest of health.

Breslow L. Am J Health Promotion 10253-257.
15
(No Transcript)
16
CHAMPS
Building a Healthier Chicago

17
The Current Situation

• The Prevalence of Obesity Among Children in Six
  Chicago Communities
• Sinai Improving Community Health Survey
• Door to door, population based health survey
• 501 randomly selected children aged 2-12 years

Humboldt Park Roseland North
Lawndale South Lawndale Norwood
Park West Town
Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
18
The Prevalence of Obesity Among Children in Six
Chicago Communities

• Three stage sample design
• Communities by probability proportionate to size
  (PPS) sampling
• Households selected at random
• Household screen survey to an adult and a
  child/caretaker.
• Survey methodology Survey Research Laboratory of
  UIC

Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
19
The Prevalence of Obesity Among Children in Six
Chicago Communities
Percent
Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
20
The Prevalence of Obesity Among Children in Six
Chicago Communities

• Major findings
• Nearly half the children (aged 2 12) in five
  of six communities were obese compared to 16.8
  nationally.
• Prior community-level evaluations have found
  only 23-25 of school children were obese.
• The prevalence of obesity exceeded the
  prevalence of overweight by a factor of four in
  Humboldt Park and a five in Roseland.
• Contrary to what would be expected.

Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
21
The Prevalence of Obesity Among Children in Six
Chicago Communities

• Other major findings
• Racial and ethnic disparities far more
  pronounced than previously reported.

Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
22
The Current Situation Diabetes

• Other issuesOverweight
• Decline in Life expectancy (Zacs e-mail)

23
The Current Situation - Diabetes

• Other issuesOverweight
• Diabetes

24
Percent Decline in Age-Adjusted Mortality Rates
for Stroke United States, 1972-92
25
The Decline in Cardiovascular Mortality Men
Age Adjusted All Races Out of hospital mortality
per 100,000 NEJM, McGovern,et al, 334, 1996
26
The Decline in Cardiovascular Mortality Women
Age Adjusted All Races Out of hospital mortality
per 100,000 NEJM, McGovern,et al, 334, 1996
27
Behavioral and Social Factors

• Despite the credit taken by the medical
  profession, the pharmaceutical industry and
  device manufacturers related to these
  improvements
• Goldman and Cook evaluated the contributions of
  lifestyle changes vs. medical interventions for
  decline of CVD mortality between 1968 and 1978
• 39.5 due to medical interventions
• CCU, CABG, BP medications, etc
• 54 explained by reductions in smoking and serum
  cholesterol (diet modification), among other
  public health interventions

Goldman L, Cook EF. Annals Internal Med.
1984101825-836
28
The Current Situation - CVD

• While dramatic improvements in CVD mortality
  declines for over 40 years have been praised as
  one of the major health accomplishments of the
  twentieth century, recent data suggests that CVD
  mortality rate declines are slowing to 1.5 per
  year
• Despite significant and notable declines in
  stroke mortality for over 60 years, stroke
  mortality is no longer falling.

R Cooper et al. Circulation, 102, no. 25
(2000)3137-3147
29
The Current Situation - CVD

• Two well-designed population based studies
• Worchester, Mass
• Olmstead County, Minnesota
• have found that the rates of new cases of heart
  disease have not fallen from 1990 forward, and
  for women, may have actually risen.
• More recent concerns of potentially increasing
  incidence of CVD and CVD mortality in men and
  women.

Goldberg RJ et al. JACC, 33 6 (1999) 1533-1539.
Roger VL et al. Annals of Internal Med.1365
(2002) 34-348. Anciero et al. American J of
Med1174 (2004)228-233. Pearson TA. Health
Affairs 261?2007) 49-60
30
The Current Situation Life Expectancy

• The Reversal of Fortunes Trends in County
  Mortality and Cross County Mortality Disparities
  in the US
• NCHS data used to calculate life expectancy for
  all US counties between 1961 and 1999.
• Between 1961 and 1982, life expectancy improved.
• From 1983 to 1999, life expectancy declined
  significantly by 1.3 years for men and women in
  48 counties (men) and 783 counties (women)

Ezzati M, Friendman AB, et al. PLoS Med (5)4e66,
April 2008
31
The Current Situation Life Expectancy

• Of note, the higher disparity partly resulted
  from stagnation or an increase in mortality among
  the worst-off segment of the population, with
  life expectancy for approximately 4 of the male
  population and 19 of the female population
  having either had statistically significant
  decline or stagnation.

Ezzati M, Friendman AB, et al. PLoS Med (5)4e66,
April 2008
32
(No Transcript)
33
Interventions

• Significant data now exists that community level
  interventions can change community-wide behavior
• Four decades of community prevention trials show
  that efforts focused on community organization,
  education, screening for risk factors,
  environmental and policy modification, can affect
  behaviors.
• Communities
• Schools
• Worksites
• Faith based sites
• Healthcare sites

Nutrition Activity Tobacco Hypertension Hyperlipid
emia
34
Community Level Interventions

• In population health, small changes have great
  impact
• A 2 point fall in SBP for a population results a
  6 reduction in stroke mortality and a 4
  reduction in CHD mortality.

35
Long Term Prospective Epidemiological Studies

• Nurses Health Study
• Women who maintain a desirable body weight, eat
  a healthy diet, exercise regularly, do not smoke
  and consume a moderate amount of alcohol have an
  84 reduction in their risk of CVD

Stampfer MJ et al. NEJM 200034316-22
36
Community Level Interventions

• Issues of dose, duration and reach
• Stanford Three Community Trial
• A two year mass media based educational campaigns
  focused on two intervention communities with
  random sampling of men and women within the
  community. One control community.

Farquhar JW et al Lancet11192-1195
37
Community Level Interventions

• Stanford Five City Project
• Minnesota Heart Health Project
• Pawtucket Heart Health Project
• All non-randomized but community matched.
• Lasted 5 to 7 years
• Tracked morbidity and mortality
• Aimed at raising public awareness of risk factors
  and changing risk related behaviors.
• Public and provider education
• Minor environmental change
• For example, grocery store and restaurant
  labeling

Winkelby MA et al. Am J Public Health
861773-1779 Sorenson G et al. Ann Rev Public
Health 1998.19379-416
38
Community Level Interventions

• Issues of policy and system change
• US studies with minimal, if any, effective
  system change through
• policy intervention
• incentive development
• focused benefit
• sustainability

39
Community Level Interventions

• The North Karelia Project
• set the gold standard for nutritional policy
  and environmental interventions that produced a
  significant, long-term impact on CVD because of
  national efforts involving interactions among
  policy makers, food growers, vendors, educators
  and residents.

Matson-Koffman D, Brownstein JN et al. Amer J
Health Promotion. 2005 193157-193.
40
Community Level Interventions

• North Karelia Project
• Grew out of concern for the highest MI risk in
  the world.
• After 10 years, significant reductions in
• Smoking (men)
• Mean serum cholesterol (men)
• Mean systolic and diastolic BP (men and women)

McAlister A. Am J Public Health, 198272 43-50.
Puska P et al. Ann Rev Public Health,
19856147-193. CDC, Worldwide efforts to improve
heart heath, 1997.
41
Community Level Interventions

• North Karelia Project
• Along with the North Karelia Cholesterol project
• Demonstrated that policy and environmental
  changes could have a significant impact on fruit,
  vegetable and fat consumption in Finland.
• Increased availability of vegetables fruits
• Price supports for berry farmers
• Increased low fat dairy and meats
• Soft, low fat butter made available to all Finns
  through the government

McAlister A. Am J Public Health, 198272 43-50.
Puska P et al. Ann Rev Public Health,
19856147-193. CDC, Worldwide efforts to improve
heart heath, 1997.
42
Community Level Interventions

• North Karelia Project
• Between 1972 and 1992, per capita annual
  consumption of fruits and vegetables increased
  from 20 kg/person to 50 kg/person.
• During same period overall CV mortality for
  Finnish men aged 35 to 64 years dropped by 55
  and 68 in women.
• Intensive school based interventions targeting
  school lunches produced significant changes in
  children aged 13 to 15.
• Decreased fat intake in boys and girls with
  decreased serum cholesterol levels found among
  girls.

CDC, Worldwide efforts to improve heart heath,
1997. McAlister A. Am J Public Health, 198272
43-50. Puska P et al. Ann Rev Public Health,
19856147-193.
43

• It is unreasonable to expect that people will
  change their behavior easily when so many forces
  in the social, cultural, and physical environment
  conspire against such change
• Institute of Medicine, 2003

44
The Social Ecological Model

• The Social Ecological Model cuts across
  disciplinary lenses and integrates multiple
  perspectives and theories.
• This framework recognizes that behavior is
  affected by multiple levels of influence,
  including interpersonal factors, interpersonal
  processes, institutional factors, community
  factors, environmental factors, social factors
  and public policy.

45

• Not everyone has opportunities to be healthy. .
  . If you are poor, less educated or a minority,
  your prospects for living a long, healthy life
  are significantly worse than if you are more
  affluent, better educated or white.

46
The choices we make

• are shaped
• by the choices we have

47
Building a Healthier Chicago
http//www.healthierchicago.org
48
Building a Healthier Chicago
GOAL To improve the health of Chicagos
residents and employees through the integration
of existing and new public health, medicine and
community health promotion activities

49
Building a Healthier Chicago
VISION Integrated, effective and sustained
community-wide partnerships for health promotion
that can be replicated nationwide

50
Building a Healthier Chicago

• Our Objectives
• Promote, coordinate and track the adoption of
  optimal programs, systems, practices, policies,
  and supportive environments throughout the health
  care organizations, worksites, schools, and
  neighborhoods of Chicago.

51
Building a Healthier Chicago

• Our Objectives (cont.)
• Develop and maintain a system of interventions
  that complement and reinforce each other to
  maximize reach and effectiveness.
• Build Synergy!

52
Building a Healthier Chicago
53
Building a Healthier Chicago
Policy
Nutrition
Hypertension
Physical Activity
Homes
Communities
Schools
Healthcare Facilities
Work Sites
Faith-Based Orgs.
Young Adults
50
Children
Adults
Neonates/ Infants
Modified from Pearson TA et al. Scand J Public
Health. 2001 2.
54
Building a Healthier Chicago

• Midwest Business Group on Health
• CHEST Foundation
• Community Health Charities
• American College of Cardiology
• National Kidney Foundation of Illinois
• Metropolitan Chicago Healthcare
• Council
• American Cancer Society
• Alliance for a Healthier Generation
• American College of Sports Medicine
• Chicago BEARS
• University of Chicago
• Northwestern University
• UIC COPH Institute for Health
• Research and Policy

• Partners (partial listing)
• City of Chicago DPH
• Parks and Recreation
• Mayors Fitness Council
• American Medical Association
• National Restaurant Association
• Chicago Medical Society
• AARP
• Chicagoland Chamber of Commerce
• American Dietetic Association
• American Heart Association
• American Diabetes Association
• CLOCC
• Health Medicine Policy Research
• Group

55
Building a Healthier Chicago

• Partners (partial listing)
• RUSH
• Butler University
• St. Xavier University
• The Public Health Institute
• YMCA
• Alliance
• Access Community Health Network
• Illinois Foundation for Healthcare
• Quality
• Erie Family Health Center
• Humana, Inc
• Rush Health Associates
• Blue Cross/Blue Shield
• Ad Council

• NBC
• Illinois Department of Public Health
• Illinois Medical Society
• JP Morgan Chase
• Proactive Partners
• Chicago Runs
• Aadman Total Wellness
• Waterton Residential
• Midwest Dairy Council
• Chicago Endurance Sports
• Takeda Pharmaceuticals
• Code Red
• Novartis

56
Building a Healthier Chicago

• Our Federal Partners
• Federal Occupational Health
• Health Risk Appraisal
• The Presidents Council on Physical Fitness
• The Presidents Challenge
• The Surgeon Generals Initiative on Obesity

57
Building a Healthier Chicago

• Our Federal Partners (continued)
• The Office of Health Promotion and Disease
  Prevention
• Metrics from Healthy People 2010/2020
• Centers For Disease Control and Prevention
• The Office of Public Health and Science

58
Building a Healthier Chicago

• Our Federal Partners (continued)
• U.S. Department of Agriculture
• Food and Nutrition Service
• Internal Revenue Service
• Small Business Administration

59
American Medical Association

• Medical Outreach
• Providers, hospitals and health programs
• Physician Advisory Council
• Healthy Lifestyle Implementation Programs
• Education/Initiatives with Chicago Medical
  Society
• 13,000 Medical Students
• Public Health Committee
• Senior Physicians Committee

60
Chicago Department of Public Health

• Multiple Initiatives
• Five to Thrive, HTN, RxChicago, etc.
• Community Health Centers
• City Employees
• City wide
• Police
• Firefighters
• Mayors Council on Physical Fitness
• Parks and Recreation

61
Building a Healthier Chicago

• The Combined Federal Wellness Campaign
• A Subcommittee of the Federal Executive Board
• Department of Health and Human Services
• Federal Occupational Health HRA model
• FEMA/Homeland Security
• Federal Aviation Administration
• Federal Bureau of Investigation
• Postal Service
• Railroad Retirement Board

62
Building a Healthier Chicago

• Our External Foci
• Broadly, supporting our partners in
• Improved activity levels
• Improved healthy eating
• Prevention, detection and control of
  hypertension

63
Building a Healthier Chicago

• Advisory Councils
• Federal
• Student
• Physician Leadership
• CEO
• Academic
• Nursing under development

64
Building a Healthier Chicago Physician Advisory
Council

• Hugo Alvarez, MD
  
  Medical Director,
  
  Access Community Health
  Network
• Michael Diamond, MA
  
  President,
  
  World Resources
  Chicago
• Joshua Evans, MD-MPH Candidate 2009 (student
  member) Feinberg School of
  Medicine,
  Northwestern University
• Margaret Gadon, MD, MPH, FACP
  
  (currently working in Ethiopia)
• James Galloway, MD, FACP, FACC, FAHA
• Assistant Surgeon General,
  
  Regional Health Administrator,
  
  US Public Health
  Service

65
Building a Healthier Chicago Physician Advisory
Council

• Allen Goldberg, MD, MBA, Master FCCP
  The CHEST
  Foundation
• Joseph Harrington
  
  Assistant Commissioner,
  
  Chicago Department of Public Health
• Lawrence Haspel, MD
  
  Senior Vice President,
  
  Metropolitan Chicago Healthcare Council
• Mary Lukancic, MD
  
  Associate Clinical Coordinator,
  
  Illinois Foundation for Quality
  Health Care
• William McDade, MD, PhD
  
  Associate Dean, Multicultural Affairs,
  
  University of Chicago Pritzker School of
  Medicine,
  President, Chicago Medical Society

66
Building a Healthier Chicago Physician Advisory
Council

• Doriane Miller, MD
  
  National Program Director, New Health
  Partnerships
  Associate Division Chief for General
  Internal Medicine,
  Stroger Hospital of Cook County
• Lynda H. Powell, PhD
  
  Chair, Department of Preventive Medicine,
  
  Rush University School of Medicine
• Steven Rothschild, MD, MPH
  
  Associate Professor, Department of Preventive
  Medicine,
  Rush University School of Medicine
• Melissa Simon, MD, MPH
  
  Assistant Professor, Department of Obstetrics and
  Gynecology, Feinberg
  School of Medicine, Northwestern University
• Eric Whitaker, MD, MPH
  
  Executive Vice President for Strategic
  Affiliations
  University of Chicago Hospitals

67
Building a Healthier Chicago Physician Advisory
Council

• Quentin Young, MD
  
  Chairman, Board of Directors
  
  Health and Medicine Policy
  Research Group
• Sonja Boone, MD
  
  Director of Physician Health and Health Care
  Disparities,
  Division of Medicine Public Health
  
  American Medical Association
• Suzen M. Moeller, PhD
  
  Senior Scientist, Nutrition Policy and Health
  Promotion,
  Division of Medicine Public Health
  
  American Medical Association
• Amber L. Ryan, MEd
  
  Project Coordinator, Building A Healthier
  Chicago
  Division of Medicine Public Health
  
  American Medical Association

68
Building a Healthier Chicago

• Our External Foci
• Active Partners in the development of Model
  Programs
• Healthy Residential High Rise Presidential
  Towers
• Healthy Office High Rise 233 N Michigan Ave
• Healthy Elementary Schools Oscar Mayar
• Healthy Corporation Hu Freidy
• Healthy Federal Agency FAA
• Healthy University University of Illinois

69
Building a Healthier Chicago

• Our Working Committees
• Worksite Wellness
• Schools Youth
• Academic Partnerships
• Community Outreach Support
• Metrics
• GIS

70
Current Activities (a select few)

• Conferences Worksite Wellness (with MBGH)
• Community Nutrition Conference Eat well, Live
  well! (with NIH others)
• Upcoming Policy Meetings
• Academic Conference
• Metric Conference
• Student Wellness Program
• Model BHC Healthy schools
• Model BHC Healthy residential high rises
• Model BHC Healthy office high rises
• Model BHC Healthy agencies
• Model BHC Healthy corporations
• Policy Development City Council Aldermen
• Community Involvement- CDPH, FQHCs, others
• Data Generation/Evaluation/GIS Mapping
• Focus Community

71
The idea that individual health choices and
personal behaviors are the most important
determinants of chronic disease is an idea whose
time has come and gone.
George Mensah, MD.
72
Individual choices are important However, it is
unlikely that individually attempted changes in
lifestyles and behaviors alone can avert the
growing epidemic of chronic disease that we are
witnessing.
73
Environmental Change Policies Practices Programs
Healthy Chicago Healthy Behavior Less Illness
Death
Collaborative Partnership
Changing Individual Behaviors
74
Environmental Change Policies Practices Programs
Healthy Chicago Healthy Behavior Less Illness
Death
Collaborative Partnership
Although partnerships have affected change in
community-wide behavior, the strongest evidence
shows that coalitions most effectively contribute
to changes in programs, services and practices.
Butterfloss FD Francisco VT. (2004) Health
Promotion Practice 5(2)108-114. Roussos ST and
Fawcett SB (2000) Annu Rev of Public Health
21369-402.
75
The Social Ecological Model

• We must
• ignite and build a social movement
• at private, public and policy levels in order to
  change broad scale social norms and create a
  social envionment supportive of health.

Sorenson G et al. Ann Rev Public Health
1998.19379-416
76
Building a Healthier Chicago

77
Building a Healthier Chicago
james.galloway_at_hhs.gov 312-353-1358 www.healthie
rchicago.org
78
Building a Healthier Chicago
http//www.healthierchicago.org